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Lin YX, Zhao FF, Kong WM. Effects of vaginal dilation therapy on vaginal length, vaginal stenosis, vaginal elasticity and sexual function of cervical cancer survivors. J OBSTET GYNAECOL 2024; 44:2317387. [PMID: 38466132 DOI: 10.1080/01443615.2024.2317387] [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: 07/26/2023] [Accepted: 12/05/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Cervical cancer survivors can experience vaginal length shortening, vaginal stenosis, vaginal elasticity deterioration, sexual frequency reduction and sexual dysfunction. This prospective, uncontrolled, monocentric clinical interventional study aimed to evaluate the effect of vaginal dilation therapy on vaginal condition and sexual function of cervical cancer survivors who had not received timely vaginal dilation. METHODS A total of 139 patients completed the study. They received 6 months of vaginal dilation therapy. We evaluated their vaginal elasticity, vaginal diameter, vaginal length and sexual function before and after vaginal dilation therapy. Their vaginal conditions were evaluated by customised vaginal moulds, and the sexual function was assessed by female sexual function index. The SPSS 25 software was used to analyse all the data. RESULTS Age, vaginal diameter and sexual intercourse frequency before diagnosis were significantly associated with female sexual dysfunction of the patients after cancer treatment. Vaginal dilation therapy improved vaginal stenosis, vaginal length and sexual function in all the patients; however, the vaginal elasticity and incidence of sexual dysfunction did not improve significantly. Sexual intercourse frequency before diagnosis, vaginal elasticity, time interval from last treatment and treatment modalities were significantly associated with the change in female sexual function index score before and after vaginal dilation therapy. Patients with a time interval from the last treatment less than 24 months or those who had moderate or good vaginal elasticity, benefitted more from vaginal dilatation therapy. CONCLUSIONS Cervical cancer survivors who had not received timely vaginal dilation still benefitted from vaginal dilation therapy, irrespective of the treatment methods they received. Moreover, vaginal dilation therapy should be performed as early as possible after cervical cancer treatment.
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Affiliation(s)
- Yu-Xuan Lin
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
| | - Fei-Fei Zhao
- Department of Gynecology and Obstetrics, Beijing Fuxing Hospital, Capital Medical University, Beijing, China
| | - Wei-Min Kong
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
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Knoth J, Sturdza A, Zaharie A, Dick V, Kronreif G, Nesvacil N, Widder J, Kirisits C, Schmid MP. Transrectal ultrasound for intraoperative interstitial needle guidance in cervical cancer brachytherapy. Strahlenther Onkol 2024; 200:684-690. [PMID: 38409394 PMCID: PMC11272749 DOI: 10.1007/s00066-024-02207-9] [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: 11/15/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE This study aimed to prospectively assess the visibility of interstitial needles on transrectal ultrasound (TRUS) in cervical cancer brachytherapy patients and evaluate its impact on implant and treatment plan quality. MATERIAL AND METHODS TRUS was utilized during and after applicator insertion, with each needle's visibility documented through axial images at the high-risk clinical target volume's largest diameter. Needle visibility on TRUS was scored from 0 (no visibility) to 3 (excellent discrimination, margins distinct). Quantitative assessment involved measuring the distance between tandem and each needle on TRUS and comparing it to respective magnetic resonance imaging (MRI) measurements. Expected treatment plan quality based on TRUS images was rated from 1 (meeting all planning objectives) to 4 (violation of High-risk clinical target volume (CTVHR) and/or organ at risk (OAR) hard constraints) and compared to the final MRI-based plan. RESULTS Analysis included 23 patients with local FIGO stage IB2-IVA, comprising 41 applications with a total of 230 needles. A high visibility rate of 99.1% (228/230 needles) was observed, with a mean visibility score of 2.5 ± 0.7 for visible needles. The maximum and mean difference between MRI and TRUS measurements were 8 mm and -0.1 ± 1.6 mm, respectively, with > 3 mm discrepancies in 3.5% of needles. Expected treatment plan quality after TRUS assessment exactly aligned with the final MRI plan in 28 out of 41 applications with only minor deviations in all other cases. CONCLUSION Real-time TRUS-guided interstitial needle placement yielded high-quality implants, thanks to excellent needle visibility during insertion. This supports the potential of TRUS-guided brachytherapy as a promising modality for gynecological indications.
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Affiliation(s)
- J Knoth
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - A Zaharie
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - V Dick
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - G Kronreif
- Austrian Center for Medical Innovation and Technology, Wiener Neustadt, Austria
| | - N Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - J Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - C Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - M P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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3
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Moore LC, Ahern F, Li L, Kallis K, Kisling K, Cortes KG, Nwachukwu C, Rash D, Yashar CM, Mayadev J, Zou J, Vasconcelos N, Meyers SM. Neural network dose prediction for cervical brachytherapy: Overcoming data scarcity for applicator-specific models. Med Phys 2024; 51:4591-4606. [PMID: 38814165 DOI: 10.1002/mp.17230] [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: 11/16/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND 3D neural network dose predictions are useful for automating brachytherapy (BT) treatment planning for cervical cancer. Cervical BT can be delivered with numerous applicators, which necessitates developing models that generalize to multiple applicator types. The variability and scarcity of data for any given applicator type poses challenges for deep learning. PURPOSE The goal of this work was to compare three methods of neural network training-a single model trained on all applicator data, fine-tuning the combined model to each applicator, and individual (IDV) applicator models-to determine the optimal method for dose prediction. METHODS Models were produced for four applicator types-tandem-and-ovoid (T&O), T&O with 1-7 needles (T&ON), tandem-and-ring (T&R) and T&R with 1-4 needles (T&RN). First, the combined model was trained on 859 treatment plans from 266 cervical cancer patients treated from 2010 onwards. The train/validation/test split was 70%/16%/14%, with approximately 49%/10%/19%/22% T&O/T&ON/T&R/T&RN in each dataset. Inputs included four channels for anatomical masks (high-risk clinical target volume [HRCTV], bladder, rectum, and sigmoid), a mask indicating dwell position locations, and applicator channels for each applicator component. Applicator channels were created by mapping the 3D dose for a single dwell position to each dwell position and summing over each applicator component with uniform dwell time weighting. A 3D Cascade U-Net, which consists of two U-Nets in sequence, and mean squared error loss function were used. The combined model was then fine-tuned to produce four applicator-specific models by freezing the first U-Net and encoding layers of the second and resuming training on applicator-specific data. Finally, four IDV models were trained using only data from each applicator type. Performance of these three model types was compared using the following metrics for the test set: mean error (ME, representing model bias) and mean absolute error (MAE) over all dose voxels and ME of clinical metrics (HRCTV D90% and D2cc of bladder, rectum, and sigmoid), averaged over all patients. A positive ME indicates the clinical dose was higher than predicted. 3D global gamma analysis with the prescription dose as reference value was performed. Dice similarity coefficients (DSC) were computed for each isodose volume. RESULTS Fine-tuned and combined models showed better performance than IDV applicator training. Fine-tuning resulted in modest improvements in about half the metrics, compared to the combined model, while the remainder were mostly unchanged. Fine-tuned MAE = 3.98%/2.69%/5.36%/3.80% for T&O/T&R/T&ON/T&RN, and ME over all voxels = -0.08%/-0.89%/-0.59%/1.42%. ME D2cc were bladder = -0.77%/1.00%/-0.66%/-1.53%, rectum = 1.11%/-0.22%/-0.29%/-3.37%, sigmoid = -0.47%/-0.06%/-2.37%/-1.40%, and ME D90 = 2.6%/-4.4%/4.8%/0.0%. Gamma pass rates (3%/3 mm) were 86%/91%/83%/89%. Mean DSCs were 0.92%/0.92%/0.88%/0.91% for isodoses ≤ 150% of prescription. CONCLUSIONS 3D BT dose was accurately predicted for all applicator types, as indicated by the low MAE and MEs, high gamma scores and high DSCs. Training on all treatment data overcomes challenges with data scarcity in each applicator type, resulting in superior performance than can be achieved by training on IDV applicators alone. This could presumably be explained by the fact that the larger, more diverse dataset allows the neural network to learn underlying trends and characteristics in dose that are common to all treatment applicators. Accurate, applicator-specific dose predictions could enable automated, knowledge-based planning for any cervical brachytherapy treatment.
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Affiliation(s)
- Lance C Moore
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Fritz Ahern
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Lingyi Li
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Karoline Kallis
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Kelly Kisling
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Katherina G Cortes
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Chika Nwachukwu
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Dominique Rash
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Catheryn M Yashar
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Jyoti Mayadev
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Jingjing Zou
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego and Moores Cancer Center, La Jolla, California, USA
| | - Nuno Vasconcelos
- Electrical and Computer Engineering, University of California San Diego, La Jolla, California, USA
| | - Sandra M Meyers
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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Roumeliotis M, Thind K, Morrison H, Burke B, Martell K, van Dyke L, Barbera L, Quirk S. The impact of advancing the standard of care in radiotherapy on operational treatment resources. J Appl Clin Med Phys 2024; 25:e14363. [PMID: 38634814 PMCID: PMC11244663 DOI: 10.1002/acm2.14363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE To demonstrate the impact of implementing hypofractionated prescription regimens and advanced treatment techniques on institutional operational hours and radiotherapy personnel resources in a multi-institutional setting. The study may be used to describe the impact of advancing the standard of care with modern radiotherapy techniques on patient and staff resources. METHODS This study uses radiation therapy data extracted from the radiotherapy information system from two tertiary care, university-affiliated cancer centers from 2012 to 2021. Across all patients in the analysis, the average fraction number for curative and palliative patients was reported each year in the decade. Also, the institutional operational treatment hours are reported for both centers. A sub-analysis for curative intent breast and lung radiotherapy patients was performed to contextualize the impact of changes to imaging, motion management, and treatment technique. RESULTS From 2012 to 2021, Center 1 had 42 214 patient plans and Center 2 had 43 252 patient plans included in the analysis. Averaged over both centers across the decade, the average fraction number per patient decreased from 6.9 to 5.2 (25%) and 21.8 to 17.2 (21%) for palliative and curative patients, respectively. The operational treatment hours for both institutions increased from 8 h 15 min to 9 h 45 min (18%), despite a patient population increase of 45%. CONCLUSION The clinical implementation of hypofractionated treatment regimens has successfully reduced the radiotherapy workload and operational treatment hours required to treat patients. This analysis describes the impact of changes to the standard of care on institutional resources.
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Affiliation(s)
- Michael Roumeliotis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kundan Thind
- Henry Ford Cancer Institute, Detroit, Michigan, USA
| | - Hali Morrison
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Ben Burke
- University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Martell
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Lisa Barbera
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Harvard Medical School, Boston, Massachusetts, USA
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Romano A, Votta C, Nardini M, Chiloiro G, Panza G, Boldrini L, Cusumano D, Galofaro E, Placidi L, Antonelli MV, Turco G, Autorino R, Gambacorta MA. Uterus motion analysis for radiotherapy planning optimization. The innovative contribution of on-board hybrid MR imaging. Clin Transl Radiat Oncol 2024; 47:100808. [PMID: 39005509 PMCID: PMC11239475 DOI: 10.1016/j.ctro.2024.100808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction Organ motion (OM) and volumetric changes pose challenges in radiotherapy (RT) for locally advanced cervical cancer (LACC). Magnetic Resonance-guided Radiotherapy (MRgRT) combines improved MRI contrast with adaptive RT plans for daily anatomical changes. Our goal was to analyze cervico-uterine structure (CUS) changes during RT to develop strategies for managing OM. Materials and methods LACC patients received chemoradiation by MRIdian system with a simultaneous integrated boost (SIB) protocol. Prescription doses of 55-50.6 Gy at PTV1 and 45-39.6 Gy at PTV2 were given in 22 and 25 fractions. Daily MRI scans were co-registered with planning scans and CUS changes were assessed.Six PTVs were created by adding 0.5, 0.7, 1, 1.3, 1.5, and 2 cm margins to the CUS, based on the simulation MRI. Adequate margins were determined to include 95 % of the CUSs throughout the entire treatment in 95 % of patients. Results Analysis of 15 LACC patients and 372 MR scans showed a 31 % median CUS volume decrease. Asymmetric margins of 2 cm cranially, 0.5 cm caudally, 1.5 cm posteriorly, 2 cm anteriorly, and 1.5 cm on both sides were optimal for PTV, adapting to CUS variations. Post-14th fraction, smaller margins of 0.7 cm cranially, 0.5 cm caudally, 1.3 cm posteriorly, 1.3 cm anteriorly, and 1.3 cm on both sides sufficed. Conclusion CUS mobility varies during RT, suggesting reduced PTV margins after the third week. MRgRT with adaptive strategies optimizes dose delivery, emphasizing the importance of streamlined IGRT with reduced PTV margins using a tailored MRgRT workflow with hybrid MRI-guided systems.
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Affiliation(s)
- Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, 07026 Olbia, Italy
| | - Elena Galofaro
- Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Marco Valerio Antonelli
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Gabriele Turco
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Rosa Autorino
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
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6
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Van Damme A, Tummers P, De Visschere P, Van Dorpe J, Van de Vijver K, Vercauteren T, De Gersem W, Denys H, Naert E, Makar A, De Neve W, Vandecasteele K. Exclusion of non-Involved uterus from the target volume (EXIT-trial): An individualized treatment for locally advanced cervical cancer using modern radiotherapy and imaging techniques followed by completion surgery. Clin Transl Radiat Oncol 2024; 47:100793. [PMID: 38798749 PMCID: PMC11126536 DOI: 10.1016/j.ctro.2024.100793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
Background and purpose Chemoradiotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer (LACC). In this study, we postulate that omitting an iconographical unaffected uterus (+12 mm distance from the tumour) from the treatment volume is safe and that no tumour will be found in the non-targeted uterus (NTU) leading to reduction of high-dose volumes of surrounding organs at risk (OARs). Material and Methods In this single-arm phase 2 study, two sets of target volumes were delineated: one standard-volume (whole uterus) and an EXIT-volume (exclusion of non-tumour-bearing parts of the uterus with a minimum 12 mm margin from the tumour). All patients underwent chemoradiotherapy targeting the EXIT-volume, followed by completion hysterectomy. In 15 patients, a plan comparison between two treatment plans (PTV vs PTV_EXIT) was performed. The primary endpoint was the pathological absence of tumour involvement in the non-targeted uterus (NTU). Secondary endpoints included dosimetric impact of target volume reduction on OARs, acute and chronic toxicity, overall survival (OS), locoregional recurrence-free survival (LRFS), and progression-free survival (PFS). Results In all 21 (FIGO stage I: 2; II: 14;III: 3; IV: 2) patients the NTU was pathologically negative. Ssignificant reductions in Dmean in bladder, sigmoid and rectum; V15Gy in sigmoid and rectum, V30Gy in bladder, sigmoid and rectum; V40Gy and V45Gy in bladder, bowel bag, sigmoid and rectum; V50Gy in rectum were achieved. Median follow-up was 54 months (range 7-79 months). Acute toxicity was mainly grade 2 and 5 % grade 3 urinary. The 3y- OS, PFS and LRFS were respectively 76,2%, 64,9% and 81 %. Conclusion MRI-based exclusion of the non-tumour-bearing parts of the uterus at a minimum distance of 12 mm from the tumour out of the target volume in LACC can be done without risk of residual disease in the NTU, leading to a significant reduction of the volume of surrounding OARS treated to high doses.
