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Guel DNB, Laverick N, MacLaren L, MacLeod N, Glegg M, Lamb G, Houston P, Carruthers R, Grocutt L, Valentine RM. Adaptive radiotherapy for muscle invasive bladder cancer: a retrospective audit of two bladder filling protocols. Radiat Oncol 2024; 19:92. [PMID: 39030548 PMCID: PMC11264890 DOI: 10.1186/s13014-024-02484-9] [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: 03/15/2024] [Accepted: 06/28/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Radical radiotherapy for muscle-invasive bladder cancer (MIBC) is challenging due to large variations in bladder shape, size and volume during treatment, with drinking protocols often employed to mitigate geometric uncertainties. Utilising adaptive radiotherapy together with CBCT imaging to select a treatment plan that best fits the bladder target and reduce normal tissue irradiation is an attractive option to compensate for anatomical changes. The aim of this retrospective study was to compare a bladder empty (BE) protocol to a bladder filling (BF) protocol with regards to variations in target volumes, plan of the day (PoD) selection and plan dosimetry throughout treatment. METHODS Forty patients were included in the study; twenty were treated with a BE protocol and twenty with a BF protocol to a total prescribed dose of 55 Gy in 20 fractions. Small, medium and large bladder plans were generated using three different CTV to PTV margins. Bladder (CTV) volumes were delineated on planning CTs and online pre-treatment CBCTs. Differences in CTV volumes throughout treatment, plan selection, PTV volumes and resulting dose metrics were compared for both protocols. RESULTS Mean bladder volume differed significantly on both the planning CTs and online pre-treatment CBCTs between the protocols (p < 0.05). Significant differences in bladder volumes were observed between the planning CT and pre-treatment CBCTs for BF (p < 0.05) but not for BE (p = 0.11). Both protocols saw a significant decrease in bladder volume between first and final treatment fractions (p < 0.05). Medium plans were preferentially selected for BE whilst when using the BF protocol the small plan was chosen most frequently. With no significant change to PTV coverage between the protocols, the volume of body receiving 25.0-45.8 Gy was found to be significantly smaller for BE patients (p < 0.05). CONCLUSIONS This work provides evidence in favour of a BE protocol compared to a BF protocol for radical radiotherapy for MIBC. The smaller treatment volumes observed in the BE protocol led to reduced OAR and total body doses and were also observed to be more consistent throughout the treatment course. These results highlight improvements in dosimetry for patients who undergo a BE protocol for MIBC.
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Affiliation(s)
- Diana Nohemi Briceño Guel
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8QQ, UK
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicola Laverick
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Linda MacLaren
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicholas MacLeod
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Martin Glegg
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Gillian Lamb
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Peter Houston
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Ross Carruthers
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Laura Grocutt
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
- CRUK RadNet Glasgow, University of Glasgow, Glasgow, G61 1QH, UK
| | - Ronan M Valentine
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK.
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Dahl DM, Karrison TG, Michaelson MD, Pham HT, Wu CL, Swanson GP, Shipley WU, Vuky J, Lee RJ, Zietman AL, Souhami L, Chang BK, Deming RL, Ellerton JA, Sandler HM, Rodgers JP, Feng FY, Efstathiou JA. Long-term Outcomes of Chemoradiation for Muscle-invasive Bladder Cancer in Noncystectomy Candidates. Final Results of NRG Oncology RTOG 0524-A Phase 1/2 Trial of Paclitaxel + Trastuzumab with Daily Radiation or Paclitaxel Alone with Daily Irradiation. Eur Urol Oncol 2024; 7:83-90. [PMID: 37442672 PMCID: PMC10782593 DOI: 10.1016/j.euo.2023.05.013] [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: 10/31/2022] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Chemo-radiation is a well-established alternative to radical cystectomy in patients with muscle-invasive bladder cancer. Many patients due to age or medical comorbidity are unfit for either radical cystectomy, or standard cisplatin- or 5-fluorouracil-based chemoradiation, and do not receive appropriate treatment with curative intent. We treated patients with a less aggressive protocol employing seven weekly doses of paclitaxel and daily irradiation. In those whose tumors showed overexpression of her2/neu, seven weekly doses of trastuzumab were also administered. OBJECTIVE To report the long-term survival outcomes and toxicity results of the of NRG Oncology RTOG 0524 study. DESIGN, SETTING, AND PARTICIPANTS Seventy patients were enrolled and 65 (median age: 76 yr) were deemed eligible. Patients were assigned to daily radiation and weekly paclitaxel + trastuzumab (group 1, 20 patients) or to daily radiation plus weekly paclitaxel (group 2, 45 patients) based on tumor her2/neu overexpression. Radiation was delivered in 1.8 Gy fractions to a total dose of 64.8 Gy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was unresolved treatment-related toxicity. The secondary endpoints were complete response rate, protocol completion rate, and disease-free and overall survival. RESULTS AND LIMITATIONS Protocol therapy was completed by 60% (group 1) and 76% (group 2); complete response rates at 12 wk were 62% in each group. Acute treatment-related adverse events (AEs) of grade ≥3 were observed in 80% in group 1 and 58% in group 2. There was one treatment-related grade 5 AE in group 1. Unresolved acute treatment-related toxicity was 35% in group 1 and 31% in group 2. The median follow-up was 2.3 yr in all patients and 7.2 yr in surviving patients. Overall survival at 5 yr was 25.0% in group 1 and 37.8% in group 2 (33.8% overall). At 5 yr, disease-free survival was 15.0% in group 1 and 31.1% in group 2. CONCLUSIONS In a cohort of patients with muscle-invasive bladder cancer who are not candidates for cystectomy or cisplatin chemotherapy, chemoradiation therapy offers a treatment with a significant response rate and 34% 5-yr overall survival. While there were many AEs in this medically fragile group, there were few grade 4 events and one grade 5 event attributable to therapy. PATIENT SUMMARY Patients with invasive bladder cancer who cannot tolerate surgery were treated with radiation and systemic therapy without surgically removing their bladders. Most patients tolerated the treatment, were able to keep their bladders, and showed a significant treatment response rate.
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Affiliation(s)
- Douglas M Dahl
- Massachusetts General Hospital Cancer Center, Boston, MA, USA.
| | - Theodore G Karrison
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA; University of Chicago, Chicago, IL, USA
| | | | | | - Chin-Lee Wu
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | | | | | - Jacqueline Vuky
- OHSU Knight Cancer Institute, Accrual-Virginia Mason CCOP, Portland, OR, USA
| | - R Jeffrey Lee
- Intermountain Medical Center, Salt Lake City, UT, USA
| | | | - Luis Souhami
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | | | - Richard L Deming
- Mercy Medical Center - Des Moines, Accrual-Penrose Cancer Center, Penrose-St. Francis Health Services, Des Moines, IA, USA
| | | | | | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Felix Y Feng
- UCSF Medical Center-Mission Bay, San Francisco, CA, USA
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3
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Yock AD, Cooney A, Morales‐Paliza M, Shinohara E, Homann K. Empirical analysis of a plan-of-the-day strategy to approximate daily online reoptimization for prostate CBCT-guided adaptive radiotherapy. J Appl Clin Med Phys 2024; 25:e14221. [PMID: 38029380 PMCID: PMC10795443 DOI: 10.1002/acm2.14221] [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: 08/06/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE Adaptive radiotherapy (ART) can improve the dose delivered to the patient in the presence of anatomic variations. However, the required time, effort, and clinical resources are intensive. This work analyzed a plan-of-the-day (POD) approach on clinical patients treated with online ART to explore implementations that balance dosimetric benefit and clinical resource cost. METHODS Eight patients treated to the prostate and proximal seminal vesicles with 26 fractions of CBCT-guided, daily online ART were retrospectively analyzed. With a plan library composed of daily adaptive plans from the initial week of treatment and the original plan, the effect of a POD approach starting the following week was investigated by simulating use of these previously generated plans under 3- and 6-degree-of-freedom patient alignment. The plan selected for each treatment was that from the library that maximized the Dice similarity coefficient of the clinical target volume with that of the current treatment fraction. The resulting distribution of several target coverage and organ-at-risk dose metrics are described relative to those achieved with the daily online reoptimized adaptive technique. RESULTS The values of target coverage and organ-at-risk dose metrics varied across patients and metrics. The POD schemas closely approximated the reference values from a fully reoptimized adaptive plan yet required less than 20% of the reoptimization effort. The POD schemas also had a much greater effect on target coverage metrics than 6-degree-of-freedom registration did. Organ-at-risk dose metrics also varied considerably across patients but did not exhibit a consistent dependence on the particular schema. CONCLUSIONS POD schemas were able to achieve the vast majority of the dosimetric benefit of daily online ART with a small fraction of the online reoptimization effort. Strategies like this might allow for more practical and strategic implementation of ART so as to benefit a greater number of patients.
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Affiliation(s)
- Adam D. Yock
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Annie Cooney
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Manuel Morales‐Paliza
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Shinohara
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kenneth Homann
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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De Hertogh O. [Bladder preservation treatments for bladder cancer: Trimodality therapy, an overview of clinical practices in 2023]. Cancer Radiother 2023; 27:562-567. [PMID: 37481342 DOI: 10.1016/j.canrad.2023.06.011] [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: 05/31/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 07/24/2023]
Abstract
Bladder cancer is the most frequent tumor of the urinary tract. Patients diagnosed at a stage when the tumor has spread into or through the muscle layer of the bladder wall are usually treated with cystectomy. The evolution of cancer treatments, related to the development of alternative treatment options to the historical surgical standard and to the implication of the patient as an actor in decision-making, trends towards organ and function preservation without sacrificing efficacy. Trimodality therapy, which is a maximal transurethral resection of the tumor followed by concurrent chemoradiation, is an interesting therapeutic alternative for patients unfit for surgery and for those wishing to benefit from organ preservation. Radiotherapy offers excellent treatment possibilities for muscle-invasive bladder cancer. In selected T2-stage patients fit for trimodality therapy, it has an equivalent oncological outcome compared to cystectomy while having less severe complications and offering organ preservation. It remains feasible in inoperable patients while offering significant perspectives of relapse-free survival. Finally, it also is an efficient palliative treatment in patients where mid-term local control and hemostasis are sought after.
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Affiliation(s)
- O De Hertogh
- Radiation oncology department, CHR Verviers East Belgium, 29, rue du Parc, 4800 Verviers, Belgique.
