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Xiao H, Han Q, Wei S, Du M, Deng X, Zhang N, Li C, Wang J, Qu A, Jiang P. Setup errors analysis in iterative kV CBCT: A clinical study of cervical cancer treated with Volumetric Modulated Arc Therapy. J Appl Clin Med Phys 2024:e14480. [PMID: 39120606 DOI: 10.1002/acm2.14480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 06/17/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVE This study aims to analyze setup errors in pelvic Volumetric Modulated Arc Therapy (VMAT) for patients with non-surgical primary cervical cancer, utilizing the onboard iterative kV cone beam CT (iCBCT) imaging system on the Varian Halcyon 2.0 ring gantry structure accelerator to enhance radiotherapy precision. METHOD We selected 132 cervical cancer patients who underwent VMAT with daily iCBCT imaging guidance. Before each treatment session, a registration method based on the bony structure was employed to acquire iCBCT images with the corresponding planning CT images. Following verification and adjustment of image registration results along the three axes (but not rotational), setup errors in the lateral (X-axis), longitudinal (Y-axis), and vertical (Z-axis) directions were recorded for each patient. Subsequently, we analyzed 3642 iCBCT image setup errors. RESULTS The mean setup errors for the X, Y, and Z axes were 4.50 ± 3.79 mm, 6.08 ± 6.30 mm, and 1.48 ± 2.23 mm, respectively. Before correction with iCBCT, setup margins based on the Van Herk formula for the X, Y, and Z axes were 6.28, 12.52, and 3.26 mm, respectively. In individuals aged 60 years and older, setup errors in the X and Y axes were significantly larger than those in the younger group (p < 0.05). Additionally, there is no significant linear correlation between setup errors and treatment fraction numbers. CONCLUSION Data analysis underscores the importance of precise Y-axis setup for cervical cancer patients undergoing VMAT. Radiotherapy centers without daily iCBCT should appropriately extend the planning target volume (PTV) along the Y-axis for cervical cancer patients receiving pelvic VMAT. Elderly patients exhibit significantly larger setup errors compared to younger counterparts. In conclusion, iCBCT-guided radiotherapy is recommended for cervical cancer patients undergoing VMAT to improve setup precision.
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Affiliation(s)
- Hui Xiao
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Qiman Han
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Shuhua Wei
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Minghao Du
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Xiuwen Deng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Nan Zhang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Chunxiao Li
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Ang Qu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
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Wang YW, Chen M, Shen WT, Xu HP. The clinical practice and dosimetric outcome of the manual adaptive planning during definitive radiotherapy for cervical cancer. J Cancer Res Clin Oncol 2024; 150:280. [PMID: 38802664 PMCID: PMC11130034 DOI: 10.1007/s00432-024-05809-z] [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: 04/14/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
PROPOSE To evaluate the advantage of the manual adaptive plans comparing to the scheduled plans, and explored clinical factors predicting patients suitable for adaptive strategy. METHODS AND MATERIALS Eighty two patients with weekly online cone-beam computed tomography (CBCT) were enrolled. The re-CT simulation was performed after 15 fractions and a manual adaptive plan was developed if a significant deviation of the planning target volume (PTV) was found. To evaluate the dosimetric benefit, D98, homogeneity index (HI) and conformity index (CI) for the planning target volume (PTV), as well as D2cc of the bowel, bladder, sigmoid and rectum were compared between manual adaptive plans and scheduled ones. The clinical factors influencing target motion during radiotherapy were analyzed by chi-square test and logistic regression analysis. RESULTS The CI and HI of the manual adaptive plans were significantly superior to the scheduled ones (P = 0.0002, 0.003, respectively), demonstrating a better dose coverage of the target volume. Compared to the scheduled plans, D98 of the manual adaptive plans increased by 3.3% (P = 0.0002), the average of D2cc to the rectum, bladder decreased 0.358 Gy (P = 0.000034) and 0.240 Gy (P = 0.03), respectively. In addition, the chi-square test demonstrated that age, primary tumor volume, and parametrial infiltration were the clinical factors influencing target motion during radiotherapy. Multivariate analysis further identified the large tumor volume (≥ 50cm3, OR = 3.254, P = 0.039) and parametrial infiltration (OR = 3.376, P = 0.018) as the independent risk factors. CONCLUSION We found the most significant organ motion happened after 15 fractions during treatment. The manual adaptive plans improved the dose coverage and decreased the OAR doses. Patients with bulky mass or with parametrial infiltration were highly suggested to adaptive strategy during definitive radiotherapy due to the significant organ motion.
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Affiliation(s)
- Yi-Wei Wang
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, No.197 Rui Jin Er Rd, Shanghai, 200025, China
| | - Min Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, No.197 Rui Jin Er Rd, Shanghai, 200025, China
| | - Wen-Tong Shen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, No.197 Rui Jin Er Rd, Shanghai, 200025, China.
| | - Hao-Ping Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, No.197 Rui Jin Er Rd, Shanghai, 200025, China.
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Zeng Z, Zhu J, Wang Z, Wang G, Yan J, Zhang F. Pelvic target volume inter-fractional motion during radiotherapy for cervical cancer with daily iterative cone beam computed tomography. Radiat Oncol 2024; 19:48. [PMID: 38622628 PMCID: PMC11017626 DOI: 10.1186/s13014-024-02438-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Tumor regression and organ movements indicate that a large margin is used to ensure target volume coverage during radiotherapy. This study aimed to quantify inter-fractional movements of the uterus and cervix in patients with cervical cancer undergoing radiotherapy and to evaluate the clinical target volume (CTV) coverage. METHODS This study analyzed 303 iterative cone beam computed tomography (iCBCT) scans from 15 cervical cancer patients undergoing external beam radiotherapy. CTVs of the uterus (CTV-U) and cervix (CTV-C) contours were delineated based on each iCBCT image. CTV-U encompassed the uterus, while CTV-C included the cervix, vagina, and adjacent parametrial regions. Compared with the planning CTV, the movement of CTV-U and CTV-C in the anterior-posterior, superior-inferior, and lateral directions between iCBCT scans was measured. Uniform expansions were applied to the planning CTV to assess target coverage. RESULTS The motion (mean ± standard deviation) in the CTV-U position was 8.3 ± 4.1 mm in the left, 9.8 ± 4.4 mm in the right, 12.6 ± 4.0 mm in the anterior, 8.8 ± 5.1 mm in the posterior, 5.7 ± 5.4 mm in the superior, and 3.0 ± 3.2 mm in the inferior direction. The mean CTV-C displacement was 7.3 ± 3.2 mm in the left, 8.6 ± 3.8 mm in the right, 9.0 ± 6.1 mm in the anterior, 8.4 ± 3.6 mm in the posterior, 5.0 ± 5.0 mm in the superior, and 3.0 ± 2.5 mm in the inferior direction. Compared with the other tumor (T) stages, CTV-U and CTV-C motion in stage T1 was larger. A uniform CTV planning treatment volume margin of 15 mm failed to encompass the CTV-U and CTV-C in 11.1% and 2.2% of all fractions, respectively. The mean volume change of CTV-U and CTV-C were 150% and 51%, respectively, compared with the planning CTV. CONCLUSIONS Movements of the uterine corpus are larger than those of the cervix. The likelihood of missing the CTV is significantly increased due to inter-fractional motion when utilizing traditional planning margins. Early T stage may require larger margins. Personal radiotherapy margining is needed to improve treatment accuracy.
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Affiliation(s)
- Zheng Zeng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, China
| | - Jiawei Zhu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, China
| | - Zhiqun Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, China
| | - Guangyu Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, China.
| | - Fuquan Zhang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 100730, Beijing, China.
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Ghosh S, Gurram L, Kumar A, Mulye G, Mittal P, Chopra S, Kharbanda D, Hande V, Ghadi Y, Scaria L, Dheera A, Varghese GB, Kole S, Ansari S, Mahantshetty U, Agarwal JP. Clinical Implementation of "Plan of the Day" Strategy in Definitive Radiation Therapy of Cervical Cancer: Online Adaptation to Address the Challenge of Organ Filling Reproducibility. Int J Radiat Oncol Biol Phys 2024; 118:605-615. [PMID: 37816473 DOI: 10.1016/j.ijrobp.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Definitive pelvic intensity modulated radiation therapy (IMRT) in cervical cancer is susceptible to geographic miss due to daily positional and volumetric variations in target and organs at risk. Hence, despite evidence of reduced acute and late treatment-related toxicities, implementation of image-guided IMRT (IG-IMRT) with a reasonable safety margin to encompass organ motion is challenging. METHODS AND MATERIALS In this prospective, nonrandomized phase 2 study, patients with cervical cancer International Federation of Gynecology and Obstetrics (2009) stage IB2-IIIB between the ages of 18 and 65 years were treated with definitive pelvic chemoradiotherapy with a prespecified organ (bladder and rectum) filling protocol. Reproducibility of organ filling was assessed along with the implementation of daily comprehensive adaptive image-guided radiotherapy (IGRT), with a library of 3 IMRT (volumetric modulated arc therapy) plans with incremental expansions of clinical target volume (CTV) to planning target volume (PTV) (primary) margins (small, 0.7 cm; adequate, 1 cm; and large, 1.5 cm) and a backup motion robust 3-dimensional conformal radiotherapy plan; the appropriate plan is chosen based on pretreatment cone beam computed tomography (CBCT) ("plan of the day" approach). RESULTS Fifty patients with a median age of 49 years (IQR, 45-56 years) received definitive radiation therapy (45-46 Gy in 23-25 fractions to pelvis, with simultaneous integrated boost to gross nodes in 15 patients) with the aforementioned IGRT protocol. In the analysis of 1171 CBCT images (in 1184 treatment sessions), the mean planning computed tomography (CT) and CBCT bladder volumes were 417 and 373 cc, respectively. Significant interfractional variation in bladder volume was noted with a mean absolute dispersion of 29.5% with respect to planning CT; significant influential random factors were postchemotherapy sessions (P ≤ .001), pre-CBCT protocol duration (P = .001), and grades of chemotherapy induced nausea vomiting (P = .001). Significantly higher variation in bladder filling was noted in patients with older age (P = .014) and larger planning CT bladder volume (P ≤ .001). Time trend analysis of fraction-wise bladder volume revealed an absolute systemic reduction of 16.3% in bladder volume means from the first to the fifth week. Variation in rectal diameter was much less pronounced, with 19.2% mean dispersion and without any significant factors affecting it. Although in 19% and 2% of sessions large IMRT PTV and 3-dimensional conformal radiotherapy were necessary to cover the primary target, respectively, reduction in treated volume was possible in 43% of sessions with small PTV selection instead of standard adequate PTV (36% sessions). Plan of the day selection had a moderate to strong correlation with nonabsolute dispersion of bladder filling (Spearman ρ =0.4; P = .001) and a weak (but significant) correlation with grades of acute toxicities. The planned protocol was well tolerated with no radiation-induced local grade 3 toxicity. CONCLUSIONS Interfractional variation in organ filling (especially bladder) is inevitable despite fixed pretreatment protocol in definitive settings (intact cervix). Despite the logistical challenges, adaptive IGRT in the form of plan of the day based on incremental CTV-to-PTV margins is a relatively simple and feasible strategy to minimize geometric uncertainties in radical IG-IMRT of cervical cancer.
