1
|
Westerhoff JM, Lalmahomed TA, Meijers L, Henke L, Teunissen FR, Bruynzeel AME, Alongi F, Hall WA, Kishan AU, Intven MPW, Verkooijen HM, van der Voort van Zyp JRN, Daamen LA. Patient reported outcomes following MR-guided radiotherapy for prostate cancer: a systematic review and meta-analysis. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00691-6. [PMID: 38838994 DOI: 10.1016/j.ijrobp.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE This systematic review provides an overview of literature on the impact of MR-guided radiotherapy (MRgRT) on patient reported outcomes (PROs) in patients with prostate cancer (PC). METHODS A systematic search was performed in October 2023 in PubMed, EMBASE and Cochrane Library. The PICOS framework (i.e., patient, intervention, comparison, outcome, study design) was used to determine eligibility criteria. Included were studies assessing PROs following MRgRT for PC with sample size >10. Methodological quality was assessed using the ROBINS-I and RoB 2. Relevant mean differences (MD) compared to pre-RT were interpreted using minimal important differences (MID). Meta-analyses were performed using random-effects models. Between-study heterogeneity was assessed using the I2-statistic. RESULTS Eleven observational studies and one randomized controlled trial (n=897) were included. Nine studies included patients with primary PC with MRgRT as first-line treatment (n=813) and three with MRgRT as second-line treatment (n=84). Substantial risk of bias was found in five studies. EORTC QLQ-C30 and EORTC QLQ-PR25 scores were pooled from three studies, and EPIC-26 scores from four studies. Relevant MDs for the urinary domain were found with the EPIC-26 (MD-10.0 [95%CI -12.0 - -8.1]; I20%) and the EORTC QLQ-PR25 (MD8.6 [95%CI -4.7-22.0]; I297%), both at end-RT to one month follow-up. Relevant MDs for the bowel domain were found with the EPIC-26 (MD-4.7 [95%CI -9.2 - -0.2]; I282%), at end-RT or one month follow-up, but not with the EORTC QLQ-PR25. For both domains, no relevant MDs were found after three months of follow-up. No relevant MDs were found in the general QoL domains of the EORTC QLQ-C30. CONCLUSION MRgRT for PC results in a temporarily worsening of patient-reported urinary and bowel symptoms during the first month after treatment compared to pre-RT, resolving at 3 months. No clinically relevant changes were found for general QoL domains. These results provide important information for patient counseling and can serve as a benchmark for future studies.
Collapse
Affiliation(s)
- J M Westerhoff
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - T A Lalmahomed
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - L Meijers
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - L Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, United States
| | - F R Teunissen
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - A M E Bruynzeel
- Department of Radiotherapy, Cancer Center Amsterdam, VU University medical center, Amsterdam, The Netherlands
| | - F Alongi
- Advanced Radiation Oncology Department-IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy; University of Brescia, Italy
| | - W A Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin, United States
| | - A U Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | - M P W Intven
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - H M Verkooijen
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | | | - L A Daamen
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| |
Collapse
|
2
|
Potkrajcic V, Gani C, Fischer SG, Boeke S, Niyazi M, Thorwarth D, Voigt O, Schneider M, Mönnich D, Kübler S, Boldt J, Hoffmann E, Paulsen F, Mueller AC, Wegener D. Online Adaptive MR-Guided Ultrahypofractionated Radiotherapy of Prostate Cancer on a 1.5 T MR-Linac: Clinical Experience and Prospective Evaluation. Curr Oncol 2024; 31:2679-2688. [PMID: 38785484 PMCID: PMC11120184 DOI: 10.3390/curroncol31050203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
The use of hypofractionated radiotherapy in prostate cancer has been increasingly evaluated, whereas accumulated evidence demonstrates comparable oncologic outcomes and toxicity rates compared to normofractionated radiotherapy. In this prospective study, we evaluate all patients with intermediate-risk prostate cancer treated with ultrahypofractionated (UHF) MRI-guided radiotherapy on a 1.5 T MR-Linac within our department and report on workflow and feasibility, as well as physician-recorded and patient-reported longitudinal toxicity. A total of 23 patients with intermediate-risk prostate cancer treated on the 1.5 T MR-Linac with a dose of 42.7 Gy in seven fractions (seven MV step-and-shoot IMRT) were evaluated within the MRL-01 study (NCT04172753). The duration of each treatment step, choice of workflow (adapt to shape-ATS or adapt to position-ATP) and technical and/or patient-sided treatment failure were recorded for each fraction and patient. Acute and late toxicity were scored according to RTOG and CTC V4.0, as well as the use of patient-reported questionnaires. The median follow-up was 12.4 months. All patients completed the planned treatment. The mean duration of a treatment session was 38.2 min. In total, 165 radiotherapy fractions were delivered. ATS was performed in 150 fractions, 5 fractions were delivered using ATP, and 10 fractions were delivered using both ATS and ATP workflows. Severe acute bother (G3+) regarding IPS-score was reported in five patients (23%) at the end of radiotherapy. However, this tended to normalize and no G3+ IPS-score was observed later at any point during follow-up. Furthermore, no other severe genitourinary (GU) or gastrointestinal (GI) acute or late toxicity was observed. One-year biochemical-free recurrence survival was 100%. We report the excellent feasibility of UHF MR-guided radiotherapy for intermediate-risk prostate cancer patients and acceptable toxicity rates in our preliminary study. Randomized controlled studies with long-term follow-up are warranted to detect possible advantages over current state-of-the-art RT techniques.
Collapse
Affiliation(s)
- Vlatko Potkrajcic
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Stefan Georg Fischer
- Department of Radiation Oncology, Klinikum Esslingen, 73730 Esslingen am Neckar, Germany
| | - Simon Boeke
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Otilia Voigt
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Moritz Schneider
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - David Mönnich
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Sarah Kübler
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Jessica Boldt
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Elgin Hoffmann
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - Arndt-Christian Mueller
- Department of Radiation Oncology and Radiotherapy, RKH-Kliniken Ludwigsburg, 71640 Ludwigsburg, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tuebingen, Germany
- Department of Radiation Oncology, Alb-Fils Kliniken GmbH, 73035 Goeppingen, Germany
| |
Collapse
|
3
|
de Mol van Otterloo S, Westerhoff J, Leer T, Rutgers R, Meijers L, Daamen L, Intven M, Verkooijen H. Patient expectation and experience of MR-guided radiotherapy using a 1.5T MR-Linac. Tech Innov Patient Support Radiat Oncol 2024; 29:100224. [PMID: 38162695 PMCID: PMC10755768 DOI: 10.1016/j.tipsro.2023.100224] [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: 07/20/2023] [Revised: 10/19/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024] Open
Abstract
Background and Purpose Online adaptive MR-guided radiotherapy (MRgRT) is a relatively new form of radiotherapy treatment, delivered using a MR-Linac. It is unknown what patients expect from this treatment and whether these expectations are met. This study evaluates whether patients' pre-treatment expectations of MRgRT are met and reports patients' on-table experience on a 1.5 T MR-Linac. Materials and methods All patients treated on the MR-Linac from November 2020 until April 2021, were eligible for inclusion. Patient expectation and experience were captured through questionnaires before, during, and three months after treatment. The on-table experience questionnaire included patient' physical and psychological coping. Patient-expected side effects, participation in daily and social activity, disease outcome and, disease related symptoms were compared to post-treatment experience. Results We included 113 patients who were primarily male (n = 100, 89 %), with a median age of 69 years (range 52-90). For on-table experience, ninety percent of patients (strongly) agreed to feeling calm during their treatment. Six and eight percent of patients found the treatment position or bed uncomfortable respectively. Twenty-eight percent of patients felt tingling sensations during treatment. After treatment, 79 % of patients' expectations were met. Most patients experienced an (better than) expected level of side effects (75 %), participation in daily- (83 %) and social activity (86 %) and symptoms (78 %). However, 33 % expected more treatment efficacy than experienced. Conclusion Treatment on the 1.5 T MR-Linac is well tolerated and meets patient expectations. Despite the fact that some patients expected greater treatment efficacy and the frequent occurrence of tingling sensations during treatment, most patient experiences were comparable or better than previously expected.
Collapse
Affiliation(s)
- S.R. de Mol van Otterloo
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - J.M. Westerhoff
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - T. Leer
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - R.H.A. Rutgers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.T.C. Meijers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.A. Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - M.P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - H.M. Verkooijen
- Division of Imaging, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
4
|
Yang B, Liu Y, Zhu J, Lu N, Dai J, Men K. Pretreatment information-aided automatic segmentation for online magnetic resonance imaging-guided prostate radiotherapy. Med Phys 2024; 51:922-932. [PMID: 37449545 DOI: 10.1002/mp.16608] [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: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND It is necessary to contour regions of interest (ROIs) for online magnetic resonance imaging (MRI)-guided adaptive radiotherapy (MRIgART). These updated contours are used for online replanning to obtain maximum dosimetric benefits. Contouring can be accomplished using deformable image registration (DIR) and deep learning (DL)-based autosegmentation methods. However, these methods may require considerable manual editing and thus prolong treatment time. PURPOSE The present study aimed to improve autosegmentation performance by integrating patients' pretreatment information in a DL-based segmentation algorithm. It is expected to improve the efficiency of current MRIgART process. METHODS Forty patients with prostate cancer were enrolled retrospectively. The online adaptive MR images, patient-specific planning computed tomography (CT), and contours in CT were used for segmentation. The deformable registration of planning CT and MR images was performed first to obtain a deformable CT and corresponding contours. A novel DL network, which can integrate such patient-specific information (deformable CT and corresponding contours) into the segmentation task of MR images was designed. We performed a four-fold cross-validation for the DL models. The proposed method was compared with DIR and DL methods on segmentation of prostate cancer. The ROIs included the clinical target volume (CTV), bladder, rectum, left femur head, and right femur head. Dosimetric parameters of automatically generated ROIs were evaluated using a clinical treatment planning system. RESULTS The proposed method enhanced the segmentation accuracy of conventional procedures. Its mean value of the dice similarity coefficient (93.5%) over the five ROIs was higher than both DIR (87.5%) and DL (87.2%). The number of patients (n = 40) that required major editing using DIR, DL, and our method were 12, 18, and 7 (CTV); 17, 4, and 1 (bladder); 8, 11, and 5 (rectum); 2, 4, and 1 (left femur head); and 3, 7, and 1 (right femur head), respectively. The Spearman rank correlation coefficient of dosimetry parameters between the proposed method and ground truth was 0.972 ± 0.040, higher than that of DIR (0.897 ± 0.098) and DL (0.871 ± 0.134). CONCLUSION This study proposed a novel method that integrates patient-specific pretreatment information into DL-based segmentation algorithm. It outperformed baseline methods, thereby improving the efficiency and segmentation accuracy in adaptive radiotherapy.