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Affiliation(s)
- Axel Van Damme
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter De Visschere
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Departement of Radiology and Nuclear Medicine, Ghent University Hospital, Belgium
| | - Jo Van Dorpe
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Koen Van de Vijver
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Werner De Gersem
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Hannelore Denys
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Eline Naert
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Amin Makar
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Katrien Vandecasteele
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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7
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Douglas R, Olanrewaju A, Mumme R, Zhang L, Beadle BM, Court LE. Evaluating automatically generated normal tissue contours for safe use in head and neck and cervical cancer treatment planning. J Appl Clin Med Phys 2024; 25:e14338. [PMID: 38610118 PMCID: PMC11244666 DOI: 10.1002/acm2.14338] [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: 05/24/2023] [Revised: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
PURPOSE Volumetric-modulated arc therapy (VMAT) is a widely accepted treatment method for head and neck (HN) and cervical cancers; however, creating contours and plan optimization for VMAT plans is a time-consuming process. Our group has created an automated treatment planning tool, the Radiation Planning Assistant (RPA), that uses deep learning models to generate organs at risk (OARs), planning structures and automates plan optimization. This study quantitatively evaluates the quality of contours generated by the RPA tool. METHODS For patients with HN (54) and cervical (39) cancers, we retrospectively generated autoplans using the RPA. Autoplans were generated using deep-learning and RapidPlan models developed in-house. The autoplans were, then, applied to the original, physician-drawn contours, which were used as a ground truth (GT) to compare with the autocontours (RPA). Using a "two one-sided tests" (TOST) procedure, we evaluated whether the autocontour normal tissue dose was equivalent to that of the ground truth by a margin, δ, that we determined based on clinical judgement. We also calculated the number of plans that met established clinically accepted dosimetric criteria. RESULTS For HN plans, 91.8% and 91.7% of structures met dosimetric criteria for automatic and manual contours, respectively; for cervical plans, 95.6% and 95.7% of structures met dosimetric criteria for automatic and manual contours, respectively. Autocontours were equivalent to the ground truth for 71% and 75% of common DVH metrics for the HN and cervix, respectively. CONCLUSIONS This study shows that dosimetrically equivalent normal tissue contours can be created for HN and cervical cancers using deep learning techniques. In general, differences between the contours did not affect the passing or failing of clinical dose tolerances.
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Affiliation(s)
- Raphael Douglas
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Adenike Olanrewaju
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Raymond Mumme
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Lifei Zhang
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Beth M. Beadle
- Department of Radiation OncologyStanford UniversityStanfordCaliforniaUSA
| | - Laurence Edward Court
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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8
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Wang Z, Guo X, Zhao H. Dose-response relationship between volume base dose and tumor local control in definitive radiotherapy for vaginal cancer. BMC Cancer 2024; 24:707. [PMID: 38851692 PMCID: PMC11162573 DOI: 10.1186/s12885-024-12486-1] [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: 02/06/2024] [Accepted: 06/07/2024] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVE This study aimed to establish the dose-response relationship between volume base dose and tumor local control for vaginal cancer, including primary vaginal cancer and recurrent gynecologic malignancies in the vagina. MATERIALS AND METHODS We identified studies that reported volume base dose and local control by searching the PubMed, the Web of Science, and the Cochrane Library Database through August 12, 2023. The regression analyses were performed using probit model between volume based dose versus clinical outcomes. Subgroup analyses were performed according to stratification: publication year, country, inclusion time of patients, patients with prior radiotherapy, age, primaries or recurrent, tumor size, concurrent chemoradiotherapy proportion, dose rate, image modality for planning, and interstitial proportion. RESULTS A total of 879 patients with vaginal cancer were identified from 18 studies. Among them, 293 cases were primary vaginal cancer, 573 cases were recurrent cancer in the vagina, and 13 cases were unknown. The probit model showed a significant relationship between the HR-CTV (or CTV) D90 versus the 2-year and 3-year local control, P values were 0.013 and 0.014, respectively. The D90 corresponding to probabilities of 90% 2-year local control were 79.0 GyEQD2,10 (95% CI: 75.3-96.6 GyEQD2,10). CONCLUSIONS A significant dependence of 2-year or 3-year local control on HR-CTV (or CTV) D90 was found. Our research findings encourage further validation of the dose-response relationship of radical radiotherapy for vaginal cancer through protocol based multicenter clinical trials.
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Affiliation(s)
- Zhiqiang Wang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China
| | - Xin Guo
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China
| | - Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, PR China.
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9
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Guigo M, Dauda MS, Lequesne J, Blache A, Pereira R, Le Gall I, Pernin VE, Gaichies L, Clarisse B, Grellard JM, Joly F, Meyer E, Balosso J. Simultaneous integrated boost on pathologic lymph nodes safely improves clinical outcomes compared to sequential boost in locally advanced cervical cancer: a multicenter retrospective study. Front Oncol 2024; 14:1353813. [PMID: 38887236 PMCID: PMC11180790 DOI: 10.3389/fonc.2024.1353813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024] Open
Abstract
Background Objective This multicenter study aimed to retrospectively evaluate the impact of high boost simultaneous integrated boost (SIB) to pathologic lymph nodes compared to Sequential boost (Seq) in patients with locally advanced cervical cancer (LACC). Materials and methods 97 patients with pelvic and/or para-aortic (PAo) node-positive LACC treated by definitive chemoradiation were included. Two groups were analyzed: Sequential boost group and simultaneous integrated boost (SIB) group. Endpoints were Distant Recurrence Free Survival (DRFS), Recurrence Free Survival (RFS), Overall Survival (OS), locoregional pelvic and PAo control and toxicities. Results 3-years DRFS in SIB and Seq groups was 65% and 31% respectively (log-rank p < 0.001). 3-years RFS was 58% and 26% respectively (log-rank p = 0.009). DRFS prognostic factors in multivariable analysis were SIB, PAo involvement and maximum pelvic node diameter ≥ 2cm. Adenocarcinoma histology and absence of brachytherapy tended to be prognostic factors. SIB provided the best pelvic control at first imaging with 97%. There was no significant difference in terms of toxicities between groups. Conclusions Nodal SIB seems to be unavoidable in the treatment of node-positive LACC. It provides the best DRFS, RFS and pelvic control without additional toxicity, with a shortened treatment duration.
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Affiliation(s)
- Marin Guigo
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
| | | | - Justine Lequesne
- Clinical Research Department, Centre François Baclesse, Caen, France
| | - Alice Blache
- Department of Radiation Oncology, Centre Hospitalier Universitaire (CHU) Amiens-Picardie, Amiens, France
| | - Renata Pereira
- Department of Radiation Oncology, Centre Guillaume Le Conquérant, Le Havre, France
| | - Ioana Le Gall
- Department of Radiation Oncology, Centre de la Baie, Avranches, France
| | | | | | | | | | - Florence Joly
- Clinical Research Department, Centre François Baclesse, Caen, France
- Institut National de la Santé Et de la Recherche Médicale (INSERM), U1086, ANTICIPE, Cancer and Cognition Platform, Ligue Nationale Contre le Cancer, Medical Oncology Department, Centre François Baclesse, Caen, France
| | - Emmanuel Meyer
- Department of Radiation Oncology, Centre Maurice Tubiana, Caen, France
| | - Jacques Balosso
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
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10
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Kuipers SC, Godart J, Corbeau A, Breedveld S, Mens JWM, de Boer SM, Nout RA, Hoogeman MS. Dosimetric impact of bone marrow sparing for robustly optimized IMPT for locally advanced cervical cancer. Radiother Oncol 2024; 195:110222. [PMID: 38471634 DOI: 10.1016/j.radonc.2024.110222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND PURPOSE To investigate the trade-off between bone marrow sparing (BMS) and dose to organs at risk (OARs) for intensity modulated proton therapy (IMPT) for women with locally advanced cervical cancer (LACC). MATERIALS AND METHODS Twenty LACC patients were retrospectively included. IMPT plans were created for each patient using automated treatment planning. These plans progressively reduced bone marrow mean doses by steps of 1 GyRBE, while constraining target coverage and conformality. The relation between bone marrow dose and bladder, small bowel, rectum, and sigmoid doses was evaluated. RESULTS A total of 140 IMPT plans were created. Plans without BMS had an average [range] bone marrow mean dose of 17.3 [14.7-21.6] GyRBE , which reduced to 12.0 [10.0-14.0] GyRBE with maximum BMS. The mean OAR dose [range] increased modestly for 1 GyRBE BMS: 0.2 [0.0 - 0.6] GyRBE for bladder, 0.3 [-0.2 - 0.7] GyRBE for rectum, 0.4 [0.1 - 0.8] GyRBE for small bowel, and 0.2 [-0.2 - 0.4] GyRBE for sigmoid. Moreover, for maximum BMS, mean OAR doses [range] escalated by 3.3 [0.1 - 6.7] GyRBE for bladder, 5.8 [1.8 - 12.4] GyRBE for rectum, 3.9 [1.6 - 5.9] GyRBE for small bowel, and 2.7 [0.6 - 5.9] GyRBE for sigmoid. CONCLUSION Achieving 1 GyRBE BMS for IMPT is feasible for LACC patients with limited dosimetric impact on other OARs. While further bone marrow dose reduction is possible for some patients, it may increase OAR doses substantially for others. Hence, we recommend a personalized approach when introducing BMS into clinical IMPT treatment planning to carefully assess individual patient benefits and risks.
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Affiliation(s)
- S C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands.
| | - J Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
| | - A Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J W M Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
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11
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Chen ZJ, Li XA, Brenner DJ, Hellebust TP, Hoskin P, Joiner MC, Kirisits C, Nath R, Rivard MJ, Thomadsen BR, Zaider M. AAPM Task Group Report 267: A joint AAPM GEC-ESTRO report on biophysical models and tools for the planning and evaluation of brachytherapy. Med Phys 2024; 51:3850-3923. [PMID: 38721942 DOI: 10.1002/mp.17062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 06/05/2024] Open
Abstract
Brachytherapy utilizes a multitude of radioactive sources and treatment techniques that often exhibit widely different spatial and temporal dose delivery patterns. Biophysical models, capable of modeling the key interacting effects of dose delivery patterns with the underlying cellular processes of the irradiated tissues, can be a potentially useful tool for elucidating the radiobiological effects of complex brachytherapy dose delivery patterns and for comparing their relative clinical effectiveness. While the biophysical models have been used largely in research settings by experts, it has also been used increasingly by clinical medical physicists over the last two decades. A good understanding of the potentials and limitations of the biophysical models and their intended use is critically important in the widespread use of these models. To facilitate meaningful and consistent use of biophysical models in brachytherapy, Task Group 267 (TG-267) was formed jointly with the American Association of Physics in Medicine (AAPM) and The Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) to review the existing biophysical models, model parameters, and their use in selected brachytherapy modalities and to develop practice guidelines for clinical medical physicists regarding the selection, use, and interpretation of biophysical models. The report provides an overview of the clinical background and the rationale for the development of biophysical models in radiation oncology and, particularly, in brachytherapy; a summary of the results of literature review of the existing biophysical models that have been used in brachytherapy; a focused discussion of the applications of relevant biophysical models for five selected brachytherapy modalities; and the task group recommendations on the use, reporting, and implementation of biophysical models for brachytherapy treatment planning and evaluation. The report concludes with discussions on the challenges and opportunities in using biophysical models for brachytherapy and with an outlook for future developments.
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Affiliation(s)
- Zhe Jay Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David J Brenner
- Center for Radiological Research, Columbia University Medical Center, New York, New York, USA
| | - Taran P Hellebust
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Center, Mount Vernon Hospital, Northwood, UK
- University of Manchester, Manchester, UK
| | - Michael C Joiner
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Christian Kirisits
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marco Zaider
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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12
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van Vliet-Pérez SM, van Paassen R, Wauben LSGL, Straathof R, Berg NJVD, Dankelman J, Heijmen BJM, Kolkman-Deurloo IKK, Nout RA. Time-action and patient experience analyses of locally advanced cervical cancer brachytherapy. Brachytherapy 2024; 23:274-281. [PMID: 38418362 DOI: 10.1016/j.brachy.2024.01.007] [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: 05/11/2023] [Revised: 10/31/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND PURPOSE Although MRI-based image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) has resulted in favorable outcomes, it can be logistically complex and time consuming compared to 2D image-based brachytherapy, and both physically and emotionally intensive for patients. This prospective study aims to perform time-action and patient experience analyses during IGABT to guide further improvements. MATERIALS AND METHODS LACC patients treated with IGABT were included for the time-action (56 patients) and patient experience (29 patients) analyses. Times per treatment step were reported on a standardized form. For the patient experience analysis, a baseline health status was established with the EQ-5D-5L questionnaire and the perceived pain, anxiety and duration for each treatment step were assessed with the NRS-11. RESULTS The median total procedure time from arrival until discharge was 530 (IQR: 480-565) minutes. Treatment planning (delineation, reconstruction, optimization) required the most time and took 175 (IQR: 145-195) minutes. Highest perceived pain was reported during applicator removal and treatment planning, anxiety during applicator removal, and duration during image acquisition and treatment planning. Perceived pain, anxiety and duration were correlated. Higher pre-treatment pain and anxiety scores were associated with higher perceived pain, anxiety and duration. CONCLUSION This study highlights the complexity, duration and impact on patient experience of the current IGABT workflow. Patient reported pre-treatment pain and anxiety can help identify patients that may benefit from additional support. Research and implementation of measures aiming at shortening the overall procedure duration, which may include logistical, staffing and technological aspects, should be prioritized.