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Affiliation(s)
- Suman Ghosh
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India.
| | - Amrendra Kumar
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Gargee Mulye
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Prachi Mittal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Disha Kharbanda
- Department of Radiation Oncology, Indraprastha Apollo Hospital, New Delhi, India
| | - Vinod Hande
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Yogesh Ghadi
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Libin Scaria
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - A Dheera
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - George Biju Varghese
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Satish Kole
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sahebuzzama Ansari
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Umesh Mahantshetty
- Homi Bhabha Cancer Hospital, Visakhapatnam, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Wang L, McQuaid D, Blackledge M, McNair H, Harris E, Lalondrelle S. Predicting cervical cancer target motion using a multivariate regression model to enable patient selection for adaptive external beam radiotherapy. Phys Imaging Radiat Oncol 2024; 29:100554. [PMID: 38419803 PMCID: PMC10901141 DOI: 10.1016/j.phro.2024.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
Background and purpose Interfraction motion during cervical cancer radiotherapy is substantial in some patients, minimal in others. Non-adaptive plans may miss the target and/or unnecessarily irradiate normal tissue. Adaptive radiotherapy leads to superior dose-volume metrics but is resource-intensive. The aim of this study was to predict target motion, enabling patient selection and efficient resource allocation. Materials and methods Forty cervical cancer patients had CT with full-bladder (CT-FB) and empty-bladder (CT-EB) at planning, and daily cone-beam CTs (CBCTs). The low-risk clinical target volume (CTVLR) was contoured. Mean coverage of the daily CTVLR by the CT-FB CTVLR was calculated for each patient. Eighty-three investigated variables included measures of organ geometry, patient, tumour and treatment characteristics. Models were trained on 29 patients (171 fractions). The Two-CT multivariate model could use all available data. The Single-CT multivariate model excluded data from the CT-EB. A univariate model was trained using the distance moved by the uterine fundus tip between CTs, the only method of patient selection found in published cervix plan-of-the-day studies. Models were tested on 11 patients (68 fractions). Accuracy in predicting mean coverage was reported as mean absolute error (MAE), mean squared error (MSE) and R2. Results The Two-CT model was based upon rectal volume, dice similarity coefficient between CT-FB and CT-EB CTVLR, and uterine thickness. The Single-CT model was based upon rectal volume, uterine thickness and tumour size. Both performed better than the univariate model in predicting mean coverage (MAE 7 %, 7 % and 8 %; MSE 82 %2, 65 %2, 110 %2; R2 0.2, 0.4, -0.1). Conclusion Uterocervix motion is complex and multifactorial. We present two multivariate models which predicted motion with reasonable accuracy using pre-treatment information, and outperformed the only published method.
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Affiliation(s)
- Lei Wang
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Dualta McQuaid
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Matthew Blackledge
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Helen McNair
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Emma Harris
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Susan Lalondrelle
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Radiother Oncol 2023; 183:109589. [PMID: 37268359 DOI: 10.1016/j.radonc.2023.109589] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n = 99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, the Netherlands
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Int J Gynecol Cancer 2023:ijgc-2022-004180. [PMID: 37258414 DOI: 10.1136/ijgc-2022-004180] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n=99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Netherlands
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Wang L, Alexander S, Mason S, Blasiak-Wal I, Harris E, McNair H, Lalondrelle S. Carpe Diem: Making the Most of Plan-of-the-Day for Cervical Cancer Radiation Therapy. Pract Radiat Oncol 2023; 13:132-147. [PMID: 36481683 DOI: 10.1016/j.prro.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy is the key treatment for locally advanced cervical cancer. Organ motion presents a challenge to accurate targeting of external beam radiation therapy. The plan-of-the-day (PotD) adaptive approach is therefore an attractive option. We present our experience and the procedural steps required to implement PotD for cervix cancer. METHODS AND MATERIALS We reviewed relevant studies on organ motion and adaptive radiation therapy identified through a literature search and cross referencing. These included 10 dosimetric and 3 quality of life studies directly assessing the PotD approach to radiation therapy in cervix cancer. RESULTS Studies show improvements in target coverage and reduction of dose received by normal tissues and suggest improved toxicity. Clinical implementation of PotD has been slow because of a number of difficulties and uncertainties, which we discuss with the aim of helping teams to implement PotD at their center. CONCLUSIONS The PotD approach improves dosimetry and may improve toxicity. We describe a framework to assist with practical implementation.
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Affiliation(s)
- Lei Wang
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom.
| | - Sophie Alexander
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Sarah Mason
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Irena Blasiak-Wal
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Emma Harris
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Helen McNair
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Susan Lalondrelle
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
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Ma CY, Zhao J, Gan GH, He XL, Xu XT, Qin SB, Wang LL, Li L, Zhou JY. Establishment of a prediction model for severe acute radiation enteritis associated with cervical cancer radiotherapy. World J Gastroenterol 2023; 29:1344-1358. [PMID: 36925455 PMCID: PMC10011961 DOI: 10.3748/wjg.v29.i8.1344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Cervical cancer is one of the most common gynecological malignant tumors. Radiation enteritis (RE) leads to radiotherapy intolerance or termination of radiotherapy, which negatively impacts the therapeutic effect and seriously affects the quality of life of patients. If the incidence of RE in patients can be predicted in advance, and targeted clinical preventive treatment can be carried out, the side effects of radiotherapy in cervical cancer patients can be significantly reduced. Furthermore, accurate prediction of RE is essential for the selection of individualized radiation dose and the optimization of the radiotherapy plan.
AIM To analyze the relationships between severe acute RE (SARE) of cervical cancer radiotherapy and clinical factors and dose-volume parameters retrospectively.
METHODS We included 50 cervical cancer patients who received volumetric modulated arc therapy (VMAT) from September 2017 to June 2018 in the Department of Radiotherapy at The First Affiliated Hospital Soochow University. Clinical and dose-volume histogram factors of patients were collected. Logistic regression analysis was used to evaluate the predictive value of each factor for SARE. A nomogram to predict SARE was developed (SARE scoring system ≥ 3 points) based on the multiple regression coefficients; validity was verified by an internal verification method.
RESULTS Gastrointestinal and hematological toxicity of cervical cancer VMAT gradually increased with radiotherapy and reached the peak at the end of radiotherapy. The main adverse reactions were diarrhea, abdominal pain, colitis, anal swelling, and blood in the stool. There was no significant difference in the incidence of gastrointestinal toxicity between the radical and postoperative adjuvant radiotherapy groups (P > 0.05). There were significant differences in the small intestine V20, V30, V40, and rectal V40 between adjuvant radiotherapy and radical radiotherapy after surgery (P < 0.05). Univariate and multivariate analyses revealed anal bulge rating (OR: 14.779, 95%CI: 1.281-170.547, P = 0.031) and disease activity index (DAI) score (OR: 53.928, 95%CI: 3.822-760.948, P = 0.003) as independent predictors of SARE.
CONCLUSION Anal bulge rating (> 0.500 grade) and DAI score (> 2.165 points) can predict SARE. The nomogram shows potential value in clinical practice.
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Affiliation(s)
- Chen-Ying Ma
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Jing Zhao
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Guang-Hui Gan
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Lan He
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Ting Xu
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Song-Bing Qin
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li-Li Wang
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li Li
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Ju-Ying Zhou
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou 215123, Jiangsu Province, China
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10
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Regression Analysis of Rectal Cancer and Possible Application of Artificial Intelligence (AI) Utilization in Radiotherapy. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12020725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Artificial Intelligence (AI) has been widely employed in the medical field in recent years in such areas as image segmentation, medical image registration, and computer-aided detection. This study explores one application of using AI in adaptive radiation therapy treatment planning by predicting the tumor volume reduction rate (TVRR). Cone beam computed tomography (CBCT) scans of twenty rectal cancer patients were collected to observe the change in tumor volume over the course of a standard five-week radiotherapy treatment. In addition to treatment volume, patient data including patient age, gender, weight, number of treatment fractions, and dose per fraction were also collected. Application of a stepwise regression model showed that age, dose per fraction and weight were the best predictors for tumor volume reduction rate.
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11
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Liang Y, Feng S, Xie W, Jiang Q, Yang Y, Luo R, Kidd EA, Zhai T, Xie L. Comparison of survival, acute toxicities, and dose-volume parameters between intensity-modulated radiotherapy with or without internal target volume delineation method and three-dimensional conformal radiotherapy in cervical cancer patients: A retrospective and propensity score-matched analysis. Cancer Med 2022; 11:151-165. [PMID: 34821082 PMCID: PMC8704157 DOI: 10.1002/cam4.4439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/25/2021] [Accepted: 10/26/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To evaluate whether the use of the internal target volume (ITV) delineation method improves the performance of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT) in terms of survival, acute toxicities, and dose-volume parameters. METHODS A total number of 477 cervical cancer patients who received concurrent chemoradiotherapy (CCRT) from January 2012 to December 2016 were retrospectively analyzed. They were divided into four groups: the non-ITV (N-ITV) + IMRT, ITV + IMRT, N-ITV + 3DCRT, and ITV + 3DCRT groups, with 76, 41, 327, and 33 patients, respectively. Survival analysis was performed with the Kaplan-Meier and the log-rank tests, and acute toxicity analysis was performed with the chi-squared test and the binary logistic regression test. Using the propensity score matching (PSM) method, 92 patients were matched among the four groups, and their dose-volume parameters were assessed with the Kruskal-Wallis method. RESULTS The median follow-up time was 49 months (1-119) for overall survival (OS). The 5-year OS rate was 66.4%. The ITV delineation method was an independent prognostic factor for OS (HR [95% CI]: 0.52 [0.27, 0.98], p = 0.044) and progression-free survival (PFS) (HR [95% CI]: 0.59 [0.36, 0.99], p = 0.045). The ITV + IMRT group had the lowest incidence rate (22%) and the N-ITV + IMRT group had the highest incidence rate of grade ≥3 hematological toxicity (HT) (46.1%) among the four groups. The pelvic bone marrow relative V10, V20, and V30 in the N-ITV + IMRT group was higher than those in the ITV + IMRT and N-ITV + 3DCRT groups (p < 0.05). CONCLUSIONS The use of ITV for IMRT treatment planning was associated with improved overall survival and progression-free survival, with lower HT rate.
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Affiliation(s)
- Yu‐Qin Liang
- Department of Radiation Oncology, Xiang’an Hospital of Xiamen University, Xiamen, China
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Sen‐Quan Feng
- Department of Radiation OncologyCancer Hospital of Shantou University Medical CollegeShantouChina
- Department of Radiation OncologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Wen‐Jia Xie
- Department of Radiation OncologyXiang’an Hospital of Xiamen UniversityXiamenChina
- Department of Radiation OncologyCancer Hospital of Shantou University Medical CollegeShantouChina
| | - Qiong‐Zhi Jiang
- Department of Radiation OncologyCancer Hospital of Shantou University Medical CollegeShantouChina
| | - Yan‐Fen Yang
- Department of Science and EducationXiang’an Hospital of Xiamen UniversityXiamenChina
| | - Ren Luo
- Department of Radiation OncologyFaculty of MedicineUniversity of FreiburgFreiburgGermany
- Faculty of BiologyUniversity of FreiburgFreiburgGermany
| | - Elizabeth A. Kidd
- Department of Radiation OncologyStanford UniversityStanfordCaliforniaUSA
| | - Tian‐Tian Zhai
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Liang‐Xi Xie
- Department of Radiation Oncology, Xiang’an Hospital of Xiamen University, Xiamen, China
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
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12
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Zhang W, Li X, Lin T, Ma F, Ma X, Wu X, Sun Y, Sun X. A model to guide the management and decision of re-planning during radiotherapy for cervical cancer. Transl Cancer Res 2021; 10:5352-5363. [PMID: 35116382 PMCID: PMC8797880 DOI: 10.21037/tcr-21-2545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND To establish a model to predict whether re-planning is needed in the process of cervical cancer radiotherapy. METHODS We collected the clinical indexes of 132 patients diagnosed with cervical cancer receiving concurrent chemotherapy and radiotherapy, including 33 factors about tumor markers [carcinoembryonic antigen (CEA), cancer antigen 125 (CA-125), squamous cell carcinoma antigen (SCC)], tumor volume, rectal volume, bladder volume, volumes receiving 30-50 Gy in organs-at-risk (OARs), and the maximum dose (Dmax) received by 1-2 cc in OARs. We established a multivariate model for re-planning evaluation via principal component analysis, and then verified the model based on the internal data. RESULTS We identified the dose index (P1), tumor size index (P2), and volumes receiving 30-50 Gy in OARs and the tumor (P3) as the three most weighted factors of the re-planning model. We set the cut-off for the re-planning modification requirement at 1. The model was consistent with R = 0.12P1 + 0.21P2 + 0.31P3, and it performed accurately that area under the test set characteristics curve (AUC) =0.826]. CONCLUSIONS Our proposed method can help to reduce image re-examination during treatment, decrease toxicities in OARs, shorten the radiotherapy course, lessen oncologists' efforts, and save medical resources.