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Morel A, Prunaretty J, Trauchessec D, Ailleres N, Fenoglietto P, Azria D. Comprehensive commissioning and quality assurance validation of Ethos™ therapy. Cancer Radiother 2023; 27:355-361. [PMID: 37085341 DOI: 10.1016/j.canrad.2022.10.001] [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: 09/22/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 04/23/2023]
Abstract
PURPOSE Adaptive radiotherapy with the Ethos® therapy Varian system has been recently implemented at the Montpellier Cancer Institute, France. This article details the commissioning performed before the implementation of this new treatment planning system (TPS). MATERIAL AND METHODS To validate the golden beam data of the machine (Halcyon linear accelerator), percentage depth doses (PDD) and profiles were measured for several field sizes and at different depths with a microdiamond chamber. The final doses calculated for different plan types with the Ethos Acuros XB algorithm and the Halcyon Eclipse Analytic Anisotropic Algorithm were compared using the gamma index method. Lastly, for the patient quality assurance (QA) process, the patient treatment plan results obtained with the Mobius3D QA platform (Varian) were compared with the portal dosimetry results obtained with Epiqa (Epidos). RESULTS Minor differences were observed for the PDD and profile curves (mean difference of 0.2% and 2%, respectively). The χ index pass rate was above 98% for all measures using the 1%/1mm and 2%/2mm criteria for PDD and profile evaluations. The Ethos AXB algorithm was validated for every configuration (fixed fields, standard IMRT and VMAT fields, and clinical plans) with 2D/3D gamma index values>99%. Seventy-three 3-arcs-VMAT QA plans and 27 9-fields-IMRT QA plans were evaluated. Both showed excellent agreement with the TPS calculations (mean gamma pass rate higher than 99%). No difference was observed between IMRT and VMAT. CONCLUSION The beam delivery, the Ethos AXB algorithm, and the patient QA were comprehensively validated using independent tools.
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Affiliation(s)
- A Morel
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - J Prunaretty
- Institut du cancer de Montpellier (ICM), Montpellier, France.
| | - D Trauchessec
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - N Ailleres
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - P Fenoglietto
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - D Azria
- Institut du cancer de Montpellier (ICM), Montpellier, France
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Bleeker M, Visser J, Goudschaal K, Bel A, Hulshof MCCM, Sonke JJ, van der Horst A. Dosimetric benefit of a library of plans versus single-plan strategy for pre-operative gastric cancer radiotherapy. Radiother Oncol 2023; 182:109582. [PMID: 36842661 DOI: 10.1016/j.radonc.2023.109582] [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: 11/10/2022] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND AND PURPOSE The stomach experiences large volume and shape changes during pre-operative gastric radiotherapy. This study evaluates the dosimetric benefit for organs-at-risk (OARs) of a library of plans (LoP) compared to the traditional single-plan (SP) strategy. MATERIALS AND METHODS Twelve patients who received SP CBCT-guided pre-operative gastric radiotherapy (45 Gy; 25 fractions) were included. Clinical target volume (CTV) consisted of CTVstomach (i.e., stomach + 10 mm uniform margin minus OARs) and CTVLN (i.e., regional lymph node stations). For LoP, five stomach volumes (approximately equidistant with fixed volumes) were created using a previously developed stomach deformation model (volume = 150-750 mL). Appropriate planning target volume (PTV) margins were calculated for CTVstomach (SP and LoP, separately) and CTVLN. Treatment plans were automatically generated/optimized and the best-fitting library plan was manually selected for each daily CBCT. OARs (i.e., liver, kidneys, heart, spleen, spinal canal) doses were accumulated and dose-volume histogram (DVH) parameters were evaluated. RESULTS The non-isotropic PTVstomach margins were significantly (p < 0.05) smaller for LoP than SP (median = 13.1 vs 19.8 mm). For each patient, the average PTV was smaller using a LoP (difference range 134-1151 mL). For all OARs except the kidneys, DVH parameters were significantly reduced using a LoP. Differences in mean dose (Dmean) for liver, heart and spleen ranged between -1.8 to 5.7 Gy. For LoP, a benefit of heart Dmean > 4 Gy and spleen Dmean > 2 Gy was found in 4 and 5 patients, respectively. CONCLUSION A LoP strategy for pre-operative gastric cancer reduced average PTV and reduced OAR dose compared to a SP strategy, thereby potentially reducing risks for radiation-induced toxicities.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jorrit Visser
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Goudschaal
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Abstract
Organ preservation for muscle-invasive bladder cancer (MIBC) may use trimodality therapy. This includes transurethral resection followed by radiation therapy. Radiosensitization has become one of the standard of care approaches for MIBC with high rates of local disease control and overall survival. The goal of organ preservation is to treat MIBC while preserving a well-functioning natural bladder. Debate remains over the best way to optimize radiation therapy in bladder cancer. In MIBC the role of partial cystectomy has been utilized in smaller solitary tumors with adequate local control and good urinary function. As radiation therapy techniques improve and modernize, smaller radiation volumes to a partial bladder may play an increasing role as we utilize imaging techniques coupled with adaptive radiation therapy planning and other techniques such as brachytherapy. In this review, we explore the use of brachytherapy and partial bladder fields of external beam radiation therapy in the treatment of MIBC.
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Zheng R, Wang B, Liang F, Xu B. Systemic therapy‐based split‐course stereotactic body radiation therapy. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rong Zheng
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University) Fuzhou Fujian China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies) Fuzhou Fujian China
| | - Bisi Wang
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
| | - Feihong Liang
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
| | - Benhua Xu
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University) Fuzhou Fujian China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies) Fuzhou Fujian China
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Optimized Adaptive Radiotherapy with Individualized Plan Library for Muscle-Invasive Bladder Cancer Using Internal Target Volume Generation. Cancers (Basel) 2022; 14:cancers14194674. [PMID: 36230598 PMCID: PMC9564375 DOI: 10.3390/cancers14194674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary The bladder is a mobile target and is subject to filling variation. This poses a considerable challenge for effective radiotherapy (RT) delivery. We applied an internal target volume to the plan library to resolve intra-fractional errors caused by bladder filling during treatment. Adaptive radiotherapy using ITV is easy to perform and a feasible treatment approach. In this study, image-guided RT-based adaptive RT showed good survival outcomes with a high local control rate. Abstract The bladder is subject to filling variation, which poses a challenge to radiotherapy (RT) delivery. We aimed to assess feasibility and clinical outcomes in patients with bladder cancer treated with adaptive RT (ART) using individualized plan libraries. We retrospectively analyzed 19 patients who underwent RT for muscle-invasive bladder cancer (MIBC) in 2015–2021. Four planning computed tomography (CT) scans were acquired at 15-min intervals, and a library of three intensity-modulated RT plans were generated using internal target volumes (ITVs). A post-treatment cone-beam CT (CBCT) scan was acquired daily to assess intra-fraction filling and coverage. All patients completed the treatment, with 408 post-treatment CBCT scans. The bladder was out of the planning target volume (PTV) range in 12 scans. The volumes of the evaluated PTV plans were significantly smaller than those of conventional PTV. The 1-year and 2-year overall survival rates were 88.2% and 63.7%, respectively. Of eight cases that experienced recurrence, only two developed MIBC. There were no grade 3 or higher RT-related adverse events. ART using plan libraries and ITVs demonstrated good survival outcomes with a high local control rate. Irradiated normal tissue volume and treatment margins may be reduced through this approach, potentially resulting in lower toxicity rates.
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Joyce E, Jackson M, Skok J, Peet B, McNair HA. Images and images: Current roles of therapeutic radiographers. Radiography (Lond) 2022; 28:1093-1100. [PMID: 36054937 DOI: 10.1016/j.radi.2022.07.016] [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: 04/05/2022] [Revised: 07/26/2022] [Accepted: 07/31/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Therapeutic radiography is a small profession and has adapted in response to advanced techniques. An increase in on-line adaptive MRI-guided radiotherapy (MRIgRT) will require role extension for therapeutic radiographers (TRs). This study will investigate the current role description for TRs and the activities they currently undertake with regards to MRIgRT. METHOD A training needs analysis was used to ask TRs about their current roles and responsibilities and essential skills required for MRIgRT. For the purposes of this paper, the authors present the results from the demographics of the individual, their current job title with roles and responsibilities, and experience with decision making and image assessment. Descriptive statistics was used to analyse the data. RESULTS 261 responses were received (n = 261). Only 28% of job titles listed contained the protected title of 'therapeutic radiographer'. Advanced clinical practice roles were expressed by participants indicating that if a service need is presented, emerging roles will be created. Variation existed across the standardised roles of TRs and this discrepancy could present challenges when training for MRIgRT. TRs are pivotal in image verification and recognition on a standard linac, and skills developed there can be transferred to MRIgRT. Decision making is crucial for adaptive techniques and there are many skills within their current scope of practice that are indispensable for the MRIgRT. CONCLUSION It has been demonstrated that TRs have a range of roles that cover vast areas of the oncology pathway and so it is important that TRs are recognised so the pivotal role they play is understood by all. TRs have extensive soft-tissue IGRT knowledge and experience, aiding the evolution of decision-making skills and application of off-protocol judgments, the basis of MRIgRT. IMPLICATIONS FOR PRACTICE Role development and changes in education for therapeutic radiographers.
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Affiliation(s)
- E Joyce
- Royal Marsden NHS Foundation Trust, UK
| | - M Jackson
- St George's University of London, UK
| | - J Skok
- St George's University of London, UK
| | - B Peet
- Royal Marsden NHS Foundation Trust, UK
| | - H A McNair
- Royal Marsden NHS Foundation Trust, UK; Institute of Cancer Research, UK.
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Fabiano E, Riou O, Pointreau Y, Périchon N, Durdux C. Role of radiotherapy in the management of bladder cancer: Recommendations of the French society for radiation oncology. Cancer Radiother 2021; 26:315-322. [PMID: 34955411 DOI: 10.1016/j.canrad.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present the recommendations of the French society of oncological radiotherapy on the indications and techniques for external beam radiotherapy for bladder cancer.