Collapse
Affiliation(s)
- Bining Yang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxiang Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji Zhu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ningning Lu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Men
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
5
|
Lorenzen EL, Celik B, Sarup N, Dysager L, Christiansen RL, Bertelsen AS, Bernchou U, Agergaard SN, Konrad ML, Brink C, Mahmood F, Schytte T, Nyborg CJ. An open-source nnU-net algorithm for automatic segmentation of MRI scans in the male pelvis for adaptive radiotherapy. Front Oncol 2023; 13:1285725. [PMID: 38023233 PMCID: PMC10654998 DOI: 10.3389/fonc.2023.1285725] [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: 08/30/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Adaptive MRI-guided radiotherapy (MRIgRT) requires accurate and efficient segmentation of organs and targets on MRI scans. Manual segmentation is time-consuming and variable, while deformable image registration (DIR)-based contour propagation may not account for large anatomical changes. Therefore, we developed and evaluated an automatic segmentation method using the nnU-net framework. Methods The network was trained on 38 patients (76 scans) with localized prostate cancer and tested on 30 patients (60 scans) with localized prostate, metastatic prostate, or bladder cancer treated at a 1.5 T MRI-linac at our institution. The performance of the network was compared with the current clinical workflow based on DIR. The segmentation accuracy was evaluated using the Dice similarity coefficient (DSC), mean surface distance (MSD), and Hausdorff distance (HD) metrics. Results The trained network successfully segmented all 600 structures in the test set. High similarity was obtained for most structures, with 90% of the contours having a DSC above 0.9 and 86% having an MSD below 1 mm. The largest discrepancies were found in the sigmoid and colon structures. Stratified analysis on cancer type showed that the best performance was seen in the same type of patients that the model was trained on (localized prostate). Especially in patients with bladder cancer, the performance was lower for the bladder and the surrounding organs. A complete automatic delineation workflow took approximately 1 minute. Compared with contour transfer based on the clinically used DIR algorithm, the nnU-net performed statistically better across all organs, with the most significant gain in using the nnU-net seen for organs subject to more considerable volumetric changes due to variation in the filling of the rectum, bladder, bowel, and sigmoid. Conclusion We successfully trained and tested a network for automatically segmenting organs and targets for MRIgRT in the male pelvis region. Good test results were seen for the trained nnU-net, with test results outperforming the current clinical practice using DIR-based contour propagation at the 1.5 T MRI-linac. The trained network is sufficiently fast and accurate for clinical use in an online setting for MRIgRT. The model is provided as open-source.
Collapse
Affiliation(s)
- Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bahar Celik
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Nis Sarup
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Lars Dysager
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | | | - Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Nielsen Agergaard
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Maximilian Lukas Konrad
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Faisal Mahmood
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | |
Collapse
|
6
|
Zhong J, Kobus M, Maitre P, Datta A, Eccles C, Dubec M, McHugh D, Buckley D, Scarsbrook A, Hoskin P, Henry A, Choudhury A. MRI-guided Pelvic Radiation Therapy: A Primer for Radiologists. Radiographics 2023; 43:e230052. [PMID: 37796729 DOI: 10.1148/rg.230052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Radiation therapy (RT) is a core pillar of oncologic treatment, and half of all patients with cancer receive this therapy as a curative or palliative treatment. The recent integration of MRI into the RT workflow has led to the advent of MRI-guided RT (MRIgRT). Using MRI rather than CT has clear advantages for guiding RT to pelvic tumors, including superior soft-tissue contrast, improved organ motion visualization, and the potential to image tumor phenotypic characteristics to identify the most aggressive or treatment-resistant areas, which can be targeted with a more focal higher radiation dose. Radiologists should be familiar with the potential uses of MRI in planning pelvic RT; the various RT techniques used, such as brachytherapy and external beam RT; and the impact of MRIgRT on treatment paradigms. Current clinical experience with and the evidence base for MRIgRT in the settings of prostate, cervical, and bladder cancer are discussed, and examples of treated cases are illustrated. In addition, the benefits of MRIgRT, such as real-time online adaptation of RT (during treatment) and interfraction and/or intrafraction adaptation to organ motion, as well as how MRIgRT can decrease toxic effects and improve oncologic outcomes, are highlighted. MRIgRT is particularly beneficial for treating mobile pelvic structures, and real-time adaptive RT for tumors can be achieved by using advanced MRI-guided linear accelerator systems to spare organs at risk. Future opportunities for development of biologically driven adapted RT with use of functional MRI sequences and radiogenomic approaches also are outlined. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
Collapse
Affiliation(s)
- Jim Zhong
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Marta Kobus
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Priyamvada Maitre
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Anubhav Datta
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Cynthia Eccles
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Michael Dubec
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Damien McHugh
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - David Buckley
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Andrew Scarsbrook
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Peter Hoskin
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Ann Henry
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| | - Ananya Choudhury
- From the Leeds Institute of Medical Research (J.Z., A.S., A.H.) and Department of Biomedical Imaging (D.B.), University of Leeds, 6 Clarendon Way, Woodhouse, Leeds LS2 9LH, England; Leeds Cancer Centre, St James's University Hospital, Leeds, England (J.Z., A.S., A.H.); Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany (M.K.); Radiation Therapy Research Group (M.K., P.M., A.D., C.E., M.D., P.H., A.C.) and Division of Cancer Sciences (D.M.), University of Manchester, Manchester, England; and The Christie NHS Foundation Trust, Manchester, England (P.M., C.E., M.D., D.M., P.H., A.C.)
| |
Collapse
|
7
|
Le Guevelou J, Bosetti DG, Castronovo F, Angrisani A, de Crevoisier R, Zilli T. State of the art and future challenges of urethra-sparing stereotactic body radiotherapy for prostate cancer: a systematic review of literature. World J Urol 2023; 41:3287-3299. [PMID: 37668718 PMCID: PMC10632210 DOI: 10.1007/s00345-023-04579-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
PURPOSE Doses delivered to the urethra have been associated with an increased risk to develop long-term urinary toxicity in patients undergoing stereotactic body radiotherapy (SBRT) for prostate cancer (PCa). Aim of the present systematic review is to report on the role of urethra-sparing SBRT (US-SBRT) techniques for prostate cancer, with a focus on outcome and urinary toxicity. METHOD A systematic review of the literature was performed on the PubMed database on May 2023. Based on the urethra-sparing technique, 13 studies were selected for the analysis and classified in the two following categories: "urethra-steering" SBRT (restriction of hotspots to the urethra) and "urethra dose-reduction" SBRT (dose reduction to urethra below the prescribed dose). RESULTS By limiting the urethra Dmax to 90GyEQD2 (α/β = 3 Gy) with urethra-steering SBRT techniques, late genitourinary (GU) grade 2 toxicity remains mild, ranging between 12.1% and 14%. With dose-reduction strategies decreasing the urethral dose below 70 GyEQD2, the risk of late GU toxicity was further reduced (< 8% at 5 years), while maintaining biochemical relapse-free survival rates up to 93% at 5 years. CONCLUSION US-SBRT techniques limiting maximum doses to urethra below a 90GyEQD2 (α/β = 3 Gy) threshold result in a low rate of acute and late grade ≥ 2 GU toxicity. A better understanding of clinical factors and anatomical substructures involved in the development of GU toxicity, as well as the development and use of adapted dose constraints, is expected to further reduce the long-term GU toxicity of prostate cancer patients treated with SBRT.
Collapse
Affiliation(s)
| | - Davide Giovanni Bosetti
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Francesco Castronovo
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Antonio Angrisani
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | | | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland.
- Facoltà Di Scienze Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| |
Collapse
|
8
|
Lee TH, Pyo H, Yoo GS, Lee HM, Jeon SS, Seo SI, Jeong BC, Jeon HG, Sung HH, Kang M, Song W, Chung JH, Bae BK, Park W. Prostate-specific antigen kinetics in hypofractionated radiation therapy alone for intermediate- and high-risk localized prostate cancer. Prostate Int 2023; 11:173-179. [PMID: 37745907 PMCID: PMC10513905 DOI: 10.1016/j.prnil.2023.07.002] [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: 06/19/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 09/26/2023] Open
Abstract
Background This study aimed to evaluate the treatment outcomes and define the prostate-specific antigen (PSA) kinetics as potential prognostic factors in patients with intermediate- or high-risk localized prostate cancer (PCa) who underwent moderately hypofractionated radiation therapy. Methods The study retrospectively reviewed the medical records of 149 patients with intermediate- or high-risk localized PCa who underwent definitive radiation therapy (70 Gy in 28 fractions) without androgen deprivation therapy. Clinical outcomes were analyzed based on risk stratification (favorable-intermediate, unfavorable-intermediate, and high-risk). The biochemical failure rate (BFR) and clinical failure rate (CFR) were stratified based on the PSA nadir and the time to the PSA nadir to identify the prognostic effect of PSA kinetics. Acute and late genitourinary and gastrointestinal adverse events were analyzed. Results Significant differences were observed in the BFR and CFR according to risk stratification. No recurrence was observed in the favorable intermediate-risk group. The 7-year BFR and CFR for the unfavorable intermediate-risk and high-risk groups were 19.2% and 9.8%, and 31.1% and 25.3%, respectively. Patients with a PSA nadir >0.33 ng/mL or a time to the PSA nadir <36 months had a significantly greater BFR and CFR. The crude rate of grade 3 late adverse events was 3.4% (genitourinary: 0.7%; gastrointestinal: 2.7%). No grade 4-5 adverse event was reported. Conclusion A significant difference in clinical outcomes was observed according to risk stratification. The PSA nadir and time to the PSA nadir were strongly associated with the BFR and CFR. Therefore, PSA kinetics during follow-up are important for predicting prognosis.
Collapse
Affiliation(s)
- Tae Hoon Lee
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minyong Kang
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wan Song
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bong Kyung Bae
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
9
|
Boldrini L, Romano A, Chiloiro G, Corradini S, De Luca V, Verusio V, D'Aviero A, Castelluccia A, Alitto AR, Catucci F, Grimaldi G, Trapp C, Hörner-Rieber J, Marchesano D, Frascino V, Mattiucci GC, Valentini V, Gentile P, Gambacorta MA. Magnetic resonance guided SBRT reirradiation in locally recurrent prostate cancer: a multicentric retrospective analysis. Radiat Oncol 2023; 18:84. [PMID: 37218005 DOI: 10.1186/s13014-023-02271-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/26/2023] [Indexed: 05/24/2023] Open
Abstract
AIMS Reirradiation of prostate cancer (PC) local recurrences represents an emerging challenge for current radiotherapy. In this context, stereotactic body radiation therapy (SBRT) allows the delivery of high doses, with curative intent. Magnetic Resonance guided Radiation Therapy (MRgRT) has shown promising results in terms of safety, feasibility and efficacy of delivering SBRT thanks to the enhanced soft tissue contrast and the online adaptive workflow. This multicentric retrospective analysis evaluates the feasibility and efficacy of PC reirradiation, using a 0.35 T hybrid MR delivery unit. METHODS Patients affected by local recurrences of PC and treated in five institutions between 2019 and 2022 were retrospectively collected. All patients had undergone previous Radiation Therapy (RT) in definitive or adjuvant setting. Re-treatment MRgSBRT was delivered with a total dose ranging from 25 to 40 Gy in 5 fractions. Toxicity according to CTCAE v 5.0 and treatment response were assessed at the end of the treatment and at follow-up. RESULTS Eighteen patients were included in this analysis. All patients had previously undergone external beam radiation therapy (EBRT) up to a total dose of 59.36 to 80 Gy. Median cumulative biologically effective dose (BED) of SBRT re-treatment was 213,3 Gy (103,1-560), considering an α/β of 1.5. Complete response was achieved in 4 patients (22.2%). No grade ≥ 2 acute genitourinary (GU) toxicity events were recorded, while gastrointestinal (GI) acute toxicity events occurred in 4 patients (22.2%). CONCLUSION The low rates of acute toxicity of this experience encourages considering MRgSBRT a feasibile therapeutic approach for the treatment of clinically relapsed PC. Accurate gating of target volumes, the online adaptive planning workflow and the high definition of MRI treatment images allow delivering high doses to the PTV while efficiently sparing organs at risk (OARs).
