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Zhu H, Dong T, Pang T, Guan Q, Yang J, Zhao F, Yang B, Qiu J. Characterization of kilovoltage x-ray image guidance system with a novel post-processing algorithm on a new slip ring-mounted radiotherapy system. J Appl Clin Med Phys 2024:e14524. [PMID: 39259864 DOI: 10.1002/acm2.14524] [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: 06/06/2024] [Revised: 07/15/2024] [Accepted: 08/14/2024] [Indexed: 09/13/2024] Open
Abstract
PURPOSE This study evaluates the performance of a kilovoltage x-ray image-guidance system equipped with a novel post-processing optimization algorithm on the newly introduced TAICHI linear accelerator (Linac). METHODS A comparative study involving image quality tests and radiation dose measurements was conducted across six scanning protocols of the kV-cone beam computed tomography (CBCT) system on the TAICHI Linac. The performance assessment utilized the conventional Feldkamp-Davis-Kress (FDK) algorithm and a novel Non-Local Means denoising and adaptive scattering correction (NLM-ASC) algorithm. Image quality metrics, including spatial resolution, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR), were evaluated using a Catphan 604 phantom. Radiation doses for low-dose and standard protocols were measured using a computed tomography dose index (CTDI) phantom, with comparative measurements from the Halcyon Linac's iterative CBCT (iCBCT). RESULTS The NLM-ASC algorithm significantly improved image quality, achieving a 300%-1000% increase in CNR and SNR over the FDK-only images and it also showed a 100%-200% improvement over the iCBCT images from Halcyon's head protocol. The optimized low-dose protocols yielded higher image quality than the standard FDK protocols, indicating potential for reduced radiation exposure. Clinical implementation confirmed the TAICHI system's utility for precise and adaptive radiotherapy. CONCLUSION The kV-IGRT system on the TAICHI Linac, with its novel post-processing algorithm, demonstrated superior image quality suitable for routine clinical use, effectively reducing image noise without compromising other quality metrics.
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Affiliation(s)
- Heling Zhu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingting Dong
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingtian Pang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiu Guan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingru Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feini Zhao
- Our United Corporation, Xi'an, Shanxi Province, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hafeez S, Warren-Oseni K, Jones K, Mohammed K, El-Ghzal A, Dearnaley D, Harris V, Khan A, Kumar P, Lalondrelle S, McDonald F, Tan M, Thomas K, Thompson A, McNair HA, Hansen VN, Huddart RA. Bladder Tumor-Focused Adaptive Radiation Therapy: Clinical Outcomes of a Phase I Dose Escalation Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03137-7. [PMID: 39069239 DOI: 10.1016/j.ijrobp.2024.07.2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 06/22/2024] [Accepted: 07/04/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE We determine the maximum tolerated tumor-focused dose (MTD) for the radical treatment of muscle invasive bladder cancer enabled by image guided adaptive radiation therapy and long-term clinical outcomes. METHODS AND MATERIALS Fifty-nine patients with T2 to T4aN0M0 unifocal urothelial muscle invasive bladder cancer suitable for daily radical radiation therapy were recruited prospectively to an ethics-approved protocol (NCT01124682). The uninvolved bladder (PTVbladder) was planned to 52 Gy in 32 fractions. The bladder tumor (PTVtumor) was planned to an assigned dose level of 68, 70, 72, or 74 Gy. If organ at risk dose constraints were violated, then PTVtumor was planned to 64 Gy. Dose level allocation was determined by concurrent toxicity assessment of all previous patients recruited. Acute toxicity was evaluated using Common Terminology Criteria for Adverse Events v3.0; late toxicity was evaluated using Radiation Therapy Oncology Group criteria. The MTD was predefined as the highest dose level with an estimated probability of ≤ 15% ≥ G3 late toxicity and an observed rate of <50% acute G3 and <10% acute G4 toxicity. RESULTS Twenty-six patients were assigned to 68 Gy, of whom 6 were planned to 64 Gy; 29 patients were assigned to 70 Gy of whom 1 was planned to 68 Gy, 2 patients were assigned and planned to 72 Gy; no patients were assigned to 74 Gy. Three patients did not complete the treatment as planned, of whom only 1 patient stopped treatment because dose-limiting toxicity occurred. The MTD was 70 Gy. Acute genito-urinary and gastro-intestinal G3 acute toxicity was seen in 19% and 7% of patients, respectively. No acute G4 genito-urinary or gastro-intestinal toxicity was seen. Late toxicity (any) G3 and G4 was seen in 14% and 2% of patients, respectively. The 5-year overall survival was 58% (95% CI, 44%-71%). The bladder preservation rate was 89% (95% CI, 88%-96%) with 6 patients not retaining native bladder function. CONCLUSIONS Bladder tumor-focused dose escalation to 70 Gy using image guided adaptive radiation therapy is feasible with acceptable toxicity. This dose level has been evaluated in a phase II randomized control trial (RAIDER NCT02447549).