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Affiliation(s)
- E Fabiano
- Département de radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - O Riou
- Département de radiothérapie, Institut régional du cancer, 34000 Montpellier, France
| | - Y Pointreau
- Département de radiothérapie, Institut interrégional de cancérologie, centre Jean-Bernard, clinique Victor-Hugo, 72000 Le Mans, France
| | - N Périchon
- Département de radiothérapie, centre Eugène-Marquis, 35000 Rennes, France
| | - C Durdux
- Département de radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
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12
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den Boer D, den Hartogh MD, Kotte AN, van der Voort van Zyp JR, Noteboom JL, Bol GH, Willigenburg T, Werensteijn-Honingh AM, Jürgenliemk-Schulz IM, van Lier AL, Kroon PS. Comparison of Library of Plans with two daily adaptive strategies for whole bladder radiotherapy. Phys Imaging Radiat Oncol 2021; 20:82-87. [PMID: 34849413 PMCID: PMC8609047 DOI: 10.1016/j.phro.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Whole bladder radiotherapy is challenging due to inter- and intrafraction size and shape changes. To account for these changes, currently a Library of Plans (LoP) technique is often applied, but daily adaptive radiotherapy is also increasingly becoming available. The aim of this study was to compare LoP with two magnetic resonance imaging guided radiotherapy (MRgRT) strategies by comparing target coverage and volume of healthy tissue inside the planning target volume (PTV) for whole bladder treatments. Methods and materials Data from 25 MRgRT lymph node oligometastases treatments (125 fractions) were used, with three MRI scans acquired at each fraction at 0, 15 and 30 min. Bladders were delineated and used to evaluate three strategies: 1) LoP with two plans for a 15 min fraction, 2) MRgRT15min for a 15 min fraction and 3) MRgRT30min for a 30 min fraction. The volumes of healthy tissue inside and bladder outside the PTV were analyzed on the simulated post-treatment images. Results MRgRT30min had 120% and 121% more healthy tissue inside the PTV than LoP and MRgRT15min. For LoP slightly more target outside the PTV was found than for MRgRT30min and MRgRT15min, with median 0% (range 0-23%) compared to 0% (0-20%) and 0% (0-10%), respectively. Conclusions Taking into account both target coverage and volume of healthy tissue inside the PTV, MRgRT15min performed better than LoP and MRgRT30min for whole bladder treatments. A 15 min daily adaptive radiotherapy workflow is needed to potentially benefit from replanning compared to LoP.
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Affiliation(s)
- Duncan den Boer
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
- Corresponding author at: Department of Radiotherapy, Amsterdam University Medical Centers, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands.
| | - Mariska D. den Hartogh
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Alexis N.T.J. Kotte
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | | | - Juus L. Noteboom
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Gijsbert H. Bol
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Thomas Willigenburg
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Anita M. Werensteijn-Honingh
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Astrid L.H.M.W. van Lier
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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13
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Portner R, Bajaj A, Elumalai T, Huddart R, Murthy V, Nightingale H, Patel K, Sargos P, Song Y, Hoskin P, Choudhury A. A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer. Clin Transl Radiat Oncol 2021; 31:1-7. [PMID: 34466667 PMCID: PMC8385113 DOI: 10.1016/j.ctro.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.
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Affiliation(s)
- R. Portner
- The Christie NHS Foundation Trust, Manchester, UK
| | - A. Bajaj
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - T. Elumalai
- The Christie NHS Foundation Trust, Manchester, UK
| | - R. Huddart
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, UK
| | - V. Murthy
- Department of Radiation Oncology, ACTREC and Tata Memorial Hospital, Homi Bhabha National University, Mumbai, India
| | | | - K. Patel
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Sargos
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Y. Song
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - A. Choudhury
- The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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14
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Tsang YM, Routsis DS. Adapting for Adaptive Radiotherapy (ART): The need to evolve our roles as Therapeutic Radiographers. Radiography (Lond) 2021; 27 Suppl 1:S39-S42. [PMID: 34535353 DOI: 10.1016/j.radi.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES 4D Adaptive Radiotherapy (4D-ART) has been stated as the future baseline standard-of-care for technical radiotherapy. Its goal is to optimise radiation dose received by 'adapting' to changes 'seen' in each individual patient, for each treatment delivery (fraction), throughout each treatment delivery. The drive for technological developments to achieve this is ongoing. To enhance the potential benefits, we should consider other aspects of the processes needed: How do changes in clinical practices and processes affect the role of the Therapeutic Radiographer? The aim is to raise the need to explore questions of Therapeutic Radiographers roles and responsibilities within 4D-ART. KEY FINDINGS Moving from using current predictive strategies (such as plan-of-the-day) to being able to dynamically adapt (real-time/4D-ART) for patient changes requires rapid clinical judgements to be made. The question becomes 'who makes these decisions'? Currently Therapeutic Radiographers maybe ideally placed for this. Dynamically adaptive radiotherapy requires Radiographers to have clinical decisions-making skills and authorities within the multi-professional team (MPT). It is not sufficient to train radiographers in the 'how' to use 4D-ART techniques and technologies; the ability to make good clinical judgments comes from understanding the principles supporting this concept by understanding the 'why'. CONCLUSION To support future service needs and ongoing developments within ART, Radiographer's roles need to adapt and evolve, as well as the way their role is perceived within the MPT. We need to provide Radiographers with the education required, abilities and authorities to act. IMPLICATIONS FOR PRACTICE Role revision is required to include greater responsibility for clinical decision making for implementing 4D-ART practices.
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Affiliation(s)
- Y M Tsang
- East and North Hertfordshire NHS Trust, Radiotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex, HA6 2RN, UK
| | - D S Routsis
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Radiotherapy Department, Hill's Road, Cambridge, UK.
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15
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Hafeez S, Dunlop A, Mitchell A, Nill S. Comment on Hunt et al., "Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer". Clin Transl Radiat Oncol 2021; 29:9-10. [PMID: 34027138 PMCID: PMC8122149 DOI: 10.1016/j.ctro.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- S. Hafeez
- Divsion of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK
| | - A. Dunlop
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, UK
| | - A. Mitchell
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, UK
| | - S. Nill
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, UK
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16
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Khalifa J, Supiot S, Pignot G, Hennequin C, Blanchard P, Pasquier D, Magné N, de Crevoisier R, Graff-Cailleaud P, Riou O, Cabaillé M, Azria D, Latorzeff I, Créhange G, Chapet O, Rouprêt M, Belhomme S, Mejean A, Culine S, Sargos P. Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder. Radiother Oncol 2021; 161:95-114. [PMID: 34118357 DOI: 10.1016/j.radonc.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations. METHODS AND MATERIALS In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy. RESULTS A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence. CONCLUSION The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France
| | - Géraldine Pignot
- Department of Urology, Institut Paoli Calmettes, Marseille, France
| | | | - Pierre Blanchard
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, Lille, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | | | - Pierre Graff-Cailleaud
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Olivier Riou
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | | | - David Azria
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | | | - Olivier Chapet
- Department of Radiotherapy, Hospices Civils de Lyon, France
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpétrière, APHP Sorbonne Université, Paris, France
| | - Sarah Belhomme
- Department of Medical Physics, Institut Bergonié, Bordeaux, France
| | - Arnaud Mejean
- Department of Urology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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17
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Hafeez S, Lewis R, Hall E, Huddart R. Advancing Radiotherapy for Bladder Cancer: Randomised Phase II Trial of Adaptive Image-guided Standard or Dose-escalated Tumour Boost Radiotherapy (RAIDER). Clin Oncol (R Coll Radiol) 2021; 33:e251-e256. [PMID: 33766502 DOI: 10.1016/j.clon.2021.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022]
Affiliation(s)
- S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
| | - R Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UKS
| | - E Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UKS
| | - R Huddart
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK
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18
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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19
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Huddart R, Hafeez S, Lewis R, McNair H, Syndikus I, Henry A, Staffurth J, Dewan M, Vassallo-Bonner C, Moinuddin SA, Birtle A, Horan G, Rimmer Y, Venkitaraman R, Khoo V, Mitra A, Hughes S, Gibbs S, Kapur G, Baker A, Hansen VN, Patel E, Hall E. Clinical Outcomes of a Randomized Trial of Adaptive Plan-of-the-Day Treatment in Patients Receiving Ultra-hypofractionated Weekly Radiation Therapy for Bladder Cancer. Int J Radiat Oncol Biol Phys 2021; 110:412-424. [PMID: 33316362 PMCID: PMC8114997 DOI: 10.1016/j.ijrobp.2020.11.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Hypofractionated radiation therapy can be used to treat patients with muscle-invasive bladder cancer unable to have radical therapy. Toxicity is a key concern, but adaptive plan-of the day (POD) image-guided radiation therapy delivery could improve outcomes by minimizing the volume of normal tissue irradiated. The HYBRID trial assessed the multicenter implementation, safety, and efficacy of this strategy. METHODS HYBRID is a Phase II randomized trial that was conducted at 14 UK hospitals. Patients with T2-T4aN0M0 muscle-invasive bladder cancer unsuitable for radical therapy received 36 Gy in 6 weekly fractions, randomized (1:1) to standard planning (SP) or adaptive planning (AP) using a minimization algorithm. For AP, a pretreatment cone beam computed tomography (CT) was used to select the POD from 3 plans (small, medium, and large). Follow-up included standard cystoscopic, radiologic, and clinical assessments. The primary endpoint was nongenitourinary Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3 (≥G3) toxicity within 3 months of radiation therapy. A noncomparative single stage design aimed to exclude ≥30% toxicity rate in each planning group in patients who received ≥1 fraction of radiation therapy. Local control at 3-months (both groups combined) was a key secondary endpoint. RESULTS Between April 15, 2014, and August 10, 2016, 65 patients were enrolled (SP, n = 32; AP, n = 33). The median follow-up time was 38.8 months (interquartile range [IQR], 36.8-51.3). The median age was 85 years (IQR, 81-89); 68% of participants (44 of 65) were male; and 98% of participants had grade 3 urothelial cancer. In 63 evaluable participants, CTCAE ≥G3 nongenitourinary toxicity rates were 6% (2 of 33; 95% confidence interval [CI], 0.7%-20.2%) for the AP group and 13% (4 of 30; 95% CI, 3.8%-30.7%) for the SP group. Disease was present in 9/48 participants assessed at 3 months, giving a local control rate of 81.3% (95% CI, 67.4%-91.1%). CONCLUSIONS POD adaptive radiation therapy was successfully implemented across multiple centers. Weekly ultrahypofractionated 36 Gy/6 fraction radiation therapy is safe and provides good local control rates in this older patient population.