Collapse
Affiliation(s)
- Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Viola De Luca
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valeria Verusio
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Andrea D'Aviero
- Radiation Oncology, Mater Olbia Hospital, Olbia, Sassari, Italy
| | - Alessandra Castelluccia
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
- Radiation Oncology, Department of Radiotherapy, Hospital "A. Perrino", ASL Brindisi, Brindisi, Italy
| | - Anna Rita Alitto
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Gianmarco Grimaldi
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | - Christian Trapp
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Juliane Hörner-Rieber
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Domenico Marchesano
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | - Vincenzo Frascino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gian Carlo Mattiucci
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Radiation Oncology, Mater Olbia Hospital, Olbia, Sassari, Italy
| | - Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Piercarlo Gentile
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
10
|
Zhou Y, Yuan J, Xue C, Poon DMC, Yang B, Yu SK, Cheung KY. A pilot study of MRI radiomics for high-risk prostate cancer stratification in 1.5 T MR-guided radiotherapy. Magn Reson Med 2023; 89:2088-2099. [PMID: 36572990 DOI: 10.1002/mrm.29564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/09/2022] [Accepted: 12/09/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate the potential value of MRI radiomics obtained from a 1.5 T MRI-guided linear accelerator (MR-LINAC) for D'Amico high-risk prostate cancer (PC) classification in MR-guided radiotherapy (MRgRT). METHODS One hundred seventy-six consecutive PC patients underwent 1.5 T MRgRT treatment were retrospectively enrolled. Each patient received one or two pretreatment T2 -weighted MRI scans on a 1.5 T MR-LINAC. The endpoint was to differentiate high-risk from low/intermediate-risk PC based on D'Amico criteria using MRI-radiomics. Totally 1023 features were extracted from clinical target volume (CTV) and planning target volume (PTV). Intraclass correlation coefficient of scan-rescan repeatability, feature correlation, and recursive feature elimination were used for feature dimension reduction. Least absolute shrinkage and selection operator regression was employed for model construction. Receiver operating characteristic area under the curve (AUC) analysis was used for model performance assessment in both training and testing data. RESULTS One hundred and eleven patients fulfilled all criteria were finally included: 76 for training and 35 for testing. The constructed MRI-radiomics models extracted from CTV and PTV achieved the AUC of 0.812 and 0.867 in the training data, without significant difference (P = 0.083). The model performances remained in the testing. The sensitivity, specificity, and accuracy were 85.71%, 64.29%, and 77.14% for the PTV-based model; and 71.43%, 71.43%, and 71.43% for the CTV-based model. The corresponding AUCs were 0.718 and 0.750 (P = 0.091) for CTV- and PTV-based models. CONCLUSION MRI-radiomics obtained from a 1.5 T MR-LINAC showed promising results in D'Amico high-risk PC stratification, potentially helpful for the future PC MRgRT. Prospective studies with larger sample sizes and external validation are warranted for further verification.
Collapse
Affiliation(s)
- Yihang Zhou
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Jing Yuan
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Cindy Xue
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Darren M C Poon
- Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Bin Yang
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Siu Ki Yu
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Kin Yin Cheung
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| |
Collapse
|
11
|
Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
| |
Collapse
|
12
|
Bryant JM, Palm RF, Herrera R, Rubens M, Hoffe SE, Kim DW, Kaiser A, Ucar A, Fleming J, De Zarraga F, Hodul P, Aparo S, Asbun H, Malafa M, Jimenez R, Denbo J, Frakes JM, Chuong MD. Multi-Institutional Outcomes of Patients Aged 75 years and Older With Pancreatic Ductal Adenocarcinoma Treated With 5-Fraction Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (A-SMART). Cancer Control 2023; 30:10732748221150228. [PMID: 36598464 PMCID: PMC9982388 DOI: 10.1177/10732748221150228] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Treatment options for pancreatic ductal adenocarcinoma (PDAC) are commonly limited for patients with advanced age due to medical comorbidities and/or poor performance status. These patients may not be candidates for more aggressive chemotherapy regimens and/or surgical resection leaving few, if any, other effective treatments. Ablative stereotactic MRI-guided adaptive radiation therapy (A-SMART) is both efficacious and safe for PDAC and can achieve excellent long-term local control, however, the appropriateness of A-SMART for elderly patients with inoperable PDAC is not well understood. METHODS A retrospective analysis was performed of inoperable non-metastatic PDAC patients aged 75 years or older treated on the MRIdian Linac at 2 institutions. Clinical outcomes of interest included overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional (LRC). Toxicity was graded according to Common Terminology Criteria for Adverse Events (CTCAE, v5). RESULTS A total of 49 patients were evaluated with a median age of 81 years (range, 75-91) and a median follow-up of 14 months from diagnosis. PDAC was classified as locally advanced (46.9%), borderline resectable (36.7%), or medically inoperable (16.3%). Neoadjuvant chemotherapy was delivered to 84% of patients and all received A-SMART to a median 50 Gy (range, 40-50 Gy) in 5 fractions. 1 Year LRC, PFS, and OS were 88.9%, 53.8%, and 78.9%, respectively. Nine patients (18%) had resection after A-SMART and benefited from PFS improvement (26 vs 6 months, P = .01). ECOG PS <2 was the only predictor of improved OS on multivariate analysis. Acute and late grade 3 + toxicity rates were 8.2% and 4.1%, respectively. CONCLUSIONS A-SMART is associated with encouraging LRC and OS in elderly patients with initially inoperable PDAC. This novel non-invasive treatment strategy appears to be well-tolerated in patients with advanced age and should be considered in this population that has limited treatment options.
Collapse
Affiliation(s)
- JM Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA,JM Bryant, Department of Radiation Oncology, Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA.
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Miami, FL, USA,Muni Rubens, Office of Clinical Research, Miami Cancer Institute, 8900 North Kendall Drive, Miami, FL 33176, USA.
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Dae Won Kim
- Department of Medical Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Antonio Ucar
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Fleming
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | | | - Pamela Hodul
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Santiago Aparo
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Horacio Asbun
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Mokenge Malafa
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Ramon Jimenez
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Denbo
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center& Research Institute, Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| |
Collapse
|
13
|
Xu D, Ma TM, Savjani R, Pham J, Cao M, Yang Y, Kishan AU, Scalzo F, Sheng K. Fully automated segmentation of prostatic urethra for MR-guided radiation therapy. Med Phys 2023; 50:354-364. [PMID: 36106703 DOI: 10.1002/mp.15983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 04/29/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Accurate delineation of the urethra is a prerequisite for urethral dose reduction in prostate radiotherapy. However, even in magnetic resonance-guided radiation therapy (MRgRT), consistent delineation of the urethra is challenging, particularly in online adaptive radiotherapy. This paper presented a fully automatic MRgRT-based prostatic urethra segmentation framework. METHODS Twenty-eight prostate cancer patients were included in this study. In-house 3D half fourier single-shot turbo spin-echo (HASTE) and turbo spin echo (TSE) sequences were used to image the Foley-free urethra on a 0.35 T MRgRT system. The segmentation pipeline uses 3D nnU-Net as the base and innovatively combines ground truth and its corresponding radial distance (RD) map during training supervision. Additionally, we evaluate the benefit of incorporating a convolutional long short term memory (LSTM-Conv) layer and spatial recurrent convolution layer (RCL) into nnU-Net. A novel slice-by-slice simple exponential smoothing (SEPS) method specifically for tubular structures was used to post-process the segmentation results. RESULTS The experimental results show that nnU-Net trained using a combination of Dice, cross-entropy and RD achieved a Dice score of 77.1 ± 2.3% in the testing dataset. With SEPS, Hausdorff distance (HD) and 95% HD were reduced to 2.95 ± 0.17 mm and 1.84 ± 0.11 mm, respectively. LSTM-Conv and RCL layers only minimally improved the segmentation precision. CONCLUSION We present the first Foley-free MRgRT-based automated urethra segmentation study. Our method is built on a data-driven neural network with novel cost functions and a post-processing step designed for tubular structures. The performance is consistent with the need for online and offline urethra dose reduction in prostate radiotherapy.
Collapse
Affiliation(s)
- Di Xu
- Department of Computer Science, University of California, Los Angeles, California, USA.,Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ricky Savjani
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Jonathan Pham
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Fabien Scalzo
- Department of Computer Science, Pepperdine University, Los Angeles, California, USA
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| |
Collapse
|
14
|
Poon DMC, Yang B, Geng H, Wong OL, Chiu ST, Cheung KY, Yu SK, Chiu G, Yuan J. Analysis of online plan adaptation for 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer. J Cancer Res Clin Oncol 2023; 149:841-850. [PMID: 35199189 PMCID: PMC8866042 DOI: 10.1007/s00432-022-03950-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To analyze and characterize the online plan adaptation of 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer (PC). METHODS PC patients (n = 107) who received adaptive 1.5 Tesla MRgSBRT were included. Online plan adaptation was implemented by either the adapt-to-position (ATP) or adapt-to-shape (ATS) methods. Patients were assigned to the ATS group if they underwent ≥ 1 ATS fraction (n = 51); the remainder were assigned to the ATP group (n = 56). The online plan adaptation records of 535 (107 × 5) fractions were retrospectively reviewed. Rationales for ATS decision-making were determined and analyzed using predefined criteria. Statistics of ATS fractions were summarized. Associations of patient characteristics and clinical factors with ATS utilization were investigated. RESULTS There were 87 (16.3%) ATS fractions and 448 ATP fractions (83.7%). The numbers of ATS adoptions in fractions 1-5 were 29 (29/107, 27.1%), 18 (16.8%), 15 (14.0%), 16 (15.0%), and 9 (8.4%), respectively, with significant differences in adoption frequency between fractions (p = 0.007). Other baseline patient characteristics and clinical factors were not significantly associated with ATS classification (all p > 0.05). Underlying criteria for the determination of ATS implementation comprised anatomical changes (77 fractions in 50 patients) and discrete multiple targets (15 fractions in 3 patients). No ATS utilization was determined using dosimetric or online quality assurance criteria. CONCLUSIONS This study contributes to facilitating the establishment of a standardized protocol for online MR-guided adaptive radiotherapy in PC.