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Karole Warren-Oseni
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Kelly Jones
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Kabir Mohammed
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Amir El-Ghzal
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - David Dearnaley
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Victoria Harris
- Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Atia Khan
- North Middlesex University Hospital, London, United Kingdom
| | - Pardeep Kumar
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Susan Lalondrelle
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Melissa Tan
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alan Thompson
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen A McNair
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Vibeke N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | - Robert A Huddart
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
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3
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Guel DNB, Laverick N, MacLaren L, MacLeod N, Glegg M, Lamb G, Houston P, Carruthers R, Grocutt L, Valentine RM. Adaptive radiotherapy for muscle invasive bladder cancer: a retrospective audit of two bladder filling protocols. Radiat Oncol 2024; 19:92. [PMID: 39030548 PMCID: PMC11264890 DOI: 10.1186/s13014-024-02484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/28/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Radical radiotherapy for muscle-invasive bladder cancer (MIBC) is challenging due to large variations in bladder shape, size and volume during treatment, with drinking protocols often employed to mitigate geometric uncertainties. Utilising adaptive radiotherapy together with CBCT imaging to select a treatment plan that best fits the bladder target and reduce normal tissue irradiation is an attractive option to compensate for anatomical changes. The aim of this retrospective study was to compare a bladder empty (BE) protocol to a bladder filling (BF) protocol with regards to variations in target volumes, plan of the day (PoD) selection and plan dosimetry throughout treatment. METHODS Forty patients were included in the study; twenty were treated with a BE protocol and twenty with a BF protocol to a total prescribed dose of 55 Gy in 20 fractions. Small, medium and large bladder plans were generated using three different CTV to PTV margins. Bladder (CTV) volumes were delineated on planning CTs and online pre-treatment CBCTs. Differences in CTV volumes throughout treatment, plan selection, PTV volumes and resulting dose metrics were compared for both protocols. RESULTS Mean bladder volume differed significantly on both the planning CTs and online pre-treatment CBCTs between the protocols (p < 0.05). Significant differences in bladder volumes were observed between the planning CT and pre-treatment CBCTs for BF (p < 0.05) but not for BE (p = 0.11). Both protocols saw a significant decrease in bladder volume between first and final treatment fractions (p < 0.05). Medium plans were preferentially selected for BE whilst when using the BF protocol the small plan was chosen most frequently. With no significant change to PTV coverage between the protocols, the volume of body receiving 25.0-45.8 Gy was found to be significantly smaller for BE patients (p < 0.05). CONCLUSIONS This work provides evidence in favour of a BE protocol compared to a BF protocol for radical radiotherapy for MIBC. The smaller treatment volumes observed in the BE protocol led to reduced OAR and total body doses and were also observed to be more consistent throughout the treatment course. These results highlight improvements in dosimetry for patients who undergo a BE protocol for MIBC.
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Affiliation(s)
- Diana Nohemi Briceño Guel
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8QQ, UK
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicola Laverick
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Linda MacLaren
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicholas MacLeod
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Martin Glegg
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Gillian Lamb
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Peter Houston
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Ross Carruthers
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Laura Grocutt
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
- CRUK RadNet Glasgow, University of Glasgow, Glasgow, G61 1QH, UK
| | - Ronan M Valentine
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK.