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Affiliation(s)
- Robert Huddart
- The Institute of Cancer Research, London, United Kingdom; Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- The Institute of Cancer Research, London, United Kingdom
| | - Helen McNair
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabelle Syndikus
- Radiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ann Henry
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - Monisha Dewan
- The Institute of Cancer Research, London, United Kingdom
| | | | - Syed Ali Moinuddin
- Academic unit of Oncology, Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Alison Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Gail Horan
- Queen Elizabeth Hospital Kings Lynn NHS Trust, Kings Lynn, United Kingdom
| | - Yvonne Rimmer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Vincent Khoo
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Anita Mitra
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Simon Hughes
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Stephanie Gibbs
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom
| | - Gaurav Kapur
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Angela Baker
- Radiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Emma Patel
- Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
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20
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Hijab A, Tocco B, Hanson I, Meijer H, Nyborg CJ, Bertelsen AS, Smeenk RJ, Smith G, Michalski J, Baumann BC, Hafeez S. MR-Guided Adaptive Radiotherapy for Bladder Cancer. Front Oncol 2021; 11:637591. [PMID: 33718230 PMCID: PMC7947660 DOI: 10.3389/fonc.2021.637591] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
Radiotherapy has an important role in the curative and palliative treatment settings for bladder cancer. As a target for radiotherapy the bladder presents a number of technical challenges. These include poor tumor visualization and the variability in bladder size and position both between and during treatment delivery. Evidence favors the use of magnetic resonance imaging (MRI) as an important means of tumor visualization and local staging. The availability of hybrid systems incorporating both MRI scanning capabilities with the linear accelerator (MR-Linac) offers opportunity for in-room and real-time MRI scanning with ability of plan adaption at each fraction while the patient is on the treatment couch. This has a number of potential advantages for bladder cancer patients. In this article, we examine the technical challenges of bladder radiotherapy and explore how magnetic resonance (MR) guided radiotherapy (MRgRT) could be leveraged with the aim of improving bladder cancer patient outcomes. However, before routine clinical implementation robust evidence base to establish whether MRgRT translates into improved patient outcomes should be ascertained.
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Affiliation(s)
- Adham Hijab
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Boris Tocco
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ian Hanson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Hanneke Meijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gillian Smith
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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21
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Cabaillé M, Gaston R, Belhomme S, Giraud A, Rouffilange J, Roubaud G, Sargos P. [Plan of the day adaptive radiotherapy for bladder cancer: Dosimetric and clinical results]. Cancer Radiother 2021; 25:308-315. [PMID: 33422418 DOI: 10.1016/j.canrad.2020.10.002] [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: 09/10/2020] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To account of individual intra-pelvic anatomical variations in muscle invasive bladder cancer (MIBC) irradiation, adaptive radiotherapy (ART) using a personalized plan library may have dosimetric and clinical benefits. MATERIAL AND METHODS The data from ten patients treated for localized MIBC according to the "plan of the day" (P0oD) individualized ART technique were collected and retrospectively analysed. Target volumes and organs at risk (OAR) were delineated at different bladder fill rates, resulting in two or three treatment plans. Daily Cone-Beam CT (CBCT) was used for the selection of PoD at each fraction. Retrospectively, we delineated rectal, intestinal and target volumes on each CBCT, to assess target volume coverage and dose sparing to healthy tissues. A comparison with the conventional radiotherapy technique was performed. The secondary objectives were toxicity and efficacy. RESULTS The target coverage was respected with the adaptive treatment: 97.3% for the bladder Clinical Target Volume (CTV) (99.5; [60.1-100]) and 98% for the bladder+lymph nodes CTV (98.6; [85.4-100]). Concerning OAR, the volume of healthy tissue spared was 43.7% on average and the V45Gy for the small bowel was 43,4cc (35; [0-129]) (versus 57,6cc). The rectal D50 was on average 18,7Gy for the adaptive treatment (15.9; [2.4-44.1]) versus 17Gy with the conventional approach. With a median follow-up of 2.94 years (95% CI: [0.92-4.02]), we observed three grade 3 toxicities (30%). No grade 4 toxicity was observed. The 2-year overall survival and progression-free survival rates were 65.6% (95% CI: [26-87.6]) and 45.7% (95% CI: [14.3-73]), respectively. CONCLUSION The ART technique using a PoD strategy showed a reduction of the irradiated healthy tissue volume while maintaining a similar bladder coverage, with an acceptable rate of toxicity.
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Affiliation(s)
- M Cabaillé
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France
| | - R Gaston
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - S Belhomme
- Département de Physique Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - A Giraud
- Unité de Recherche Épidémiologique et Clinique, Institut Bergonié, 33076 Bordeaux cedex, France
| | - J Rouffilange
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - G Roubaud
- Département d'Oncologie Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - P Sargos
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France.
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22
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Cabaillé M, Khalifa J, Tessier AM, Belhomme S, Créhange G, Sargos P. [A review of adaptive radiotherapy for bladder cancer]. Cancer Radiother 2021; 25:271-278. [PMID: 33402293 DOI: 10.1016/j.canrad.2020.08.046] [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: 07/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Radiation therapy (RT) for muscle invasive bladder cancer (MIBC) is challenging, with observed variations in bladder shape and size resulting in inappropriate coverage of the target volumes (CTV). Large margins were historically applied around the CTV, increasing the dose delivered to organs at risk (OAR). With repositioning imaging and visualization of soft tissues during image guided RT, an opportunity to consider these movements and deformations appeared possible with an adaptive RT approach (ART). MATERIALS AND METHODS A bibliographic search on the PubMed database has been done in January 2019. Studies focusing on patients with MIBC, treating on ART, with the objectives of feasibility, clinical and/or dosimetric evaluation and comparison with a standard irradiation technique were eligible. The purpose of this review was to define the different ART techniques used in clinical practice, to discuss their advantages compared to conventional RT in terms of target volume's coverage and OAR dose and to describe their feasibility in clinical practice. RESULTS A total of 30 studies were selected. The strategies known as "composite offline", "plan of the day" not individualized or individualized, and "re-optimization" have been identified. All the studies have shown a significant benefit of ART in target coverage and dose of OAR, especially the rectum and small bowel. All ART plans produced are not used during RT sessions. Inter-observer variability for the selection of these plans can be observed. The practical implementation within a department required staff education and training, and increases the duration of treatment preparation. The "A-POLO" approach seems to be the most suitable for practice. CONCLUSION ART is the technique of choice for bladder cancer RT. The "plan of the day" approach, individualized according to the A-POLO methodology, seems to be the most effective. The emergence of daily re-optimization, especially using MRI-Linac, is promising. The correlation between dosimetric benefits and clinical efficacy and safety results should be demonstrated into future trials.
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Affiliation(s)
- M Cabaillé
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - J Khalifa
- Département de radiothérapie, Institut universitaire du Cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - A M Tessier
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - G Créhange
- Département de radiothérapie, Institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - P Sargos
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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23
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Hafeez S, Webster A, Hansen VN, McNair HA, Warren-Oseni K, Patel E, Choudhury A, Creswell J, Foroudi F, Henry A, Kron T, McLaren DB, Mitra AV, Mostafid H, Saunders D, Miles E, Griffin C, Lewis R, Hall E, Huddart R. Protocol for tumour-focused dose-escalated adaptive radiotherapy for the radical treatment of bladder cancer in a multicentre phase II randomised controlled trial (RAIDER): radiotherapy planning and delivery guidance. BMJ Open 2020; 10:e041005. [PMID: 33384390 PMCID: PMC7780718 DOI: 10.1136/bmjopen-2020-041005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily radiotherapy delivered with radiosensitisation offers patients with muscle invasive bladder cancer (MIBC) comparable outcomes to cystectomy with functional organ preservation. Most recurrences following radiotherapy occur within the bladder. Increasing the delivered radiotherapy dose to the tumour may further improve local control. Developments in image-guided radiotherapy have allowed bladder tumour-focused 'plan of the day' radiotherapy delivery. We aim to test within a randomised multicentre phase II trial whether this technique will enable dose escalation with acceptable rates of toxicity. METHODS AND ANALYSIS Patients with T2-T4aN0M0 unifocal MIBC will be randomised (1:1:2) between standard/control whole bladder single plan radiotherapy, standard dose adaptive tumour-focused radiotherapy or dose-escalated adaptive tumour-focused radiotherapy (DART). Adaptive tumour-focused radiotherapy will use a library of three plans (small, medium and large) for treatment. A cone beam CT taken prior to each treatment will be used to visualise the anatomy and inform selection of the most appropriate plan for treatment.Two radiotherapy fractionation schedules (32f and 20f) are permitted. A minimum of 120 participants will be randomised in each fractionation cohort (to ensure 57 evaluable DART patients per cohort).A comprehensive radiotherapy quality assurance programme including pretrial and on-trial components is instituted to ensure standardisation of radiotherapy planning and delivery.The trial has a two-stage non-comparative design. The primary end point of stage I is the proportion of patients meeting predefined normal tissue constraints in the DART group. The primary end point of stage II is late Common Terminology Criteria for Adverse Events grade 3 or worse toxicity aiming to exclude a rate of >20% (80% power and 5% alpha, one sided) in each DART fractionation cohort. Secondary end points include locoregional MIBC control, progression-free survival overall survival and patient-reported outcomes. ETHICS AND DISSEMINATION This clinical trial is approved by the London-Surrey Borders Research Ethics Committee (15/LO/0539). The results when available will be disseminated via peer-reviewed scientific journals, conference presentations and submission to regulatory authorities. TRIAL REGISTRATION NUMBER NCT02447549; Pre-results.
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Affiliation(s)
- Shaista Hafeez
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Amanda Webster
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Vibeke N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Helen A McNair
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Karole Warren-Oseni
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Patel
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Ananya Choudhury
- Division of Cancer Studies, The University of Manchester, Manchester, UK
- Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Joanne Creswell
- Department of Urology, James Cook University Hospital, Middlesbrough, UK
| | - Farshad Foroudi
- Department of Radiation Oncology, Austin Health, Heidelberg, Victoria, Australia
| | - Ann Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, West Yorkshire, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Duncan B McLaren
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Anita V Mitra
- Cancer Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hugh Mostafid
- The Stokes Centre for Urology, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Daniel Saunders
- Department of Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Robert Huddart
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
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24
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Hunt A, Hanson I, Dunlop A, Barnes H, Bower L, Chick J, Cruickshank C, Hall E, Herbert T, Lawes R, McQuaid D, McNair H, Mitchell A, Mohajer J, Morgan T, Oelfke U, Smith G, Nill S, Huddart R, Hafeez S. Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer. Clin Transl Radiat Oncol 2020; 25:46-51. [PMID: 33015380 PMCID: PMC7522378 DOI: 10.1016/j.ctro.2020.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/15/2022] Open
Abstract
Whole bladder magnetic resonance image-guided radiotherapy using the 1.5 Telsa MR-linac is feasible. Full online adaptive planning workflow based on the anatomy seen at each fraction was performed. This was delivered within 45 min. Intra-fraction bladder filling did not compromise target coverage. Patients reported acceptable tolerance of treatment.