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Affiliation(s)
- Wei Zhang
- Department of Radiation Oncology, Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiuhua Li
- Department of Gynaecology, Fujian Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tingting Lin
- Department of Radiation and Medical Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, China
| | - Fang Ma
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaoyu Ma
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaoli Wu
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yingming Sun
- Department of Radiation and Medical Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, China
| | - Xiaoge Sun
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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13
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Set-Up Errors, Organ Motion, Tumour Regression and its Implications on Internal Target Volume-Planning Target Volume During Cervical Cancer Radiotherapy: Results From a Prospective Study. Clin Oncol (R Coll Radiol) 2021; 34:189-197. [PMID: 34736842 DOI: 10.1016/j.clon.2021.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/24/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022]
Abstract
AIMS Uterocervical motions and organ filling during cervical cancer conformal radiotherapy is complex. This prospective, observational study investigated set-up margins (clinical target vo, ume [CTV] to planning target volume [PTV]) for pelvic nodal CTV and internal margin (CTV to internal target volume [ITV]) expansions for uterocervical movements during cervical cancer radiotherapy. MATERIALS AND METHODS During cervical cancer radiotherapy, a daily kilovoltage, cone-beam computed tomography (CBCT) scan was acquired. Bony anatomy-based rigid co-registration and matching to vessels/pelvic nodal region was carried out to document shifts, errors (systematic and random) and to calculate CTV to PTV margins. Subsequently, soft-tissue matching was carried out at the mid-cervical region and uterine fundus to record shifts, errors and to calculate CTV to ITV margins. RESULTS In 67 patients, 1380 CBCT scans were analysed. The mean (±standard deviation) couch shifts for CTV pelvic nodal region in all directions were within 4.5-5.3 mm, systematic and random errors 3.0-3.6 mm and set-up margins of within 10 mm (except anterior margin 10.3 mm). For the mid-cervical region, mean shifts were 4.5-5.5 mm, systematic and random errors 2-4 mm amounting to <10 mm internal margins (CTV-ITV for cervix) and for uterine fundus mean (±standard deviation) shifts were larger in the superior direction (12.1 mm) but 4.0-7.5 mm in other directions, systematic and random errors 2-7 mm amounting to anisotropic margins in various directions (10 mm in anterior-posterior and lateral directions, 12-20 mm in superior-inferior directions) (CTV-ITV for uterine fundus). CONCLUSION Our study suggests anisotropic CTV to ITV and CTV to PTV margins for cervical cancer radiotherapy.
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14
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Wang W, Liu X, Wang D, Ren K, Zhou Y, Zhou Z, Qiu J, Zhang F, Hu K. The 100 Most Cited Papers in Radiotherapy or Chemoradiotherapy for Cervical Cancer: 1990-2020. Front Oncol 2021; 11:642018. [PMID: 34540655 PMCID: PMC8440989 DOI: 10.3389/fonc.2021.642018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 08/16/2021] [Indexed: 12/09/2022] Open
Abstract
Objective This work aims to analyze the 100 most cited papers in radiotherapy or chemoradiotherapy for cervical cancer. Methods The 100 most cited papers in radiotherapy or chemoradiotherapy between 1990 and 2020 were identified with Thompson Reuters Web of Science citation indexing on August 24, 2020. The publication years, source titles, countries/regions, total citations, and average citations per year were extracted from the Web of Science. The research type and research domain were classified by the authors. Results These 100 papers were cited a total of 28,714 times, and the median number of citations was 169.5 (ranging from 116 to 1,700 times). The most cited paper was “Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer” by Rose et al., with a total citation of 1,700 times. The International Journal of Radiation Oncology Biology Physics (40 papers), Radiotherapy and Oncology (14 papers), and the Journal of Clinical Oncology (12 papers) published the largest number of papers. USA (47 papers), Austria (18 papers), Canada (13 papers), and England (13 papers) contributed the largest number of papers. Image-guided adaptive brachytherapy (IGABT) had the largest number of papers (25 papers). Concurrent chemotherapy was the most cited research domain, with 10,663 total citations and 592.4 citations per paper. Conclusion In the present study, we conducted a bibliometric analysis of the 100 most cited papers in radiotherapy or concurrent chemoradiotherapy for cervical cancer in the past 30 years. IGABT and concurrent chemotherapy were the most cited research domains.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang Ren
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ziqi Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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15
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Ahangari S, Hansen NL, Olin AB, Nøttrup TJ, Ryssel H, Berthelsen AK, Löfgren J, Loft A, Vogelius IR, Schnack T, Jakoby B, Kjaer A, Andersen FL, Fischer BM, Hansen AE. Toward PET/MRI as one-stop shop for radiotherapy planning in cervical cancer patients. Acta Oncol 2021; 60:1045-1053. [PMID: 34107847 DOI: 10.1080/0284186x.2021.1936164] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Radiotherapy (RT) planning for cervical cancer patients entails the acquisition of both Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Further, molecular imaging by Positron Emission Tomography (PET) could contribute to target volume delineation as well as treatment response monitoring. The objective of this study was to investigate the feasibility of a PET/MRI-only RT planning workflow of patients with cervical cancer. This includes attenuation correction (AC) of MRI hardware and dedicated positioning equipment as well as evaluating MRI-derived synthetic CT (sCT) of the pelvic region for positioning verification and dose calculation to enable a PET/MRI-only setup. MATERIAL AND METHODS 16 patients underwent PET/MRI using a dedicated RT setup after the routine CT (or PET/CT), including eight pilot patients and eight cervical cancer patients who were subsequently referred for RT. Data from 18 patients with gynecological cancer were added for training a deep convolutional neural network to generate sCT from Dixon MRI. The mean absolute difference between the dose distributions calculated on sCT and a reference CT was measured in the RT target volume and organs at risk. PET AC by sCT and a reference CT were compared in the tumor volume. RESULTS All patients completed the examination. sCT was inferred for each patient in less than 5 s. The dosimetric analysis of the sCT-based dose planning showed a mean absolute error (MAE) of 0.17 ± 0.12 Gy inside the planning target volumes (PTV). PET images reconstructed with sCT and CT had no significant difference in quantification for all patients. CONCLUSIONS These results suggest that multiparametric PET/MRI can be successfully integrated as a one-stop-shop in the RT workflow of patients with cervical cancer.
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Affiliation(s)
- Sahar Ahangari
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Naja Liv Hansen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Beck Olin
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Trine Jakobi Nøttrup
- Department of Oncology, Section of Radiotherapy, University of Copenhagen, Rigshospitalet, Denmark
| | - Heidi Ryssel
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Kiil Berthelsen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Johan Löfgren
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika Loft
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ivan Richter Vogelius
- Department of Oncology, Section of Radiotherapy, University of Copenhagen, Rigshospitalet, Denmark
| | - Tine Schnack
- Department of Gynecology, University of Copenhagen, Copenhagen, Denmark
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | | | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Cluster for Molecular Imaging, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Littrup Andersen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Barbara Malene Fischer
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The PET Centre, School of Biomedical Engineering and Imaging Sciences, Kings College London, St Thomas’ Hospital, London, UK
| | - Adam Espe Hansen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Diagnostic Radiology, Rigshospitalet, University of Copenhagen, Denmark Copenhagen
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16
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Singh G, Tyagi A, Thaper D, Kamal R, Kumar V, Oinam AS, Srivastava R, Halder S, Hukku S. Dosimetric analysis of cervical cancer stage IIB patients treated with volumetric modulated arc therapy using plan uncertainty parameters module of Varian Eclipse treatment planning system. Biomed Phys Eng Express 2021; 7. [PMID: 33862601 DOI: 10.1088/2057-1976/abf90a] [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: 12/22/2020] [Accepted: 04/16/2021] [Indexed: 11/11/2022]
Abstract
Introduction. The present study aims to investigate the dosimetric and radiobiological impact of patient setup errors (PSE) on the target and organs at risk (OAR) of the cervix carcinoma stage IIB patients treated with volumetric-modulated arc therapy (VMAT) delivery technique using plan uncertainty parameters module of Varian Eclipse treatment planning system and in-house developed DVH Analyzer program.Materials and Methods. A total of 976 VMAT plans were generated to simulate the PSE in the base plan that varies from -10 mm to 10 mm in a step size of 1 mm in x- (lateral), y- (craniocaudal), and z- (anteroposterior) directions. The different OAR and tumor (PTV) volumes were delineated in each case. Various plan quality metrics, such as conformity index (CI) and homogeneity index (HI), as well as radiobiological quantities, such as tumor control probability (TCP) and normal tissue control probability (NTCP), were calculated from the DVH bands generated from the cohort of treatment plans associated with each patient case, using an in-house developed 'DVH Analyzer' program. The extracted parameters were statistically analyzed and compared with the base plan's dosimetric parameters having no PSE.Results. The maximum variation of (i) 2.4%, 21.5%, 0.8%, 2.5% in D2ccof bladder, rectum, small bowel and sigmoid colon respectively; (ii) 19.3% and 18.9% in Dmaxof the left and right femoral heads (iii) 16.9% in D95%of PTV (iv) 12.1% in NTCP of sigmoid colon were observed with change of PSE in all directions. TCP was found to be considerably affected for PSEs larger than 4 mm in x+, y+, z+directions and 7 mm in x-, y-and z-directions, respectively.Conclusion. This study presents the effect of PSE on TCP and NTCP for the cervix carcinoma cases treated with VMAT technique and also recommends daily image guidance to mitigate the effects of PSE.