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4
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Zhao H, Liang X, Meng B, Dohopolski M, Choi B, Cai B, Lin MH, Bai T, Nguyen D, Jiang S. Progressive auto-segmentation for cone-beam computed tomography-based online adaptive radiotherapy. Phys Imaging Radiat Oncol 2024; 31:100610. [PMID: 39132556 PMCID: PMC11315102 DOI: 10.1016/j.phro.2024.100610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 08/13/2024] Open
Abstract
Background and purpose Accurate and automated segmentation of targets and organs-at-risk (OARs) is crucial for the successful clinical application of online adaptive radiotherapy (ART). Current methods for cone-beam computed tomography (CBCT) auto-segmentation face challenges, resulting in segmentations often failing to reach clinical acceptability. Current approaches for CBCT auto-segmentation overlook the wealth of information available from initial planning and prior adaptive fractions that could enhance segmentation precision. Materials and methods We introduce a novel framework that incorporates data from a patient's initial plan and previous adaptive fractions, harnessing this additional temporal context to significantly refine the segmentation accuracy for the current fraction's CBCT images. We present LSTM-UNet, an innovative architecture that integrates Long Short-Term Memory (LSTM) units into the skip connections of the traditional U-Net framework to retain information from previous fractions. The models underwent initial pre-training with simulated data followed by fine-tuning on a clinical dataset. Results Our proposed model's segmentation predictions yield an average Dice similarity coefficient of 79% from 8 Head & Neck organs and targets, compared to 52% from a baseline model without prior knowledge and 78% from a baseline model with prior knowledge but no memory. Conclusions Our proposed model excels beyond baseline segmentation frameworks by effectively utilizing information from prior fractions, thus reducing the effort of clinicians to revise the auto-segmentation results. Moreover, it works together with registration-based methods that offer better prior knowledge. Our model holds promise for integration into the online ART workflow, offering precise segmentation capabilities on synthetic CT images.
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Affiliation(s)
- Hengrui Zhao
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Xiao Liang
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Boyu Meng
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Michael Dohopolski
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Byongsu Choi
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Bin Cai
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Mu-Han Lin
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ti Bai
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Dan Nguyen
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Steve Jiang
- Medical Artificial Intelligence and Automation Laboratory and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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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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7
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Meyers SM, Winter JD, Obeidi Y, Chung P, Menard C, Warde P, Fong H, McPartlin A, Parameswaran S, Berlin A, Bayley A, Catton C, Craig T. A feasibility study of adaptive radiation therapy for postprostatectomy prostate cancer. Med Dosim 2023; 49:150-158. [PMID: 37985297 DOI: 10.1016/j.meddos.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 11/22/2023]
Abstract
Postoperative prostate radiotherapy requires large planning target volume (PTV) margins to account for motion and deformation of the prostate bed. Adaptive radiation therapy (ART) can incorporate image-guidance data to personalize PTVs that maintain coverage while reducing toxicity. We present feasibility and dosimetry results of a prospective study of postprostatectomy ART. Twenty-one patients were treated with single-adaptation ART. Conventional treatments were delivered for fractions 1 to 6 and adapted plans for the remaining 27 fractions. Clinical target volumes (CTVs) and small bowel delineated on fraction 1 to 4 CBCT were used to generate adapted PTVs and planning organ-at-risk (OAR) volumes for adapted plans. PTV volume and OAR dose were compared between ART and conventional using Wilcoxon signed-rank tests. Weekly CBCT were used to assess the fraction of CTV covered by PTV, CTV D99, and small bowel D1cc. Clinical metrics were compared using a Student's t-test (p < 0.05 significant). Offline adaptive planning required 1.9 ± 0.4 days (mean ± SD). ART decreased mean adapted PTV volume 61 ± 37 cc and bladder wall D50 compared with conventional treatment (p < 0.01). The CTV was fully covered for 96% (97%) of fractions with ART (conventional). Reconstructing dose on weekly CBCT, a nonsignificant reduction in CTV D99 was observed with ART (94%) compared to conventional (96%). Reduced CTV D99 with ART was significantly correlated with large anterior-posterior rectal diameter on simulation CT. ART reduced the number of fractions exceeding our institution's small bowel D1c limit from 14% to 7%. This study has demonstrated the feasibility of offline ART for post-prostatectomy cancer. ART facilitates PTV volume reduction while maintaining reasonable CTV coverage and can reduce the dose to adjacent normal tissues.