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Affiliation(s)
- Sharline M van Vliet-Pérez
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands; Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands.
| | - Rosemarijn van Paassen
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Linda S G L Wauben
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Robin Straathof
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands; Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Nick J van de Berg
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands; Erasmus MC Cancer Institute, Department of Gynaecological Oncology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jenny Dankelman
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Ben J M Heijmen
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Inger-Karine K Kolkman-Deurloo
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remi A Nout
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
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13
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Abdul-Latif M, Chowdhury A, Tharmalingam H, Taylor NJ, Lakhani A, Padhani A, Hoskin P, Tsang Y. Exploratory study of using Magnetic resonance Prognostic Imaging markers for Radiotherapy In Cervix cancer (EMPIRIC): a prospective cohort study protocol. BMJ Open 2024; 14:e077390. [PMID: 38637128 PMCID: PMC11029356 DOI: 10.1136/bmjopen-2023-077390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 02/29/2024] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION Radical chemoradiotherapy represents the gold standard for locally advanced cervical cancer. However, despite significant progress in improving local tumour control, distant relapse continues to impact overall survival. The development of predictive and prognostic biomarkers is consequently important to risk-stratify patients and identify populations at higher risk of poorer treatment response and survival outcomes. Exploratory study of using Magnetic resonance Prognostic Imaging markers for Radiotherapy In Cervix cancer (EMPIRIC) is a prospective exploratory cohort study, which aims to investigate the role of multiparametric functional MRI (fMRI) using diffusion-weighed imaging (DWI), dynamic contrast-enhanced (DCE) and blood oxygen level-dependent imaging (BOLD) MRI to assess treatment response and predict outcomes in patients undergoing radical chemoradiotherapy for cervical cancer. METHODS AND ANALYSIS The study aims to recruit 40 patients across a single-centre over 2 years. Patients undergo multiparametric fMRI (DWI, DCE and BOLD-MRI) at three time points: before, during and at the completion of external beam radiotherapy. Tissue and liquid biopsies are collected at diagnosis and post-treatment to identify potential biomarker correlates against fMRI. The primary outcome is to evaluate sensitivity and specificity of quantitative parameters derived from fMRI as predictors of progression-free survival at 2 years following radical chemoradiotherapy for cervical cancer. The secondary outcome is to investigate the roles of fMRI as predictors of overall survival at 2 years and tumour volume reduction across treatment. Statistical analyses using regression models and survival analyses are employed to evaluate the relationships between the derived parameters, treatment response and clinical outcomes. ETHICS AND DISSEMINATION The EMPIRIC study received ethical approval from the NHS Health Research Authority (HRA) on 14 February 2022 (protocol number RD2021-29). Confidentiality and data protection measures are strictly adhered to throughout the study. The findings of this study will be disseminated through peer-reviewed publications and scientific conferences, aiming to contribute to the growing body of evidence on the use of multiparametric MRI in cervical cancer management. TRIAL REGISTRATION NUMBER NCT05532930.
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Affiliation(s)
- Mohammed Abdul-Latif
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Amani Chowdhury
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | | | | | | | | | - Peter Hoskin
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Yatman Tsang
- Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
- Radiation Medicine, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
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14
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Rouhi R, Niyoteka S, Carré A, Achkar S, Laurent PA, Ba MB, Veres C, Henry T, Vakalopoulou M, Sun R, Espenel S, Mrissa L, Laville A, Chargari C, Deutsch E, Robert C. Automatic gross tumor volume segmentation with failure detection for safe implementation in locally advanced cervical cancer. Phys Imaging Radiat Oncol 2024; 30:100578. [PMID: 38912007 PMCID: PMC11192799 DOI: 10.1016/j.phro.2024.100578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 06/25/2024] Open
Abstract
Background and Purpose Automatic segmentation methods have greatly changed the RadioTherapy (RT) workflow, but still need to be extended to target volumes. In this paper, Deep Learning (DL) models were compared for Gross Tumor Volume (GTV) segmentation in locally advanced cervical cancer, and a novel investigation into failure detection was introduced by utilizing radiomic features. Methods and materials We trained eight DL models (UNet, VNet, SegResNet, SegResNetVAE) for 2D and 3D segmentation. Ensembling individually trained models during cross-validation generated the final segmentation. To detect failures, binary classifiers were trained using radiomic features extracted from segmented GTVs as inputs, aiming to classify contours based on whether their Dice Similarity Coefficient ( DSC ) < T and DSC ⩾ T . Two distinct cohorts of T2-Weighted (T2W) pre-RT MR images captured in 2D sequences were used: one retrospective cohort consisting of 115 LACC patients from 30 scanners, and the other prospective cohort, comprising 51 patients from 7 scanners, used for testing. Results Segmentation by 2D-SegResNet achieved the best DSC, Surface DSC (SDSC 3 mm ), and 95th Hausdorff Distance (95HD): DSC = 0.72 ± 0.16,SDSC 3 mm =0.66 ± 0.17, and 95HD = 14.6 ± 9.0 mm without missing segmentation ( M =0) on the test cohort. Failure detection could generate precision ( P = 0.88 ), recall ( R = 0.75 ), F1-score ( F = 0.81 ), and accuracy ( A = 0.86 ) using Logistic Regression (LR) classifier on the test cohort with a threshold T = 0.67 on DSC values. Conclusions Our study revealed that segmentation accuracy varies slightly among different DL methods, with 2D networks outperforming 3D networks in 2D MRI sequences. Doctors found the time-saving aspect advantageous. The proposed failure detection could guide doctors in sensitive cases.
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Affiliation(s)
- Rahimeh Rouhi
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Stéphane Niyoteka
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Alexandre Carré
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Samir Achkar
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Pierre-Antoine Laurent
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Mouhamadou Bachir Ba
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
- Radiotherapy Department of the University Hospital Center of Dalal Jamm, Guédiawaye, Senegal
| | - Cristina Veres
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Théophraste Henry
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Medical Imaging, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maria Vakalopoulou
- Laboratoire Mathématiques et Informatique pour la Complexité et les Systèmes, CentraleSupélec, Université Paris-Saclay, Gif-sur-Yvette, France
| | - Roger Sun
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Sophie Espenel
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Linda Mrissa
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Adrien Laville
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
| | - Cyrus Chargari
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Eric Deutsch
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Charlotte Robert
- Université Paris-Saclay, Institut Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, 94800 Villejuif, France
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
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Cordoba A, Gesta E, Escande A, Noeuveglise A, Cayez R, Halty A, Ladjimi MT, Narducci F, Hudry D, Martinez Gomez C, Cordoba S, Le Deley MC, Barthoulot M, Lartigau EF. Interstitial needles versus intracavitary applicators only for locally advanced cervical cancer: results from real-life dosimetric comparisons. Front Oncol 2024; 14:1347727. [PMID: 38567146 PMCID: PMC10985138 DOI: 10.3389/fonc.2024.1347727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/09/2024] [Indexed: 04/04/2024] Open
Abstract
Background and purpose Image-guided adapted brachytherapy (IGABT) is superior to other radiotherapy techniques in the treatment of locally advanced cervical cancer (LACC). We aimed to investigate the benefit of interstitial needles (IN) for a combined intracavitary/interstitial (IC/IS) approach using IGABT over the intracavitary approach (IC) alone in patients with LACC after concomitant external beam radiotherapy (EBRT) and chemotherapy. Materials and methods We included consecutive patients with LACC who were treated with IC/IS IGABT after radiochemotherapy (RCT) in our retrospective, observational study. Dosimetric gain and sparing of organs at risk (OAR) were investigated by comparing the IC/IS IGABT plan with a simulated plan without needle use (IC IGABT plan) and the impact of other clinical factors on the benefit of IC/IS IGABT. Results Ninety-nine patients were analyzed, with a mean EBRT dose of 45.5 ± 1.7 Gy; 97 patients received concurrent chemotherapy. A significant increase in median D90% High Risk Clinical target volume (HR-CTV) was found for IC/IS (82.8 Gy) vs IC (76.2 Gy) (p < 10-4). A significant decrease of the delivered dose for all OAR was found for IC/IS vs IC for median D2cc to the bladder (77.2 Gy), rectum (68 Gy), sigmoid (53.2 Gy), and small bowel (47 Gy) (all p < 10-4). Conclusion HR-CTV coverage was higher with IC/IS IGABT than with IC IGABT, with lower doses to the OAR in patients managed for LACC after RCT. Interstitial brachytherapy in the management of LACC after radiotherapy provides better coverage of the target volumes, this could contribute to better local control and improved survival of patients.
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Affiliation(s)
- Abel Cordoba
- Department of Radiotherapy and Brachytherapy, Oscar Lambret Center, Lille, France
| | - Estelle Gesta
- Department of Radiotherapy and Brachytherapy, Oscar Lambret Center, Lille, France
| | | | | | - Romain Cayez
- Department Medical Physics, Oscar Lambret Center, Lille, France
| | - Adrien Halty
- Department Medical Physics, Oscar Lambret Center, Lille, France
| | | | - Fabrice Narducci
- Department Gynecologic surgical Oncology, Oscar Lambret Center, Lille, France
| | - Delphine Hudry
- Department Gynecologic surgical Oncology, Oscar Lambret Center, Lille, France
| | | | - Sofia Cordoba
- Department of Radiotherapy and Brachytherapy, Hospital Puerta de Hierro, Madrid, Spain
| | | | - Maël Barthoulot
- Department Biostatistics and Methodology, Oscar Lambret Center, Lille, France
| | - Eric F. Lartigau
- Department of Radiotherapy and Brachytherapy, Oscar Lambret Center, Lille, France
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16
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Bélanger C, Aubin S, Lavallée MC, Beaulieu L. Simultaneous catheter and multicriteria optimization for HDR cervical cancer brachytherapy with a complex intracavity/interstitial applicator. Med Phys 2024; 51:2128-2143. [PMID: 38043067 DOI: 10.1002/mp.16874] [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: 08/03/2023] [Revised: 10/24/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Complex intracavity and interstitial (IC/IS) applicators, such as the Venezia applicator, can improve the HR-CTV coverage while adequately protecting organs at risk in the treatment of cervical cancer with high-dose-rate (HDR) brachytherapy. Although the Venezia applicator offers more choice for catheter selection, commercially available catheter and dose optimization algorithms are still missing for complex applicators. Moreover, studies on catheter and dose optimization for IC/IS implants in the treatment of cervical cancer are still limited. PURPOSE This work aims to combine a GPU-based multi-criteria optimization (gMCO) algorithm with a sparse catheter (SC) optimization algorithm for the Venezia applicator. METHODS Fifty-eight cervical cancer patients who received 28 Gy in 4 fx of HDR brachytherapy with the Venezia applicator (combination to external beam radiation therapy) are retrospectively revisited. The modelization of the applicator is done by virtually reconstructing all the IS catheters passing through the ring. Template catheters are reconstructed using an in-house python script. To perform simultaneous MCO and SC optimization (SC+MCO), the objective function includes aggregated dose objectives in a weighted sum and a group sparsity term that individually penalizes the contribution of IS catheters. Plans generated with the SC+MCO algorithm are compared with plans generated with MCO using clinical catheters (CC+MCO) and the clinical plans (CP). The EMBRACE II soft constraints (planning aims) and hard constraints (limits for prescribed dose) are used as plan evaluation criteria. RESULTS CC+MCO gives the most important gain with an increase up to 20.7% in meeting all EMBRACE II soft constraints compared with CP. The SC+MCO algorithm (adding catheter optimization to MCO) provides a second order increase (up to 12.1% with total acceptance rate of 60.3% or 35/58) in the acceptance rate versus CC+MCO (total increase of 32.8% vs. CP). Acceptance rate in EMBRACE II hard constraints is 98.3% (57/58) for both CC+MCO and SC+MCO versus 91.4% (53/58) for CP. The median SC+MCO optimization time is 11 s to generate a total of 5000 Pareto-optimal plans with different catheter configurations (position and number) for each fraction. CONCLUSIONS Simultaneous catheter and MCO optimization is clinically feasible for HDR cervical cancer brachytherapy using the Venezia applicator. Clinical catheter configurations could be improved and/or the catheter number could be reduced without decreasing plan quality using SC+MCO compared with the CP.
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Affiliation(s)
- Cédric Bélanger
- Département de physique, de génie physique et d'optique et Centre de recherche sur le cancer de l'Université Laval, Québec, Canada
- Service de physique médicale et de radioprotection, Centre intégré de cancérologie, CHU de Québec - Université Laval et Centre de recherche du CHU de Québec, Québec, Canada
| | - Sylviane Aubin
- Service de physique médicale et de radioprotection, Centre intégré de cancérologie, CHU de Québec - Université Laval et Centre de recherche du CHU de Québec, Québec, Canada
| | - Marie-Claude Lavallée
- Service de physique médicale et de radioprotection, Centre intégré de cancérologie, CHU de Québec - Université Laval et Centre de recherche du CHU de Québec, Québec, Canada
| | - Luc Beaulieu
- Département de physique, de génie physique et d'optique et Centre de recherche sur le cancer de l'Université Laval, Québec, Canada
- Service de physique médicale et de radioprotection, Centre intégré de cancérologie, CHU de Québec - Université Laval et Centre de recherche du CHU de Québec, Québec, Canada
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17
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Lin YX, Kong WM. Effects of vaginal dilation therapy on vaginal condition and sexual function of endometrial cancer patients treated with radiotherapy after surgery. J Obstet Gynaecol Res 2024; 50:485-493. [PMID: 38097390 DOI: 10.1111/jog.15857] [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: 08/17/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE This study aimed to evaluate the effect of vaginal dilation therapy on vaginal length, vaginal stenosis, vaginal elasticity, and sexual function of endometrial cancer patients treated with radiotherapy after surgery. METHODS A total of 117 women were enrolled in this study. They received 6 months of vaginal dilation therapy. We evaluated their vaginal length, vaginal diameter, vaginal elasticity, and sexual function before radiotherapy, after radiotherapy, and after 6 months of vaginal dilation therapy. Their vaginal condition was assessed by customized vaginal dilating molds. Their sexual function was assessed by female sexual function index. The SPSS 25 software was used to analyze all the data. RESULTS According to multivariate analysis, vaginal diameter (β = 0.300, 95% CI [0.217-1.446], p = 0.010) and sexual intercourse frequency before diagnosis (β = 0.424, 95% CI [0.164-0.733], p = 0.006) were significantly correlated with female sexual function after radiotherapy. Vaginal dilation therapy helped increase vaginal length, improve vaginal stenosis and sexual function (p < 0.05), though most of the figures at the end of the intervention did not fully return to those before radiotherapy. Noticeably, vaginal dilation therapy was ineffective in improving vaginal elasticity and the incidence rate of female sexual dysfunction (p > 0.05). Moreover, patients with medium or good vaginal elasticity benefited more from vaginal dilation therapy than patients with poor vaginal elasticity (p < 0.05). CONCLUSION Vaginal dilation therapy should be carried out timely and preventatively in endometrial cancer patients treated with radiotherapy after surgery to improve their vaginal condition and sexual function.