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Affiliation(s)
- Gaganpreet Singh
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiotherapy, PGIMER, Chandigarh, India
| | - Atul Tyagi
- Department of Radiation Oncology, Dr B L Kapur Memorial Hospital, Delhi, India
| | - Deepak Thaper
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiotherapy, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rose Kamal
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiotherapy, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vivek Kumar
- Centre for Medical Physics, Panjab University, Chandigarh, India
| | - Arun S Oinam
- Department of Radiotherapy, PGIMER, Chandigarh, India
| | - Ranjana Srivastava
- Department of Radiation Oncology, Dr B L Kapur Memorial Hospital, Delhi, India
| | - Shikha Halder
- Department of Radiation Oncology, Dr B L Kapur Memorial Hospital, Delhi, India
| | - Shelly Hukku
- Department of Radiation Oncology, Dr B L Kapur Memorial Hospital, Delhi, India
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17
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Rigaud B, Anderson BM, Yu ZH, Gobeli M, Cazoulat G, Söderberg J, Samuelsson E, Lidberg D, Ward C, Taku N, Cardenas C, Rhee DJ, Venkatesan AM, Peterson CB, Court L, Svensson S, Löfman F, Klopp AH, Brock KK. Automatic Segmentation Using Deep Learning to Enable Online Dose Optimization During Adaptive Radiation Therapy of Cervical Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1096-1110. [DOI: 10.1016/j.ijrobp.2020.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/24/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
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18
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Impact of a fiducial marker based ART strategy on margins in postoperative IMRT of gynecological tumors. Radiother Oncol 2021; 158:1-6. [PMID: 33587973 DOI: 10.1016/j.radonc.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/24/2020] [Accepted: 01/29/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate the potential of an offline Adaptive Radiotherapy (ART) strategy, based on the interfractional vagina motion (IVM) measured using fiducial markers (FM) during an initial number of fractions, on the CTV to PTV margins in post-operative gynecological patients. MATERIALS AND METHODS In 18 patients, treated post-operatively for gynecological tumors, the systematic residual IVM was quantified after simulating an offline ART procedure, utilizing the average IVM measured with FM for a varying initial numbers of fractions to find the optimal moment to adapt the treatment plan and a threshold for selecting patients for replanning. Clinical margins for a zero, 2 and 5 mm threshold based strategy were calculated to assess the possible margin reduction. RESULTS Applying an ART strategy based on the average IVM of the initial 5 fractions reduces the systematic IVM significantly (P < 0.025), allowing a reduction of the clinical margin of 3 mm (20%) in the CC direction and 2 mm (13%) in the AP direction. A 2 mm threshold for selecting patients for replanning shows no difference in the reduction of the clinical margin, but reduces the workload with 12%. CONCLUSION An ART strategy based on adapting on the average IVM during the initial 5 fractions of treatment provides an opportunity to reduce the CTV to PTV margins in postoperative gynecological tumors. To keep the workload in balance with the best achievable margin reduction, a threshold for selecting patients for plan adaptation is recommended.
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19
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Arend F, Oechsner M, Weidenbächer CB, Combs SE, Borm KJ, Duma MN. Correlations of UICC tumor stage and tumor regression on T2-weighted MRI sequences during definitive radiotherapy of cervical cancer. TUMORI JOURNAL 2020; 107:139-144. [PMID: 32701045 DOI: 10.1177/0300891620940024] [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: 11/17/2022]
Abstract
BACKGROUND The purpose of this study is to detect a correlation between the preradiation tumor staging and the relative volumetric regression of the primary tumor through external beam radiation therapy (EBRT). METHODS Clinical data of 32 patients with a mean age of 60±12 years treated with primary radiation therapy (RT) of cervical carcinoma were analyzed. Union Internationale Contre le Cancer (UICC) stages were T1 = 4 patients, T2 = 15 patients, T3 = 8 patients, T4 = 5 patients; N1 = 26 patients, N0 = 6 patients; and M0 = 25 patients, M1 = 7 patients. All patients received pelvic magnetic resonance imaging (MRI) before RT as well as during RT. The cervical primary tumor was delineated as gross tumor volume (ptGTV) in T2-weighted MRI sequences. We compared ptGTV reduction by stage, lymph node status, metastatic status, and grading. RESULTS Mean ptGTV reduction during RT was 61.4±28.9%. T1 tumors shrank by 88.2±13.4%, T2 by 67.6±28.7%, T3 by 50.8±23.6%, and T4 by 38.7±27.2%. The difference in tumor shrinkage was statistically significant between the lower T stages and the higher T stages (p < 0.05). There was no statistical difference in the mean ptGTV before treatment in the group with lymph node metastases (LNM) (54.1±47.7 cm3) as compared to the group without LNM (76.6±52.2 cm3). Nonetheless, ptGTV shrank significantly differently: by 68.9±25.7% (N1 patients) and by 29.0±17.7% (N0 patients). No significant differences in ptGTV shrinkage were observed in M0 versus M1 and G2 versus G3 tumors. CONCLUSION There is a correlation between mean ptGTV reduction during EBRT and tumor stages. Tumors with higher T stages shrank less under radiation treatment, and the ptGTV of N1 patients responded better than that of N0 patients.
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Affiliation(s)
- Florian Arend
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany.,Faculty of Medicine, Technical University Munich, München, Bayern, Germany
| | - Markus Oechsner
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany
| | - Clara B Weidenbächer
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany
| | - Stephanie E Combs
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany.,Institute of Innovative Radiotherapy, Helmholtz Zentrum München, München, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, München, Germany
| | - Kai J Borm
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany
| | - Marciana N Duma
- Department of Radiotherapy, Klinikum Rechts der Isar, Technical University Munich, München, Bayern, Germany.,Department of Radiotherapy and Radiation Oncology, University Hospital of the Friedrich Schiller University, Jena, Germany
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Viani GA, dos Santos FM, Pavoni JF. Significant impact on the oncologic outcomes with intensity modulated radiotherapy and conformational radiotherapy over conventional radiotherapy in cervix cancer patients treated with radiotherapy. Rep Pract Oncol Radiother 2020; 25:678-683. [PMID: 32565745 PMCID: PMC7298565 DOI: 10.1016/j.rpor.2020.06.001] [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: 01/30/2020] [Revised: 05/10/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE We designed a retrospective cohort of women with cervix cancer treated by radiation therapy with an extended follow-up to evaluate if the incorporation of modern radiation techniques was a prognostic factor. MATERIAL AND METHODS We studied a cohort of patients with cervix cancer FIGO stage I-IVa treated in the last fifteen years. Patients were treated with radiotherapy alone (RT) or chemoradiation alone (CRT) using conventional radiotherapy (2DRT), conformational radiotherapy (3DRT), or intensity-modulated radiotherapy (IMRT) followed by high dose rate brachytherapy. Univariate and multivariate analysis was conducted to identify significant prognostic factors (p < 0.05). RESULTS 228 patients with cervix cancer were included. The treatment groups were CRT (64.8%), and RT (34.2%), with 31.6% submitted to 2DRT and 68.4% to IMRT/3DRT. The median follow-up was 6.3 years, the OS in 5 years according to the treatment groups was 48% for CRT, and 27.8% for RT (p < 0.001). The early-stage I-IIa (p = 0.001), CRT, and IMRT/3DRT were significant factors for better overall survival (OS) in the multivariate analysis. For the cancer-specific survival (CSS), chemoradiation, age <60 years, and IMRT/3DRT were significant. Treatment with IMRT/3DRT was the only prognostic factor associated with event-free survival (EFS). CONCLUSION In a long-term follow-up, chemoradiation, early-clinical stage, and age <60 years were significant factors associated with better OS and CSS at 5 and 8 years. The incorporation of new radiation techniques, such as IMRT/3DRT, over time has a significant impact on all endpoints (EFS, OS, and CSS) of this cohort. These outcomes are useful to decide about the radiation technique to achieve satisfactory oncological results outside a clinical trial.
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Affiliation(s)
- Gustavo Arruda Viani
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Fred Muller dos Santos
- Universidade de São Paulo (USP), Faculdade de Filosofia Ciências e Letras (FFCL), Departamento de Física (DF), Ribeirão Preto, SP, Brazil
| | - Juliana Fernandes Pavoni
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto da (FMRP), Ribeirão Preto, SP, Brazil
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21
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Lucia F, Bourbonne V, Gujral D, Dissaux G, Miranda O, Mauguen M, Pradier O, Abgral R, Schick U. Impact of suboptimal dosimetric coverage of pretherapeutic 18F-FDG PET/CT hotspots on outcome in patients with locally advanced cervical cancer treated with chemoradiotherapy followed by brachytherapy. Clin Transl Radiat Oncol 2020; 23:50-59. [PMID: 32435702 PMCID: PMC7229342 DOI: 10.1016/j.ctro.2020.05.004] [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: 03/18/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Areas of high uptake on pre-treatment 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT), denoted as "hotspots", have been identified as preferential sites of local relapse in locally advanced cervical cancer (LACC). The purpose of this study was to analyze the dosimetric coverage of these hotspots with high dose-rate brachytherapy (BT). METHODS For each patient, a rigid registration of the CT from the pre-treatment PET/CT with the radiotherapy planning CT was performed using 3D SlicerTM, followed by a manual volume correction by translation and deformation if necessary. The fuzzy locally adaptive Bayesian (FLAB) algorithm was applied to PET images to simultaneously define an overall tumour volume and the high-uptake sub-volume V1. The inclusion of V1 in the high-risk clinical target volume (CTV HR) and its dosimetric coverage were evaluated using 3D SlicerTM. The average of the 3-4 BT sessions was reported. RESULTS Forty-two patients with recurrence after chemoradiotherapy (CRT) for LACC were matched to 42 patients without recurrence. Mean ± standard deviation follow-up was 26 ± 11 months. In the recurrence group, V1 was not included in the CTV HR and not covered by the 85 Gy isodose in 17/42 patients (41%) (1/20 with pelvic recurrence and 16/22 with distant recurrence) and not by the 80 Gy isodose in 7/42 patients (17%) (all with distant recurrence). In the non-recurrence group, V1 was not included in CTV HR and not covered by the 85 Gy isodose in 3 patients only (7%). The hotspots coverage by the 85 Gy isodose was significantly better in patients who did not recur, but only when compared to patients with distant relapse (p < 0.0001). CONCLUSION Suboptimal dosimetric coverage of high FDG uptakes on pretherapeutic PET could be associated with an increased risk of recurrence.
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Affiliation(s)
- François Lucia
- Radiation Oncology Department, University Hospital, Brest, France
| | | | - Dorothy Gujral
- Clinical Oncology Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Hammersmith, London, UK
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Gurvan Dissaux
- Radiation Oncology Department, University Hospital, Brest, France
| | - Omar Miranda
- Radiation Oncology Department, University Hospital, Brest, France
| | - Maelle Mauguen
- Radiation Oncology Department, University Hospital, Brest, France
| | - Olivier Pradier
- Radiation Oncology Department, University Hospital, Brest, France
| | - Ronan Abgral
- Nuclear Medicine Department, University Hospital, Brest, France
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital, Brest, France
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22
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Siddique S, Chow JC. Artificial intelligence in radiotherapy. Rep Pract Oncol Radiother 2020; 25:656-666. [PMID: 32617080 PMCID: PMC7321818 DOI: 10.1016/j.rpor.2020.03.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/06/2020] [Accepted: 03/27/2020] [Indexed: 02/06/2023] Open
Abstract
Artificial intelligence (AI) has already been implemented widely in the medical field in the recent years. This paper first reviews the background of AI and radiotherapy. Then it explores the basic concepts of different AI algorithms and machine learning methods, such as neural networks, that are available to us today and how they are being implemented in radiotherapy and diagnostic processes, such as medical imaging, treatment planning, patient simulation, quality assurance and radiation dose delivery. It also explores the ongoing research on AI methods that are to be implemented in radiotherapy in the future. The review shows very promising progress and future for AI to be widely used in various areas of radiotherapy. However, basing on various concerns such as availability and security of using big data, and further work on polishing and testing AI algorithms, it is found that we may not ready to use AI primarily in radiotherapy at the moment.