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Affiliation(s)
- Sandra M Meyers
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Menard
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Padraig Warde
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Heng Fong
- The Ministry of Health Malaysia, Daerah Timur Laut, Penang, Malaysia
| | - Andrew McPartlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Charles Catton
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Optimized Adaptive Radiotherapy with Individualized Plan Library for Muscle-Invasive Bladder Cancer Using Internal Target Volume Generation. Cancers (Basel) 2022; 14:cancers14194674. [PMID: 36230598 PMCID: PMC9564375 DOI: 10.3390/cancers14194674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary The bladder is a mobile target and is subject to filling variation. This poses a considerable challenge for effective radiotherapy (RT) delivery. We applied an internal target volume to the plan library to resolve intra-fractional errors caused by bladder filling during treatment. Adaptive radiotherapy using ITV is easy to perform and a feasible treatment approach. In this study, image-guided RT-based adaptive RT showed good survival outcomes with a high local control rate. Abstract The bladder is subject to filling variation, which poses a challenge to radiotherapy (RT) delivery. We aimed to assess feasibility and clinical outcomes in patients with bladder cancer treated with adaptive RT (ART) using individualized plan libraries. We retrospectively analyzed 19 patients who underwent RT for muscle-invasive bladder cancer (MIBC) in 2015–2021. Four planning computed tomography (CT) scans were acquired at 15-min intervals, and a library of three intensity-modulated RT plans were generated using internal target volumes (ITVs). A post-treatment cone-beam CT (CBCT) scan was acquired daily to assess intra-fraction filling and coverage. All patients completed the treatment, with 408 post-treatment CBCT scans. The bladder was out of the planning target volume (PTV) range in 12 scans. The volumes of the evaluated PTV plans were significantly smaller than those of conventional PTV. The 1-year and 2-year overall survival rates were 88.2% and 63.7%, respectively. Of eight cases that experienced recurrence, only two developed MIBC. There were no grade 3 or higher RT-related adverse events. ART using plan libraries and ITVs demonstrated good survival outcomes with a high local control rate. Irradiated normal tissue volume and treatment margins may be reduced through this approach, potentially resulting in lower toxicity rates.
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9
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Hansen CR, Hussein M, Bernchou U, Zukauskaite R, Thwaites D. Plan quality in radiotherapy treatment planning - Review of the factors and challenges. J Med Imaging Radiat Oncol 2022; 66:267-278. [PMID: 35243775 DOI: 10.1111/1754-9485.13374] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022]
Abstract
A high-quality treatment plan aims to best achieve the clinical prescription, balancing high target dose to maximise tumour control against sufficiently low organ-at-risk dose for acceptably low toxicity. Treatment planning (TP) includes multiple steps from simulation/imaging and segmentation to technical plan production and reporting. Consistent quality across this process requires close collaboration and communication between clinical and technical experts, to clearly understand clinical requirements and priorities and also practical uncertainties, limitations and compromises. TP quality depends on many aspects, starting from commissioning and quality management of the treatment planning system (TPS), including its measured input data and detailed understanding of TPS models and limitations. It requires rigorous quality assurance of the whole planning process and it links to plan deliverability, assessable by measurement-based verification. This review highlights some factors influencing plan quality, for consideration for optimal plan construction and hence optimal outcomes for each patient. It also indicates some challenges, sources of difference and current developments. The topics considered include: the evolution of TP techniques; dose prescription issues; tools and methods to evaluate plan quality; and some aspects of practical TP. The understanding of what constitutes a high-quality treatment plan continues to evolve with new techniques, delivery methods and related evidence-based science. This review summarises the current position, noting developments in the concept and the need for further robust tools to help achieve it.