Collapse
Affiliation(s)
- Darren M. C. Poon
- grid.414329.90000 0004 1764 7097Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Bin Yang
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Hui Geng
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Oi Lei Wong
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Sin Ting Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Kin Yin Cheung
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Siu Ki Yu
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - George Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Jing Yuan
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| |
Collapse
|
15
|
Glicksman RM, Cheung P, Korol R, Niglas M, Nusrat H, Erler D, Vesprini D, Swaminath A, Davidson M, Zhang L, Chu W. Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncological and Renal Function Outcomes. Clin Oncol (R Coll Radiol) 2023; 35:20-28. [PMID: 35948465 DOI: 10.1016/j.clon.2022.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/24/2022] [Accepted: 06/17/2022] [Indexed: 01/04/2023]
Abstract
AIMS To evaluate oncological and renal function outcomes of stereotactic body radiotherapy (SBRT) for medically inoperable patients with localised renal cell carcinoma. MATERIALS AND METHODS Consecutive patients treated with curative intent SBRT (30-45 Gy in five fractions or 42 Gy in three fractions) were included. Data on local control (Response Evaluation Criteria in Solid Tumors [RECIST] v1.1), distant metastasis, impact on estimated glomerular filtration rate (eGFR) and proportional ipsilateral and contralateral renal functions (measured through renal scans) were collected. Univariate and multivariable analyses were conducted to determine association of variables with oncological and renal function outcomes. RESULTS Seventy-four patients were analysed. The median follow-up was 27.8 months (interquartile range 17.6-41.7). Fifty-seven per cent had tumours ≥ T1b. One-, 2- and 4-year cumulative incidence of local failure was 5.85, 7.77 and 7.77%, respectively. The cumulative incidence of distant metastasis at 2 years was 4.24%. On multivariable analysis, a lower planning target volume (PTV) mean dose (P = 0.019) and a larger PTV (P = 0.005) were significantly associated with the risk of developing local failure. A lower PTV maximum dose (P = 0.039) was significantly associated with the risk of developing distant metastasis. The median change in global eGFR (ml/min) from pre-SBRT levels was -7.0 (interquartile range -14.5 to -1.0) at 1 year and -11.5 (interquartile range -19.5 to -4.0) at 2 years. The proportion of ipsilateral (differential) renal function decreased over time from 47% of overall renal function pre-SBRT to 36% at 2 years, whereas the proportion of contralateral renal function correspondingly improved. On multivariable analysis, a higher volume of uninvolved renal cortex (P < 0.0001) was significantly associated with a smaller decrease in eGFR over time. CONCLUSION In this large institutional cohort, oncological outcomes of renal cell carcinoma treated with SBRT were favourable and a longitudinal decline in renal function in the ipsilateral kidney and compensatory increase in the contralateral kidney were observed. Clinical and dosimetric factors were significantly associated with oncological and renal function outcomes.
Collapse
Affiliation(s)
- R M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
| | - P Cheung
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - R Korol
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - M Niglas
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health, Oshawa, Ontario, Canada
| | - H Nusrat
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - D Erler
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - D Vesprini
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - A Swaminath
- Juravinski Cancer Centre, Hamilton, Ontario, Canada; Department of Radiation Oncology, McMaster University, Hamilton, Ontario, Canada
| | - M Davidson
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - W Chu
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Gelbart Pridan O, Ben David MA, Zalmanov S, Lipski Y, Grinberg V, Levin D, Apter S, Guindi M, Epstein D, Radus R, Arsenault O, Hod K, Tamami Q, Pfeffer R. Outcome of the first 200 patients with prostate cancer treated with MRI-Linac at Assuta MC. Front Oncol 2023; 13:1151256. [PMID: 37035136 PMCID: PMC10076851 DOI: 10.3389/fonc.2023.1151256] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Background We present our experience with MR-guided stereotactic body radiotherapy (SBRT) for 200 consecutive patients with prostate cancer with minimum 3-month follow-up. Methods Treatment planning included fusion of the 0.35-Tesla planning MRI with multiparametric MRI and PET-PSMA for Group Grade (GG) 2 or higher and contour review with an expert MRI radiologist. No fiducials or rectal spacers were used. Prescription dose was 36.25 Gy in 5 fractions over 2 weeks to the entire prostate with 3-mm margins. Daily plan was adapted if tumor and organs at risk (OAR) doses differed significantly from the original plan. The prostate was monitored during treatment that was automatically interrupted if the target moved out of the PTV range. Results Mean age was 72 years. Clinical stage was T1c, 85.5%; T2, 13%; and T3, 1.5%. In addition, 20% were GG1, 50% were GG2, 14.5% were GG3, 13% were GG4, and one patient was GG5. PSA ranged from 1 to 77 (median, 6.2). Median prostate volume was 57cc, and 888/1000 (88%) fractions required plan adaptation. The most common acute GU toxicity was Grade I, 31%; dysuria and acute gastrointestinal toxicity were rare. Three patients required temporary catheterization. Prostate size of over 100cc was associated with acute fatigue, urinary hesitance, and catheter insertion. Prostate Specific Antigen (PSA) decreased in 99% of patients, and one patient had regional recurrence. Conclusion MR-guided prostate SBRT shows low acute toxicity and excellent short-term outcomes. Real-time MRI ensures accurate positioning and SBRT delivery.
Collapse
Affiliation(s)
| | - Merav Akiva Ben David
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- *Correspondence: Merav Akiva Ben David,
| | - Svetlana Zalmanov
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Yoav Lipski
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | | | - Daphne Levin
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Sara Apter
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Guindi
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Innovation Division, Assuta Medical Center, Tel Aviv, Israel
| | - Dan Epstein
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Roman Radus
- Radiation Oncology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Orit Arsenault
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Keren Hod
- Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel
| | - Qusai Tamami
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Raphael Pfeffer
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| |
Collapse
|
17
|
1.5T MR-Guided Daily-Adaptive SBRT for Prostate Cancer: Preliminary Report of Toxicity and Quality of Life of the First 100 Patients. J Pers Med 2022; 12:jpm12121982. [PMID: 36556203 PMCID: PMC9785799 DOI: 10.3390/jpm12121982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose: The present study reports the preliminary outcomes in terms of adverse events and quality of life in the first 100 patients treated with 1.5T MR-guided daily-adaptive stereotactic body radiotherapy for prostate cancer. Methods: From October 2019 to December 2020, 100 patients, enrolled in a prospective study, received MR-guided SBRT for prostate cancer. Rectal spacer insertion was optional and administered in 37 patients. In total, 32 patients received androgen deprivation therapy in accordance with international guidelines. A prospective collection of data regarding toxicity and quality of life was performed. Results: The median age was 71 years (range, 52-84). The median total dose delivered was 35 Gy (35-36.25 Gy) in five sessions, either on alternate days (n = 25) or consecutive days (n = 75). For acute toxicity, we recorded: seven cases of acute G2 urinary pain and four cases of G2 gastrointestinal events. The median follow-up was 12 months (3-20), recording three late G2 urinary events and one G3 case, consisting of a patient who required a TURP 8 months after the treatment. For gastrointestinal toxicity, we observed 3 G ≥ 2 GI events, including one patient who received argon laser therapy for radiation-induced proctitis. Up to the last follow-up, all patients are alive and with no evidence of biochemical relapse, except for an M1 low-volume patient in distant progression two months after radiotherapy. QoL evaluation reported a substantial resolution of any discomfort within the second follow-up after radiotherapy, with the only exception being sexual items. Notably, after one year, global health items were improved compared to the baseline assessment. Conclusions: This study reports very promising outcomes in terms of adverse events and QoL, supporting the role of 1.5T MR-guided SBRT for prostate cancer. To date, this series is one of the first and largest available in the literature. Long-term results are warranted.
Collapse
|
18
|
Teunissen FR, Willigenburg T, Tree AC, Hall WA, Choi SL, Choudhury A, Christodouleas JP, de Boer JCJ, de Groot-van Breugel EN, Kerkmeijer LGW, Pos FJ, Schytte T, Vesprini D, Verkooijen HM, van der Voort van Zyp JRN. Magnetic Resonance-Guided Adaptive Radiation therapy for Prostate Cancer: The First Results from the MOMENTUM study-An International Registry for the Evidence-Based Introduction of Magnetic Resonance-Guided Adaptive Radiation Therapy. Pract Radiat Oncol 2022; 13:e261-e269. [PMID: 36462619 DOI: 10.1016/j.prro.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Magnetic resonance (MR)-guided radiation therapy (MRgRT) is a new technique for treatment of localized prostate cancer (PCa). We report the 12-month outcomes for the first PCa patients treated within an international consortium (the MOMENTUM study) on a 1.5T MR-Linac system with ultrahypofractionated radiation therapy. METHODS AND MATERIALS Patients treated with 5 × 7.25 Gy were identified. Prostate specific antigen-level, physician-reported toxicity (Common Terminology Criteria for Adverse Events [CTCAE]), and patient-reported outcomes (Quality of Life Questionnaire PR25 and Quality of Life Questionnaire C30 questionnaires) were recorded at baseline and at 3, 6, and 12 months of follow-up (FU). Pairwise comparative statistics were conducted to compare outcomes between baseline and FU. RESULTS The study included 425 patients with localized PCa (11.4% low, 82.0% intermediate, and 6.6% high-risk), and 365, 313, and 186 patients reached 3-, 6-, and 12-months FU, respectively. Median prostate specific antigen level declined significantly to 1.2 ng/mL and 0.1 ng/mL at 12 months FU for the nonandrogen deprivation therapy (ADT) and ADT group, respectively. The peak of genitourinary and gastrointestinal CTCAE toxicity was reported at 3 months FU, with 18.7% and 1.7% grade ≥2, respectively. The QLQ-PR25 questionnaire outcomes showed significant deterioration in urinary domain score at all FU moments, from 8.3 (interquartile range [IQR], 4.1-16.6) at baseline to 12.4 (IQR, 8.3-24.8; P = .005) at 3 months, 12.4 (IQR, 8.3-20.8; P = .018;) at 6 months, and 12.4 (IQR, 8.3-20.8; P = .001) at 12 months. For the non-ADT group, physician- and patient-reported erectile function worsened significantly between baseline and 12 months FU. CONCLUSIONS Ultrahypofractionated MR-guided radiation therapy for localized PCa using a 1.5T MR-Linac is effective and safe. The peak of CTCAE genitourinary and gastrointestinal toxicity was reported at 3 months FU. Furthermore, for patients without ADT, a significant increase in CTCAE erectile dysfunction was reported at 12 months FU. These data are useful for educating patients on expected outcomes and informing study design of future comparative-effectiveness studies.