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Affiliation(s)
- A. Hunt
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - I. Hanson
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - A. Dunlop
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - H. Barnes
- The Royal Marsden NHS Foundation Trust, London, UK
| | - L. Bower
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - J. Chick
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - C. Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - E. Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - T. Herbert
- The Royal Marsden NHS Foundation Trust, London, UK
| | - R. Lawes
- The Royal Marsden NHS Foundation Trust, London, UK
| | - D. McQuaid
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - H. McNair
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - A. Mitchell
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - J. Mohajer
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - T. Morgan
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - U. Oelfke
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - G. Smith
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S. Nill
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - R. Huddart
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S. Hafeez
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
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25
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Dos Reis RB, Muglia VF, Rodrigues AA, Viani G. Editorial Comment: Endoclips as novel fiducial markers in trimodality bladder preserving therapy of muscle-invasive bladder carcinoma: feasibility and patient out-comes. Int Braz J Urol 2020; 47:100-102. [PMID: 33047915 PMCID: PMC7712691 DOI: 10.1590/s1677-5538.ibju.2019.0713.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rodolfo Borges Dos Reis
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Valdair Francisco Muglia
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
| | - Antônio Antunes Rodrigues
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Gustavo Viani
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
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26
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Hafeez S, Patel E, Webster A, Warren-Oseni K, Hansen V, McNair H, Miles E, Lewis R, Hall E, Huddart R. Protocol for hypofractionated adaptive radiotherapy to the bladder within a multicentre phase II randomised trial: radiotherapy planning and delivery guidance. BMJ Open 2020; 10:e037134. [PMID: 32461298 PMCID: PMC7259864 DOI: 10.1136/bmjopen-2020-037134] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Patients with muscle invasive bladder cancer (MIBC) who are unfit and unsuitable for standard radical treatment with cystectomy or daily radiotherapy present a large unmet clinical need. Untreated, they suffer high cancer specific mortality and risk significant disease-related local symptoms. Hypofractionated radiotherapy (delivering higher doses in fewer fractions/visits) is a potential treatment solution but could be compromised by the mobile nature of the bladder, resulting in target misses in a significant proportion of fractions. Adaptive 'plan of the day' image-guided radiotherapy delivery may improve the precision and accuracy of treatment. We aim to demonstrate within a randomised multicentre phase II trial feasibility of plan of the day hypofractionated bladder radiotherapy delivery with acceptable rates of toxicity. METHODS AND ANALYSIS Patients with T2-T4aN0M0 MIBC receiving 36 Gy in 6-weekly fractions are randomised (1:1) between treatment delivered using a single-standard plan or adaptive radiotherapy using a library of three plans (small, medium and large). A cone beam CT taken prior to each treatment is used to visualise the anatomy and select the most appropriate plan depending on the bladder shape and size. A comprehensive radiotherapy quality assurance programme has been instituted to ensure standardisation of radiotherapy planning and delivery. The primary endpoint is to exclude >30% acute grade >3 non-genitourinary toxicity at 3 months for adaptive radiotherapy in patients who received >1 fraction (p0=0.7, p1=0.9, α=0.05, β=0.2). Secondary endpoints include local disease control, symptom control, late toxicity, overall survival, patient-reported outcomes and proportion of fractions benefiting from adaptive planning. Target recruitment is 62 patients. ETHICS AND DISSEMINATION The trial is approved by the London-Surrey Borders Research Ethics Committee (13/LO/1350). The results will be disseminated via peer-reviewed scientific journals, conference presentations and submission to regulatory authorities. TRIAL REGISTRATION NUMBER NCT01810757.
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Affiliation(s)
- Shaista Hafeez
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy and Imaging, The Royal Marsden Hospital NHS Trust, London, UK
| | - Emma Patel
- Mount Vernon Hospital, National Radiotherapy Trials Quality Assurance Group, Northwood, UK
| | - Amanda Webster
- Mount Vernon Hospital, National Radiotherapy Trials Quality Assurance Group, Northwood, UK
| | - Karole Warren-Oseni
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy and Imaging, The Royal Marsden Hospital NHS Trust, London, UK
| | - Vibeke Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Helen McNair
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy and Imaging, The Royal Marsden Hospital NHS Trust, London, UK
| | - Elizabeth Miles
- Mount Vernon Hospital, National Radiotherapy Trials Quality Assurance Group, Northwood, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Robert Huddart
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy and Imaging, The Royal Marsden Hospital NHS Trust, London, UK
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27
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Bleeker M, Goudschaal K, Bel A, Sonke JJ, Hulshof MCCM, van der Horst A. Feasibility of cone beam CT-guided library of plans strategy in pre-operative gastric cancer radiotherapy. Radiother Oncol 2020; 149:49-54. [PMID: 32387491 DOI: 10.1016/j.radonc.2020.04.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The stomach displays large anatomical changes in size, shape and position, which implies the need for plan adaptation for gastric cancer patients who receive pre-operative radiotherapy. We evaluated the feasibility and necessity of a CBCT-guided library of plans (LoP) strategy in gastric cancer radiotherapy. METHODS Eight gastric cancer patients treated with 24-25 fractions of single-plan radiotherapy with daily CBCT imaging were included. The target was delineated on the pre-treatment CT and first 5 CBCTs to create a patient-specific LoP. Plan selections were performed by 12 observers in a training stage (2-3 CBCTs per patient) and an assessment stage (17 CBCTs per patient). The observers were asked to select the smallest plan that encompassed the target on the CBCT. A total of 136 plan selections were evaluated in the assessment stage. RESULTS Delineations on CBCTs showed that in 90% of the 40 delineated fractions part of the CTV was outside the PTV based on the pre-treatment CT. At least two-thirds of the observers agreed on the selected plan in 65.2% and 70% of the fractions in the training stage and the assessment stage, respectively. For each patient, at least two different plans from the LoP were the most selected plan. CONCLUSION A CBCT-guided patient-specific LoP strategy is feasible for gastric cancer patients, yielding good agreement in plan selections. Unless generous margins are used to avoid frequent geometric misses, it is likely that part of the target will be missed with single-plan radiotherapy.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Karin Goudschaal
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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28
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Patel E, Tsang Y, Baker A, Callender J, Hafeez S, Hall E, Hansen VN, Lewis R, McNair H, Miles E, Huddart R. Quality assuring "Plan of the day" selection in a multicentre adaptive bladder trial: Implementation of a pre-accrual IGRT guidance and assessment module. Clin Transl Radiat Oncol 2019; 19:27-32. [PMID: 31388568 PMCID: PMC6675972 DOI: 10.1016/j.ctro.2019.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Hypofractionated bladder RT with or without image guided adaptive planning (HYBRID) is a multicentre clinical trial investigating "Plan of the Day" (PoD) adaptive radiotherapy for bladder cancer. To ensure correct PoD selection a pre-accrual guidance and assessment module was developed as part of an image guided radiotherapy quality assurance (IGRT QA) credentialing programme. This study aimed to evaluate its feasibility and effectiveness across multiple recruiting centres. MATERIALS AND METHODS Individuals from participating centres remotely accessed an image database in order to complete the PoD module. An assessment score of ≥83% was required in order to receive QA approval. A questionnaire was used to gather user feedback on the module. PoD decisions for the first patient at each recruiting centre were retrospectively reviewed for protocol adherence. RESULTS 71 radiation therapists (RTTs) from 10 centres completed the PoD module. The median assessment score was 92% (Range: 58-100%) with 79% of RTTs passing the assessment on first attempt. All questionnaire respondents reported that the PoD module prepared them for plan selection. In 51/60 of on-trial treatments reviewed, the PoD selected by the centre agreed with QA reviewers. CONCLUSIONS The PoD QA module was successfully implemented in a multicentre trial and enabled pre-accrual assessment of protocol understanding. This increased operator confidence and resulted in appropriate PoD selection on-trial.
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Affiliation(s)
- Emma Patel
- Radiotherapy Physics Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yat Tsang
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Angela Baker
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Shaista Hafeez
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Vibeke Nordmark Hansen
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Helen McNair
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Robert Huddart
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
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29
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Wilson C, Moseshvili E, Tacey M, Quin I, Lawrentschuk N, Bolton D, Joon DL, Chao M, Dunshea T, Kron T, Foroudi F. Assessment of Intrafraction Motion of the Urinary Bladder Using Magnetic Resonance Imaging (cineMRI). Clin Oncol (R Coll Radiol) 2019; 32:101-109. [PMID: 31607612 DOI: 10.1016/j.clon.2019.09.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/06/2019] [Accepted: 08/29/2019] [Indexed: 11/18/2022]
Abstract
AIM To assess the intrafraction motion of the urinary bladder and delineate the appropriate margin size for radiotherapy planning, for both the full and empty bladder. MATERIALS AND METHODS This was a single-site, single-arm study of 20 patients planned to undergo radical cystectomy for histologically confirmed muscle-invasive bladder cancer. Patients underwent magnetic resonance imaging (cineMRI) of the entire pelvis using a 3-Tesla system, prior to cystectomy. Patients first underwent a cineMRI with a full bladder, then voided and underwent a second MRI with an empty bladder. All MRI sequences were acquired over 18 min. We assessed the differences in bladder filling and subsequent bladder wall displacement, between the empty and full bladder, during a time period consistent with radiotherapy treatment delivery. RESULTS Twenty patients underwent cineMRI of the entire pelvis. The maximum mean directional displacements of the bladder walls over the 18 min duration of the scan for the empty bladders were 9.8 mm superiorly, 1.1 mm inferiorly, 2.39 mm anteriorly, 3.73 mm posteriorly, 2.74 mm to the left and 2.48 mm to the right. The maximal mean displacements for the full bladders were 9.2 mm superiorly, 1.1 mm inferiorly, 2.28 mm anteriorly, 1.08 mm posteriorly, 1.85 mm to the left and 1.73 mm to the right. Statistically significant differences were seen in the posterior, left and right displacements but were quantitatively small. CONCLUSIONS Intrafractional motion secondary to bladder filling showed minimal variation between the full and empty bladder. Similar clinical target volume to planning target volume margins can be applied for the delivery of radiotherapy for a full and empty bladder.