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Affiliation(s)
- Sarkar Siddique
- Department of Physics, Ryerson University, Toronto, ON M5B 2K3, Canada
| | - James C.L. Chow
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1X6, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
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23
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Contreras J, Srivastava A, Chundury A, Schwarz JK, Markovina S, Thaker PH, Massad LS, Mutch DG, Powell MA, Grigsby PW, Lin AJ. Long-term outcomes of intensity-modulated radiation therapy (IMRT) and high dose rate brachytherapy as adjuvant therapy after radical hysterectomy for cervical cancer. Int J Gynecol Cancer 2020; 30:1157-1161. [PMID: 32527770 DOI: 10.1136/ijgc-2020-001412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Compared with 3D-planned pelvic radiation, intensity-modulated radiation therapy (IMRT) has been shown to reduce acute toxicity in cervical cancer patients after radical hysterectomy. This study evaluated late toxicity and patterns of failure after post-operative pelvic IMRT interdigitated weekly with high dose rate brachytherapy. METHODS This retrospective study included 53 cervical cancer patients treated between January 2006 and August 2019 with radical hysterectomy, lymphadenectomy, and post-operative IMRT and high dose rate brachytherapy. The decision to include chemotherapy was made by the treating gynecologic oncologist based on patient-specific criteria including positive pelvic lymph nodes, positive surgical margins, or positive parametrial invasion. The actuarial rates of genitourinary and gastrointestinal toxicity, vaginal cuff/regional nodal/distant failure, and overall survival were calculated using the Kaplan-Meier method. RESULTS Median follow-up was 70 months (range 5.4-148) months and age at diagnosis was 47 (range 24-73) years. The 2018 International Federation of Gynecology and Obstetrics (FIGO) clinical stages were IB1 (n=19), IB2 (n=7), IIB (n=7), IIIC1 (n=19), and IIIC2 (n=1). Median radiation dose delivered in 160 cGy daily fractions was 5120 (range 4640-5120) cGy. Median brachytherapy dose prescribed to the vaginal surface delivered in six weekly fractions was 2400 (range 1200-4800) cGy. Concurrent chemotherapy was delivered in 35 (66%) patients. There were no acute grade >3 genitourinary or gastrointestinal toxicities. Late grade >3 occurred in two (3.8%) patients, including a small bowel obstruction and a ureteral stricture. The 5-year actuarial rate for gastrointestinal or genitourinary toxicity was 1.9%. There were no vaginal cuff recurrences. The 5-year actuarial rates for regional nodal failure, distant failure outside the radiation field, any failure, and overall survival were 11%, 11%, 14%, and 85%, respectively. CONCLUSIONS Post-operative IMRT with high dose rate brachytherapy for patients with cervical cancer is associated with excellent outcomes and limited rates of radiation-related non-hematologic toxicity.
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Affiliation(s)
| | - Amar Srivastava
- Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Anupama Chundury
- Radiation Oncology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Julie K Schwarz
- Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Stephanie Markovina
- Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - L Stewart Massad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - David G Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Matthew A Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Perry W Grigsby
- Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alexander J Lin
- Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
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Rigaud B, Cazoulat G, Vedam S, Venkatesan AM, Peterson CB, Taku N, Klopp AH, Brock KK. Modeling Complex Deformations of the Sigmoid Colon Between External Beam Radiation Therapy and Brachytherapy Images of Cervical Cancer. Int J Radiat Oncol Biol Phys 2020; 106:1084-1094. [PMID: 32029345 DOI: 10.1016/j.ijrobp.2019.12.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE In this study, we investigated registration methods for estimating the large interfractional sigmoid deformations that occur between external beam radiation therapy (EBRT) and brachytherapy (BT) for cervical cancer. METHODS AND MATERIALS Sixty-three patients were retrospectively analyzed. The sigmoid colon was delineated on 2 computed tomography images acquired during EBRT (without applicator) and BT (with applicator) for each patient. Five registration approaches were compared to propagate the contour of the sigmoid from BT to EBRT anatomies: rigid registration, commercial hybrid (ANAtomically CONstrained Deformation Algorithm), controlling ROI surface projection of RayStation, and the classical and constrained symmetrical thin-plate spline robust point matching (sTPS-RPM) methods. Deformation of the sigmoid due to insertion of the BT applicator was reported. Registration performance was compared by using the Dice similarity coefficient (DSC), distance to agreement, and Hausdorff distance. The 2 sTPS-RPM methods were compared by using surface triangle quality criteria between deformed surfaces. Using the deformable approaches, the BT dose of the sigmoid was deformed toward the EBRT anatomy. The displacement and discrepancy between the deformable methods to propagate the planned D1cm3 and D2cm3 of the sigmoid from BT to EBRT anatomies were reported for 55 patients. RESULTS Large and complex deformations of the sigmoid were observed for each patient. Rigid registration resulted in poor sigmoid alignment with a mean DSC of 0.26. Using the contour to drive the deformation, ANAtomically CONstrained Deformation Algorithm was able to slightly improve the alignment of the sigmoid with a mean DSC of 0.57. Using only the sigmoid surface as controlling ROI, the mean DSC was improved to 0.79. The classical and constrained sTPS-RPM methods provided mean DSCs of 0.95 and 0.96, respectively, with an average inverse consistency error <1 mm. The constrained sTPS-RPM provided more realistic deformations and better surface topology of the deformed sigmoids. The planned mean (range) D1cm3 and D2cm3 of the sigmoid were 13.4 Gy (1-24.1) and 12.2 Gy (1-21.5) on the BT anatomy, respectively. Using the constrained sTPS-RPM to deform the sigmoid from BT to EBRT anatomies, these hotspots had a mean (range) displacement of 27.1 mm (6.8-81). CONCLUSIONS Large deformations of the sigmoid were observed between the EBRT and BT anatomies, suggesting that the D1cm3 and D2cm3 of the sigmoid would unlikely to be at the same position throughout treatment. The proposed constrained sTPS-RPM seems to be the preferred approach to manage the large deformation due to BT applicator insertion. Such an approach could be used to map the EBRT dose to the BT anatomy for personalized BT planning optimization.
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Affiliation(s)
- Bastien Rigaud
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Guillaume Cazoulat
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sastry Vedam
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aradhana M Venkatesan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christine B Peterson
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nicolette Taku
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy K Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Mason SA, White IM, Lalondrelle S, Bamber JC, Harris EJ. The Stacked-Ellipse Algorithm: An Ultrasound-Based 3-D Uterine Segmentation Tool for Enabling Adaptive Radiotherapy for Uterine Cervix Cancer. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1040-1052. [PMID: 31926750 PMCID: PMC7043010 DOI: 10.1016/j.ultrasmedbio.2019.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 06/10/2023]
Abstract
The stacked-ellipse (SE) algorithm was developed to rapidly segment the uterus on 3-D ultrasound (US) for the purpose of enabling US-guided adaptive radiotherapy (RT) for uterine cervix cancer patients. The algorithm was initialised manually on a single sagittal slice to provide a series of elliptical initialisation contours in semi-axial planes along the uterus. The elliptical initialisation contours were deformed according to US features such that they conformed to the uterine boundary. The uterus of 15 patients was scanned with 3-D US using the Clarity System (Elekta Ltd.) at multiple days during RT and manually contoured (n = 49 images and corresponding contours). The median (interquartile range) Dice similarity coefficient and mean surface-to-surface-distance between the SE algorithm and manual contours were 0.80 (0.03) and 3.3 (0.2) mm, respectively, which are within the ranges of reported inter-observer contouring variabilities. The SE algorithm could be implemented in adaptive RT to precisely segment the uterus on 3-D US.
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Affiliation(s)
- Sarah A Mason
- Joint Department of Physics, Institute of Cancer Research, London, United Kingdom
| | - Ingrid M White
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Susan Lalondrelle
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jeffrey C Bamber
- Joint Department of Physics, Institute of Cancer Research, London, United Kingdom
| | - Emma J Harris
- Joint Department of Physics, Institute of Cancer Research, London, United Kingdom.
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Swamidas J, Kirisits C, De Brabandere M, Hellebust TP, Siebert FA, Tanderup K. Image registration, contour propagation and dose accumulation of external beam and brachytherapy in gynecological radiotherapy. Radiother Oncol 2020; 143:1-11. [DOI: 10.1016/j.radonc.2019.08.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
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Mortazavi H, Nikfar B, Esmaeili SA, Rafieenia F, Saburi E, Chaichian S, Heidari Gorji MA, Momtazi-Borojeni AA. Potential cytotoxic and anti-metastatic effects of berberine on gynaecological cancers with drug-associated resistance. Eur J Med Chem 2019; 187:111951. [PMID: 31821990 DOI: 10.1016/j.ejmech.2019.111951] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 12/20/2022]
Abstract
Gynaecological disorders, such as cervical, ovarian, and endometrial cancers are the second most prevalent cancer types in women worldwide. Therapeutic approaches for gynaecological cancers involve chemotherapy, radiation, and surgery. However, lifespan is not improved, and novel medications are required. Among various phytochemicals, berberine, a well-known natural product, has been shown to be a promising cancer chemopreventive agent. Pharmacokinetics, safety, and efficacy of berberine have been investigated in the several experiments against numerous diseases. Here, we aimed to provide a literature review from available published investigations showing the anticancer effects of berberine and its various synthetic analogues against gynaecological disorders, including cervical, ovarian, and endometrial cancers. In conclusion, berberine has been found to efficiently inhibit viability, proliferation, and migration of cancer cells, mainly, via induction of apoptosis by both mitochondrial dependent and -independent pathways. Additionally, structural modification of berberine showed that berberine analogues can improve its antitumor effects against gynaecological cancers.
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Affiliation(s)
- Hamed Mortazavi
- Geriatric Care Research Center, Department of Geriatric Nursing, School of Nursing and Midwifery, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Banafsheh Nikfar
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed-Alireza Esmaeili
- Immunology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Immunology Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Rafieenia
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Saburi
- Medical Genetics and Molecular Medicine Department, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shahla Chaichian
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Heidari Gorji
- Diabetes Research Center, Department of Medical-Surgical Nursing, Nasibeh Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Amir Abbas Momtazi-Borojeni
- Halal Research Center of IRI, FDA, Tehran, Iran; Nanotechnology Research Center, Bu-Ali Research Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medical Biotechnology, Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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Wu Y, Zhu B, Han J, Xu H, Gong Z, Yang Y, Huang J, Lu E. A comparative dosimetric study of cervical cancer patients with para-aortic lymph node metastasis treated with volumetric modulated arc therapy vs. 9-field intensity-modulated radiation therapy. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:675. [PMID: 31930076 DOI: 10.21037/atm.2019.10.53] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background To compare the dosimetric characteristics between volumetric modulated arc therapy (VMAT) and 9-field intensity-modulated radiation therapy (9F-IMRT) for cervical cancer patients with para-aortic lymph node (PALN) metastasis. Methods We selected 20 patients who had received extended-field radiotherapy for cervical cancer with PALN metastasis. IMRT and VMAT plans were compared in terms of target, organs at risk (OARs), homogeneity index (HI), conformity index (CI), the number of monitor units (MUs) and treatment time (s). Results The CI and HI of VMAT plans were superior to those of IMRT plans (P<0.05). As for OARs, the mean maximum doses (Dmean) to the kidneys in the VMAT plans were all lower than those in IMRT plans (P<0.001). V40, V50 of the rectum, and V40 of the bladder in VMAT plans involved fewer doses than IMRT plans (P<0.001). Compared with IMRT plans, VMAT reduced the average number of MUs by 51% and the average treatment time by 31%. Conclusions Both VMAT and IMRT plans can satisfy clinical dosimetric demands and protect OARs. VMAT has the best performance on CI and HI and can better protect the OARs. VMAT plans have fewer MUs and improve treatment efficiency.
