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Brand DH, Brüningk SC, Wilkins A, Naismith O, Gao A, Syndikus I, Dearnaley DP, Hall E, van As N, Tree AC, Gulliford S. Gastrointestinal Toxicity Prediction Not Influenced by Rectal Contour or Dose-Volume Histogram Definition. Int J Radiat Oncol Biol Phys 2023; 117:1163-1173. [PMID: 37433374 PMCID: PMC10680426 DOI: 10.1016/j.ijrobp.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/01/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Rectal dose delivered during prostate radiation therapy is associated with gastrointestinal toxicity. Treatment plans are commonly optimized using rectal dose-volume constraints, often whole-rectum relative-volumes (%). We investigated whether improved rectal contouring, use of absolute-volumes (cc), or rectal truncation might improve toxicity prediction. METHODS AND MATERIALS Patients from the CHHiP trial (receiving 74 Gy/37 fractions [Fr] vs 60 Gy/20 Fr vs 57 Gy/19 Fr) were included if radiation therapy plans were available (2350/3216 patients), plus toxicity data for relevant analyses (2170/3216 patients). Whole solid rectum relative-volumes (%) dose-volume-histogram (DVH), as submitted by treating center (original contour), was assumed standard-of-care. Three investigational rectal DVHs were generated: (1) reviewed contour per CHHiP protocol; (2) original contour absolute volumes (cc); and (3) truncated original contour (2 versions; ±0 and ±2 cm from planning target volume [PTV]). Dose levels of interest (V30, 40, 50, 60, 70, 74 Gy) in 74 Gy arm were converted by equivalent-dose-in-2 Gy-Fr (EQD2α/β= 3 Gy) for 60 Gy/57 Gy arms. Bootstrapped logistic models predicting late toxicities (frequency G1+/G2+, bleeding G1+/G2+, proctitis G1+/G2+, sphincter control G1+, stricture/ulcer G1+) were compared by area-undercurve (AUC) between standard of care and the 3 investigational rectal definitions. RESULTS The alternative dose/volume parameters were compared with the original relative-volume (%) DVH of the whole rectal contour, itself fitted as a weak predictor of toxicity (AUC range, 0.57-0.65 across the 8 toxicity measures). There were no significant differences in toxicity prediction for: (1) original versus reviewed rectal contours (AUCs, 0.57-0.66; P = .21-.98); (2) relative- versus absolute-volumes (AUCs, 0.56-0.63; P = .07-.91); and (3) whole-rectum versus truncation at PTV ± 2 cm (AUCs, 0.57-0.65; P = .05-.99) or PTV ± 0 cm (AUCs, 0.57-0.66; P = .27-.98). CONCLUSIONS We used whole-rectum relative-volume DVH, submitted by the treating center, as the standard-of-care dosimetric predictor for rectal toxicity. There were no statistically significant differences in prediction performance when using central rectal contour review, with the use of absolute-volume dosimetry, or with rectal truncation relative to PTV. Whole-rectum relative-volumes were not improved upon for toxicity prediction and should remain standard-of-care.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Health Science and Technology, ETH Zurich, Basel, Switzerland; Swiss Institute for Bioinformatics (SIB), Lausanne, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Ebert MA, Gulliford S, Acosta O, de Crevoisier R, McNutt T, Heemsbergen WD, Witte M, Palma G, Rancati T, Fiorino C. Spatial descriptions of radiotherapy dose: normal tissue complication models and statistical associations. Phys Med Biol 2021; 66:12TR01. [PMID: 34049304 DOI: 10.1088/1361-6560/ac0681] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/28/2021] [Indexed: 12/20/2022]
Abstract
For decades, dose-volume information for segmented anatomy has provided the essential data for correlating radiotherapy dosimetry with treatment-induced complications. Dose-volume information has formed the basis for modelling those associations via normal tissue complication probability (NTCP) models and for driving treatment planning. Limitations to this approach have been identified. Many studies have emerged demonstrating that the incorporation of information describing the spatial nature of the dose distribution, and potentially its correlation with anatomy, can provide more robust associations with toxicity and seed more general NTCP models. Such approaches are culminating in the application of computationally intensive processes such as machine learning and the application of neural networks. The opportunities these approaches have for individualising treatment, predicting toxicity and expanding the solution space for radiation therapy are substantial and have clearly widespread and disruptive potential. Impediments to reaching that potential include issues associated with data collection, model generalisation and validation. This review examines the role of spatial models of complication and summarises relevant published studies. Sources of data for these studies, appropriate statistical methodology frameworks for processing spatial dose information and extracting relevant features are described. Spatial complication modelling is consolidated as a pathway to guiding future developments towards effective, complication-free radiotherapy treatment.