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Affiliation(s)
- C Wilson
- Austin Health, Heidelberg, Victoria, Australia.
| | | | - M Tacey
- Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - I Quin
- GenesisCare, Wembley, Western Australia, Australia
| | | | - D Bolton
- Austin Health, Heidelberg, Victoria, Australia
| | - D L Joon
- Austin Health, Heidelberg, Victoria, Australia
| | - M Chao
- Austin Health, Heidelberg, Victoria, Australia
| | - T Dunshea
- Austin Health, Heidelberg, Victoria, Australia; MIA Radiology, Heidelberg, Victoria, Australia
| | - T Kron
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Foroudi
- Austin Health, Heidelberg, Victoria, Australia
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30
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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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31
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Corradini S, Alongi F, Andratschke N, Belka C, Boldrini L, Cellini F, Debus J, Guckenberger M, Hörner-Rieber J, Lagerwaard FJ, Mazzola R, Palacios MA, Philippens MEP, Raaijmakers CPJ, Terhaard CHJ, Valentini V, Niyazi M. MR-guidance in clinical reality: current treatment challenges and future perspectives. Radiat Oncol 2019; 14:92. [PMID: 31167658 PMCID: PMC6551911 DOI: 10.1186/s13014-019-1308-y] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022] Open
Abstract
Magnetic Resonance-guided radiotherapy (MRgRT) marks the beginning of a new era. MR is a versatile and suitable imaging modality for radiotherapy, as it enables direct visualization of the tumor and the surrounding organs at risk. Moreover, MRgRT provides real-time imaging to characterize and eventually track anatomical motion. Nevertheless, the successful translation of new technologies into clinical practice remains challenging. To date, the initial availability of next-generation hybrid MR-linac (MRL) systems is still limited and therefore, the focus of the present preview was on the initial applicability in current clinical practice and on future perspectives of this new technology for different treatment sites.MRgRT can be considered a groundbreaking new technology that is capable of creating new perspectives towards an individualized, patient-oriented planning and treatment approach, especially due to the ability to use daily online adaptation strategies. Furthermore, MRL systems overcome the limitations of conventional image-guided radiotherapy, especially in soft tissue, where target and organs at risk need accurate definition. Nevertheless, some concerns remain regarding the additional time needed to re-optimize dose distributions online, the reliability of the gating and tracking procedures and the interpretation of functional MR imaging markers and their potential changes during the course of treatment. Due to its continuous technological improvement and rapid clinical large-scale application in several anatomical settings, further studies may confirm the potential disruptive role of MRgRT in the evolving oncological environment.
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Affiliation(s)
- S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - F. Alongi
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - C. Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - L. Boldrini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - F. Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - J. Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - J. Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - F. J. Lagerwaard
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - R. Mazzola
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - M. A. Palacios
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - M. E. P. Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. P. J. Raaijmakers
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. H. J. Terhaard
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - V. Valentini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - M. Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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Krishnan A, Tsang YM, Stewart-Lord A. The impact of intra-fractional bladder filling on "Plan of the day" adaptive bladder radiotherapy. Tech Innov Patient Support Radiat Oncol 2019; 9:31-34. [PMID: 32095593 PMCID: PMC7033786 DOI: 10.1016/j.tipsro.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 12/22/2018] [Accepted: 01/03/2019] [Indexed: 01/04/2023] Open
Abstract
A retrospective audit on the "Plan of the day" (POD) selection and intra-fractional bladder fillings were carried out on twenty adaptive bladder radiotherapy patients at a single institution. Treatment time, differences in bladder volume and displacement of outer bladder wall expansion over the treatment fraction were analysed. Average treatment time was 8.9 min. The mean percentage difference in bladder volume pre and post treatment was 13.7%, resulting in expansion of the bladder predominately in the superior and anterior directions. This audit confirmed that the institution's POD process sufficed without being significantly affected by the intra-fractional bladder filings.
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Affiliation(s)
- Aisling Krishnan
- East and North Hertfordshire NHS Trust, Radiotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, United Kingdom
| | - Yat Man Tsang
- East and North Hertfordshire NHS Trust, Radiotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, United Kingdom
| | - Adéle Stewart-Lord
- School of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, United Kingdom
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Antico M, Prinsen P, Cellini F, Fracassi A, Isola AA, Cobben D, Fontanarosa D. Real-time adaptive planning method for radiotherapy treatment delivery for prostate cancer patients, based on a library of plans accounting for possible anatomy configuration changes. PLoS One 2019; 14:e0213002. [PMID: 30818345 PMCID: PMC6394960 DOI: 10.1371/journal.pone.0213002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE In prostate cancer treatment with external beam radiation therapy (EBRT), prostate motion and internal changes in tissue distribution can lead to a decrease in plan quality. In most currently used planning methods, the uncertainties due to prostate motion are compensated by irradiating a larger treatment volume. However, this could cause underdosage of the treatment volume and overdosage of the organs at risk (OARs). To reduce this problem, in this proof of principle study we developed and evaluated a novel adaptive planning method. The strategy proposed corrects the dose delivered by each beam according to the actual position of the target in order to produce a final dose distribution dosimetrically as similar as possible to the prescribed one. MATERIAL AND METHODS Our adaptive planning method was tested on a phantom case and on a clinical case. For the first, a pilot study was performed on an in-silico pelvic phantom. A "library" of intensity modulated RT (IMRT) plans corresponding to possible positions of the prostate during a treatment fraction was generated at planning stage. Then a 3D random walk model was used to simulate possible displacements of the prostate during the treatment fraction. At treatment stage, at the end of each beam, based on the current position of the target, the beam from the library of plans, which could reproduce the best approximation of the prescribed dose distribution, was selected and delivered. In the clinical case, the same approach was used on two prostate cancer patients: for the first a tissue deformation was simulated in-silico and for the second a cone beam CT (CBCT) taken during the treatment was used to simulate an intra-fraction change. Then, dosimetric comparisons with the standard treatment plan and, for the second patient, also with an isocenter shift correction, were performed. RESULTS For the phantom case, the plan generated using the adaptive planning method was able to meet all the dosimetric requirements and to correct for a misdosage of 13% of the dose prescription on the prostate. For the first clinical case, the standard planning method caused underdosage of the seminal vesicles, respectively by 5% and 4% of the prescribed dose, when the position changes for the target were correctly taken into account. The proposed adaptive planning method corrected any possible missed target coverage, reducing at the same time the dose on the OARs. For the second clinical case, both with the standard planning strategy and with the isocenter shift correction target coverage was significantly worsened (in particular uniformity) and some organs exceeded some toxicity objectives. While with our approach, the most uniform coverage for the target was produced and systematically the lowest toxicity values for the organs at risk were achieved. CONCLUSIONS In our proof of principle study, the adaptive planning method performed better than the standard planning and the isocenter shift methods for prostate EBRT. It improved the coverage of the treatment volumes and lowered the dose to the OARs. This planning method is particularly promising for hypofractionated IMRT treatments in which a higher precision and control on dose deposition are needed. Further studies will be performed to test more extensively the proposed adaptive planning method and to evaluate it at a full clinical level.
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Affiliation(s)
- Maria Antico
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, Queensland, Australia
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
- Delft University of Technology, Delft, The Netherlands
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - Peter Prinsen
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli, IRCCS—Università Cattolica Sacro Cuore, Roma, Italia
| | - Alice Fracassi
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
- University of Rome Tor Vergata, Rome, Italy
| | - Alfonso A. Isola
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - David Cobben
- North West Cancer Centre, Altnagelvin Hospital, Derry-Londonderry, Northern Ireland
- The University of Manchester, Division of Cancer Studies, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Clinical Oncology, Manchester, United Kingdom
| | - Davide Fontanarosa
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
- School of Clinical Sciences, Queensland University of Technology, Gardens Point Campus, Brisbane, QLD, Australia
- * E-mail:
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Kong V, Taylor A, Chung P, Rosewall T. Evaluation of resource burden for bladder adaptive strategies: A timing study. J Med Imaging Radiat Oncol 2018; 62:861-865. [DOI: 10.1111/1754-9485.12787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Vickie Kong
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
| | - Amy Taylor
- Sheffield Hallam University; Sheffield UK
| | - Peter Chung
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
| | - Tara Rosewall
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
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Tree AC, Jones K, Hafeez S, Sharabiani MTA, Harrington KJ, Lalondrelle S, Ahmed M, Huddart RA. Dose-limiting Urinary Toxicity With Pembrolizumab Combined With Weekly Hypofractionated Radiation Therapy in Bladder Cancer. Int J Radiat Oncol Biol Phys 2018; 101:1168-1171. [PMID: 30012528 DOI: 10.1016/j.ijrobp.2018.04.070] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/10/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
Abstract
There is currently significant interest in the potential benefits of combining radiation and immune checkpoint blockade (ICB) to stimulate both regional and distant abscopal immune responses. In melanoma and lung cancer, patients who have received radiation therapy during ICB appear to have prolonged survival. The PLUMMB trial (Pembrolizumab in Muscle-invasive/Metastatic Bladder cancer) (NCT02560636) is a phase I study to test the tolerability of a combination of weekly radiation therapy with pembrolizumab in patients with metastatic or locally advanced urothelial cancer of the bladder. In the first dose-cohort, patients received pembrolizumab 100 mg 3-weekly, starting 2 weeks before commencing weekly adaptive bladder radiation therapy to a dose of 36 Gy in 6 fractions. The first dose-cohort was stopped after 5 patients, having met the predefined definition of dose-limiting toxicity. Three patients experienced grade 3 urinary toxicities, 2 of which were attributable to therapy. One patient experienced a grade 4 rectal perforation. In view of these findings, the trial has been paused and the protocol will be amended to reduce radiation therapy dose per fraction. The authors advise caution to those combining radiation therapy and ICB, particularly when radiation therapy is given at high dose per fraction for pelvic tumours. The PLUMMB trial met the protocol-defined definition of dose-limiting toxicity and will be amended to reduce radiation therapy dose.
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Affiliation(s)
- Alison Claire Tree
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK.
| | - Kelly Jones
- Royal Marsden NHS Foundation Trust, London, UK
| | - Shaista Hafeez
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
| | | | | | - Susan Lalondrelle
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
| | - Merina Ahmed
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
| | - Robert Anthony Huddart
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
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Collins SD, Leech MM. A review of plan library approaches in adaptive radiotherapy of bladder cancer. Acta Oncol 2018; 57:566-573. [PMID: 29299945 DOI: 10.1080/0284186x.2017.1420908] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Large variations in the shape and size of the bladder volume are commonly observed in bladder cancer radiotherapy (RT). The clinical target volume (CTV) is therefore frequently inadequately treated and large isotropic margins are inappropriate in terms of dose to organs at risk (OAR); thereby making adaptive radiotherapy (ART) attractive for this tumour site. There are various methods of ART delivery, however, for bladder cancer, plan libraries are frequently used. MATERIAL AND METHODS A review of published studies on plan libraries for bladder cancer using four databases (Pubmed, Science Direct, Embase and Cochrane Library) was conducted. The endpoints selected were accuracy and feasibility of initiation of a plan library strategy into a RT department. RESULTS Twenty-four articles were included in this review. The majority of studies reported improvement in accuracy with 10 studies showing an improvement in planning target volume (PTV) and CTV coverage with plan libraries, some by up to 24%. Seventeen studies showed a dose reduction to OARs, particularly the small bowel V45Gy, V40Gy, V30Gy and V10Gy, and the rectal V30Gy. However, the occurrence of no suitable plan was reported in six studies, with three studies showing no significant difference between adaptive and non-adaptive strategies in terms of target coverage. In addition, inter-observer variability in plan selection appears to remain problematic. The additional resources, education and technology required for the initiation of plan library selection for bladder cancer may hinder its routine clinical implementation, with eight studies illustrating increased treatment time required. CONCLUSIONS While there is a growing body of evidence in support of plan libraries for bladder RT, many studies differed in their delivery approach. The advent of the clinical use of the MRI-linear accelerator will provide RT departments with the opportunity to consider daily online adaption for bladder cancer as an alternate to plan library approaches.