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Affiliation(s)
- Yaqin Wu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Biqing Zhu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Jingjing Han
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Hanzi Xu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Zhen Gong
- Department of Gynecology, The Affiliated Obstetrics and Gynaecology Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| | - Yongqin Yang
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Jian Huang
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Emei Lu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
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Kumar T, Achkar S, Haie-Meder C, Chargari C. Curiethérapie guidée par imagerie multimodale : l’exemple du cancer du col utérin. Cancer Radiother 2019; 23:765-772. [DOI: 10.1016/j.canrad.2019.07.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022]
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Wiersma RD, Liu X. A conceptual study on real-time adaptive radiation therapy optimization through ultra-fast beamlet control. Biomed Phys Eng Express 2019; 5. [DOI: 10.1088/2057-1976/ab3ba9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Vedasoundaram P, Vandanasetti S, Periasamy K, Kandasamy S. Measurement of Cervical Regression and Optimizing Brachytherapy Schedule Concurrently with External Beam Radiation Therapy in Cervical Carcinoma. Cureus 2019; 11:e5316. [PMID: 31588384 PMCID: PMC6776105 DOI: 10.7759/cureus.5316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction This study aimed to measure cervical regression during external beam radiation therapy (EBRT) and optimize the scheduling of brachytherapy concurrently with EBRT. Methods Fifty consecutive patients with carcinoma of the cervix stage IIA to IIIB received concurrent chemoradiotherapy with weekly Cisplatin 40 mg/m2. Cervical regression was evaluated using serial CT scans obtained before and during concurrent chemoradiotherapy (on the third, fourth, and fifth weeks). High dose rate brachytherapy was introduced after 30Gy of EBRT. A total of 25.5Gy in three fractions were delivered during the third, fourth, and fifth weeks of EBRT. Cervical volumes were recorded from the CT scan for cervical regression. Results The mean cervical volume at baseline (i.e., before the start of treatment) was 85.53 cubic centimetres (cc). The mean cervical volumes at the end of the third, fourth, and fifth week were 28.95cc, 24.92cc, and 21.80cc, respectively. The mean cervical regression from baseline to the end of the third, fourth, and fifth week was 60%, 65%, and 69%, respectively. The time for 50% cervical regression was calculated to be 18 days and occurred around 27Gy of EBRT. Conclusion More than 50% of cervical regressions occur at the end of the third week (i.e., after delivery of 30Gy of EBRT), so it is optimal to introduce brachytherapy at the end of the third week. A conventional point-based plan can cover the high-risk clinical target volume (HRCTV) if the volume is <25cc, but an HRCTV >25cc may be well covered with optimization or a combination of intracavitary and interstitial brachytherapy.
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Affiliation(s)
| | - Santhosh Vandanasetti
- Radiation Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Kannan Periasamy
- Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Saravanan Kandasamy
- Medical Physics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Visser J, de Boer P, Crama KF, van Kesteren Z, Rasch CRN, Stalpers LJA, Bel A. Dosimetric comparison of library of plans and online MRI-guided radiotherapy of cervical cancer in the presence of intrafraction anatomical changes. Radiat Oncol 2019; 14:126. [PMID: 31300000 PMCID: PMC6624982 DOI: 10.1186/s13014-019-1322-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/18/2019] [Indexed: 12/05/2022] Open
Abstract
Background Online magnetic resonance imaging (MRI)-guided radiotherapy of cervical cancer has the potential to further reduce dose to organs at risk (OAR) as compared to a library of plans (LOP) approach. This study presents a dosimetric comparison of an MRI-guided strategy with a LOP strategy taking intrafraction anatomical changes into account. Methods The 14 patients included in this study were treated with chemo radiation at our institute and received weekly MRIs after informed consent. The MRI-guided strategy consisted of treatment plans created on the weekly sagittal MRI with 3 mm and 5 mm planning target volume (PTV) margin for clinical target volume (CTV) cervix-uterus (MRI_3mm and MRI_5mm). The plans for the LOP strategy were based on interpolations of CTV cervix-uterus on pretreatment full and empty bladder scans. Dose volume histogram (DVH) parameters were compared for targets and OARs as delineated on the weekly transversal MRI, which was acquired on average 10 min after the sagittal MRI. Results For the MRI_5mm strategy D98% of the high-risk CTV was at least 95% for all weekly MRIs of all patients, while for the LOP and MRI_3mm strategy this requirement was not satisfied for at least one weekly MRI for 1 and 3 patients, respectively. The average reduction of the volume of the reference dose (95% of the prescribed dose) as compared to the LOP strategy was 464 cm3 for the MRI_3mm strategy, and 422 cm3 for the MRI_5mm strategy. The bowel bag constraint V40Gy < 350 cm3 was violated for 13 patients for the LOP strategy and for 5 patients for both MRI_3mm and MRI_5mm strategy. Conclusions With online MRI-guided radiotherapy of cervical cancer considerable sparing of OARs can be achieved. If a new treatment plan can be generated and delivered within 10 min, an online MRI-guided strategy with a 5 mm PTV margin for CTV cervix-uterus is sufficient to account for intrafraction anatomical changes. Trial registration NL44492.018.13. Electronic supplementary material The online version of this article (10.1186/s13014-019-1322-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Visser
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| | - P de Boer
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Present Address: Radiotherapeutisch Instituut Friesland, Borniastraat 36, Leeuwarden, the Netherlands
| | - K F Crama
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Z van Kesteren
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Present Address: Department of Radiation Oncology, Leiden University Medical Center, University of Leiden, Albinusdreef 2, Leiden, The Netherlands
| | - L J A Stalpers
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - A Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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de Boer P, Spijkerboer AM, Bleeker MCG, van Lonkhuijzen LRCW, Monraats MA, Nederveen AJ, van de Vijver MJ, Kenter GG, Bel A, Rasch CRN, Stoker J, Stalpers LJA. Prospective validation of craniocaudal tumour size on MR imaging compared to histoPAthology in patients with uterine cervical cancer: The MPAC study. Clin Transl Radiat Oncol 2019; 18:9-15. [PMID: 31341971 PMCID: PMC6610701 DOI: 10.1016/j.ctro.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/03/2022] Open
Abstract
Tumour extension on MRI was compared with histopathology using three methods. MRI visualises tumour extension within a margin of 10 mm compared to microscopy. The major source of measurement uncertainty is post-surgical change of organ.
Purpose To determine the accuracy of MRI in detecting craniocaudal tumour extension, compared to histopathology, of the hysterectomy specimen in patients with early-stage uterine cervical cancer. Three complementary methods were investigated. Materials and methods Thirty-four patients with early-stage cervical cancer had pre-operative MRI, followed by radical hysterectomy or trachelectomy. 1) craniocaudal tumour extension was measured on MRI by two radiologists and compared to microscopy by a pathologist, 2) to compensate for changes in uterine shape between pre-operative MRI and the surgical specimen, craniocaudal tumour extensions were directly compared and appreciated as being a part of a 3-dimensional tumour by a radiation oncologist and resident, and 3) tumour size on MRI was compared macroscopically after digital non-rigid registration of the uterus, uterine cavity and tumour of both modalities. Results The craniocaudal tumour extension measured on histopathology minus MRI gives: 1) on average +3 mm difference when measured by a radiologist compared to the microscopic extension (range −13 to +15 mm), 2) −0.2 mm (range −11 to +6.0 mm) when evaluated on MRI by a radiation oncologist compared to the macroscopic tumour; 3) after non-rigid organ registration, a margin of 10 mm around the tumour on MRI would be needed to cover 95% of the tumour in 90% of the patients. Conclusions Results indicate that microscopic tumour extension towards the uterine fundus is within a margin of 10 mm around the visible tumour on MRI. The major source of measurement uncertainty is post-surgical change of organ shape and form.
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Affiliation(s)
- Peter de Boer
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Anje M Spijkerboer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Maaike C G Bleeker
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Luc R C W van Lonkhuijzen
- Department of Gynaecology and Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Mélanie A Monraats
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Aart J Nederveen
- Department of Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Marc J van de Vijver
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Gemma G Kenter
- Department of Gynaecology and Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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White IM, Scurr E, Wetscherek A, Brown G, Sohaib A, Nill S, Oelfke U, Dearnaley D, Lalondrelle S, Bhide S. Realizing the potential of magnetic resonance image guided radiotherapy in gynaecological and rectal cancer. Br J Radiol 2019; 92:20180670. [PMID: 30933550 PMCID: PMC6592079 DOI: 10.1259/bjr.20180670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/24/2019] [Accepted: 03/21/2019] [Indexed: 12/25/2022] Open
Abstract
CT-based radiotherapy workflow is limited by poor soft tissue definition in the pelvis and reliance on rigid registration methods. Current image-guided radiotherapy and adaptive radiotherapy models therefore have limited ability to improve clinical outcomes. The advent of MRI-guided radiotherapy solutions provides the opportunity to overcome these limitations with the potential to deliver online real-time MRI-based plan adaptation on a daily basis, a true "plan of the day." This review describes the application of MRI guided radiotherapy in two pelvic tumour sites likely to benefit from this approach.
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Affiliation(s)
- Ingrid M White
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Erica Scurr
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Andreas Wetscherek
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Gina Brown
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Aslam Sohaib
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Simeon Nill
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Uwe Oelfke
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - David Dearnaley
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Susan Lalondrelle
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Shreerang Bhide
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
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Rigaud B, Klopp A, Vedam S, Venkatesan A, Taku N, Simon A, Haigron P, de Crevoisier R, Brock KK, Cazoulat G. Deformable image registration for dose mapping between external beam radiotherapy and brachytherapy images of cervical cancer. Phys Med Biol 2019; 64:115023. [PMID: 30913542 DOI: 10.1088/1361-6560/ab1378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
For locally advanced cervical cancer (LACC), anatomy correspondence with and without BT applicator needs to be quantified to merge the delivered doses of external beam radiation therapy (EBRT) and brachytherapy (BT). This study proposed and evaluated different deformable image registration (DIR) methods for this application. Twenty patients who underwent EBRT and BT for LACC were retrospectively analyzed. Each patient had a pre-BT CT at EBRT boost (without applicator) and a CT and MRI at BT (with applicator). The evaluated DIR methods were the diffeomorphic Demons, commercial intensity and hybrid methods, and three different biomechanical models. The biomechanical models considered different boundary conditions (BCs). The impact of the BT devices insertion on the anatomy was quantified. DIR method performances were quantified using geometric criteria between the original and deformed contours. The BT dose was deformed toward the pre-CT BT by each DIR method. The impact of boundary conditions to drive the biomechanical model was evaluated based on the deformation vector field and dose differences. The GEC-ESTRO guideline dose indices were reported. Large organ displacements, deformations, and volume variations were observed between the pre-BT and BT anatomies. Rigid registration and intensity-based DIR resulted in poor geometric accuracy with mean Dice similarity coefficient (DSC) inferior to 0.57, 0.63, 0.42, 0.32, and 0.43 for the rectum, bladder, vagina, cervix and uterus, respectively. Biomechanical models provided a mean DSC of 0.96 for all the organs. By considering the cervix-uterus as one single structure, biomechanical models provided a mean DSC of 0.88 and 0.94 for the cervix and uterus, respectively. The deformed doses were represented for each DIR method. Caution should be used when performing DIR for this application as standard techniques may have unacceptable results. The biomechanical model with the cervix-uterus as one structure provided the most realistic deformations to propagate the BT dose toward the EBRT boost anatomy.