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Affiliation(s)
- Yu-Xuan Lin
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Wei-Min Kong
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
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18
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Kong W, Oud M, Habraken SJM, Huiskes M, Astreinidou E, Rasch CRN, Heijmen BJM, Breedveld S. SISS-MCO: large scale sparsity-induced spot selection for fast and fully-automated robust multi-criteria optimisation of proton plans. Phys Med Biol 2024; 69:055035. [PMID: 38224619 DOI: 10.1088/1361-6560/ad1e7a] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/15/2024] [Indexed: 01/17/2024]
Abstract
Objective.Intensity modulated proton therapy (IMPT) is an emerging treatment modality for cancer. However, treatment planning for IMPT is labour-intensive and time-consuming. We have developed a novel approach for multi-criteria optimisation (MCO) of robust IMPT plans (SISS-MCO) that is fully automated and fast, and we compare it for head and neck, cervix, and prostate tumours to a previously published method for automated robust MCO (IPBR-MCO, van de Water 2013).Approach.In both auto-planning approaches, the applied automated MCO of spot weights was performed with wish-list driven prioritised optimisation (Breedveld 2012). In SISS-MCO, spot weight MCO was applied once for every patient after sparsity-induced spot selection (SISS) for pre-selection of the most relevant spots from a large input set of candidate spots. IPBR-MCO had several iterations of spot re-sampling, each followed by MCO of the weights of the current spots.Main results.Compared to the published IPBR-MCO, the novel SISS-MCO resulted in similar or slightly superior plan quality. Optimisation times were reduced by a factor of 6 i.e. from 287 to 47 min. Numbers of spots and energy layers in the final plans were similar.Significance.The novel SISS-MCO automatically generated high-quality robust IMPT plans. Compared to a published algorithm for automated robust IMPT planning, optimisation times were reduced on average by a factor of 6. Moreover, SISS-MCO is a large scale approach; this enables optimisation of more complex wish-lists, and novel research opportunities in proton therapy.
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Affiliation(s)
- W Kong
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - M Oud
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S J M Habraken
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - M Huiskes
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - B J M Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
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Van Anh DT, Thang VH, Dung TA, Huyen TT, Nhan DTT, Van Giang B, Huyen PT. Outcome and toxicity of chemoradiation using volumetric modulated arc therapy followed by 3D image-guided brachytherapy for cervical cancer: Vietnam National Cancer Hospital experience. Rep Pract Oncol Radiother 2024; 28:784-793. [PMID: 38515819 PMCID: PMC10954271 DOI: 10.5603/rpor.98735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/20/2023] [Indexed: 03/23/2024] Open
Abstract
Background Volumetric modulated arc therapy (VMAT) and 3D image-guided brachytherapy (3D-IGBT) have recently been introduced in Vietnam for the treatment of locally advanced cervical cancer. This study aims to assess the outcomes and toxicities of chemoradiation using VMAT followed by 3D-IGBT in Vietnamese cervical cancer patients. Materials and methods A prospective interventional study on 72 patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IB3-IIIC2 disease who underwent concurrent chemoradiation using VMAT, followed by 3D-IGBT according to EMBRACE-II protocol. Primary endpoints were locoregional control; secondary endpoints were systemic control and toxicity. Results Median body volume received 43 Gy was 1589.1 cm3 (range 1214.8-2574.8). Median high-risk clinical target volume (CTV-HR) was 18.8 cm3 (range 8.6-61.2) with a median dose to 90% (D90) of CTV-HR of 90.6 Gy (range 86.8-99.6). Mean doses to 2cc (D2cc) of bladder, rectum, and sigmoid were 75.8, 55.2, and 62.1 Gy, respectively. At median 19-month follow-up (range 12-25), locoregional control and systemic control were 95.8% and 81.9%, respectively. Systemic control was the lowest in N2 disease (54.5%). Grade ≥ 3 acute toxicities were less than 10%, except neutropenia (31.9%). Extended-field radiation increased significantly nausea, fatigue, and thrombocytopenia. No grade ≥ 3 proctitis or cystitis; 8.3% had grade 3 vaginal stenosis. Conclusions VMAT-based chemoradiation therapy followed by 3D-IGBT achieved high locoregional control with manageable toxicities in locally advanced cervical cancer. Systemic control correlated with disease stage.
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Affiliation(s)
- Dang Thi Van Anh
- Hanoi Medical University, Hanoi, Vietnam
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Vu Hong Thang
- Hanoi Medical University, Hanoi, Vietnam
- Department of Medical Oncology 4, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - To Anh Dung
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | | | - Dao Thi Thanh Nhan
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | | | - Phung Thi Huyen
- Department of Medical Oncology 6, Vietnam National Cancer Hospital, Hanoi, Vietnam
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20
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Jamadagni S, Ponni TR A, P R. Dosimetric comparison of intra-cavitary brachytherapy technique with free-hand (intra-cavitary + interstitial) technique in cervical cancer. J Contemp Brachytherapy 2024; 16:28-34. [PMID: 38584889 PMCID: PMC10993890 DOI: 10.5114/jcb.2024.135629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/19/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose The aim of the study was to dosimetrically compare intra-cavitary brachytherapy technique (ICBT) with free-hand (intra-cavitary + interstitial, IC + IS) technique. Material and methods Twenty seven locally advanced carcinoma cervix patients were included in the study. Patients with more than medial 1/3rd parametrial residual disease without extending upto lateral pelvic wall were included, following external beam radiotherapy (EBRT), in which cobalt-60 high-dose-rate (60Co HDR) brachytherapy source was used. Dose for both plans were 6.5 Gy × 4 fractions, 2 fractions per day, 6 hours apart, over 2 days. Free-hand brachytherapy technique, consisted of placement of central tandem and 2 ovoids along with needles without using template, was applied. Two plans were generated by activating and deactivating the needles, and compared by normalizing to V100. Results A total of 79 needles were applied. Using paired-t test, dosimetric comparison of both the plans was done. Free-hand plan had a significant higher mean V90 (volume receiving 90% of the dose) of 94.2% compared with 87.22% in ICBT plan (p ≤ 0.0001). Free-hand and ICBT plans presented a mean V100 values of 89.06% and 81.51% (p ≤ 0.0001), respectively, favoring free-hand plan. The mean D90 (dose to 90% volume), D98, and D100 of free-hand plan were 6.28 Gray (Gy), 4.91 Gy, and 3.62 Gy, respectively, but equivalent parameters in ICBT plan were 5.26 Gy, 3.72 Gy, and 2.61 Gy, with p value ≤ 0.0001. In both the plans, D2cc of the bladder, rectum, and sigmoid were 4.59 Gy, 3.98 Gy, 2.77 Gy, and 4.46 Gy, 3.90 Gy, 2.67 Gy, respectively, with no statistical significance. Conclusions Free-hand brachytherapy (IC + IS) achieves a statistically significant better dose distribution to high-risk clinical target volume (HR-CTV) comparing with ICBT technique with similar dose to organs at risk.
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Affiliation(s)
- Sumukh Jamadagni
- Department of Radiation Oncology, Vijayanagar Institute of Medical Sciences, Bellary, India
| | - Arul Ponni TR
- Department of Radiation Oncology, Ramaiah Medical College and Hospitals, Ramaiah University of Applied Sciences, Bengaluru, India
| | - Revathy P
- Department of Radiation Oncology, Ramaiah Medical College and Hospitals, Ramaiah University of Applied Sciences, Bengaluru, India
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21
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Andersen SN, Bonnen MD, Ludwig MS, Dalwadi SM. Quality Assurance for Stereotactic Body Radiation Therapy for Gynecologic Malignancies. Cureus 2024; 16:e53470. [PMID: 38435154 PMCID: PMC10909451 DOI: 10.7759/cureus.53470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
The use of stereotactic body radiation therapy (SBRT) is not well studied or reported in the treatment of gynecologic malignancies, despite its success in the definitive management of other cancer sites. This report describes a rigorous quality assurance process for patients to undergo dose escalation to the pelvis via stereotactic photon beam irradiation. Patients who receive SBRT must be ineligible for conventional brachytherapy boost and undergo comprehensive informed consent. Fiducial placement, bowel prep, Foley catheter placement with standardized bladder filling, computerized tomography (CT) simulation with whole-body immobilization, magnetic resonance imaging (MRI)-assisted target delineation, planning aims based on the established brachytherapy literature, and physics consultation for SBRT plan optimization are necessary. Prior to each fraction, the simulation position is reproduced and verified with on-table cone beam CT, and the position is maintained with whole-body immobilization. Following treatment, the treating physician is active in survivorship and toxicity management. Gynecologic SBRT is an ongoing area of study, and preliminary successes in delivering high-quality stereotactic dose escalation suggest prospective investigation is warranted. By adhering to strict quality control measures and following a pre-defined best standard of practice, patients with gynecologic malignancies who are ineligible for traditional brachytherapy procedures can be safely treated with SBRT.
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Affiliation(s)
- Samuel N Andersen
- Radiation Oncology, University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, USA
| | - Mark D Bonnen
- Radiation Oncology, University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, USA
| | | | - Shraddha M Dalwadi
- Radiation Oncology, University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, USA
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22
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Lee SW, Kim A, Lee SJ, Kim SH, Lee JH. Intensity-Modulated Radiation Therapy for Uterine Cervical Cancer to Reduce Toxicity and Enhance Efficacy - an Option or a Must?: A Narrative Review. Cancer Res Treat 2024; 56:1-17. [PMID: 37654111 PMCID: PMC10789959 DOI: 10.4143/crt.2023.562] [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: 04/10/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023] Open
Abstract
Radiotherapy (RT) is a fundamental modality in treatment of cervical cancer. With advancement of technology, conventional RT used for external beam radiotherapy (EBRT) for over half a century has been rapidly replaced with intensity-modulated radiation therapy (IMRT) especially during the last decade. This newer technique is able to differentiate the intensity of radiation within the same field, thus reduces the inevitable exposure of radiation to normal organs and enables better dose delivery to tumors. Recently, the American Society for Radiation Oncology has released a guideline for RT in cervical cancer. Although a section of the guideline recommends IMRT for the purpose of toxicity reduction, a thorough review of the literature is necessary to understand the current status of IMRT in cervical cancer. This narrative review updates the recent high-level evidences regarding the efficacy and toxicity of IMRT and provides a better understanding of the most innovative techniques currently available for EBRT enabled by IMRT.
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Affiliation(s)
- Sea-Won Lee
- Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Aeran Kim
- Department of Biomedicine & Health Sciences, The Catholic University of Korea, Seoul, Korea
| | - Sung Jong Lee
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Wang E, Yen A, Hrycushko B, Wang S, Lin J, Zhong X, Dohopolski M, Nwachukwu C, Iqbal Z, Albuquerque K. The accuracy of artificial intelligence deformed nodal structures in cervical online cone-beam-based adaptive radiotherapy. Phys Imaging Radiat Oncol 2024; 29:100546. [PMID: 38369990 PMCID: PMC10869256 DOI: 10.1016/j.phro.2024.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Background and Purpose Online cone-beam-based adaptive radiotherapy (ART) adjusts for anatomical changes during external beam radiotherapy. However, limited cone-beam image quality complicates nodal contouring. Despite this challenge, artificial-intelligence guided deformation (AID) can auto-generate nodal contours. Our study investigated the optimal use of such contours in cervical online cone-beam-based ART. Materials and Methods From 136 adaptive fractions across 21 cervical cancer patients with nodal disease, we extracted 649 clinically-delivered and AID clinical target volume (CTV) lymph node boost structures. We assessed geometric alignment between AID and clinical CTVs via dice similarity coefficient, and 95% Hausdorff distance, and geometric coverage of clinical CTVs by AID planning target volumes by false positive dice. Coverage of clinical CTVs by AID contour-based plans was evaluated using D100, D95, V100%, and V95%. Results Between AID and clinical CTVs, the median dice similarity coefficient was 0.66 and the median 95 % Hausdorff distance was 4.0 mm. The median false positive dice of clinical CTV coverage by AID planning target volumes was 0. The median D100 was 1.00, the median D95 was 1.01, the median V100% was 1.00, and the median V95% was 1.00. Increased nodal volume, fraction number, and daily adaptation were associated with reduced clinical CTV coverage by AID-based plans. Conclusion In one of the first reports on pelvic nodal ART, AID-based plans could adequately cover nodal targets. However, physician review is required due to performance variation. Greater attention is needed for larger, daily-adapted nodes further into treatment.