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Affiliation(s)
- Shane D. Collins
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
| | - Michelle M. Leech
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
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10 - Nuove Tecnologie in Radioterapia E Prospettive Future. TUMORI JOURNAL 2018; 104:S39-S41. [DOI: 10.1177/0300891618766114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Huddart RA, Birtle A, Maynard L, Beresford M, Blazeby J, Donovan J, Kelly JD, Kirkbank T, McLaren DB, Mead G, Moynihan C, Persad R, Scrase C, Lewis R, Hall E. Clinical and patient-reported outcomes of SPARE - a randomised feasibility study of selective bladder preservation versus radical cystectomy. BJU Int 2017; 120:639-650. [PMID: 28453896 PMCID: PMC5655733 DOI: 10.1111/bju.13900] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To test the feasibility of a randomised trial in muscle-invasive bladder cancer (MIBC) and compare outcomes in patients who receive neoadjuvant chemotherapy followed by radical cystectomy (RC) or selective bladder preservation (SBP), where definitive treatment [RC or radiotherapy (RT)] is determined by response to chemotherapy. PATIENTS AND METHODS SPARE is a multicentre randomised controlled trial comparing RC and SBP in patients with MIBC staged T2-3 N0 M0, fit for both treatment strategies and receiving three cycles of neoadjuvant chemotherapy. Patients were randomised between RC and SBP before a cystoscopy after cycle three of neoadjuvant chemotherapy. Patients with ≤T1 residual tumour received a fourth cycle of neoadjuvant chemotherapy in both groups, followed by radical RT in the SBP group and RC in in the RC group; non-responders in both groups proceeded immediately to RC following cycle three. Feasibility study primary endpoints were accrual rate and compliance with assigned treatment strategy. The phase III trial was designed to demonstrate non-inferiority of SBP in terms of overall survival (OS) in patients whose tumours responded to neoadjuvant chemotherapy. Secondary endpoints included patient-reported quality of life, clinician assessed toxicity, loco-regional recurrence-free survival, and rate of salvage RC after SBP. RESULTS Trial recruitment was challenging and below the predefined target with 45 patients recruited in 30 months (25 RC; 20 SBP). Non-compliance with assigned treatment strategy was frequent, six of the 25 patients (24%) randomised to RC received RT. Long-term bladder preservation rate was 11/15 (73%) in those who received RT per protocol. OS survival was not significantly different between groups. CONCLUSIONS Randomising patients with MIBC between RC and SBP based on response to neoadjuvant chemotherapy was not feasible in the UK health system. Strong clinician and patient preferences for treatments impacted willingness to undergo randomisation and acceptance of treatment allocation. Due to the few participants, firm conclusions about disease and toxicity outcomes cannot be drawn.
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Affiliation(s)
- Robert A. Huddart
- The Institute of Cancer ResearchLondonUK
- Royal Marsden NHS Foundation TrustLondonUK
| | - Alison Birtle
- Royal Preston HospitalPreston and University of ManchesterManchesterUK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Emma Hall
- The Institute of Cancer ResearchLondonUK
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Adaptive Radiotherapy for Bladder Cancer—A Systematic Review. J Med Imaging Radiat Sci 2017; 48:199-206. [DOI: 10.1016/j.jmir.2016.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/20/2022]
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Hafeez S, McDonald F, Lalondrelle S, McNair H, Warren-Oseni K, Jones K, Harris V, Taylor H, Khoo V, Thomas K, Hansen V, Dearnaley D, Horwich A, Huddart R. Clinical Outcomes of Image Guided Adaptive Hypofractionated Weekly Radiation Therapy for Bladder Cancer in Patients Unsuitable for Radical Treatment. Int J Radiat Oncol Biol Phys 2017; 98:115-122. [PMID: 28586948 PMCID: PMC5392498 DOI: 10.1016/j.ijrobp.2017.01.239] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/23/2017] [Accepted: 01/31/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE AND OBJECTIVES We report on the clinical outcomes of a phase 2 study assessing image guided hypofractionated weekly radiation therapy in bladder cancer patients unsuitable for radical treatment. METHODS AND MATERIALS Fifty-five patients with T2-T4aNx-2M0-1 bladder cancer not suitable for cystectomy or daily radiation therapy treatment were recruited. A "plan of the day" radiation therapy approach was used, treating the whole (empty) bladder to 36 Gy in 6 weekly fractions. Acute toxicity was assessed weekly during radiation therapy, at 6 and 12 weeks using the Common Terminology Criteria for Adverse Events version 3.0. Late toxicity was assessed at 6 months and 12 months using Radiation Therapy Oncology Group grading. Cystoscopy was used to assess local control at 3 months. Cumulative incidence function was used to determine local progression at 1 at 2 years. Death without local progression was treated as a competing risk. Overall survival was estimated using the Kaplan-Meier method. RESULTS Median age was 86 years (range, 68-97 years). Eighty-seven percent of patients completed their prescribed course of radiation therapy. Genitourinary and gastrointestinal grade 3 acute toxicity was seen in 18% (10/55) and 4% (2/55) of patients, respectively. No grade 4 genitourinary or gastrointestinal toxicity was seen. Grade ≥3 late toxicity (any) at 6 and 12 months was seen in 6.5% (2/31) and 4.3% (1/23) of patients, respectively. Local control after radiation therapy was 92% of assessed patients (60% total population). Cumulative incidence of local progression at 1 year and 2 years for all patients was 7% (95% confidence interval [CI] 2%-17%) and 17% (95% CI 8%-29%), respectively. Overall survival at 1 year was 63% (95% CI 48%-74%). CONCLUSION Hypofractionated radiation therapy delivered weekly with a plan of the day approach offers good local control with acceptable toxicity in a patient population not suitable for radical bladder treatment.
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MESH Headings
- Aged
- Aged, 80 and over
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Transitional Cell/mortality
- Carcinoma, Transitional Cell/pathology
- Carcinoma, Transitional Cell/radiotherapy
- Cystectomy
- Disease Progression
- Female
- Gastrointestinal Diseases/etiology
- Humans
- Kaplan-Meier Estimate
- Male
- Prospective Studies
- Radiation Dose Hypofractionation
- Radiation Injuries/pathology
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Image-Guided/adverse effects
- Radiotherapy, Image-Guided/methods
- Time Factors
- Treatment Outcome
- Urinary Bladder/radiation effects
- Urinary Bladder Neoplasms/mortality
- Urinary Bladder Neoplasms/pathology
- Urinary Bladder Neoplasms/radiotherapy
- Urination Disorders/etiology
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey.
| | | | | | - Helen McNair
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Karole Warren-Oseni
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Kelly Jones
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | | | | | | | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Vibeke Hansen
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - David Dearnaley
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Alan Horwich
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Robert Huddart
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
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Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
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Thörnqvist S, Hysing LB, Tuomikoski L, Vestergaard A, Tanderup K, Muren LP, Heijmen BJM. Adaptive radiotherapy strategies for pelvic tumors - a systematic review of clinical implementations. Acta Oncol 2016; 55:943-58. [PMID: 27055486 DOI: 10.3109/0284186x.2016.1156738] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Introdution: Variation in shape, position and treatment response of both tumor and organs at risk are major challenges for accurate dose delivery in radiotherapy. Adaptive radiotherapy (ART) has been proposed to customize the treatment to these motion/response patterns of the individual patients, but increases workload and thereby challenges clinical implementation. This paper reviews strategies and workflows for clinical and in silico implemented ART for prostate, bladder, gynecological (gyne) and ano-rectal cancers. MATERIAL AND METHODS Initial identification of papers was based on searches in PubMed. For each tumor site, the identified papers were screened independently by two researches for selection of studies describing all processes of an ART workflow: treatment monitoring and evaluation, decision and execution of adaptations. Both brachytherapy and external beam studies were eligible for review. RESULTS The review consisted of 43 clinical studies and 51 in silico studies. For prostate, 1219 patients were treated with offline re-planning, mainly to adapt prostate motion relative to bony anatomy. For gyne 1155 patients were treated with online brachytherapy re-planning while 25 ano-rectal cancer patients were treated with offline re-planning, all to account for tumor regression detected by magnetic resonance imaging (MRI)/computed tomography (CT). For bladder and gyne, 161 and 64 patients, respectively, were treated with library-based online plan selection to account for target volume and shape variations. The studies reported sparing of rectum (prostate and bladder cancer), bladder (ano-rectal cancer) and bowel cavity (gyne and bladder cancer) as compared to non-ART. CONCLUSION Implementations of ART were dominated by offline re-planning and online brachytherapy re-planning strategies, although recently online plan selection workflows have increased with the availability of cone-beam CT. Advantageous dosimetric and outcome patterns using ART was documented by the studies of this review. Despite this, clinical implementations were scarce due to challenges in target/organ re-contouring and suboptimal patient selection in the ART workflows.