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Affiliation(s)
- B Rigaud
- Univ Rennes, CLCC Eugène Marquis, Inserm, LTSI-UMR 1099, F-35000 Rennes, France. Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America. Author to whom any correspondence should be addressed
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de Boer P, Mandija S, Werensteijn-Honingh AM, van den Berg CAT, de Leeuw AAC, Jürgenliemk-Schulz IM. Cervical cancer apparent diffusion coefficient values during external beam radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 9:77-82. [PMID: 33458429 PMCID: PMC7807732 DOI: 10.1016/j.phro.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 01/22/2023]
Abstract
Background and purpose Apparent diffusion coefficient (ADC) reflects micro-enviromental changes and therefore might be useful in predicting recurrence prior to brachytherapy. The purpose of this study is to evaluate change in ADC of the primary tumour and pathologic lymph nodes during treatment and to correlate this with clinical outcome. Material and methods Twenty patients were included who received chemoradiation for locally advanced cervical cancer between July 2016 and November 2017. All patients underwent magnetic resonance imaging (MRI) prior to treatment, and three MRIs in weeks 1/2, 3 and 4 of treatment, including T2 and diffusion weighted imaging (b-values 0, 200, 800 s/mm2) for determining an ADC-map. Primary tumour was delineated on T2 and ADC-map and pathologic lymph nodes were delineated only on ADC-map. Results At time of analysis median follow-up was 15 (range 7-22) months. From MRI one to four, primary tumour on ADC-map showed a significant signal increase of 0.94 (range 0.74-1.46) × 10-3 mm2/s to 1.13 (0.98-1.49) × 10-3 mm2/s (p < 0.001). When tumour was delineated on T2, ADC-value signal increase (in tumour according to T2) was similar. All 46 delineated pathologic lymph nodes showed an ADC-value increase on average from 0.79 (range 0.33-1.12) × 10-3 mm2/s to 1.14 (0.59-1.75) × 10-3 mm2/s (p < 0.001). The mean tumour/suspected lymph node volumes decreased respectively 51/40%. Four patients developed relapse (one local and three nodal), without clear relation with ΔADC. However, the median volume decrease of the primary tumour was substantially lower in the failing patients compared to the group without relapse (19 vs. 57%). Conclusions ADC values can be acquired using T2-based tumour delineations unless there are substantial shifts between ADC-mapping and T2 acquisition. It remains plausible that ΔADC is a predictor for response to EBRT. However, the correlation in this study was not statistically significant.
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Affiliation(s)
- Peter de Boer
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands.,Department of Radiation Oncology, Amsterdam University Medical Centres (Amsterdam UMC) - University of Amsterdam (UvA), The Netherlands
| | - Stefano Mandija
- Centre for Image Sciences, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | | | - Cornelis A T van den Berg
- Centre for Image Sciences, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Astrid A C de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
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Oh J, Seol KH, Choi YS, Lee JW, Bae JY. Clinical significance of lymph node size in locally advanced cervical cancer treated with concurrent chemoradiotherapy. Yeungnam Univ J Med 2019; 36:115-123. [PMID: 31620623 PMCID: PMC6784628 DOI: 10.12701/yujm.2019.00143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 11/05/2022] Open
Abstract
Background This study aimed to assess the in-field lymph node (LN) failure rate according to LN size and to investigate effect of LN size on the survival outcome of patients with locally advanced cervical carcinoma treated with concurrent chemoradiotherapy (CCRT). Methods A total of 310 patients with locally advanced cervical carcinoma treated with CCRT were enrolled in retrospective study. LN status was evaluated by magnetic resonance imaging. All patients received conventional external beam irradiation and high-dose rate brachytherapy, and concurrent cisplatin-based chemotherapy. In-field LN failure rate according to LN size was analyzed. Results The median follow-up period was 83 months (range, 3-201 months). In-field LN failure rate in patients with pelvic LN size more than 10 mm was significantly higher than that in patients with pelvic LN size less than 10 mm (p<0.001). A similar finding was observed in the in-field para-aortic LN (PALN) failure rate (p=0.024). The pelvic and PALN size (≥10 mm) was a significant prognostic factor of overall-survival (OS) and disease-free survival rate in univariate and multivariate analyses. The OS rate was significantly different between groups according to LN size (<10 mm vs. ≥10 mm). Conclusion A LN of less than 10 mm in size in an imaging study is controlled by CCRT. On the other hand, in LN of more than 10 mm in size, the in-field LN failure rate increase and the prognosis deteriorate. Therefore, a more aggressive treatment strategy is needed.
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Affiliation(s)
- Jinju Oh
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Ho Seol
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Youn Seok Choi
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jeong Won Lee
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jin Young Bae
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
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Liu X, Wiersma RD. Optimization based trajectory planning for real-time 6DoF robotic patient motion compensation systems. PLoS One 2019; 14:e0210385. [PMID: 30633766 PMCID: PMC6329492 DOI: 10.1371/journal.pone.0210385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/21/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose Robotic stabilization of a therapeutic radiation beam with respect to a dynamically moving tumor target can be accomplished either by moving the radiation source, the patient, or both. As the treatment beam is on during this process, the primary goal is to minimize exposure of normal tissue to radiation as much as possible when moving the target back to the desired position. Due to the complex mechanical structure of 6 degree-of-freedom (6DoF) robots, it is not intuitive as to what 6 dimensional (6D) correction trajectory is optimal in achieving such a goal. With proportional-integrative-derivative (PID) and other controls, the potential exists that the controller may generate a trajectory that is highly curved, slow, or suboptimal in that it leads to unnecessary exposure of healthy tissue to radiation. This work investigates a novel feedback planning method that takes into account a robot’s mechanical joint structure, patient safety tolerances, and other system constraints, and performs real-time optimization to search the entire 6D trajectory space in each time cycle so it can respond with an optimal 6D correction trajectory. Methods Computer simulations were created for two 6DoF robotic patient support systems: a Stewart-Gough platform for moving a patient’s head in frameless maskless stereotactic radiosurgery, and a linear accelerator treatment table for moving a patient in prostate cancer radiation therapy. Motion planning was formulated as an optimization problem and solved at real-time speeds using the L-BFGS algorithm. Three planning methods were investigated, moving the platform as fast as possible (platform-D), moving the target along a straight-line (target-S), and moving the target based on the fastest descent of position error (target-D). Both synthetic motion and prior recorded human motion were used as input data and output results were analyzed. Results For randomly generated 6D step-like and sinusoidal synthetic input motion, target-D planning demonstrated the smallest net trajectory error in all cases. On average, optimal planning was found to have a 45% smaller target trajectory error than platform-D control, and a 44% smaller target trajectory error than target-S planning. For patient head motion compensation, only target-D planning was able to maintain a ≤0.5mm and ≤0.5deg clinical tolerance objective for 100% of the treatment time. For prostate motion, both target-S planning and target-D planning outperformed platform-D control. Conclusions A general 6D target trajectory optimization framework for robotic patient motion compensation systems was investigated. The method was found to be flexible as it allows control over various performance requirements such as mechanical limits, velocities, acceleration, or other system control objectives.
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Affiliation(s)
- Xinmin Liu
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL 60637, United States of America
| | - Rodney D. Wiersma
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL 60637, United States of America
- * E-mail:
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Jensen NBK, Assenholt MS, Fokdal LU, Vestergaard A, Schouboe A, Kjaersgaard EB, Boejen A, Nyvang L, Lindegaard JC, Tanderup K. Cone beam computed tomography-based monitoring and management of target and organ motion during external beam radiotherapy in cervical cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 9:14-20. [PMID: 33458421 PMCID: PMC7807672 DOI: 10.1016/j.phro.2018.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 12/18/2022]
Abstract
Background and purpose Organ motion is a challenge during high-precision external beam radiotherapy in cervical cancer, and improved strategies for treatment adaptation and monitoring of target dose coverage are needed. This study evaluates a cone beam computed tomography (CBCT)-based approach. Materials and methods In twenty-three patients, individualized internal target volumes (ITVs) were generated from pre-treatment MRI and CT scans with full and empty bladders. The target volumes encompassed high-risk clinical target volume (CTV-T HR) (gross tumor volume + remaining cervix) and low risk (LR) CTV-T (CTV-T HR + uterus + parametriae + upper vagina). Volumetric Modulated Arc Therapy (VMAT) was used to deliver a dose of 45 Gy in 25 fractions. CBCTs were used for setup and for radiation therapists (RTTs) to evaluate the target coverage (inside/outside the planning target volume). CBCTs were reviewed offline. Estimates of the dose delivered with minimum (point) doses across all fractions to CTV-T HR (aim 42.75 Gy) and CTV-T LR (aim 40 Gy) were assessed. In patients with insufficient dose coverage, re-plans were generated based on previous imaging. Results Median (range) of the ITV-margins (mean of anterior-posterior margins) related to uterus and cervix was 1.2 (0.5–2.2 and 1.0–2.1) cm. RTTs were able to assess the target coverage in 90% of all CBCTs (505/563). With re-planning, one patient had considerable benefit (12.7 Gy increase of minimum dose) to CTV-T LR_vagina, four patients had improved dose to the CTV-T LR_uterus (1.2–1.8 Gy), and 3 patients did not benefit from re-planning. Conclusions Daily CBCT-based monitoring of target coverage by the RTTs has proven safe with limited workload. It allows for reduction in the treated volumes without compromising the target dose coverage.
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Affiliation(s)
| | | | - Lars Ulrik Fokdal
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Annette Schouboe
- Danish Centre for Particle Therapy, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | | | - Annette Boejen
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Lars Nyvang
- Department of Medical Physics, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
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Wang W, Zhang F, Hu K, Hou X. Image-guided, intensity-modulated radiation therapy in definitive radiotherapy for 1433 patients with cervical cancer. Gynecol Oncol 2018; 151:444-448. [DOI: 10.1016/j.ygyno.2018.09.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/17/2018] [Accepted: 09/20/2018] [Indexed: 01/02/2023]
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Radiothérapie guidée par l’image des cancers gynécologiques. Cancer Radiother 2018; 22:608-616. [DOI: 10.1016/j.canrad.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/26/2018] [Indexed: 11/24/2022]
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Dosimetric comparison between three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) in the treatment of different stages of nasopharyngeal carcinoma. JOURNAL OF RADIOTHERAPY IN PRACTICE 2018. [DOI: 10.1017/s1460396918000377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackgroundThis work aims to compare the dosimetric performance of three-dimensional conformal radiotherapy (3D-CRT), a relatively available technique in developing countries, to intensity-modulated radiotherapy (IMRT) in the treatment of different stages of nasopharyngeal carcinoma (NPC).Materials and MethodsAccording to the diagnostic stages, 40 NPC patients were divided into two equal groups. Three planning techniques such as 3D-CRT, seven-field IMRT (7F-IMRT) and nine-field IMRT (9F-IMRT) were compared. Dose prescriptions of 70 and 66 Gy were delivered in 35 fractions to gross planning target volume (PTV1) and bilateral retropharyngeal carcinoma (PTV2), respectively.ResultsStage I dose data for almost all of the three investigated planning techniques obey the international recommendations. The dose delivered to PTV1 and PTV2 for 3D-CRT and 7F-IMRT are statistically similar, whereas 9F-IMRT is significantly better than 3D-CRT. For organs at risk (OARs), the delivered dose is significantly better for 9F-IMRT compared with the other two techniques, whereas 7F-IMRT is significantly better than 3D-CRT.Conclusions3D-CRT is an acceptable alternative treatment technique for stage I NPC patients in developing countries suffering from the lack of advanced radiotherapy treatment techniques. 3D-CRT and 7F-IMRT have comparable performance in PTVs, while 9F-IMRT is superior in PTVs and OARs.