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Affiliation(s)
- Ethan Wang
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Allen Yen
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Brian Hrycushko
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Siqiu Wang
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Jingyin Lin
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Xinran Zhong
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Michael Dohopolski
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Chika Nwachukwu
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Zohaib Iqbal
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Kevin Albuquerque
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
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Zhang W, Yu H, Xiu Y, Meng F, Wang Z, Zhao K, Wang Y, Chen Z, Liu J, Chen J, Sun B. Clinical Outcomes and Prognostic Factors in Stage III C Cervical Cancer Patients Treated with Radical Radiotherapy or Radiochemotherapy. Technol Cancer Res Treat 2024; 23:15330338241254075. [PMID: 38720626 PMCID: PMC11085003 DOI: 10.1177/15330338241254075] [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: 10/23/2022] [Revised: 05/02/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
Objective: Since the update of the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging criteria, there have been few reports on the prognosis of stage III C cervical cancer. Moreover, some studies have drawn controversial conclusions, necessitating further verification. This study aims to evaluate the clinical outcomes and determine the prognostic factors for stage III C cervical cancer patients treated with radical radiotherapy or radiochemotherapy. Methods: The data of 117 stage III C cervical cancer patients (98 III C1 and 19 III C2) who underwent radical radiotherapy or radiochemotherapy were retrospectively analyzed. We evaluated 3-year overall survival (OS) and disease-free survival (DFS) using the Kaplan-Meier method. Prognostic factors were analyzed using the Log-rank test and Cox proportional hazard regression model. The risk of para-aortic lymph node metastasis (LNM) in all patients was assessed through Chi-squared test and logistic regression analysis. Results: For stage III C1 and III C2 patients, the 3-year OS rates were 77.6% and 63.2% (P = .042), and the 3-year DFS rates were 70.4% and 47.4% (P = .003), respectively. The pretreatment location of pelvic LNM, histological type, and FIGO stage was associated with OS (P = .033, .003, .042, respectively); the number of pelvic LNM and FIGO stage were associated with DFS (P = .015, .003, respectively). The histological type was an independent prognostic indicator for OS, and the numbers of pelvic LNM and FIGO stage were independent prognostic indicators for DFS. Furthermore, a pelvic LNM largest short-axis diameter ≥ 1.5 cm and the presence of common iliac LNM were identified as high-risk factors influencing para-aortic LNM in stage III C patients (P = .046, .006, respectively). Conclusions: The results of this study validated the 2018 FIGO staging criteria for stage III C cervical cancer patients undergoing concurrent chemoradiotherapy. These findings may enhance our understanding of the updated staging criteria and contribute to better management of patients in stage III C.
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Affiliation(s)
- Wenting Zhang
- School of Clinical Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Hong Yu
- Jilin Province Institute of Cancer Prevention and Treatment, Jilin Province Cancer Hospital, Changchun, China
| | - Yuting Xiu
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Fanxu Meng
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Zhuo Wang
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Kangkang Zhao
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Yunlong Wang
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Zhishen Chen
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
| | - Juntian Liu
- School of Clinical Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Jie Chen
- School of Clinical Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Baosheng Sun
- Department of Radiotherapy, Jilin Province Cancer Hospital, Changchun, China
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Nakashima T, Matsumoto K, Yoshitake T, Wakiyama H, Hisano O, Uehara R, Takaki M, Oshima T, Yahata H, Ishigami K. Transvaginal approach combined intracavitary and interstitial brachytherapy assisted by transrectal ultrasound: results from 30 patients with locally advanced cervical cancer. Jpn J Radiol 2024; 42:96-101. [PMID: 37587315 PMCID: PMC10764555 DOI: 10.1007/s11604-023-01481-4] [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: 05/16/2023] [Accepted: 08/05/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE This study evaluated the efficacy and safety of transvaginal approach combined intracavitary and interstitial brachytherapy (IC/IS BT) assisted by transrectal ultrasound (TRUS) for treatment of locally advanced cervical cancer (LACC). MATERIALS AND METHODS A total of 30 patients of LACC treated with external beam radiotherapy and IC/IS BT via transvaginal approach assisted by transrectal ultrasound were observed retrospectively. The 2-year local control (LC), progression-free survival (PFS), and overall survival (OS) were analyzed using the Kaplan-Meier method. Late adverse events were also evaluated to assess the safety of IC/IS BT. RESULTS The median follow-up period was 22 months. The 2-year LC, PFS, and OS were 90%, 61%, and 82%, respectively. We observed no critical complications related to the IC/IS BT technique. Late adverse events of grade 3 or more included one case of grade 4 colon perforation. CONCLUSION Our patient series demonstrated that radiotherapy combined with transvaginal approach, TRUS-assisted IC/IS BT achieves favorable local control and safety for LACC.
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Affiliation(s)
- Takaaki Nakashima
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keiji Matsumoto
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tadamasa Yoshitake
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Hiroaki Wakiyama
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Osamu Hisano
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Ryuji Uehara
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Masanori Takaki
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takeshi Oshima
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hideaki Yahata
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Wang L, McQuaid D, Blackledge M, McNair H, Harris E, Lalondrelle S. Predicting cervical cancer target motion using a multivariate regression model to enable patient selection for adaptive external beam radiotherapy. Phys Imaging Radiat Oncol 2024; 29:100554. [PMID: 38419803 PMCID: PMC10901141 DOI: 10.1016/j.phro.2024.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
Background and purpose Interfraction motion during cervical cancer radiotherapy is substantial in some patients, minimal in others. Non-adaptive plans may miss the target and/or unnecessarily irradiate normal tissue. Adaptive radiotherapy leads to superior dose-volume metrics but is resource-intensive. The aim of this study was to predict target motion, enabling patient selection and efficient resource allocation. Materials and methods Forty cervical cancer patients had CT with full-bladder (CT-FB) and empty-bladder (CT-EB) at planning, and daily cone-beam CTs (CBCTs). The low-risk clinical target volume (CTVLR) was contoured. Mean coverage of the daily CTVLR by the CT-FB CTVLR was calculated for each patient. Eighty-three investigated variables included measures of organ geometry, patient, tumour and treatment characteristics. Models were trained on 29 patients (171 fractions). The Two-CT multivariate model could use all available data. The Single-CT multivariate model excluded data from the CT-EB. A univariate model was trained using the distance moved by the uterine fundus tip between CTs, the only method of patient selection found in published cervix plan-of-the-day studies. Models were tested on 11 patients (68 fractions). Accuracy in predicting mean coverage was reported as mean absolute error (MAE), mean squared error (MSE) and R2. Results The Two-CT model was based upon rectal volume, dice similarity coefficient between CT-FB and CT-EB CTVLR, and uterine thickness. The Single-CT model was based upon rectal volume, uterine thickness and tumour size. Both performed better than the univariate model in predicting mean coverage (MAE 7 %, 7 % and 8 %; MSE 82 %2, 65 %2, 110 %2; R2 0.2, 0.4, -0.1). Conclusion Uterocervix motion is complex and multifactorial. We present two multivariate models which predicted motion with reasonable accuracy using pre-treatment information, and outperformed the only published method.
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Affiliation(s)
- Lei Wang
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Dualta McQuaid
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Matthew Blackledge
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Helen McNair
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Emma Harris
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Susan Lalondrelle
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
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Reijtenbagh D, Godart J, Penninkhof J, Quint S, Zolnay A, Mens JW, Hoogeman M. Nine years of plan of the day for cervical cancer: Plan library remains effective compared to fully online-adaptive techniques. Radiother Oncol 2024; 190:110009. [PMID: 37972735 DOI: 10.1016/j.radonc.2023.110009] [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: 08/03/2023] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND PURPOSE Since 2011, our center has been using a library-based Plan-of-the-Day (PotD) strategy for external beam radiotherapy of cervical cancer patients to reduce normal tissue dose while maintaining adequate target coverage. With the advent of fully online-adaptive techniques such as daily online-adaptive replanning, further dose reduction may be possible. However, it is unknown how this reduction relates to plan library approaches, and how the most recent PotD strategies relate to no adaptation. In this study we compare the performance of our current PotD strategy with non-adaptive and fully online-adaptive techniques in terms of target volume size and normal tissue sparing. MATERIALS AND METHODS Treatment data of 376 patients treated with the PotD protocol between June 2011 and April 2020 were included. The size of the Planning Target Volumes (PTVs) was reconstructed for different strategies: full online adaptation, no adaptation, and the latest clinical version of the PotD protocol. Normal tissue sparing was estimated by the difference in margin volume to construct the PTV and the volume overlap of the PTV with bladder and rectum. RESULTS The current version of our PotD approach reduced the PTV margin volume by a median of 250 cm3 compared to no adaptation. Bladder-PTV overlap decreased from a median of 142 to 71 cm3, and from 39 to 16 cm3 for rectum-PTV. Fully online-adaptive approaches could further decrease the PTV volume by 144 cm3 using a 5 mm margin for residual errors. In this scenario, bladder-PTV overlap was reduced to 35 cm3 and rectum-PTV overlap to 11 cm3. CONCLUSION The current version of the PotD protocol is an effective technique to improve normal tissue sparing compared to no adaptation. Further sparing can be achieved using fully online-adaptive techniques, but at the cost of a more complex workflow and with a potentially limited impact. PotD-type protocols can therefore be considered as a suitable alternative to fully online-adaptive approaches.
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Affiliation(s)
- Dominique Reijtenbagh
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Jérémy Godart
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Joan Penninkhof
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sandra Quint
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - András Zolnay
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jan-Willem Mens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mischa Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
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Decabooter E, Hilgers GC, De Rouck J, Salvo K, Van Wingerden J, Bosmans H, van der Heyden B, Qamhiyeh S, Papalazarou C, Kaatee R, Pittomvils G, Bogaert E. Survey on fan-beam computed tomography for radiotherapy: Imaging for dose calculation and delineation. Phys Imaging Radiat Oncol 2024; 29:100522. [PMID: 38152701 PMCID: PMC10750173 DOI: 10.1016/j.phro.2023.100522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Abstract
Background and purpose To obtain an understanding of current practice, professional needs and future directions in the field of fan-beam CT in RT, a survey was conducted. This work presents the collected information regarding the use of CT imaging for dose calculation and structure delineation. Materials and methods An online institutional survey was distributed to medical physics experts employed at Belgian and Dutch radiotherapy institutions to assess the status, challenges, and future directions of QA practices for fan-beam CT. A maximum of 143 questions covered topics such as CT scanner availability, CT scanner specifications, QA protocols, treatment simulation workflow, and radiotherapy dose calculation. Answer forms were collected between 1-Sep-2022 and 10-Oct-2022. Results A 66 % response rate was achieved, yielding data on a total of 58 CT scanners. For MV photon therapy, all single-energy CT scans are reconstructed in Hounsfield Units for delineation or dose calculation, and a direct- or stoichiometric method was used to convert CT numbers for dose calculation. Limited use of dual-energy CT is reported for photon (N = 3) and proton dose calculations (N = 1). For brachytherapy, most institutions adopt water-based dose calculation, while approximately 26 % of the institutions take tissue heterogeneity into account. Commissioning and regular QA include eleven tasks, which are performed by two or more professions (29/31) with varying frequencies. Conclusions Dual usage of a planning CT limits protocol optimization for both tissue characterization and delineation. DECT has been implemented only gradually. A variation of QA testing frequencies and tests are reported.
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Affiliation(s)
- Esther Decabooter
- Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Joke De Rouck
- Department of Radiotherapy, AZ Sint Lucas, Ghent, Belgium
| | - Koen Salvo
- Department of Radiotherapy, AZ Sint-Maarten, Mechelen, Belgium
| | - Jacobus Van Wingerden
- Department of Medical Physics, Haaglanden Medical Centre, Leidschendam, The Netherlands
| | - Hilde Bosmans
- Department of Medical Radiation Physics, University Hospital Leuven, Belgium
| | - Brent van der Heyden
- IBiTech-MEDISIP, Department of Electronics and Information Systems, Ghent University, Ghent, Belgium
- Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sima Qamhiyeh
- University Hospitals Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - Chrysi Papalazarou
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert Kaatee
- Radiotherapy Institute Friesland, Leeuwarden, The Netherlands
| | - Geert Pittomvils
- Department of Radiation-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Evelien Bogaert
- Department of Radiation-Oncology, Ghent University Hospital, Ghent, Belgium
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Kamio Y, Roy MÈ, Morgan LA, Barkati M, Beauchemin MC, DeBlois F, Basaric B, Carrier JF, Bedwani S. The Montreal split ring applicator: Towards highly adaptive gynecological brachytherapy using 3D-printed biocompatible patient-specific interstitial caps. J Contemp Brachytherapy 2023; 15:453-464. [PMID: 38230395 PMCID: PMC10789156 DOI: 10.5114/jcb.2023.133676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose The addition of interstitial (IS) needles to intra-cavitary (IC) brachytherapy applicators is associated with improved outcomes in locally advanced cervical cancers involving parametrial tumor extensions. The purpose of this work was to validate a clinical workflow involving 3D-printed caps for a commercial IC split ring applicator that enable using IS needle trajectories tailored to each treatment. Material and methods A dedicated software module was developed in this work allowing users to design patient-specific IS caps without knowledge of computer-aided design (CAD) software. This software module was integrated to 3D Brachy, a commercial software developed by Adaptiiv Medical Technologies Inc. For validation of the workflow, CAD models of ground truth caps with five IS needle trajectories were designed with Fusion 360™, 3D-printed, assembled with a split ring applicator, and CT-scanned with radio-opaque markers. 3D Brachy was then applied to generate a replica based on trajectories reconstructed from the radio-opaque markers. A comparison between ground truth and replicated IS needle trajectories was done using intersection points with planes at the level of the cervix (z = 0 cm) and a representative needle depth (z = 3 cm). Results Prototypes of interstitial caps 3D-printed in both BioMed Amber and BioMed Clear SLA resins were tested to be functional both pre- and post-sterilization for IS needles with obliquity angles ≤ 45°. Distance-to-agreement at z = 0 cm and 3 cm as well as deviations in pitch and yaw angles of the five IS needle trajectories were found to have mean values of 3.3 ±2.1 mm, 7.3 ±2.0 mm, 2.9° ±2.3°, and 7.0° ±7.0°, respectively. Conclusions The clinical workflow for image-guided adaptive cervical cancer brachytherapy using the Montreal split ring applicator was validated.
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Affiliation(s)
- Yuji Kamio
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Pharmacologie et Physiologie, Université de Montréal, Montréal, QC, Canada
| | - Marie-Ève Roy
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | | | - Maroie Barkati
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | | | - François DeBlois
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
| | - Borko Basaric
- Adaptiiv Medical Technologies Inc., Halifax, NS, Canada
| | - Jean-François Carrier
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
| | - Stéphane Bedwani
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
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Tu Y, Wang J, Chen Y, Chen Y, Tang Q. Clinical implementation of three-dimensional standardized template-guided brachytherapy for patients with locally advanced cervical cancer. J Contemp Brachytherapy 2023; 15:405-413. [PMID: 38230396 PMCID: PMC10789161 DOI: 10.5114/jcb.2023.134170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose Although customized three-dimensional (3D) templates have shown advantages in brachytherapy, widespread application is still full of challenges. The present work proposed the use of a commercial 3D standardized template-guided intracavitary/interstitial brachytherapy (IC/ISBT) that could provide simple and reproducible needles' insertion. Material and methods 43 patients received external beam radiotherapy (EBRT) with 45-50.4 Gy and subsequent IC/ISBT with 28 Gy in 4 fractions. In terms of IC/ISBT, 24 patients were treated with 3D standardized templates (ST group), and 19 patients were treated using free-hand implantation (FH group). Consistency of implantation for all needles and dosimetric differences for target and organs at risk (OARs) were then compared between two groups. Results The mean variation of tip position between insertions for needles was 1.41 mm and 2.74 mm in ST group and FH group, respectively (p < 0.001). ST group was superior in terms of dosimetric conformity index (CI) and D90 for high-risk clinical target volume (HR-CTV), significantly improving to 23.21% (p < 0.001) and 3.58% (p = 0.031) compared with FH group. The D2cc of the bladder and sigmoid in the ST group were lower than those in the FH group (p < 0.05). Meanwhile, a strong correlation between the volume of HR-CTV and its CI in the ST group (R = 0.865, p < 0.001) was found with Spearman's correlation analysis. Conclusions The implementation of 3D standardized template can potentially improve the precision and consistency in the needle insertion procedure that may replace some customized 3D templates, and achieve clinical satisfied dose distribution in IC/ISBT plans for patients with LACC.