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Affiliation(s)
- Sara Thörnqvist
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Potential dosimetric benefit of an adaptive plan selection strategy for short-course radiotherapy in rectal cancer patients. Radiother Oncol 2016; 119:525-30. [DOI: 10.1016/j.radonc.2016.04.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 11/20/2022]
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Hafeez S, Warren-Oseni K, McNair HA, Hansen VN, Jones K, Tan M, Khan A, Harris V, McDonald F, Lalondrelle S, Mohammed K, Thomas K, Thompson A, Kumar P, Dearnaley D, Horwich A, Huddart R. Prospective Study Delivering Simultaneous Integrated High-dose Tumor Boost (≤70 Gy) With Image Guided Adaptive Radiation Therapy for Radical Treatment of Localized Muscle-Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2016; 94:1022-30. [PMID: 27026308 DOI: 10.1016/j.ijrobp.2015.12.379] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Image guided adaptive radiation therapy offers individualized solutions to improve target coverage and reduce normal tissue irradiation, allowing the opportunity to increase the radiation tumor dose and spare normal bladder tissue. METHODS AND MATERIALS A library of 3 intensity modulated radiation therapy plans were created (small, medium, and large) from planning computed tomography (CT) scans performed at 30 and 60 minutes; treating the whole bladder to 52 Gy and the tumor to 70 Gy in 32 fractions. A "plan of the day" approach was used for treatment delivery. A post-treatment cone beam CT (CBCT) scan was acquired weekly to assess intrafraction filling and coverage. RESULTS A total of 18 patients completed treatment to 70 Gy. The plan and treatment for 1 patient was to 68 Gy. Also, 1 patient's plan was to 70 Gy but the patient was treated to a total dose of 65.6 Gy because dose-limiting toxicity occurred before dose escalation. A total of 734 CBCT scans were evaluated. Small, medium, and large plans were used in 36%, 48%, and 16% of cases, respectively. The mean ± standard deviation rate of intrafraction filling at the start of treatment (ie, week 1) was 4.0 ± 4.8 mL/min (range 0.1-19.4) and at end of radiation therapy (ie, week 5 or 6) was 1.1 ± 1.6 mL/min (range 0.01-7.5; P=.002). The mean D98 (dose received by 98% volume) of the tumor boost and bladder as assessed on the post-treatment CBCT scan was 97.07% ± 2.10% (range 89.0%-104%) and 99.97% ± 2.62% (range 96.4%-112.0%). At a median follow-up period of 19 months (range 4-33), no muscle-invasive recurrences had developed. Two patients experienced late toxicity (both grade 3 cystitis) at 5.3 months (now resolved) and 18 months after radiation therapy. CONCLUSIONS Image guided adaptive radiation therapy using intensity modulated radiation therapy to deliver a simultaneous integrated tumor boost to 70 Gy is feasible, with acceptable toxicity, and will be evaluated in a randomized trial.
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom.
| | - Karole Warren-Oseni
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Helen A McNair
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Vibeke N Hansen
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kelly Jones
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Melissa Tan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Attia Khan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Victoria Harris
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kabir Mohammed
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Thompson
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Pardeep Kumar
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - David Dearnaley
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Horwich
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Robert Huddart
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
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Evaluating the need for adaptive therapy when delivering conformal bladder radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396915000539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground and purposeThe purpose of this study was to audit positioning errors during bladder image-guided radiotherapy (IGRT) and quantify survival outcomes.Materials and methodsWe carried out a retrospective review of 141 patients treated between March 2007 and July 2010 with three-dimensional conformal radiotherapy. An offline imaging protocol using kV cone beam computed tomography (CBCT) was used. Positioning errors, clinical interventions and re-planning rates were quantified. Cancer outcomes and survival were collected by review of patient notes and a registry search.ResultsAmong all, 43% of the patients required no intervention. Isocentre corrections were used for systematic bony set-up error in 13% and to improve bladder coverage in 28%. Clinical interventions to improve bladder coverage were required in 16% of the patients and repeat computed tomography planning in a further 16%. Overall, 44% of the patients demonstrated some form of organ deformation that would have resulted in inadequate dose to the bladder or significant overdose to an organ at risk if not corrected for. Post-treatment check cystoscopy was undertaken in 107 patients (76%) with 72 noted to have a complete response. Overall survival was 47·8% at 3 years.ConclusionsOrgan deformation during radiotherapy for bladder cancer is a significant problem for over 40% of patients. Strategies to compensate are essential to ensure optimal plan delivery.
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Vestergaard A, Hafeez S, Muren LP, Nill S, Høyer M, Hansen VN, Grønborg C, Pedersen EM, Petersen JB, Huddart R, Oelfke U. The potential of MRI-guided online adaptive re-optimisation in radiotherapy of urinary bladder cancer. Radiother Oncol 2016; 118:154-9. [PMID: 26631646 DOI: 10.1016/j.radonc.2015.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Adaptive radiotherapy (ART) using plan selection is being introduced clinically for bladder cancer, but the challenge of how to compensate for intra-fractional motion remains. The purpose of this study was to assess target coverage with respect to intra-fractional motion and the potential for normal tissue sparing in MRI-guided ART (MRIGART) using isotropic (MRIGARTiso), an-isotropic (MRIGARTanIso) and population-based margins (MRIGARTpop). MATERIALS AND METHODS Nine bladder cancer patients treated in a phase II trial of plan selection underwent 6-7 weekly repeat MRI series, each with volumetric scans acquired over a 10 min period. Adaptive re-planning on the 0 min MRI scans was performed using density override, simulating a hypo-fractionated schedule. Target coverage was evaluated on the 10 min scan to quantify the impact of intra-fractional motion. RESULTS MRIGARTanIso reduced the course-averaged PTV by median 304 cc compared to plan selection. Bladder shifts affected target coverage in individual fractions for all strategies. Two patients had a v95% of the bladder below 98% for MRIGARTiso. MRIGARTiso decreased the bowel V25 with 15-46 cc compared to MRIGARTpop. CONCLUSION Online re-optimised ART has a considerable normal tissue sparing potential. MRIGART with online corrections for target shift during a treatment fraction should be considered in ART for bladder cancer.
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Affiliation(s)
- Anne Vestergaard
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark; Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Shaista Hafeez
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Ludvig P Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Simeon Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Morten Høyer
- Department of Oncology, AarhusUniversity/Aarhus University Hospital, Denmark
| | - Vibeke N Hansen
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Caroline Grønborg
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Erik M Pedersen
- Department of Radiology, Aarhus University/Aarhus University Hospital, Denmark
| | - Jørgen B Petersen
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Robert Huddart
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Clinical Outcomes With Dose-Escalated Adaptive Radiation Therapy for Urinary Bladder Cancer: A Prospective Study. Int J Radiat Oncol Biol Phys 2016; 94:60-66. [DOI: 10.1016/j.ijrobp.2015.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/04/2015] [Accepted: 09/09/2015] [Indexed: 11/17/2022]
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A comparison between two clinically applied plan library strategies in adaptive radiotherapy of bladder cancer. Radiother Oncol 2015; 117:448-52. [DOI: 10.1016/j.radonc.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/28/2015] [Accepted: 10/09/2015] [Indexed: 11/18/2022]
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Kibrom AZ, Knight KA. Adaptive radiation therapy for bladder cancer: a review of adaptive techniques used in clinical practice. J Med Radiat Sci 2015; 62:277-85. [PMID: 27512574 PMCID: PMC4968556 DOI: 10.1002/jmrs.129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/18/2022] Open
Abstract
Significant changes in the shape, size and position of the bladder during radiotherapy (RT) treatment for bladder cancer have been correlated with high local failure rates; typically due to geographical misses. To account for this, large margins are added around the target volumes in conventional RT; however, this increases the volume of healthy tissue irradiation. The availability of cone beam computed tomography (CBCT) has not only allowed in‐room volumetric imaging of the bladder, but also the development of adaptive radiotherapy (ART) for modification of plans to patient‐specific changes. The aim of this review is to: (1) identify and explain the different ART techniques being used in clinical practice and (2) compare and contrast these different ART techniques to conventional RT in terms of target coverage and dose to healthy tissue: A literature search was conducted using EMBASE, MEDLINE and Scopus with the key words ‘bladder, adaptive, radiotherapy/radiation therapy’. 11 studies were obtained that compared different adaptive RT techniques to conventional RT in terms of target volume coverage and healthy tissue sparing. All studies showed superior target volume coverage and/or healthy tissue sparing in adaptive RT compared to conventional RT. Cross‐study comparison between different adaptive techniques could not be made due to the difference in protocols used in different studies. However, one study found daily re‐optimisation of plans to be superior to plan of the day technique. The use of adaptive RT for bladder cancer is promising. Further study is required to assess adaptive RT versus conventional RT in terms of local control and long‐term toxicity.
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Affiliation(s)
- Awet Z Kibrom
- Department of Medical Imaging and Radiation Sciences Faculty of Medicine, Nursing and Health Sciences School of Biomedical Sciences Monash University Clayton Victoria Australia
| | - Kellie A Knight
- Department of Medical Imaging and Radiation Sciences Faculty of Medicine, Nursing and Health Sciences School of Biomedical Sciences Monash University Clayton Victoria Australia
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McNair HA, Harris EJ, Hansen VN, Thomas K, South C, Hafeez S, Huddart R, Dearnaley DP. Magnitude of observer error using cone beam CT for prostate interfraction motion estimation: effect of reducing scan length or increasing exposure. Br J Radiol 2015; 88:20150208. [PMID: 26246041 PMCID: PMC4730970 DOI: 10.1259/bjr.20150208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/30/2015] [Accepted: 08/04/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Cone beam CT (CBCT) enables soft-tissue registration to planning CT for position verification in radiotherapy. The aim of this study was to determine the interobserver error (IOE) in prostate position verification using a standard CBCT protocol, and the effect of reducing CBCT scan length or increasing exposure, compared with standard imaging protocol. METHODS CBCT images were acquired using a novel 7 cm length image with standard exposure (1644 mAs) at Fraction 1 (7), standard 12 cm length image (1644 mAs) at Fraction 2 (12) and a 7 cm length image with higher exposure (2632 mAs) at Fraction 3 (7H) on 31 patients receiving radiotherapy for prostate cancer. Eight observers (two clinicians and six radiographers) registered the images. Guidelines and training were provided. The means of the IOEs were compared using a Kruzkal-Wallis test. Levene's test was used to test for differences in the variances of the IOEs and the independent prostate position. RESULTS No significant difference was found between the IOEs of each image protocol in any direction. Mean absolute IOE was the greatest in the anteroposterior direction. Standard deviation (SD) of the IOE was the least in the left-right direction for each of the three image protocols. The SD of the IOE was significantly less than the independent prostate motion in the anterior-posterior (AP) direction only (1.8 and 3.0 mm, respectively: p = 0.017). IOEs were within 1 SD of the independent prostate motion in 95%, 77% and 96% of the images in the RL, SI and AP direction. CONCLUSION Reducing CBCT scan length and increasing exposure did not have a significant effect on IOEs. To reduce imaging dose, a reduction in CBCT scan length could be considered without increasing the uncertainty in prostate registration. Precision of CBCT verification of prostate radiotherapy is affected by IOE and should be quantified prior to implementation. ADVANCES IN KNOWLEDGE This study shows the importance of quantifying the magnitude of IOEs prior to CBCT implementation.
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Affiliation(s)
- Helen A McNair
- Royal Marsden NHS Foundation Trust, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | - Emma J Harris
- Royal Marsden NHS Foundation Trust, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | | | | | - Christopher South
- Department of Physics, St Luke's Cancer Centre, The Royal County Hospital NHS Foundation Trust, Guilford, Surrey
| | - Shaista Hafeez
- Royal Marsden NHS Foundation Trust, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | - Robert Huddart
- Royal Marsden NHS Foundation Trust, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | - David P Dearnaley
- Royal Marsden NHS Foundation Trust, Sutton, UK
- Institute of Cancer Research, Sutton, UK
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