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Affiliation(s)
- Martin A Ebert
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- 5D Clinics, Claremont, Western Australia, Australia
| | - Sarah Gulliford
- Department of Radiotherapy Physics, University College Hospitals London, United Kingdom
- Department of Medical Physics and Bioengineering, University College London, United Kingdom
| | - Oscar Acosta
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI-UMR 1099, F-35000 Rennes, France
| | | | - Todd McNutt
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Marnix Witte
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council, Napoli, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Relationships between rectal and perirectal doses and rectal bleeding or tenesmus in pooled voxel-based analysis of 3 randomised phase III trials. Radiother Oncol 2020; 150:281-292. [PMID: 32745667 DOI: 10.1016/j.radonc.2020.07.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to identify anatomically-localised regions where planned radiotherapy dose is associated with gastrointestinal toxicities in healthy tissues throughout the pelvic anatomy. MATERIALS AND METHODS Planned dose distributions for up to 657 patients of the Trans Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar computed tomography dataset. Voxel-based multiple comparison permutation dose difference testing, Cox regression modelling and LASSO feature selection were used to identify regions where dose-increase was associated with grade ≥2 rectal bleeding (RB) or tenesmus, according to the LENT/SOMA scale. This was externally validated by registering dose distributions from the RT01 (n = 388) and CHHiP (n = 241) trials onto the same exemplar and repeating the tests on each of these data sets, and on all three datasets combined. RESULTS Voxel-based Cox regression and permutation dose difference testing revealed regions where increased dose was correlated with gastrointestinal toxicity. Grade ≥2 RB was associated with posteriorly extended lateral beams that manifested high doses (>55 Gy) in a small rectal volume adjacent to the clinical target volume. A correlation was found between grade ≥2 tenesmus and increased low-intermediate dose (∼25 Gy) at the posterior beam region, including the posterior rectum and perirectal fat space (PRFS). CONCLUSIONS The serial response of the rectum with respect to RB has been demonstrated in patients with posteriorly extended lateral beams. Similarly, the parallel response of the PRFS with respect to tenesmus has been demonstrated in patients treated with the posterior beam.
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Affiliation(s)
- Marco Marcello
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia.
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia
| | - Lois C Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia
| | - Jason A Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; CSIRO, Herston, Australia
| | - Michael G Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - David J Joseph
- School of Surgery, University of Western Australia, Crawley, Australia; 5D Clinics, Claremont, Australia; GenesisCare WA, Wembley, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, Australia
| | - Mathew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, United Kingdom
| | - Martin A Ebert
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia; 5D Clinics, Claremont, Australia
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In Reply to Loganadane et al. Int J Radiat Oncol Biol Phys 2019; 103:777-778. [DOI: 10.1016/j.ijrobp.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 11/21/2022]
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Roach D, Holloway LC, Jameson MG, Dowling JA, Kennedy A, Greer PB, Krawiec M, Rai R, Denham J, De Leon J, Lim K, Berry ME, White RT, Bydder SA, Tan HT, Croker JD, McGrath A, Matthews J, Smeenk RJ, Ebert MA. Multi-observer contouring of male pelvic anatomy: Highly variable agreement across conventional and emerging structures of interest. J Med Imaging Radiat Oncol 2019; 63:264-271. [PMID: 30609205 DOI: 10.1111/1754-9485.12844] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION This study quantified inter-observer contouring variations for multiple male pelvic structures, many of which are of emerging relevance for prostate cancer radiotherapy progression and toxicity response studies. METHODS Five prostate cancer patient datasets (CT and T2-weighted MR) were distributed to 13 observers for contouring. CT structures contoured included the clinical target volume (CTV), seminal vesicles, rectum, colon, bowel bag, bladder and peri-rectal space (PRS). MR contours included CTV, trigone, membranous urethra, penile bulb, neurovascular bundle and multiple pelvic floor muscles. Contouring variations were assessed using the intraclass correlation coefficient (ICC), Dice similarity coefficient (DSC), and multiple additional metrics. RESULTS Clinical target volume (CT and MR), bladder, rectum and PRS contours showed excellent inter-observer agreement (median ICC = 0.97; 0.99; 1.00; 0.95; 0.90, DSC = 0.83 ± 0.05; 0.88 ± 0.05; 0.93 ± 0.03; 0.81 ± 0.07; 0.80 ± 0.06, respectively). Seminal vesicle contours were more variable (ICC = 0.75, DSC = 0.73 ± 0.14), while colon and bowel bag contoured volumes were consistent (ICC = 0.97; 0.97), but displayed poor overlap (DSC = 0.58 ± 0.22; 0.67 ± 0.21). Smaller MR structures showed significant inter-observer variations, with poor overlap for trigone, membranous urethra, penile bulb, and left and right neurovascular bundles (DSC = 0.44 ± 0.22; 0.41 ± 0.21; 0.66 ± 0.21; 0.16 ± 0.17; 0.15 ± 0.15). Pelvic floor muscles recorded moderate to strong inter-observer agreement (ICC = 0.50-0.97), although large outlier variations were observed. CONCLUSIONS Inter-observer contouring variation was significant for multiple pelvic structures contoured on MR.