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Affiliation(s)
- Yeqiang Tu
- Department of Radiation Oncology, Women’s Hospital School of Medicine Zhejiang University, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, China
| | - Jiahao Wang
- Department of Radiation Oncology, Women’s Hospital School of Medicine Zhejiang University, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, China
| | - Yukai Chen
- Department of Radiation Oncology, Women’s Hospital School of Medicine Zhejiang University, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, China
| | - Yuanyuan Chen
- Department of Radiation Oncology, Women’s Hospital School of Medicine Zhejiang University, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, China
| | - Qiu Tang
- Department of Radiation Oncology, Women’s Hospital School of Medicine Zhejiang University, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, China
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31
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Mao Z, Zhao H. 3D-printed vaginal cylindrical template with curved needle channels in MRI-guided vaginal cuff brachytherapy. J Contemp Brachytherapy 2023; 15:422-431. [PMID: 38230399 PMCID: PMC10789162 DOI: 10.5114/jcb.2023.133227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/21/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose To present a new technique for the treatment of vaginal cuff recurrences using 3D-printed vaginal cylindrical template (3D-PVCT) with curved needle channels in brachytherapy. Material and methods Two patients with vaginal cuff tumor treated with external beam radiotherapy and MRI-guided interstitial brachytherapy were selected for the present study. Prior to treatment, a vaginal cylinder with the same size as 3D-PVCT was inserted into the vagina. Magnetic resonance scan was performed to identify target volumes and organs at risk (OARs). By registration techniques, the implantation angle was determined, appropriate needle channels were selected, and the depth of each needle position was recorded. During the actual treatment, patients were under general anesthesia, and real-time guidance of trans-rectal ultrasound was applied referring to a pre-determined treatment plan. Results For patient No. 1, 9 needles were inserted into the tumor, with 4 curved needle channels and 5 straight channels. For patient No. 2, 7 needles were inserted into the vaginal cuff tumor, with 6 curved needle channels and 1 straight channel. Doses delivered to volumes of targets and OARs for both patients met the EMBRACE II dose constraints. After follow-up of 15 and 18 months, respectively, both patients showed complete response, with no evidence of tumor recurrence. No significant acute or late toxicities were reported. Conclusions With careful pre-planning, 3D-PVCT provides good target coverage and sparing of OARs. The results from these two patients indicate that this approach is very promising due to its flexibility and potential widespread application in the future.
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Affiliation(s)
- Zhuang Mao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun City, PR China
| | - Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun City, PR China
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Toft Morén A, Bull C, Bergmark K. Remarkable effects of infliximab on severe radiation-induced side effects in a patient with uterine cervical cancer: a case report. J Int Med Res 2023; 51:3000605231208596. [PMID: 38082467 PMCID: PMC10718054 DOI: 10.1177/03000605231208596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/29/2023] [Indexed: 12/18/2023] Open
Abstract
Pelvic radiotherapy is a powerful treatment for a broad range of cancers, including gynecological, prostate, rectal, and anal cancers. Despite improvements in the delivery of ionizing beams, damage to non-cancerous tissue can cause long-term effects that are potentially severe, affecting quality of life and daily function. There is an urgent need for new strategies to treat and reverse the side effects of pelvic radiotherapy without compromising the antitumor effect. A woman with severe radiation-induced intestinal side effects was treated with the tumor necrosis factor-alpha inhibitor infliximab with a dose of 3 mg/kg every 4 to 6 weeks. With infliximab treatment, a remarkable improvement in her bowel health was observed. The patient's late bowel toxicity was reduced from Grade 2 to Grade 0 (RTOG/EORTC Late Radiation Morbidity Scale). Although it is necessary to proceed cautiously because of the risk of serious side effects from immunosuppressants, our case suggests that infliximab can be used to treat symptoms of chronic bowel dysfunction after radiotherapy.
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Affiliation(s)
- Amelie Toft Morén
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Cecilia Bull
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Karin Bergmark
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
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Funderud M, Hoem IS, Guleng MAD, Eidem M, Almberg SS, Alsaker MD, Ståhl-Kornerup J, Frengen J, Marthinsen ABL. Script-based automatic radiotherapy planning for cervical cancer. Acta Oncol 2023; 62:1798-1807. [PMID: 37881003 DOI: 10.1080/0284186x.2023.2267171] [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] [Accepted: 10/01/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND This study aimed to develop fully automated script-based radiotherapy treatment plans for cervical cancer patients, and evaluate them against clinically accepted plans, as validation before clinical implementation. MATERIAL AND METHODS In this retrospective planning study, treatment plans for 25 locally advanced cervical cancer (LACC) patients with up to three dose levels were included. Fully automated plans were created using an in-house developed Python script in RayStation, and compared to clinically accepted manually made plans. Quantitatively, relevant dose statistics were compared, and average dose volume histograms (DVHs) were analyzed. Qualitatively, a blinded plan comparison was conducted between the clinical and automatic plans. The accuracy of treatment plan delivery was verified with the Delta4 Phantom+. RESULTS The quantitative evaluation showed that target coverage was acceptable for all the automatic and clinical plans. The automatic plans were significantly more conformal than the clinical plans; median of 1.03 vs. 1.12. Mean doses to almost all organs at risk (OARs) were reduced in the automatic plans, with a median reduction of between 0.6 Gy and 1.9 Gy. In the blinded plan comparison, the automatic plans were the preferred plans or of equal quality as the clinical plans in 99% of the cases. In addition, plan delivery was excellent, with a mean gamma passing rate of 99.8%. Complete script-based plans were generated in 30-45 min; about four to ten times faster than manually made plans. CONCLUSION The automatic plans had acceptable target coverage, lower doses to almost all OARs, more conformal dose distributions, and were predominantly preferred by the clinicians. Based on these results, our institution has implemented the script for clinical use.
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Affiliation(s)
- Marit Funderud
- Department of Radiotherapy, St. Olavs Hospital, Trondheim, Norway
| | - Ingvild Straumsheim Hoem
- Department of Radiotherapy, St. Olavs Hospital, Trondheim, Norway
- Department of Physics, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | | | - Monika Eidem
- Department of Radiotherapy, St. Olavs Hospital, Trondheim, Norway
| | | | | | | | - Jomar Frengen
- Department of Radiotherapy, St. Olavs Hospital, Trondheim, Norway
| | - Anne Beate Langeland Marthinsen
- Department of Radiotherapy, St. Olavs Hospital, Trondheim, Norway
- Department of Physics, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Cobussen A, Petric P, Wulff CN, Buus S, Spejlborg H, Nielsen SK, Traberg A, Meisner B, Hokland S, Lindegaard JC. Clinical outcomes using a 3D printed tandem-needle-template and the EMBRACE-II planning aims for image guided adaptive brachytherapy in locally advanced cervical cancer. Acta Oncol 2023; 62:1470-1478. [PMID: 37594195 DOI: 10.1080/0284186x.2023.2246642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Extensive local disease or narrow vagina may compromise brachytherapy (BT) in patients with cervical cancer. This is the first study to analyze long-term outcomes of using 3D printed vaginal tandem-needle templates (3DP TNT) for transvaginal insertion of needles in parallel (P) or parallel and oblique (P&O) direction to the tandem. MATERIAL AND METHODS All patients treated with BT using 3DP TNT from 2015-2020 were included. Decision to use a 3DP TNT and preplanning were made after 4-5 weeks of external beam radiotherapy, based on gynecological examination and MRI with a tandem-ring applicator in situ. The TNT was 3D-printed in house consisting of a circular template with P&O holes for guidance of plastic needles and a shaft fitting the uterine tandem. Thus, the radioactive source was never in direct contact with the 3DP TNT. The TNT was 3D printed in a standard or personalized configuration. Planning aims were based on the Embrace II protocol. RESULTS 101 patients (median age of 63 years) were included: 49 with P needles only and 52 with P&O needles. Personalized TNT was used in 19 patients in the P&O group. Performance status (WHO) was > 0 in 48%. FIGO2018 stage III-IV was present in 77%. T-score at diagnosis and BT was 9.1 and 6.3 respectively, with a significantly higher T-score in the P&O compared to P group. The mean high-risk CTV D90 was 93 Gy with no significant difference between the two groups. Three-year local control rates were 85%, 95%, 75% for the overall, P- and P&O group respectively and 68%, 80% and 56% for cancer specific survival. Grade ≥3 treatment related complications were observed in 10 (10%) patients. CONCLUSIONS 3DP TNT for BT in cervical cancer provides successful management of very extensive local disease and/or unfavorable anatomy with the possibility for treatment individualization.
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Affiliation(s)
- Anne Cobussen
- Department of Oncology, Aarhus University Hospital, Denmark
- Department of Radiation Oncology, MAASTRO clinic, the Netherlands
| | - Primoz Petric
- Department of Oncology, Aarhus University Hospital, Denmark
- Department of Radiation Oncology, Zürich University Hospital, Switzerland
| | | | - Simon Buus
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | - Anders Traberg
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Bjarne Meisner
- Department of Oncology, Aarhus University Hospital, Denmark
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de Hond YJM, van Haaren PMA, Verrijssen AE, Tijssen RHN, Hurkmans CW. Inter-observer variability in library plan selection on iterative CBCT and synthetic CT images of cervical cancer patients. J Appl Clin Med Phys 2023; 24:e14170. [PMID: 37788333 PMCID: PMC10647946 DOI: 10.1002/acm2.14170] [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: 05/25/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION In the Library-of-Plans (LoP) approach, correct plan selection is essential for delivering radiotherapy treatment accurately. However, poor image quality of the cone-beam computed tomography (CBCT) may introduce inter-observer variability and thereby hamper accurate plan selection. In this study, we investigated whether new techniques to improve the CBCT image quality and improve consistency in plan selection, affects the accuracy of LoP selection in cervical cancer patients. MATERIALS AND METHODS CBCT images of 12 patients were used to investigate the inter-observer variability of plan selection based on different CBCT image types. Six observers were asked to individually select a plan based on clinical X-ray Volumetric Imaging (XVI) CBCT, iterative reconstructed CBCT (iCBCT) and synthetic CTs (sCT). Selections were performed before and after a consensus meeting with the entire group, in which guidelines were created. A scoring by all observers on the image quality and plan selection procedure was also included. For plan selection, Fleiss' kappa (κ) statistical test was used to determine the inter-observer variability within one image type. RESULTS The agreement between observers was significantly higher on sCT compared to CBCT. The consensus meeting improved the duration and inter-observer variability. In this manuscript, the guidelines attributed the overall results in the plan selection. Before the meeting, the gold standard was selected in 76% of the cases on XVI CBCT, 74% on iCBCT, and 76% on sCT. After the meeting, the gold standard was selected in 83% of the cases on XVI CBCT, 81% on iCBCT, and 90% on sCT. CONCLUSION The use of sCTs can increase the agreement of plan selection among observers and the gold standard was indicated to be selected more often. It is important that clear guidelines for plan selection are implemented in order to benefit from the increased image quality, accurate selection, and decrease inter-observer variability.
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Affiliation(s)
- Yvonne J. M. de Hond
- Department of Radiation OncologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | | | | | - Rob H. N. Tijssen
- Department of Radiation OncologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Coen W. Hurkmans
- Department of Radiation OncologyCatharina Hospital EindhovenEindhovenThe Netherlands
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Lee J, Lin JB, Weng CS, Chen SJ, Chen TC, Chen YJ. Impact of reduced margin pelvic radiotherapy on gastrointestinal toxicity and outcome in gynecological cancer. Clin Transl Radiat Oncol 2023; 43:100671. [PMID: 37692995 PMCID: PMC10482739 DOI: 10.1016/j.ctro.2023.100671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/09/2023] [Accepted: 08/27/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose To investigate the effect of reduced margin pelvic radiotherapy on gastrointestinal toxicity and outcomes in gynecological cancer. Materials and methods This retrospective study analyzed data of 590 patients who underwent hysterectomy and adjuvant pelvic radiotherapy between 2010 and 2020 at two tertiary centers. The pelvic nodal region was delineated based on a reduced margin definition or the Radiation Therapy Oncology Group (RTOG) guidelines. All patients were treated with intensity-modulated radiotherapy with imaging guidance. Gastrointestinal toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) and the Patient-Reported Outcome version (PRO-CTCAE). Results Overall, 352 (59.7%) and 238 (40.3%) patients underwent RTOG and reduced margin pelvic radiotherapy, respectively. Median follow-up was 6.4 years (IQR: 3.7-9.6). Reduced margin pelvic radiotherapy significantly lowered the radiation dose to the small bowel. For CTCAE grade ≥ 2 or 3, acute gastrointestinal toxicity was lower in the reduced margin group than in the RTOG group (16.4% vs. 33.5%, p < 0.001; 2.9% vs. 8.5%, p < 0.001). The reduced margin group reported less severe acute gastrointestinal toxicity (PRO-CTCAE score ≥ 3) than the RTOG group (12.5% vs. 28.7%, p < 0.001). Late grade 3 gastrointestinal toxicity was lower in the reduced margin group than in the RTOG group (0.8% vs. 4.8%, p = 0.006). The 5-year pelvic recurrence-free survival and disease-free survival in the RTOG and reduced margin pelvic radiotherapy groups were 97.4% and 97.9% (p = 0.55) and 80.7% and 83.5% (p = 0.18), respectively. Conclusion Reduced margin pelvic radiotherapy decreased acute and late gastrointestinal toxicity and achieved favorable outcomes.