Collapse
Affiliation(s)
- Frederik R Teunissen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas Willigenburg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison C Tree
- Department of Urological Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seungtaek L Choi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - John P Christodouleas
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Elekta AB, Stockholm, Sweden
| | - Johannes C J de Boer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Helena M Verkooijen
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht University, Utrecht, The Netherlands
| | | |
Collapse
|
19
|
Chuong MD, Ann Clark M, Henke LE, Kishan AU, Portelance L, Parikh PJ, Bassetti MF, Nagar H, Rosenberg SA, Mehta MP, Refaat T, Rineer JM, Smith A, Seung S, Zaki BI, Fuss M, Mak RH. Patterns of Utilization and Clinical Adoption of 0.35 Tesla MR-guided Radiation Therapy in the United States - Understanding the Transition to Adaptive, Ultra-Hypofractionated Treatments. Clin Transl Radiat Oncol 2022; 38:161-168. [DOI: 10.1016/j.ctro.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
|
20
|
Hall WA, Kishan AU, Hall E, Nagar H, Vesprini D, Paulson E, Van der Heide UA, Lawton CAF, Kerkmeijer LGW, Tree AC. Adaptive magnetic resonance image guided radiation for intact localized prostate cancer how to optimally test a rapidly emerging technology. Front Oncol 2022; 12:962897. [PMID: 36132128 PMCID: PMC9484536 DOI: 10.3389/fonc.2022.962897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Prostate cancer is a common malignancy for which radiation therapy (RT) provides an excellent management option with high rates of control and low toxicity. Historically RT has been given with CT based image guidance. Recently, magnetic resonance (MR) imaging capabilities have been successfully integrated with RT delivery platforms, presenting an appealing, yet complex, expensive, and time-consuming method of adapting and guiding RT. The precise benefits of MR guidance for localized prostate cancer are unclear. We sought to summarize optimal strategies to test the benefits of MR guidance specifically in localized prostate cancer. Methods A group of radiation oncologists, physicists, and statisticians were identified to collectively address this topic. Participants had a history of treating prostate cancer patients with the two commercially available MRI-guided RT devices. Participants also had a clinical focus on randomized trials in localized prostate cancer. The goal was to review both ongoing trials and present a conceptual focus on MRI-guided RT specifically in the definitive treatment of prostate cancer, along with developing and proposing novel trials for future consideration. Trial hypotheses, endpoints, and areas for improvement in localized prostate cancer that specifically leverage MR guided technology are presented. Results Multiple prospective trials were found that explored the potential of adaptive MRI-guided radiotherapy in the definitive treatment of prostate cancer. Different primary areas of improvement that MR guidance may offer in prostate cancer were summarized. Eight clinical trial design strategies are presented that summarize options for clinical trials testing the potential benefits of MRI-guided RT. Conclusions The number and scope of trials evaluating MRI-guided RT for localized prostate cancer is limited. Yet multiple promising opportunities to test this technology and potentially improve outcomes for men with prostate cancer undergoing definitive RT exist. Attention, in the form of multi-institutional randomized trials, is needed.
Collapse
Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Emma Hall
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Himanshu Nagar
- Depart of Radiation Oncology, Weill Cornell Medicine, Department of Radiation Oncology, New York, NY, United States
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uulke A. Van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Colleen A. F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Linda G. W. Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, and the Institute of Cancer Research, Sutton, United Kingdom
| |
Collapse
|
21
|
Michalet M, Riou O, Azria D, Decoene C, Crop F. News in magnetic resonance imaging use for radiation oncology. Cancer Radiother 2022; 26:784-788. [PMID: 36031496 DOI: 10.1016/j.canrad.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
Abstract
The purpose of this article is to give a summary of the progress of magnetic resonance imaging (MRI) in radiotherapy. MRI is an important imaging modality for treatment planning in radiotherapy. However, the registration step with the simulation scanner can be a source of errors, motivating the implementation of all-MRI simulation methods and new accelerators coupled with on-board MRI. First, practical MRI imaging for radiotherapy is detailed, but also the importance of a coherent imaging workflow incorporating all imaging modalities. Second, future evolutions and research domains such as quantitative imaging biomarkers, MRI-only pseudo computed tomography and radiomics are discussed. Finally, the application of MRI during radiotherapy treatment is reviewed: the use of MR-linear accelerators. MRI is increasingly integrated into radiotherapy. Advances in diagnostic imaging can thus benefit radiotherapy, but specific radiotherapy constraints lead to additional challenges and require close collaboration between radiologists, radiation oncologists, technologists and physicists. The integration of quantitative imaging biomarkers in the radiotherapy process will result in mutual benefit for diagnostic imaging and radiotherapy. MRI-guided radiotherapy has already been used for several years in clinical routine. Abdominopelvic neoplasias (pancreas, liver, prostate) are the preferred locations for treatment because of their favourable contrast in MRI, their movement during irradiation and their proximity to organs at risk of radiation exposure, making the tracking and daily adaptation of the plan essential. MRI has emerged as an increasingly necessary imaging modality for radiotherapy planning. Inclusion of patients in clinical trials evaluating new MRI-guided radiotherapy techniques and associated quantitative imaging biomarkers will be necessary to assess the benefits.
Collapse
Affiliation(s)
- M Michalet
- Institut du cancer de Montpellier, Fédération universitaire d'oncologie-radiothérapie d'Occitanie Méditerranée (Forom), Inserm U1194 IRCM, 208, avenue des Apothicaires, 34298 Montpellier, France.
| | - O Riou
- Institut du cancer de Montpellier, Fédération universitaire d'oncologie-radiothérapie d'Occitanie Méditerranée (Forom), Inserm U1194 IRCM, 208, avenue des Apothicaires, 34298 Montpellier, France
| | - D Azria
- Institut du cancer de Montpellier, Fédération universitaire d'oncologie-radiothérapie d'Occitanie Méditerranée (Forom), Inserm U1194 IRCM, 208, avenue des Apothicaires, 34298 Montpellier, France
| | - C Decoene
- Medical physics, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - F Crop
- Medical physics, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| |
Collapse
|
22
|
Delpon G, Barateau A, Beneux A, Bessières I, Latorzeff I, Welmant J, Tallet A. [What do we need to deliver "online" adapted radiotherapy treatment plans?]. Cancer Radiother 2022; 26:794-802. [PMID: 36028418 DOI: 10.1016/j.canrad.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
During the joint SFRO/SFPM session of the 2019 congress, a state of the art of adaptive radiotherapy announced a strong impact in our clinical practice, in particular with the availability of treatment devices coupled to an MRI system. Three years later, it seems relevant to take stock of adaptive radiotherapy in practice, and especially the "online" strategy because it is indeed more and more accessible with recent hardware and software developments, such as coupled accelerators to a three-dimensional imaging device and algorithms based on artificial intelligence. However, the deployment of this promising strategy is complex because it contracts the usual time scale and upsets the usual organizations. So what do we need to deliver adapted treatment plans with an "online" strategy?
Collapse
Affiliation(s)
- G Delpon
- Institut de cancérologie de l'Ouest, Saint-Herblain et IMT Atlantique, Nantes université, CNRS/IN2P3, Subatech, Nantes, France.
| | - A Barateau
- Université Rennes, CLCC Eugène-Marquis, Inserm, LTSI-UMR 1099, Rennes, France
| | - A Beneux
- Hospices Civils de Lyon, Lyon, France
| | - I Bessières
- Centre Georges-François Leclerc, Dijon, France
| | | | - J Welmant
- Institut du cancer de Montpellier, Montpellier, France
| | - A Tallet
- Institut Paoli-Calmettes, Marseille, France
| |
Collapse
|
23
|
Slotman BJ, Clark MA, Özyar E, Kim M, Itami J, Tallet A, Debus J, Pfeffer R, Gentile P, Hama Y, Andratschke N, Riou O, Camilleri P, Belka C, Quivrin M, Kim B, Pedersen A, van Overeem Felter M, Kim YI, Kim JH, Fuss M, Valentini V. Clinical adoption patterns of 0.35 Tesla MR-guided radiation therapy in Europe and Asia. Radiat Oncol 2022; 17:146. [PMID: 35996192 PMCID: PMC9396857 DOI: 10.1186/s13014-022-02114-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Magnetic resonance-guided radiotherapy (MRgRT) utilization is rapidly expanding, driven by advanced capabilities including better soft tissue imaging, continuous intrafraction target visualization, automatic triggered beam delivery, and the availability of on-table adaptive replanning. Our objective was to describe patterns of 0.35 Tesla (T)-MRgRT utilization in Europe and Asia among early adopters of this novel technology.
Methods Anonymized administrative data from all 0.35T-MRgRT treatment systems in Europe and Asia were extracted for patients who completed treatment from 2015 to 2020. Detailed treatment information was analyzed for all MR-linear accelerators (linac) and -cobalt systems.
Results From 2015 through the end of 2020, there were 5796 completed treatment courses delivered in 46,389 individual fractions. 23.5% of fractions were adapted. Ultra-hypofractionated (UHfx) dose schedules (1–5 fractions) were delivered for 63.5% of courses, with 57.8% of UHfx fractions adapted on-table. The most commonly treated tumor types were prostate (23.5%), liver (14.5%), lung (12.3%), pancreas (11.2%), and breast (8.0%), with increasing compound annual growth rates (CAGRs) in numbers of courses from 2015 through 2020 (pancreas: 157.1%; prostate: 120.9%; lung: 136.0%; liver: 134.2%). Conclusions This is the first comprehensive study reporting patterns of utilization among early adopters of a 0.35T-MRgRT system in Europe and Asia. Intrafraction MR image-guidance, advanced motion management, and increasing adoption of on-table adaptive RT have accelerated a transition to UHfx regimens. MRgRT has been predominantly used to treat tumors in the upper abdomen, pelvis and lungs, and increasingly with adaptive replanning, which is a radical departure from legacy radiotherapy practices.
Collapse
Affiliation(s)
| | - Mary Ann Clark
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA.
| | - Enis Özyar
- Department of Radiation Oncology, School of Medicine, Acibadem MAA University, Istanbul, Turkey
| | - Myungsoo Kim
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Itami
- Radiation Oncology, National Cancer Center Japan, Tokyo, Japan
| | - Agnès Tallet
- Radiation Therapy Department, Institut Paoli-Calmettes, Marseille, France.,CRCM Inserm UMR1068, Marseille, France
| | - Jürgen Debus
- Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centers, Tel Aviv, Israel
| | - PierCarlo Gentile
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | | | | | - Olivier Riou
- Montpellier Cancer Institute (ICM), University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier University, INSERM U1194 IRCM, 34298, Montpellier, France
| | | | - Claus Belka
- Radiation Oncology, Klinikum der Universität München, Munich, Germany
| | - Magali Quivrin
- Radiation Oncology, Centre Georges-Francois Leclerc, Dijon, France
| | - BoKyong Kim
- Department of Radiation Oncology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | | | | | - Young Il Kim
- Radiation Oncology, Chungnam National University Sejong Hospital, Daejeon, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Martin Fuss
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA
| | - Vincenzo Valentini
- Radiology, Radiation Oncology and Hematology Dept., Università Cattolica S.Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
24
|
MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges. Int J Radiat Oncol Biol Phys 2022; 114:950-967. [PMID: 35901978 DOI: 10.1016/j.ijrobp.2022.07.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting. METHODS AND MATERIALS We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT. RESULTS Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered. CONCLUSIONS The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.