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Cree A, Livsey J, Barraclough L, Dubec M, Hambrock T, Van Herk M, Choudhury A, McWilliam A. The Potential Value of MRI in External-Beam Radiotherapy for Cervical Cancer. Clin Oncol (R Coll Radiol) 2018; 30:737-750. [PMID: 30209010 DOI: 10.1016/j.clon.2018.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 01/01/2023]
Abstract
The reference standard treatment for cervical cancer is concurrent chemoradiotherapy followed by magnetic resonance imaging (MRI)-guided brachytherapy. Improvements in brachytherapy have increased local control rates, but late toxicity remains high with rates of 11% grade ≥3. The primary clinical target volume (CTV) for external-beam radiotherapy includes the cervix and uterus, which can show significant inter-fraction motion. This means that generous margins are required to cover the primary CTV, increasing the radiation dose to organs at risk and, therefore, toxicity. A number of image-guided radiotherapy techniques (IGRT) have been developed, but motion can be random and difficult to predict prior to treatment. In light of the development of integrated MRI linear accelerators, this review discusses the potential value of MRI in external-beam radiotherapy. Current solutions for managing pelvic organ motion are reviewed, including the potential for online adaptive radiotherapy. The impacts of the use of MRI in tumour delineation and in the delivery of stereotactic ablative body radiotherapy (SABR) are highlighted. The potential role and challenges of using multi parametric MRI to guide radiotherapy are also discussed.
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Affiliation(s)
- A Cree
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - J Livsey
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - L Barraclough
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - M Dubec
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - T Hambrock
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - M Van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - A Choudhury
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK
| | - A McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust Christie Hospital, Manchester Academic Health Science Centre, Manchester M20 4BX, UK.
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Rigaud B, Simon A, Gobeli M, Lafond C, Leseur J, Barateau A, Jaksic N, Castelli J, Williaume D, Haigron P, De Crevoisier R. CBCT-guided evolutive library for cervical adaptive IMRT. Med Phys 2018; 45:1379-1390. [DOI: 10.1002/mp.12818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 12/29/2017] [Accepted: 02/02/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Bastien Rigaud
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
| | - Antoine Simon
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
| | - Maxime Gobeli
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Caroline Lafond
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Julie Leseur
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Anais Barateau
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
| | - Nicolas Jaksic
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Joël Castelli
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Danièle Williaume
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
| | - Pascal Haigron
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
| | - Renaud De Crevoisier
- LTSI; Université de Rennes 1; Campus de Beaulieu Rennes F-35042 France
- INSERM; U1099, Campus de Beaulieu Rennes F-35042 France
- Radiotherapy Department; Centre Eugene Marquis; Rennes F-35000 France
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Appropriate magnetic resonance imaging techniques for gross tumor volume delineation in external beam radiation therapy of locally advanced cervical cancer. Oncotarget 2018. [PMID: 29515794 PMCID: PMC5839375 DOI: 10.18632/oncotarget.24071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Accurate delineation of the gross tumor volumes (GTV) is a prerequisite for precise radiotherapy planning and delivery. Different MRI sequences have different advantages and limitations in their ability to discriminate primary cervical tumor from normal tissue. The purpose of this work is to determine appropriate MRI techniques for GTV delineation for external-beam radiation therapy of locally advanced cervical cancer (LACC). Materials and Methods GTVs were delineated on the MRI, CT, and PET images acquired for 23 LACC patients in treatment positions to obtain GTVs on CT (GTV-CT), on various MRI sequences including T1 (GTV-T1), T2 (GTV-T2), T1 with fat suppression and contrast (GTV-T1F+), DWI-ADC (GTV-ADC) and on PET were generated using the threshold of 40% of maximum SUV (GTV-SUV40%) as well as SUV of 2.5 (GTV-SUV2.5). MRI, CT and PET were registered for comparison. The GTVs defined by MRI were compared using the overlap ratio (OR) and relative volume ratio (RVR). The union of GTV-T2 and GTV-ADC was generated to represent the MRI-based GTV (GTV-MRI). Results The differences between GTV-T2 and other MRI GTVs are significant (P < 0.05). The average ORs for GTV-T1, GTV-T1F+, and GTV-ADC related to GTV-T2 were 86.3%, 81.6%, and 61.6% with the corresponding average RVRs 113.8%, 112.3% and 77.2%, respectively. There is no significant difference between GTV-T1 and GTV-T1F+. GTV-ADC was generally smaller than GTV-T2, however, encompassed suspicious regions that are uncovered in GTV-T2 (up to 16% of GTV-T2) because of different imaging mechanisms. There was significant difference between GTV-MRI, GTV-SUV2.5, GTV-SUV40%, and GTV-CT. On average, GTV-MRI is 18.4% smaller than GTV-CT. Conclusions MRI provides improved visualization of disease over CT or PET for cervical cancer. The GTV from the union of GTV-T2 and GTV-ADC provides a reasonable GTV including tumor region defined anatomically and functionally with MRI and substantially reduces the conventional GTV defined on CT.
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Wang W, Meng Q, Hou X, Lian X, Yan J, Sun S, Liu Z, Miao Z, Wang D, Liu X, Hu K, Zhang F. Efficacy and toxicity of image-guided intensity-modulated radiation therapy combined with dose-escalated brachytherapy for stage IIB cervical cancer. Oncotarget 2017; 8:102965-102973. [PMID: 29262537 PMCID: PMC5732703 DOI: 10.18632/oncotarget.22434] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/27/2017] [Indexed: 11/25/2022] Open
Abstract
Considering internal organ motion and tumor regression, it is controversial to use intensity-modulated radiation therapy (IMRT) in definitive radiotherapy for cervical cancer. In this study, we evaluated the efficacy and toxicity of IMRT combined with dose-escalated intracavitary brachytherapy (ICBT) for cervical cancer. In total, 373 consecutive FIGO-stage-IIB cervical cancer patients treated with IMRT combined with ICBT and concurrent chemotherapy were included in this study. A dose of 50.4 Gy in 28 fractions was delivered to the pelvis for IMRT. Weekly cone-beam computed tomography or daily megavoltage computed tomography was used for image guiding. For ICBT, 30–36 Gy in five to seven fractions were prescribed to point A. All patients received concurrent chemotherapy. The median follow-up duration was 32.5 months (range, 3.1–119.8 months). The three-year overall survival, disease-free survival and local control rates were 87.5%, 82.2% and 92.5%, respectively. Sixty patients (16.1%) experienced treatment failure, including 23 patients (6.2%) with pelvic relapse. The incidences of ≥grade 3 chronic gastrointestinal and genitourinary toxicity were 2.7% and 2.4%, respectively. These findings indicate that image-guided IMRT combined with dose-escalated ICBT results in good survival with acceptable toxicity in stage IIB cervical cancer patients.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Xin Lian
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shuai Sun
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Zhikai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Zheng Miao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
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Mahmoud O, Kilic S, Khan AJ, Beriwal S, Small W. External beam techniques to boost cervical cancer when brachytherapy is not an option-theories and applications. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:207. [PMID: 28603722 DOI: 10.21037/atm.2017.03.102] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The management of locally advanced cervical cancer relies on brachytherapy (BT) as an integral part of the radiotherapy delivery armamentarium. Occasionally, intracavitary BT is neither possible nor available. In these circumstances, post-external beam radiotherapy (EBRT) interstitial brachytherapy and/or hysterectomy may represent viable options that must be adequately executed in a timely manner. However, if these options are not applicable due to patient related or facility related reasons, a formal contingency plan should be in place. Innovative EBRT techniques such as intensity modulated and stereotactic radiotherapy may be considered for patients unable to undergo brachytherapy. Relying on provocative arguments and recent data, this review explores the rationale for and limitations of non-brachytherapy substitutes in that setting aiming to establish a formal process for the optimal execution of this alternative plan.
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Affiliation(s)
- Omar Mahmoud
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Sarah Kilic
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers, the State University of New Jersey, Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Radiation Oncology, Rutgers, the State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Sushil Beriwal
- Departement of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - William Small
- Department of Radiation Oncology, Loyola University, Chicago, IL, USA
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Moriya S, Tachibana H, Kitamura N, Sawant A, Sato M. Dose warping performance in deformable image registration in lung. Phys Med 2017; 37:16-23. [DOI: 10.1016/j.ejmp.2017.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 02/13/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022] Open
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de Boer P, Jürgenliemk-Schulz IM, Westerveld H, de Leeuw AAC, Dávila-Fajardo R, Rasch CRN, Pieters BR, Stalpers LJA. Patterns of care survey: Radiotherapy for women with locally advanced cervical cancer. Radiother Oncol 2017; 123:306-311. [PMID: 28434797 DOI: 10.1016/j.radonc.2017.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Regarding latest developments, the need of a radiotherapy 'Patterns of Care' survey was expressed by the Dutch National Platform Radiotherapy for Gynaecological Cancer (LPRGT). Therefore, this study investigated current practice for cervical cancer in all 16 radiation oncology centres in the Netherlands specialised in gynaecological oncology. MATERIAL AND METHODS A structured 'patterns of care' questionnaire was completed and followed by an in-depth interview with radiation oncologists from all radiotherapy centres specialised in gynaecological oncology. Specific topics addressed were: definition of target volumes, treatment preparation, imaging for treatment planning, treatment planning, and image-guided adaptive radiotherapy for external beam radiotherapy and brachytherapy. RESULTS Current radiotherapy practice in the Netherlands for cervical cancer appears to be in accordance with international standards. However, at the time of the survey some differences were revealed that might have relevant clinical impact. For instance: 1) Half of the centres acquired positron emission tomography combined with CT (PET-CT) for staging and target delineation for every patient, 2) The definition of upper border of the para-aortal lymph node area and dose prescription for external beam radiotherapy varied between the centres, and 3) 12 centres used a single treatment plan for delivering EBRT, and four used a plan-of-the-day strategy with a library of 3-4 treatment plans. CONCLUSIONS Most differences were found at the cutting edge of clinical evidence. However, the majority of these uncertainties are topics being addressed in current and planned (inter)national studies.
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Affiliation(s)
- Peter de Boer
- Department of Radiation Oncology, Academic Medical Centre (AMC) - University of Amsterdam, The Netherlands.
| | | | - Henrike Westerveld
- Department of Radiation Oncology, Academic Medical Centre (AMC) - University of Amsterdam, The Netherlands
| | - Astrid A C de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Raquel Dávila-Fajardo
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Centre (AMC) - University of Amsterdam, The Netherlands
| | - Bradley R Pieters
- Department of Radiation Oncology, Academic Medical Centre (AMC) - University of Amsterdam, The Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, Academic Medical Centre (AMC) - University of Amsterdam, The Netherlands
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Arnesen MR, Hellebust TP, Malinen E. Impact of dose escalation and adaptive radiotherapy for cervical cancers on tumour shrinkage—a modelling study. Phys Med Biol 2017; 62:N107-N119. [DOI: 10.1088/1361-6560/aa5de2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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