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Affiliation(s)
- Jie Lee
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Sui Weng
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Sue-Jar Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Tze-Chien Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
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Mishra VK, Rastogi M, Gandhi AK, Khurana R, Hadi R, Sapru S, Mishra SP, Srivastava AK, Singh N. Combination of image-guided IMRT and IGBT in locally advanced carcinoma cervix: Prospective evaluation of toxicities and clinical outcomes from a tertiary cancer center in India. J Contemp Brachytherapy 2023; 15:308-316. [PMID: 38026079 PMCID: PMC10669915 DOI: 10.5114/jcb.2023.132553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose We aimed to assess the toxicity profile and clinical outcome in patients with locally advanced cervical cancer (LACC) treated with a combination of image-guided intensity-modulated radiation therapy (IG-IMRT) and image-guided brachytherapy (IGBT). Material and methods 25 LACC patients were recruited in this single-arm prospective study. Whole pelvis IG-IMRT was delivered (45 Gy with simultaneously integrated nodal boost of 55 Gy in 25 fractions), with concurrent weekly cisplatin (40 mg/m2). Patients received IGBT of 7 Gy each in 4 fractions to high-risk clinical target volume (HR-CTV). First fraction was done under MRI, and subsequent fractions were performed under CT guidance. Primary endpoint was acute toxicity, and secondary endpoints were 2-year loco-regional control and late toxicity. Results The median age was 52 years, and FIGO 2018 stage distribution was IIA2, IIB, IIIB, and IIIC1 in 12%, 40%, 20%, and 28% patients, respectively. All patients received concurrent chemotherapy with median number of 5 cycles (range, 4-5 cycles). Grade 1 and 2 diarrhea, and grade 1 cystitis was reported in 4 (16%), 3 (12%), and 2 (8%) patients, respectively. Grade 1 and 2 anemia, and grade 1 and 2 dermatitis were observed in 3 (12%) and 2 (8%), and 3 (12%) and 3 (12%) patients, respectively. No patient reported grade 3-4 acute toxicity. At median follow-up of 29.5 months (range, 25-37 months), late grade 1 bladder toxicity was observed in 1 (4%) patient. Loco-regional control at 1 and 2 years were 96% and 92%, respectively. Conclusions The combination of IG-IMRT and IGBT yielded excellent outcomes in terms of acute toxicity and loco-regional control.
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Affiliation(s)
- Vachaspati Kumar Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Madhup Rastogi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Ajeet Kumar Gandhi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rohini Khurana
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rahat Hadi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Shantanu Sapru
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Surendra Prasad Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Anoop Kumar Srivastava
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Neetu Singh
- Department of Obstetrics and Gynecology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
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Hopfensperger KM, Adams QE, Kim Y, Wu X, Xu W, Patwardhan K, Flynn RT. The population percentile allowance method for determining systematic spatial error tolerances for temporary intensity modulated brachytherapy. Med Phys 2023; 50:6469-6478. [PMID: 37643427 PMCID: PMC10592112 DOI: 10.1002/mp.16668] [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: 10/25/2022] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Multiple approaches are under development for delivering temporary intensity modulated brachytherapy (IMBT) using partially shielded applicators wherein the delivered dose distributions are sensitive to spatial uncertainties in both the applicator position and shield orientation, rather than only applicator position as with conventional high-dose-rate brachytherapy (HDR-BT). Sensitivity analyses to spatial uncertainties have been reported as components of publications on these emerging technologies, however, a generalized framework for the rigorous determination of the spatial uncertainty tolerances of dose-volume parameters is needed. PURPOSE To derive and present the population percentile allowance (PPA) method, a generalized mathematical and statistical framework to evaluate the tolerance of temporary IMBT approaches to spatial uncertainties in applicator position and shield orientation. METHODS A mathematical formalism describing geometric applicator position and shield orientation shifts was derived that supports straight and curved applicators and applies to serial and helical rotating shield brachytherapy (RSBT) and direction modulated brachytherapy (DMBT). The PPA method entails defining the percentage of a patient population receiving a given therapy that is, allowed to receive dose-volume errors in the target volume and specified organs at risk of a defined percentage or less, then determining what combinations of applicator position and shield orientation systematic errors would be expected to produce that outcome in the population. The PPA method was applied to the use case of multi-shield helical 169 Yb-based RSBT for cervical cancer, with 45° and 180° shield emission angles. A total of 37 cervical cancer patients were considered in the population, with average (± 1 standard deviation) HR-CTV volumes of 79 cm3 ± 37 cm3 and optimized baseline treatment plans (no spatial uncertainties applied) created for each patient to meet dose-volume requirements of 85 GyEQD2 (equivalent uniform dose in 2 Gy fraction), with D2cc tolerance doses of 90 GyEQD2 , 75 GyEQD2 , and 75 GyEQD2 for bladder, rectum, and sigmoid colon, respectively. RESULTS For the PPA requirement that 90% of cervical cancer patients receiving multi-shield helical RSBT could have a maximum dose-volume uncertainty of 10% for high-risk clinical target volume (HR-CTV) D90 (minimum dose to hottest 90%) and bladder, rectum, and sigmoid colon D2cc (minimum dose to hottest 2 cm3 ), the tolerance systematic applicator position and shield orientation uncertainties were approximately ± 1.0 mm and ± 4.25°, respectively. For ± 1.5 mm and ± 5° systematic applicator position and shield orientation tolerances, 90% of the patients considered would have a maximum dose-volume uncertainty of 12.8% or less. CONCLUSION The PPA method was formalized to determine the temporary IMBT spatial uncertainty tolerances that would be expected to result in an allowed percentage of a population of patients receiving relative dose-volume errors above a defined percentage. Multi-shield, helical 169 Yb-based RSBT for cervical cancer was evaluated and tolerances determined, which, if applied on each treatment fraction, would represent an extreme situation. The PPA method is applicable to a variety of temporary IMBT approaches and can be used to rigorously determine the design parameters for the delivery systems such as mechanical driver motor accuracy, shield angle backlash, applicator rotation, and applicator fixation stability.
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Affiliation(s)
| | - Quentin E Adams
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Yusung Kim
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Xiaodong Wu
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa, USA
- Department of Electrical and Computer Engineering, Seamans Center for the Engineering Arts and Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Weiyu Xu
- Department of Electrical and Computer Engineering, Seamans Center for the Engineering Arts and Sciences, University of Iowa, Iowa City, Iowa, USA
| | | | - Ryan T Flynn
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa, USA
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Elburg DV, Meyer T, Martell K, Quirk S, Roumeliotis M. Assessment of dose to vaginal mucosa for gynecologic template interstitial high-dose-rate brachytherapy using Monte Carlo simulation. J Contemp Brachytherapy 2023; 15:317-324. [PMID: 38026077 PMCID: PMC10669914 DOI: 10.5114/jcb.2023.131781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose This study investigated reliable vaginal mucosa dose-volume histogram (DVH) metrics in gynecologic template interstitial high-dose-rate brachytherapy (HDR-BT) for the purpose of standardized dose reporting. Material and methods Gynecologic template (Syed/Neblett) interstitial HDR-BT patients treated from September 2016 to November 2022 at the study institute were included in the cohort. Each patient implant included a vaginal mucosa contour defined by a 5 mm expansion from vaginal cylinder, then another volume with clinical target volume subtracted. DVH metrics were investigated between D0.1cc to D4cc. Clinical plans were re-calculated using Monte Carlo (MC) simulations both in heterogeneous material and in water. Results The patient cohort included 61 patients with clinical plans using conventional homogeneous dose calculation (TG43). Heterogeneous vs. water MC dose differences were between -1.1% and -1.4% for all metrics investigated. DVH metrics D1cc and smaller resulted in > 5% discrepancies between TG43 and MC dose (to water) calculation due to the proximity of source positions in/nearby the vaginal mucosa. Reliability improved when DVH metric volume was larger (D2cc and D4cc). Both D2cc and D4cc presented very high linear correlation between TG43 and MC reported doses for the vagina, and average ± standard deviation dose difference was 4.6 ±2.9% and -3.0 ±1.9%, respectively. Dose differences decreased when the clinical target volume was removed: -1.5 ±3.5% and -0.8 ±2.1% for D2cc and D4cc, respectively. Conclusions For perineal template gynecologic HDR-BT procedures, the 2 cc volume is the smallest representative volume that reliably reports vaginal dose and at minimum should be reported to establish dose and outcome evaluation.
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Affiliation(s)
- Devin Van Elburg
- Department of Physics & Astronomy, University of Calgary, Calgary AB, Canada
- Medical Physics Department, Tom Baker Cancer Centre, Calgary AB, Canada
| | - Tyler Meyer
- Department of Physics & Astronomy, University of Calgary, Calgary AB, Canada
- Medical Physics Department, Tom Baker Cancer Centre, Calgary AB, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary AB, Canada
| | - Kevin Martell
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary AB, Canada
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Roumeliotis
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA Institution of research: Tom Baker Cancer Centre, Calgary, AB, Canada, T2N 4N2
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Wang L. Instant Oncology: EMBRACE-I. Clin Oncol (R Coll Radiol) 2023; 35:e571-e572. [PMID: 37550137 DOI: 10.1016/j.clon.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023]
Affiliation(s)
- L Wang
- The Royal Marsden Hospital, Sutton, UK.
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Caricato P, Trivellato S, Pellegrini R, Montanari G, Daniotti MC, Bordigoni B, Faccenda V, Panizza D, Meregalli S, Bonetto E, Voet P, Arcangeli S, De Ponti E. Updating approach for lexicographic optimization-based planning to improve cervical cancer plan quality. Discov Oncol 2023; 14:180. [PMID: 37775613 PMCID: PMC10541351 DOI: 10.1007/s12672-023-00800-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND To investigate the capability of a not-yet commercially available fully automated lexicographic optimization (LO) planning algorithm, called mCycle (Elekta AB, Stockholm, Sweden), to further improve the plan quality of an already-validated Wish List (WL) pushing on the organs-at-risk (OAR) sparing without compromising target coverage and plan delivery accuracy. MATERIAL AND METHODS Twenty-four mono-institutional consecutive cervical cancer Volumetric-Modulated Arc Therapy (VMAT) plans delivered between November 2019 and April 2022 (50 Gy/25 fractions) have been retrospectively selected. In mCycle the LO planning algorithm was combined with the a-priori multi-criterial optimization (MCO). Two versions of WL have been defined to reproduce manual plans (WL01), and to improve the OAR sparing without affecting minimum target coverage and plan delivery accuracy (WL02). Robust WLs have been tuned using a subset of 4 randomly selected patients. The remaining plans have been automatically re-planned by using the designed WLs. Manual plans (MP) and mCycle plans (mCP01 and mCP02) were compared in terms of dose distributions, complexity, delivery accuracy, and clinical acceptability. Two senior physicians independently performed a blind clinical evaluation, ranking the three competing plans. Furthermore, a previous defined global quality index has been used to gather into a single score the plan quality evaluation. RESULTS The WL tweaking requests 5 and 3 working days for the WL01 and the WL02, respectively. The re-planning took in both cases 3 working days. mCP01 best performed in terms of target coverage (PTV V95% (%): MP 98.0 [95.6-99.3], mCP01 99.2 [89.7-99.9], mCP02 96.9 [89.4-99.5]), while mCP02 showed a large OAR sparing improvement, especially in the rectum parameters (e.g., Rectum D50% (Gy): MP 41.7 [30.2-47.0], mCP01 40.3 [31.4-45.8], mCP02 32.6 [26.9-42.6]). An increase in plan complexity has been registered in mCPs without affecting plan delivery accuracy. In the blind comparisons, all automated plans were considered clinically acceptable, and mCPs were preferred over MP in 90% of cases. Globally, automated plans registered a plan quality score at least comparable to MP. CONCLUSIONS This study showed the flexibility of the Lexicographic approach in creating more demanding Wish Lists able to potentially minimize toxicities in RT plans.
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Affiliation(s)
- Paolo Caricato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
- Department of Physics, University of Milan, Milan, Italy.
| | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | | | - Gianluca Montanari
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milano Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Sofia Meregalli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elisa Bonetto
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Peter Voet
- Research Clinical Liaison, Elekta AB, Stockholm, Sweden
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Muramoto Y, Murakami N, Karino T, Sugimoto S, Takatsu J, Oshima M, Kosugi Y, Kawamoto T, Hirayama T, Fujino K, Terao Y, Shikama N. MucoUp® as a spacer in brachytherapy for uterine cervical cancer: A first-in-human experience. Clin Transl Radiat Oncol 2023; 42:100659. [PMID: 37519921 PMCID: PMC10372547 DOI: 10.1016/j.ctro.2023.100659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
We first used MucoUp®, a hyaluronic acid used in endoscopic resection, as a spacer in brachytherapy. In five cervical cancer patients, MucoUp® insertion increased a 90% dose of the high-risk CTV to over 80 Gy while decreasing the dose of organs at risk. No related adverse events were observed.
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Affiliation(s)
- Yoichi Muramoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Satoru Sugimoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Jun Takatsu
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Takashi Hirayama
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Kazunari Fujino
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
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Kahvecioglu A, Gurlek E, Yedekci FY, Sari SY, Gultekin M, Yildiz F. Simultaneous integrated or sequential boost to clinically involved lymph nodes in patients with locally advanced cervical cancer treated with definitive chemoradiotherapy. Gynecol Oncol 2023; 176:10-15. [PMID: 37413947 DOI: 10.1016/j.ygyno.2023.06.020] [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: 05/12/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE The optimal treatment of metastatic lymph nodes (LNs) in locally-advanced cervical cancer (LACC) is controversial. With the widespread use of modern radiotherapy (RT) techniques, it is become possible to perform dose escalation in clinically involved LNs. This study aimed to evaluate the oncologic outcomes of dose escalation to the involved LNs with the simultaneous-integrated (SIB) or sequential boost (SEB) techniques as a part of definitive chemoradiotherapy (CRT) for patients with LACC. METHODS The data of 47 patients treated with definitive CRT with either a SIB or SEB technique to the metastatic LNs between 2015 and 2021 were retrospectively analyzed. All patients received 50.4 Gy/28 fractions of external-beam RT and 28 Gy/4 fractions of brachytherapy. RESULTS The number of boosted LNs was 146. The median size of the LNs was 2 cm (range, 1-5 cm). The median cumulative equivalent dose in 2-Gy fractions for the LNs was 64.2 Gy (range, 57.6-71.2 Gy). During the median 30 months of follow-up (range, 14-91 months), no boosted LNs recurred and the local control (LC) rate was 100%. The 2-year overall, disease-free, local recurrence-free, and distant metastasis-free survival rate was 83.1%, 70.5%, 77.5%, and 74.4%, respectively. In multivariate analysis, the non-squamous cell histology was the only negative independent prognostic factor for DFS and DMFS. Treatment was well tolerated without any serious acute toxicity. Serious late toxicity developed in three (6%) patients as ureteral stenosis, rectal bleeding and pelvic fracture in one patient each. CONCLUSIONS RT dose escalation provides excellent LC for the clinically involved LNs, even for bulky ones, with a low toxicity profile. Routine LN dissection may not be necessary. However, randomized trials are needed to determine the optimal treatment approach.