Collapse
|
25
|
Tetar SU, Bruynzeel AM, Verweij L, Bohoudi O, Slotman BJ, Rosario T, Palacios MA, Lagerwaard FJ. Magnetic resonance imaging-guided radiotherapy for intermediate- and high-risk prostate cancer: Trade-off between planning target volume margin and online plan adaption. Phys Imaging Radiat Oncol 2022; 23:92-96. [PMID: 35844255 PMCID: PMC9283928 DOI: 10.1016/j.phro.2022.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Magnetic resonance-guided radiotherapy with daily plan adaptation for intermediate- and high-risk prostate cancer is time and labor intensive. Fifty adapted plans with 3 mm planning target volume (PTV)-margin were compared with non-adapted plans using 3 or 5 mm margins. Adequate (V95% ≥ 95%) prostate coverage was achieved in 49 fractions with 5 mm PTV without plan adaptation, however, coverage of the seminal vesicles (SV) was insufficient in 15 of 50 fractions. There was no insufficient coverage for prostate and SV using plan adaptation with 3 mm. Hence, daily adaptation is recommended to obtain adequate SV-coverage when using 3 mm PTV.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Frank J. Lagerwaard
- Corresponding author at: Amsterdam UMC, location VUmc, Postbox 7057, 1007 MB Amsterdam, The Netherlands.
| |
Collapse
|
26
|
Kissel M, Créhange G, Graff P. Stereotactic Radiation Therapy versus Brachytherapy: Relative Strengths of Two Highly Efficient Options for the Treatment of Localized Prostate Cancer. Cancers (Basel) 2022; 14:2226. [PMID: 35565355 PMCID: PMC9105931 DOI: 10.3390/cancers14092226] [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: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) has become a valid option for the treatment of low- and intermediate-risk prostate cancer. In randomized trials, it was found not inferior to conventionally fractionated external beam radiation therapy (EBRT). It also compares favorably to brachytherapy (BT) even if level 1 evidence is lacking. However, BT remains a strong competitor, especially for young patients, as series with 10-15 years of median follow-up have proven its efficacy over time. SBRT will thus have to confirm its effectiveness over the long-term as well. SBRT has the advantage over BT of less acute urinary toxicity and, more hypothetically, less sexual impairment. Data are limited regarding SBRT for high-risk disease while BT, as a boost after EBRT, has demonstrated superiority against EBRT alone in randomized trials. However, patients should be informed of significant urinary toxicity. SBRT is under investigation in strategies of treatment intensification such as combination of EBRT plus SBRT boost or focal dose escalation to the tumor site within the prostate. Our goal was to examine respective levels of evidence of SBRT and BT for the treatment of localized prostate cancer in terms of oncologic outcomes, toxicity and quality of life, and to discuss strategies of treatment intensification.
Collapse
Affiliation(s)
| | | | - Pierre Graff
- Department of Radiation Oncology, Institut Curie, 26 Rue d’Ulm, 75005 Paris, France; (M.K.); (G.C.)
| |
Collapse
|
27
|
Ristau J, Hörner-Rieber J, Buchele C, Klüter S, Jäkel C, Baumann L, Andratschke N, Garcia Schüler H, Guckenberger M, Li M, Niyazi M, Belka C, Herfarth K, Debus J, Koerber SA. Stereotactic MRI-guided radiation therapy for localized prostate cancer (SMILE): a prospective, multicentric phase-II-trial. Radiat Oncol 2022; 17:75. [PMID: 35428327 PMCID: PMC9011377 DOI: 10.1186/s13014-022-02047-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Normofractionated radiation regimes for definitive prostate cancer treatment usually extend over 7–8 weeks. Recently, moderate hypofractionation with doses per fraction between 2.2 and 4 Gy has been shown to be safe and feasible with oncologic non-inferiority compared to normofractionation. Radiobiologic considerations lead to the assumption that prostate cancer might benefit in particular from hypofractionation in terms of tumor control and toxicity. First data related to ultrahypofractionation demonstrate that the overall treatment time can be reduced to 5–7 fractions with single doses > 6 Gy safely, even with simultaneous focal boosting of macroscopic tumor(s). With MR-guided linear accelerators (MR-linacs) entering clinical routine, invasive fiducial implantations become unnecessary. The aim of the multicentric SMILE study is to evaluate the use of MRI-guided stereotactic radiotherapy for localized prostate cancer in 5 fractions regarding safety and feasibility. Methods The study is designed as a prospective, one-armed, two-stage, multi-center phase-II-trial with 68 patients planned. Low- and intermediate-risk localized prostate cancer patients will be eligible for the study as well as early high-risk patients (cT3a and/or Gleason Score ≤ 8 and/or PSA ≤ 20 ng/ml) according to d’Amico. All patients will receive definitive MRI-guided stereotactic radiation therapy with a total dose of 37.5 Gy in 5 fractions (single dose 7.5 Gy) on alternating days. A focal simultaneous integrated boost to MRI-defined tumor(s) up to 40 Gy can optionally be applied. The primary composite endpoint includes the assessment of urogenital or gastrointestinal toxicity ≥ grade 2 or treatment-related discontinuation of therapy. The use of MRI-guided radiotherapy enables online plan adaptation and intrafractional gating to ensure optimal target volume coverage and protection of organs at risk. Discussion With moderate hypofractionation being the standard in definitive radiation therapy for localized prostate cancer at many institutions, ultrahypofractionation could be the next step towards reducing treatment time without compromising oncologic outcomes and toxicities. MRI-guided radiotherapy could qualify as an advantageous tool as no invasive procedures have to precede in therapeutic workflows. Furthermore, MRI guidance combined with gating and plan adaptation might be essential in order to increase treatment effectivity and reduce toxicity at the same time.
Collapse
|
28
|
Yuan J, Poon DMC, Lo G, Wong OL, Cheung KY, Yu SK. A narrative review of MRI acquisition for MR-guided-radiotherapy in prostate cancer. Quant Imaging Med Surg 2022; 12:1585-1607. [PMID: 35111651 PMCID: PMC8739116 DOI: 10.21037/qims-21-697] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/20/2021] [Indexed: 08/24/2023]
Abstract
Magnetic resonance guided radiotherapy (MRgRT), enabled by the clinical introduction of the integrated MRI and linear accelerator (MR-LINAC), is a novel technique for prostate cancer (PCa) treatment, promising to further improve clinical outcome and reduce toxicity. The role of prostate MRI has been greatly expanded from the traditional PCa diagnosis to also PCa screening, treatment and surveillance. Diagnostic prostate MRI has been relatively familiar in the community, particularly with the development of Prostate Imaging - Reporting and Data System (PI-RADS). But, on the other hand, the use of MRI in the emerging clinical practice of PCa MRgRT, which is substantially different from that in PCa diagnosis, has been so far sparsely presented in the medical literature. This review attempts to give a comprehensive overview of MRI acquisition techniques currently used in the clinical workflows of PCa MRgRT, from treatment planning to online treatment guidance, in order to promote MRI practice and research for PCa MRgRT. In particular, the major differences in the MRI acquisition of PCa MRgRT from that of diagnostic prostate MRI are demonstrated and explained. Limitations in the current MRI acquisition for PCa MRgRT are analyzed. The future developments of MRI in the PCa MRgRT are also discussed.
Collapse
Affiliation(s)
- Jing Yuan
- Medical Physics and Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Darren M. C. Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Gladys Lo
- Department of Diagnostic & Interventional Radiology, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Oi Lei Wong
- Medical Physics and Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Kin Yin Cheung
- Medical Physics and Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Siu Ki Yu
- Medical Physics and Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, China
| |
Collapse
|
29
|
Cellini F, Tagliaferri L, Frascino V, Alitto AR, Fionda B, Boldrini L, Romano A, Casà C, Catucci F, Mattiucci GC, Valentini V. Radiation therapy for prostate cancer: What's the best in 2021. Urologia 2022; 89:5-15. [PMID: 34496707 DOI: 10.1177/03915603211042335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Radiotherapy is highly involved in the management of prostate cancer. Its features and potential applications experienced a radical evolution over last decades, as they are associated to the continuous evolution of available technology and current oncological innovations. Some application of radiotherapy like brachytherapy have been recently enriched by innovative features and multidisciplinary dedications. In this report we aim to put some questions regarding the following issues regarding multiple aspects of modern application of radiation oncology: the current application of radiation oncology; the modern role of stereotactic body radiotherapy (SBRT) for both the management of primary lesions and for lymph-nodal recurrence; the management of the oligometastatic presentations; the role of brachytherapy; the aid played by the application of the organ at risk spacer (spacer OAR), fiducial markers, electromagnetic tracking systems and on-line Magnetic Resonance guided radiotherapy (MRgRT), and the role of the new opportunity represented by radiomic analysis.
Collapse
Affiliation(s)
- Francesco Cellini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Luca Tagliaferri
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Vincenzo Frascino
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Anna Rita Alitto
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Bruno Fionda
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Luca Boldrini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Angela Romano
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Calogero Casà
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Gian Carlo Mattiucci
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
- Radiation Oncology, Mater Olbia Hospital, Olbia, Italy
| | - Vincenzo Valentini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
| |
Collapse
|
30
|
Hall WA, Paulson E, Li XA, Erickson B, Schultz C, Tree A, Awan M, Low DA, McDonald BA, Salzillo T, Glide-Hurst CK, Kishan AU, Fuller CD. Magnetic resonance linear accelerator technology and adaptive radiation therapy: An overview for clinicians. CA Cancer J Clin 2022; 72:34-56. [PMID: 34792808 PMCID: PMC8985054 DOI: 10.3322/caac.21707] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) continues to play an important role in the treatment of cancer. Adaptive RT (ART) is a novel method through which RT treatments are evolving. With the ART approach, computed tomography or magnetic resonance (MR) images are obtained as part of the treatment delivery process. This enables the adaptation of the irradiated volume to account for changes in organ and/or tumor position, movement, size, or shape that may occur over the course of treatment. The advantages and challenges of ART maybe somewhat abstract to oncologists and clinicians outside of the specialty of radiation oncology. ART is positioned to affect many different types of cancer. There is a wide spectrum of hypothesized benefits, from small toxicity improvements to meaningful gains in overall survival. The use and application of this novel technology should be understood by the oncologic community at large, such that it can be appropriately contextualized within the landscape of cancer therapies. Likewise, the need to test these advances is pressing. MR-guided ART (MRgART) is an emerging, extended modality of ART that expands upon and further advances the capabilities of ART. MRgART presents unique opportunities to iteratively improve adaptive image guidance. However, although the MRgART adaptive process advances ART to previously unattained levels, it can be more expensive, time-consuming, and complex. In this review, the authors present an overview for clinicians describing the process of ART and specifically MRgART.