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Affiliation(s)
- Dale Roach
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Lois C Holloway
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Michael G Jameson
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Jason A Dowling
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Australian e-Health Research Centre, CSIRO, Royal Brisbane Hospital, Brisbane, Queensland, Australia.,School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Angel Kennedy
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia.,Calvary Mater Newcastle Hospital, Newcastle, New South Wales, Australia
| | - Michele Krawiec
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robba Rai
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Jim Denham
- School of Medicine and Population Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeremiah De Leon
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Karen Lim
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Megan E Berry
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Rohen T White
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sean A Bydder
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hendrick T Tan
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Alycea McGrath
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Matthews
- Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin A Ebert
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Physics and Astrophysics, Faculty of Science, University of Western Australia, Perth, Western Australia, Australia
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Cicchetti A, Avuzzi B, Palorini F, Ballarini F, Stucchi C, Fellin G, Gabriele P, Vavassori V, Esposti CD, Cozzarini C, Fiorino C, Rancati T, Valdagni R. Predicting Late Fecal Incontinence Risk After Radiation Therapy for Prostate Cancer: New Insights From External Independent Validation. Int J Radiat Oncol Biol Phys 2018; 102:127-136. [PMID: 29970313 DOI: 10.1016/j.ijrobp.2018.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/30/2018] [Accepted: 05/02/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE This study aimed to validate a previously published predictive model for late fecal incontinence (FI) in a contemporary population of prostate cancer patients treated with radical radiation therapy. METHODS AND MATERIALS The validation included patients treated with intensity-modulated radiation therapy (IMRT) (2010-2014). Prescribed dose range was 65-80 Gy, including conventional and moderate hypo-fractionated treatments. Rectal toxicity was scored using LENT/SOMA, a minimum 2-year follow up was considered. We chose to validate the model published by Rancati et al for predicting chronic FI, developed on a 3-dimensional conformal radiation therapy (3DCRT) population. It considered a longitudinal endpoint defined as the average toxicity grade during the follow up. This continuous endpoint was dichotomized using a cut-off value of mean FI grade >1. The model included mean rectal dose (Dmean), previous diseases of the colon (COLO) and previous abdominal surgery (SURG). Doses were corrected to 2 Gy/fraction using the linear-quadratic model and applying alpha/beta ratio = 4.8 Gy. RESULTS 228 patients constituted the validation population. A mean FI grade >1 was scored in 25 patients (11%). Logistic regression confirmed risk factors reported in the literature, with similar odds ratios (ORs) for Dmean (1.04 ± 0.03 vs 1.06 ± 0.04) and SURG (1.9 ± 1.7 vs 1.6 ± 1.45); COLO was not confirmed. Consequently, the predictive models including Dmean/Dmean + SURG were evaluated using calibration plots. Both showed a clear discriminative trend, but the absolute observed toxicity rates were underestimated (ie, absolute predicted rates were always lower than corresponding absolute observed rates). This result was consistent with an unexpected effect of hypofractionation (OR = 2.20, conventional = 8.1% vs hypofractionated = 17.4%) beyond the standard correction using linear-quadratic model. Nevertheless, the FI rate in the conventionally treated group was almost double the rate observed in the previously studied cohort (4.3% vs 8.1%). CONCLUSIONS The study confirms previously published results indicating that abdominal surgery and rectal mean dose are risk factors for late FI. Calibration plots highlight a possible role of hypofractionation beyond linear-quadratic correction.
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Affiliation(s)
- Alessandro Cicchetti
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Università degli Studi di Pavia, Physics Department, Pavia, Italy
| | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy
| | - Federica Palorini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy
| | - Francesca Ballarini
- Università degli Studi di Pavia, Physics Department, Pavia, Italy; INFN-Section of Pavia, Pavia, Italy
| | - Claudio Stucchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Medical Physics, Milan, Italy
| | | | - Pietro Gabriele
- Istituto di Candiolo- Fondazione del Piemonte per l'Oncologia IRCCS, Radiotherapy, Torino, Italy
| | | | | | - Cesare Cozzarini
- San Raffaele Scientific Institute, Radiation Oncology, Milan, Italy
| | - Claudio Fiorino
- San Raffaele Scientific Institute, Medical Physics, Milan, Italy
| | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy.
| | - Riccardo Valdagni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy; Università degli Studi di Milano, Department of Oncology and Hemato-oncology, Milan, Italy
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