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Affiliation(s)
- Alper Kahvecioglu
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
| | - Ezgi Gurlek
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
| | - Fazli Yagiz Yedekci
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
| | - Sezin Yuce Sari
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
| | - Melis Gultekin
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
| | - Ferah Yildiz
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
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Jaffray DA, Knaul F, Baumann M, Gospodarowicz M. Harnessing progress in radiotherapy for global cancer control. NATURE CANCER 2023; 4:1228-1238. [PMID: 37749355 DOI: 10.1038/s43018-023-00619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/22/2023] [Indexed: 09/27/2023]
Abstract
The pace of technological innovation over the past three decades has transformed the field of radiotherapy into one of the most technologically intense disciplines in medicine. However, the global barriers to access this highly effective treatment are complex and extend beyond technological limitations. Here, we review the technological advancement and current status of radiotherapy and discuss the efforts of the global radiation oncology community to formulate a more integrative 'diagonal approach' in which the agendas of science-driven advances in individual outcomes and the sociotechnological task of global cancer control can be aligned to bring the benefit of this proven therapy to patients with cancer everywhere.
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Affiliation(s)
- David A Jaffray
- Departments of Radiation Physics and Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Felicia Knaul
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Mary Gospodarowicz
- Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Mirzavand Boroujeni N, Richard JPP, Sterling D, Wilke C. A linear optimization model for high dose rate brachytherapy using a novel distance metric. Phys Med Biol 2023; 68:175018. [PMID: 37489861 DOI: 10.1088/1361-6560/acea55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/25/2023] [Indexed: 07/26/2023]
Abstract
Purpose.We propose a linear network-based optimization model (LNBM) for high dose rate brachytherapy (HDR-BT) that uses a novel distance metric to measure the discrepancy between the dose delivered and the prescription. Unlike models in the literature, LNBM takes advantage of the adjacency structure of the patients' voxels by formalizing them into a network.Methods.We apply LNBM to a set of 7 cervical cancer cases treated with HDR-BT. State-of-the-art commercial optimization software solves LNBM to global optimality. The results of LNBM are compared with those of inverse planning by simulated annealing (IPSA) based on tumor coverage, dosimetric indices for the critical organs at risk (OARs), isodose contour plots, and two metrics of homogeneity new to this work (hot-spots volumes and diameters).Results.LNBM produces plans with improved tumor coverage and with improved isodose contour plots and dosimetric indices for OARs that receive highest dose (bladder and rectum in this study) when compared with IPSA. Using new metrics of homogeneity, we also demonstrate that LNBM produces more homogeneous plans on these cases. An analysis of the solutions of LNBM shows that they use a significant part of the voxel network structure, providing evidence that the plans produced are different from those created using traditional penalty approaches and are more directly guided by the geometry of the patients' anatomy.Conclusions.The proposed linear network-based optimization model efficiently generates more homogeneous high quality treatment plans for HDR-BT.
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Affiliation(s)
- Nasim Mirzavand Boroujeni
- Department of Industrial and Systems Engineering, University of Minnesota, 100 Union Street SE, Minneapolis, MN 55455, United States of America
| | - Jean-Philippe P Richard
- Department of Industrial and Systems Engineering, University of Minnesota, 100 Union Street SE, Minneapolis, MN 55455, United States of America
| | - David Sterling
- Department of Radiation Oncology, University of Minnesota, 516 Delaware Street SE, Minneapolis MN, 55455, United States of America
| | - Christopher Wilke
- Department of Radiation Oncology, University of Minnesota, 516 Delaware Street SE, Minneapolis MN, 55455, United States of America
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Li Z, Yang Z, Lu J, Zhu Q, Wang Y, Zhao M, Li Z, Fu J. Deep learning-based dose map prediction for high-dose-rate brachytherapy. Phys Med Biol 2023; 68:175015. [PMID: 37589292 DOI: 10.1088/1361-6560/acecd2] [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: 03/27/2023] [Accepted: 08/02/2023] [Indexed: 08/18/2023]
Abstract
Background. Creating a clinically acceptable plan in the time-sensitive clinic workflow of brachytherapy is challenging. Deep learning-based dose prediction techniques have been reported as promising solutions with high efficiency and accuracy. However, current dose prediction studies mainly target EBRT which are inappropriate for brachytherapy, the model designed specifically for brachytherapy has not yet well-established.Purpose. To predict dose distribution in brachytherapy using a novel Squeeze and Excitation Attention Net (SE_AN) model.Method. We hypothesized the tracks of192Ir inside applicators are essential for brachytherapy dose prediction. To emphasize the applicator contribution, a novel SE module was integrated into a Cascaded UNet to recalibrate informative features and suppress less useful ones. The Cascaded UNet consists of two stacked UNets, with the first designed to predict coarse dose distribution and the second added for fine-tuning 250 cases including all typical clinical applicators were studied, including vaginal, tandem and ovoid, multi-channel, and free needle applicators. The developed SE_AN was subsequently compared to the classic UNet and classic Cascaded UNet (without SE module) models. The model performance was evaluated by comparing the predicted dose against the clinically approved plans using mean absolute error (MAE) of DVH metrics, includingD2ccandD90%.Results. The MAEs of DVH metrics demonstrated that SE_AN accurately predicted the dose with 0.37 ± 0.25 difference for HRCTVD90%, 0.23 ± 0.14 difference for bladderD2cc, and 0.28 ± 0.20 difference for rectumD2cc. In comparison studies, UNet achieved 0.34 ± 0.24 for HRCTV, 0.25 ± 0.20 for bladder, 0.25 ± 0.21 for rectum, and Cascaded UNet achieved 0.42 ± 0.31 for HRCTV, 0.24 ± 0.19 for bladder, 0.23 ± 0.19 for rectum.Conclusion. We successfully developed a method specifically for 3D brachytherapy dose prediction. Our model demonstrated comparable performance to clinical plans generated by experienced dosimetrists. The developed technique is expected to improve the standardization and quality control of brachytherapy treatment planning.
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Affiliation(s)
- Zhen Li
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Zhenyu Yang
- Duke University, Durham, NC, United States of America
| | - Jiayu Lu
- Boston University, Boston, MA, United States of America
| | - Qingyuan Zhu
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Yanxiao Wang
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Mengli Zhao
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Zhaobin Li
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Jie Fu
- Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
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Carvalho HDA, Mauro GP. History of radiotherapy in the treatment of uterine cervix cancer: an overview. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S126. [PMID: 37556645 PMCID: PMC10411717 DOI: 10.1590/1806-9282.2023s126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/17/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Heloisa de Andrade Carvalho
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Radiologia e Oncologia, Serviço de Radioterapia – São Paulo (SP), Brazil
| | - Geovanne Pedro Mauro
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Radiologia e Oncologia, Serviço de Radioterapia – São Paulo (SP), Brazil
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Fischer AM, Hague T, Hoskin PJ. CBCT-based deformable dose accumulation of external beam radiotherapy in cervical cancer. Acta Oncol 2023; 62:923-931. [PMID: 37488951 DOI: 10.1080/0284186x.2023.2238543] [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: 03/24/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
Background: Delivered radiotherapy doses do not exactly match those planned for a course of treatment, largely due to inter-fraction changes in anatomy. In this study, accumulated delivered dose was calculated for a sample of cervical cancer patients, by deformably registering daily cone beam computed tomography (CBCT) images to the planning computed tomography (CT) scan. Planned and accumulated doses were compared for the clinical target volume (CTV), bladder, and rectum.Material and Methods: For 10 patients receiving 45 Gy in 25 fractions of external beam radiotherapy, daily dose distributions were calculated on CBCT. These images were deformed onto the planning CT and the dose was accumulated using Velocity 4.1 (Varian Medical Systems, Palo Alto, USA). The quality of deformable image registration was evaluated visually and by calculating Dice similarity coefficients and mean distance to agreement.Results: V95%>99% was achieved for the primary CTV in 9/10 patients for the planned dose distribution and 7/10 patients for the accumulated dose distribution. Primary CTV coverage by 95% of the prescription dose was reduced in one patient, due to an increase in anterior-posterior separation. Comparison of planned and accumulated dose volume histograms (DVHs) for the bladder and rectum found agreement within 5% at low and intermediate doses, but differences exceeded 20% at higher doses. Direct addition of CBCT DVHs was seen to be a poor estimate for the accumulated DVH at higher doses.Conclusion: Computation of delivered radiotherapy dose that accounts for inter-fraction anatomical changes is important for establishing dose-effect relationships. Updating delivered dose distributions after each fraction would support informed clinical decision making on any potential treatment interventions.
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Affiliation(s)
| | | | - Peter J Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
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Wang Y, Qin X, Yu L, Hou X, Hu K, Yan J, Zhang F. The application of 3D brachytherapy in cervical stump cancer: A retrospective study. J Contemp Brachytherapy 2023; 15:275-282. [PMID: 37799122 PMCID: PMC10548426 DOI: 10.5114/jcb.2023.130898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/21/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Cervical stump cancer is a carcinoma that grows on the cervical stump after a sub-total hysterectomy. There have been no studies on the application of 3D brachytherapy in cervical stump cancer. In the present study, we aimed to compare the curative effects, toxicity, and dosimetry of 3D and 2D brachytherapy in cervical stump cancer. Material and methods Thirty-one patients admitted between 2012 and 2021, who were concurrently treated with intensity-modulated radiation therapy and brachytherapy for cervical stump cancer were divided into three groups according to the brachytherapy techniques: 2D brachytherapy, 3D image-guided brachytherapy (3D-IGBT), and 2D + 3D. For patients undergoing 2D brachytherapy and 3D-IGBT, data on survival, complications, and dose to target area or organs at risk (OARs) were collected and compared. Furthermore, dosimetry difference was investigated by reconstructing the 2D plan into a 3D plan. Results The median follow-up duration of all patients was 58 months. The overall 5-year progression-free survival, overall survival, and local control rates were 69.6%, 90.2%, and 78.2%, respectively. Late complications in the rectum, sigmoid colon, and bladder were milder in 3D brachytherapy than in 2D brachytherapy. Concerning the D90 value of clinical target volume (CTV) and D2cm3 value of OARs in EQD2, the 3D brachytherapy provided a lower dose to CTV (76.5 Gy vs. 95.9 Gy, on average) and OARs compared with 2D brachytherapy. Conclusions Despite lacking statistical significance, 3D brachytherapy showed better outcomes regarding late toxicity than 2D brachytherapy, owing to the lower dose coverage in the bladder, rectum, sigmoid colon, and small intestine.
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Affiliation(s)
- Yuxuan Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Peking Union Medical College, MD Program; No. 9 Dongdansantiao, Beijing, China
| | - Xue Qin
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Obstetrics and Gynecology, Luohe Central Hospital, Luohe, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Wang YN, Zhong ML, Liang MR, Yang JT, Zeng SY. The Therapeutic Value of Adjuvant Chemotherapy after Concurrent Chemoradiotherapy for Locally Advanced Cervical Cancer. Gynecol Obstet Invest 2023; 88:286-293. [PMID: 37497957 DOI: 10.1159/000533122] [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: 09/27/2022] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the therapeutic value and treatment-related complications of adjuvant chemotherapy after concurrent chemoradiotherapy (CCRT) for locally advanced cervical cancer (LACC). DESIGN The medical records of LACC patients who underwent CCRT were reviewed retrospectively. METHODS A total of 1,138 patients with LACC who had been treated at our hospital between January 2013 and December 2017 were included in the study and classified into two groups: the CCRT group, comprising 726 patients who had received only CCRT, and the CCRT + adjuvant chemotherapy (ACT) group, comprising 412 patients who had received three cycles of adjuvant chemotherapy after CCRT. 39 patients in the CCRT group and 50 patients in the CCRT + ACT group had undergone lymphadenectomy, which revealed pathology-positive lymph nodes in 22 patients and 35 patients, respectively. Progression-free survival (PFS), overall survival (OS), and adverse events were compared. RESULTS The median follow-up time was 61 months (range: 2-96 months). No significant differences in PFS and OS were found between the two groups (p > 0.05), but more grade 3-4 acute hematologic toxicities were observed in the CCRT + ACT group than in the CCRT group (24.8% vs. 31.8%, p = 0.01). A subgroup analysis of patients with pathology-positive lymph nodes showed that the 5-year PFS and OS rates were 76.5% and 74.9%, respectively, for the CCRT + ACT group and 45.0% and 49.2%, respectively, for the CCRT group; the differences were statistically significant (p = 0.015 and 0.042, respectively). LIMITATIONS First, the sample size of the subgroup of patients with pathology-positive lymph nodes was too small for a confirmative conclusion. The heterogeneous population and the selection bias resulting from the retrospective design were the other flaws of our study. CONCLUSION The application of adjuvant chemotherapy after CCRT may be worth investigating further for women with LACC and pathology-positive lymph nodes, but this approach is associated with an increase in acute hematology toxicities.
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Affiliation(s)
- Ya-Nan Wang
- Graduate Department of the Medical College of Nanchang University, Nanchang, China
| | - Mei-Ling Zhong
- Oncology Department of Jiangxi Maternal and Child Health Care Hospital, Nanchang, China,
| | - Mei-Rong Liang
- Oncology Department of Jiangxi Maternal and Child Health Care Hospital, Nanchang, China
| | - Jian-Tong Yang
- Oncology Department of Jiangxi Maternal and Child Health Care Hospital, Nanchang, China
| | - Si-Yuan Zeng
- Graduate Department of the Medical College of Nanchang University, Nanchang, China
- Oncology Department of Jiangxi Maternal and Child Health Care Hospital, Nanchang, China
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