Collapse
MESH Headings
- History, 20th Century
- History, 21st Century
- Humans
- Magnetic Resonance Imaging, Interventional/history
- Magnetic Resonance Imaging, Interventional/instrumentation
- Magnetic Resonance Imaging, Interventional/methods
- Magnetic Resonance Imaging, Interventional/trends
- Neoplasms/diagnostic imaging
- Neoplasms/radiotherapy
- Particle Accelerators
- Radiation Oncology/history
- Radiation Oncology/instrumentation
- Radiation Oncology/methods
- Radiation Oncology/trends
- Radiotherapy Planning, Computer-Assisted/history
- Radiotherapy Planning, Computer-Assisted/instrumentation
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy Planning, Computer-Assisted/trends
Collapse
Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alison Tree
- The Royal Marsden National Health Service Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel A. Low
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Brigid A. McDonald
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Travis Salzillo
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Carri K. Glide-Hurst
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
31
|
1.5T Magnetic Resonance-Guided Stereotactic Body Radiotherapy for Localized Prostate Cancer: Preliminary Clinical Results of Clinician- and Patient-Reported Outcomes. Cancers (Basel) 2021; 13:cancers13194866. [PMID: 34638348 PMCID: PMC8508440 DOI: 10.3390/cancers13194866] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) offers the potential for achieving better prostate cancer (PC) treatment outcomes. This study reports the preliminary clinical results of 1.5T MRgSBRT in localized PC, based on both clinician-reported outcome measurement (CROM) and patient-reported outcome measurement (PROM). METHODS Fifty-one consecutive localized PC patients were prospectively enrolled with a median follow-up of 199 days. MRgSBRT was delivered in five fractions of 7.25-8 Gy with daily online adaptation. Clinician-reported gastrointestinal (GI) and genitourinary (GU) adverse events based on the Common Terminology Criteria for Adverse Events (CTCAE) Scale v. 5.0 were assessed. The Expanded Prostate Cancer Index Composite Questionnaire was collected at baseline, 1 month, and every 3 months thereafter. Serial prostate-specific antigen measurements were longitudinally recorded. RESULTS The maximum cumulative clinician-reported grade ≥ 2 acute GU and GI toxicities were 11.8% (6/51) and 2.0% (1/51), respectively, while grade ≥ 2 subacute GU and GI toxicities were 2.3% (1/43) each. Patient-reported urinary, bowel, and hormonal domain summary scores were reduced at 1 month, then gradually returned to baseline levels, with the exception of the sexual domain. Domain-specific subscale scores showed similar longitudinal changes. All patients had early post-MRgSBRT biochemical responses. CONCLUSIONS The finding of low toxicity supports the accumulation of clinical evidence for 1.5T MRgSBRT in localized PC.
Collapse
|
32
|
Farjam R, Mahase SS, Chen SL, Coonce M, Pennell RT, Fecteau R, Chughtai B, Dewyngaert JK, Kang J, Ch Formenti S, Nagar H. Quantifying the impact of SpaceOAR hydrogel on inter-fractional rectal and bladder dose during 0.35 T MR-guided prostate adaptive radiotherapy. J Appl Clin Med Phys 2021; 22:49-58. [PMID: 34342134 PMCID: PMC8425860 DOI: 10.1002/acm2.13344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the impact of rectal spacing on inter-fractional rectal and bladder dose and the need for adaptive planning in prostate cancer patients undergoing SBRT with a 0.35 T MRI-Linac. MATERIALS AND METHODS We evaluated and compared SBRT plans from prostate cancer patients with and without rectal spacer who underwent treatment on a 0.35 T MRI-Linac. Each group consisted of 10 randomly selected patients that received prostate SBRT to a total dose of 36.25 Gy in five fractions. Dosimetric differences in planned and delivered rectal and bladder dose and the number of fractions violating OAR constraints were quantified. We also assessed whether adaptive planning was needed to meet constraints for each fraction. RESULTS On average, rectal spacing reduced the maximum dose delivered to the rectum by more than 8 Gy (p < 0.001). We also found that D3cc received by the rectum could be 12 Gy higher in patients who did not have rectal spacer (p < 9E-7). In addition, the results show that a rectal spacer can reduce the maximum dose and D15cc to the bladder wall by more than 1 (p < 0.004) and 8 (p < 0.009) Gy, respectively. Our study also shows that using a rectal spacer could reduce the necessity for adaptive planning. The incidence of dose constraint violation was observed in almost 91% of the fractions in patients without the rectal spacer and 52% in patients with implanted spacer. CONCLUSION Inter-fractional changes in rectal and bladder dose were quantified in patients who underwent SBRT with/without rectal SpaceOAR hydrogel. Rectal spacer does not eliminate the need for adaptive planning but reduces its necessity.
Collapse
Affiliation(s)
- Reza Farjam
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Sean S. Mahase
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Shu Ling Chen
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Madeline Coonce
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Ryan T. Pennell
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Ryan Fecteau
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Bilal Chughtai
- Department of UrologyWeill Cornell Medical CollegeNew YorkNYUSA
| | | | - Josephine Kang
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Silvia Ch Formenti
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Himanshu Nagar
- Department of Radiation OncologyWeill Cornell Medical CollegeNew YorkNYUSA
| |
Collapse
|
33
|
Evaluation of T2-Weighted MRI for Visualization and Sparing of Urethra with MR-Guided Radiation Therapy (MRgRT) On-Board MRI. Cancers (Basel) 2021; 13:cancers13143564. [PMID: 34298777 PMCID: PMC8307202 DOI: 10.3390/cancers13143564] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Stereotactic body radiation therapy (SBRT) has become a standard of care option for prostate cancer patients, utilizing large fractionated dose to shorten treatment times. However, genitourinary (GU) toxicity associated with urethral injury remains prevalent due to non-trivial urethra delineation and sparing at treatment planning and treatment delivery. The aim of our study was to evaluate two optimized urethral MRI sequences (3D HASTE and 3D TSE) with a 0.35T MR-guided radiotherapy (MRgRT) system for urethral visibility and delineation. Among 11 prostate cancer patients, a radiation oncologist qualitatively scored MRgRT 3D HASTE as having the best urethra visibility, superior to CT, clinical MRgRT 3D bSSFP, MRgRT 3D TSE, and similar to diagnostic 3T (2D/3D) T2-weighetd MRI. Moreover, urethra contours from different imaging and clinical workflows demonstrated significant urethra localization variability. Optimized 3D MRgRT HASTE can provide urethral visualization and delineation within an MRgRT workflow for urethral sparing, avoiding cross-modality/system registration errors. Abstract Purpose: To evaluate urethral contours from two optimized urethral MRI sequences with an MR-guided radiotherapy system (MRgRT). Methods: Eleven prostate cancer patients were scanned on a MRgRT system using optimized urethral 3D HASTE and 3D TSE. A resident radiation oncologist contoured the prostatic urethra on the patients’ planning CT, diagnostic 3T T2w MRI, and both urethral MRIs. An attending radiation oncologist reviewed/edited the resident’s contours and additionally contoured the prostatic urethra on the clinical planning MRgRT MRI (bSSFP). For each image, the resident radiation oncologist, attending radiation oncologist, and a senior medical physicist qualitatively scored the prostatic urethra visibility. Using MRgRT 3D HASTE-based contouring workflow as baseline, prostatic urethra contours drawn on CT, diagnostic MRI, clinical bSSFP and 3D TSE were evaluated relative to the contour on 3D HASTE using 95th percentile Hausdorff distance (HD95), mean-distance-to-agreement (MDA), and DICE coefficient. Additionally, prostatic urethra contrast-to-noise-ratios (CNR) were calculated for all images. Results: For two out of three observers, the urethra visibility score for 3D HASTE was significantly higher than CT, and clinical bSSFP, but was not significantly different from diagnostic MRI. The mean HD95/MDA/DICE values were 11.35 ± 3.55 mm/5.77 ± 2.69 mm/0.07 ± 0.08 for CT, 7.62 ± 2.75 mm/3.83 ± 1.47 mm/0.12 ± 0.10 for CT + diagnostic MRI, 5.49 ± 2.32 mm/2.18 ± 1.19 mm/0.35 ± 0.19 for 3D TSE, and 6.34 ± 2.89 mm/2.65 ± 1.31 mm/0.21 ± 0.12 for clinical bSSFP. The CNR for 3D HASTE was significantly higher than CT, diagnostic MRI, and clinical bSSFP, but was not significantly different from 3D TSE. Conclusion: The urethra’s visibility scores showed optimized urethral MRgRT 3D HASTE was superior to the other tested methodologies. The prostatic urethra contours demonstrated significant variability from different imaging and workflows. Urethra contouring uncertainty introduced by cross-modality registration and sub-optimal imaging contrast may lead to significant treatment degradation when urethral sparing is implemented to minimize genitourinary toxicity.
Collapse
|
34
|
Møller PK, Pappot H, Bernchou U, Schytte T, Dieperink KB. Development of patient-reported outcomes item set to evaluate acute treatment toxicity to pelvic online magnetic resonance-guided radiotherapy. J Patient Rep Outcomes 2021; 5:47. [PMID: 34160732 PMCID: PMC8220120 DOI: 10.1186/s41687-021-00326-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 01/04/2023] Open
Abstract
Background A new technology in cancer treatment, the MR-linac, provides online magnetic resonance-guided radiotherapy (MRgRT) that combines real-time visualization of the tumor and surrounding tissue with radiation therapy to deliver treatment more accurately. Online MRgRT makes it possible to minimize treatment volume, potentially reducing acute treatment toxicity. Patient-reported outcomes (PRO) add the patient perspective to evaluating treatment toxicity related to new technology. The objective of this mixed-methods study was to develop and explore the content validity of a set of PRO items to evaluate acute pelvic toxicity to radiotherapy including online MRgRT. Methods A literature review and chart audit were conducted to identify symptomatic adverse events (AEs) to be selected from the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) library and European Organisation for Research and Treatment of Cancer (EORTC) item library. To validate the content, the item set was applied in a prospective pilot cohort of patients referred for primary pelvic RT with curative intent. Patients reported symptoms weekly during RT (4–8 weeks) and the subsequent 4 weeks. Follow-up reports were collected at 8, 12, and 24 weeks after RT. To ensure symptom coverage clinician-reported toxicity and individual patient interviews were conducted. The symptomatic AEs were included in the final item set if ≥20% of patients reported them. Results Eighteen acute symptomatic AEs were selected for the initial item set. Forty patients (32 prostate cancer, 8 cervical cancer) were included in the pilot study. Patients with prostate cancer and those with cervical cancer both reported all 18 acute AEs. However, vomiting was not reported by > 20% of patients thus excluded from the item set. Adding a few diagnosis-specific AEs to the final item set was required for both prostate and cervical cancer patients. Conclusions A PRO item set for patients with pelvic cancer treated with radiotherapy with a curative intent was developed and content validity explored. In the pilot study, the item set captured the most common acute symptomatic AEs for patients with prostate and cervical cancer related to pelvic RT including online MRgRT. Further validation of the content in broader disease sites would be needed in future studies. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-021-00326-w.
Collapse
Affiliation(s)
- P K Møller
- Department of Oncology, Odense University Hospital, AgeCare, Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - H Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - U Bernchou
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - T Schytte
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - K B Dieperink
- Department of Oncology, Odense University Hospital, AgeCare, Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
35
|
MR-Guided Hypofractionated Radiotherapy: Current Emerging Data and Promising Perspectives for Localized Prostate Cancer. Cancers (Basel) 2021; 13:cancers13081791. [PMID: 33918650 PMCID: PMC8070332 DOI: 10.3390/cancers13081791] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary The biological features of prostate cancer as a tumor with a low alpha beta ratio have led clinicians to consider the use of higher doses per fraction, thus gaining an advantage both in terms of clinical outcomes and of logistic opportunities. To date, moderate hypofractionated schedules are supported by several international clinical guidelines. The subsequent step was represented by the adoption of extreme hypofractionated schedules, for which recent literature data report non-inferiority results for the five-fractions regimens. In this scenario, the recent introduction of MR-guided daily adaptive radiotherapy is a potential paradigm shift, given the ability to increase the resolution of the pelvis anatomy and to take into account of the daily variations in shape and size of the nearby healthy structures. Abstract In this review we summarize the currently available evidence about the role of hybrid machines for MR-guided radiotherapy for prostate stereotactic body radiotherapy. Given the novelty of this technology, to date few data are accessible, but they all report very promising results in terms of tolerability and preliminary clinical outcomes. Most of the studies highlight the favorable impact of on-board magnetic resonance imaging as a means to improve target and organs at risk identification with a consequent advantage in terms of dosimetric results, which is expected to relate to a more favorable toxicity pattern. Still, the longer treatment time per session may potentially affect the patient’s compliance to the treatment, although first quality of life assessment studies have reported substantial tolerability and no major impact on quality of life. Finally, in this review we hypothesize some future scenarios of further investigation, based on the possibility to explore the superior anatomy visualization and the role of daily adapted treatments provided by hybrid MR-Linacs.
Collapse
|
36
|
Boldrini L, Corradini S, Gani C, Henke L, Hosni A, Romano A, Dawson L. MR-Guided Radiotherapy for Liver Malignancies. Front Oncol 2021; 11:616027. [PMID: 33869001 PMCID: PMC8047407 DOI: 10.3389/fonc.2021.616027] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
MR guided radiotherapy represents one of the most promising recent technological innovations in the field. The possibility to better visualize therapy volumes, coupled with the innovative online adaptive radiotherapy and motion management approaches, paves the way to more efficient treatment delivery and may be translated in better clinical outcomes both in terms of response and reduced toxicity. The aim of this review is to present the existing evidence about MRgRT applications for liver malignancies, discussing the potential clinical advantages and the current pitfalls of this new technology.
Collapse
Affiliation(s)
- Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University, Tübingen, Germany
| | - Lauren Henke
- Department of Radiation Oncology, Washington University in St Louis, St Louis, MO, United States
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Laura Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
37
|
Koerber SA, Beuthien-Baumann B. [Modern radiation therapy planning and image-guided radiotherapy using the example of prostate cancer]. Radiologe 2021; 61:28-35. [PMID: 33057736 DOI: 10.1007/s00117-020-00763-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CLINICAL/METHODICAL ISSUE Optimizing radiotherapy demands precise delineation of the target structure, not only before but also during the course of radiotherapy. STANDARD RADIOLOGICAL METHODS For many years, planning of external radiation treatment planning has been based on computer tomography data. METHODOLOGICAL INNOVATIONS With the advent of image-guided radiotherapy (IGRT), magnetic resonance imaging (MRI) and functional hybrid imaging are increasingly being integrated into radiation treatment planning. The development of the MR-linac can be seen as an innovation. PERFORMANCE The integration of MRI and hybrid imaging (positron emission tomography [PET]/CT, PET/MRI) in the treatment planning process enables more precise treatment planning due to the better morphological and functional information. The integration of MRI data on the MR-linac in daily position control enables adaptation of the irradiation plan to the current conditions. ACHIEVEMENTS Technical innovation such as the MR-linac as well as increasing use of hybrid imaging contribute to the objective of further individualization within (radio)oncology. PRACTICAL RECOMMENDATIONS Using the example of prostate cancer, the application of prostate-specific membrane antigen (PSMA) ligands and hybrid imaging offers great potential for individualized strategic treatment decisions. The MR-linac appears to be particularly suitable for radiation therapy of prostate cancer. Special attention must be paid to the technical aspects of positioning and data acquisition for the purpose of radiation treatment planning.
Collapse
Affiliation(s)
- Stefan A Koerber
- Klinik für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland. .,Nationales Centrum für Tumorerkrankungen (NCT), Heidelberg, Deutschland. .,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Deutschland.
| | | |
Collapse
|
38
|
Bohoudi O, Bruynzeel AME, Tetar S, Slotman BJ, Palacios MA, Lagerwaard FJ. Dose accumulation for personalized stereotactic MR-guided adaptive radiation therapy in prostate cancer. Radiother Oncol 2021; 157:197-202. [PMID: 33545251 DOI: 10.1016/j.radonc.2021.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Adaptive MR-guided radiotherapy (MRgRT) is an innovative approach for delivering stereotactic body radiotherapy (SBRT) in prostate cancer (PC). Despite the increased clinical use of SBRT for PC, there is limited data on the relation between the actual delivered dose and toxicity. We aimed to identify dose parameters based on the total accumulated delivered bladder dose (DOSEACCTX). Furthermore, for future personalization, we studied whether prospective accumulation of the first 3 of 5 fractions (DOSEACC3FR) could be used as a representative of DOSEACCTX. MATERIALS AND METHODS We deployed a recently validated deformable image registration-based dose accumulation strategy to reconstruct DOSEACCTX and DOSEACC3FR in 101 PC patients treated with stereotactic MRgRT. IPSS scores at baseline, end of MRgRT, at 6 and 12 weeks after treatment were analyzed to identify a clinically relevant increase of acute urinary symptoms. A receiver operator characteristic curve analysis was used to investigate the correlation of an increase in IPSS and bladder DOSEACCTX (range V5-V36.25 Gy, D1cc, D5cc) and DOSEACC3FR (range V6-V21.8 Gy, D1cc, D5cc) parameters. RESULTS A clinically relevant increase in IPSS in the three months following MRgRT was observed in 25 patients. The V20Gy-32Gy from DOSEACCTX and V15Gy-18Gy from DOSEACC3FR showed good correlation with IPSS increase with area under the curve (AUC) values ranging from 0.71 to 0.75. In contrast, baseline dosimetry showed a poor correlation with AUC values between 0.53 and 0.62. CONCLUSION DOSEACCTX was superior to baseline dosimetry in predicting acute urinary symptoms. Because DOSEACC3FR also showed good correlation, this can potentially be used to optimize MRgRT for the remaining fractions.
Collapse
Affiliation(s)
- Omar Bohoudi
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
| | - Anna M E Bruynzeel
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Shyama Tetar
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ben J Slotman
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Miguel A Palacios
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frank J Lagerwaard
- Dept. Of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| |
Collapse
|
39
|
Hörner-Rieber J, Klüter S, Debus J, Adema G, Ansems M, Verheij M. MR-Guided Radiotherapy: The Perfect Partner for Immunotherapy? Front Oncol 2021; 10:615697. [PMID: 33604296 PMCID: PMC7884826 DOI: 10.3389/fonc.2020.615697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022] Open
Abstract
During the last years, preclinical and clinical studies have emerged supporting the rationale to integrate radiotherapy and immunotherapy. Radiotherapy may enhance the effects of immunotherapy by improving tumor antigen release, antigen presentation, and T-cell infiltration. Recently, magnetic resonance guided radiotherapy (MRgRT) has become clinically available. Compared to conventional radiotherapy techniques, MRgRT firstly allows for daily on-table treatment adaptation, which enables both dose escalation for increasing tumor response and superior sparing of radiosensitive organs-at-risk for reducing toxicity. The current review focuses on the potential of combining MR-guided adaptive radiotherapy with immunotherapy by providing an overview on the current status of MRgRT, latest developments in preclinical and clinical radio-immunotherapy, and the unique opportunities and challenges for MR-guided radio-immunotherapy. MRgRT might especially assist in answering open questions in radio-immunotherapy regarding optimal radiation dose, fractionation, timing of immunotherapy, appropriate irradiation volumes, and response prediction.
Collapse
Affiliation(s)
- Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Gosse Adema
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marleen Ansems
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
40
|
Tocco BR, Kishan AU, Ma TM, Kerkmeijer LGW, Tree AC. MR-Guided Radiotherapy for Prostate Cancer. Front Oncol 2020; 10:616291. [PMID: 33363041 PMCID: PMC7757637 DOI: 10.3389/fonc.2020.616291] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/09/2020] [Indexed: 01/08/2023] Open
Abstract
External beam radiotherapy remains the primary treatment modality for localized prostate cancer. The radiobiology of prostate carcinoma lends itself to hypofractionation, with recent studies showing good outcomes with shorter treatment schedules. However, the ability to accurately deliver hypofractionated treatment is limited by current image-guided techniques. Magnetic resonance imaging is the main diagnostic tool for localized prostate cancer and its use in the therapeutic setting offers anatomical information to improve organ delineation. MR-guided radiotherapy, with daily re-planning, has shown early promise in the accurate delivery of radiotherapy. In this article, we discuss the shortcomings of current image-guidance strategies and the potential benefits and limitations of MR-guided treatment for prostate cancer. We also recount present experiences of MR-linac workflow and the opportunities afforded by this technology.
Collapse
Affiliation(s)
- Boris R. Tocco
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Amar U. Kishan
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Ting Martin Ma
- University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Alison C. Tree
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Department of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| |
Collapse
|
41
|
Boyle PJ, Huynh E, Boyle S, Campbell J, Penney J, Usta I, Neubauer Sugar E, Hacker F, Williams C, Cagney D, Mak R, Singer L. Use of a healthy volunteer imaging program to optimize clinical implementation of stereotactic MR-guided adaptive radiotherapy. Tech Innov Patient Support Radiat Oncol 2020; 16:70-76. [PMID: 33305025 PMCID: PMC7710639 DOI: 10.1016/j.tipsro.2020.10.004] [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: 07/27/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 11/11/2022] Open
Abstract
PURPOSE MR-linacs (MRLs) have enabled the use of stereotactic magnetic resonance (MR) guided online adaptive radiotherapy (SMART) across many cancers. As data emerges to support SMART, uncertainty remains regarding optimal technical parameters, such as optimal patient positioning, immobilization, image quality, and contouring protocols. Prior to clinical implementation of SMART, we conducted a prospective study in healthy volunteers (HVs) to determine optimal technical parameters and to develop and practice a multidisciplinary SMART workflow. METHODS HVs 18 years or older were eligible to participate in this IRB-approved study. Using a 0.35 T MRL, simulated adaptive treatments were performed by a multi-disciplinary treatment team in HVs. For each scan, image quality parameters were assessed on a 5-point scale (5 = extremely high, 1 = extremely poor). Adaptive recontouring times were compared between HVs and subsequent clinical cases with a t-test. RESULTS 18 simulated treatments were performed in HVs on MRL. Mean parameters for visibility of target, visibility of nearby organs, and overall image quality were 4.58, 4.62, and 4.62, respectively (range of 4-5 for all measures). In HVs, mean ART was 15.7 min (range 4-35), comparable to mean of 16.1 (range 7-33) in the clinical cases (p = 0.8963). Using HV cases, optimal simulation and contouring guidelines were developed across a range of disease sites and have since been implemented clinically. CONCLUSIONS Prior to clinical implementation of SMART, scans of HVs on an MRL resulted in acceptable image quality and target visibility across a range of organs with similar ARTs to clinical SMART. We continue to utilize HV scans prior to clinical implementation of SMART in new disease sites and to further optimize target tracking and immobilization. Further study is needed to determine the optimal duration of HV scanning prior to clinical implementation.
Collapse
Affiliation(s)
- Patrick J. Boyle
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Huynh
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Sara Boyle
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jennifer Campbell
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jessica Penney
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Emily Neubauer Sugar
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Fred Hacker
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Christopher Williams
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Daniel Cagney
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Raymond Mak
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Lisa Singer
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| |
Collapse
|