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Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia.,Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - David Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
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10
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Dower K, Ford A, Sandford M, Doherty A, Greenham S, Kerin L, Dwyer P, Hansen C, Westhuyzen J, Shakespeare T. Retrospective evaluation of planning margins for patients undergoing radical radiation therapy treatment for bladder cancer using volumetric modulated arc therapy and cone beam computed tomography. J Med Radiat Sci 2021; 68:371-378. [PMID: 34288566 PMCID: PMC8656189 DOI: 10.1002/jmrs.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 06/20/2021] [Accepted: 07/09/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Current contouring guidelines for curative radiation therapy for muscle-invasive bladder cancer (MIBC) recommend margins of 1.5-2.0 cm, applied to the clinical target volume (CTV). This study assessed whether the use of volumetric modulated arc therapy (VMAT), cone beam computed tomography (CBCT) and strict bladder preparation allowed for a reduced planning target volume (PTV) expansion, resulting in lower doses to surrounding organs at risk (OARs). METHODS Daily CBCT images for 12 patients (382 scans total) were retrospectively reviewed against four potential PTV margins created on and exported with the reference CT scan. To form the PTVs, three isotropic expansions of 0.5, 1.0 and 1.5 cm were applied to the CTV, as well as an anisotropic expansion of 1.5 cm superiorly and 1.0 cm in all other dimensions. Following treatment completion, the CBCTs were visually assessed to determine the margins encapsulating the bladder. For retrospective planning purposes, the 1.0-cm and anisotropic margins were compared with the previously recommended margins to determine differences in OAR doses. RESULTS The 0.5-, 1.0- and 1.5-cm isotropic margins (IM) and the anisotropic margin (ANIM) covered the CTV in 46.1, 96.8, 100 and 100% of CBCTs retrospectively. Doses to OARs were significantly lower for the reduced margin plans for the small bowel, rectum and sigmoid. CONCLUSION Bladder planning target volumes may be safely reduced. We endorse a PTV margin of 1.0cm anteriorly, posteriorly and inferiorly with 1.0-1.5 cm superiorly for radical whole bladder cases using strict bladder preparation, VMAT and pretreatment CBCTs.
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Affiliation(s)
- Kathleene Dower
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Andriana Ford
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Michael Sandford
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Andrew Doherty
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Stuart Greenham
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Luke Kerin
- Mid North Coast Cancer Institute Port MacquariePort MacquarieNew South WalesAustralia
| | - Patrick Dwyer
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Carmen Hansen
- Mid North Coast Cancer Institute Port MacquariePort MacquarieNew South WalesAustralia
| | - Justin Westhuyzen
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Thomas Shakespeare
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
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11
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Paganetti H, Botas P, Sharp GC, Winey B. Adaptive proton therapy. Phys Med Biol 2021; 66:10.1088/1361-6560/ac344f. [PMID: 34710858 PMCID: PMC8628198 DOI: 10.1088/1361-6560/ac344f] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy treatments are typically planned based on a single image set, assuming that the patient's anatomy and its position relative to the delivery system remains constant during the course of treatment. Similarly, the prescription dose assumes constant biological dose-response over the treatment course. However, variations can and do occur on multiple time scales. For treatment sites with significant intra-fractional motion, geometric changes happen over seconds or minutes, while biological considerations change over days or weeks. At an intermediate timescale, geometric changes occur between daily treatment fractions. Adaptive radiation therapy is applied to consider changes in patient anatomy during the course of fractionated treatment delivery. While traditionally adaptation has been done off-line with replanning based on new CT images, online treatment adaptation based on on-board imaging has gained momentum in recent years due to advanced imaging techniques combined with treatment delivery systems. Adaptation is particularly important in proton therapy where small changes in patient anatomy can lead to significant dose perturbations due to the dose conformality and finite range of proton beams. This review summarizes the current state-of-the-art of on-line adaptive proton therapy and identifies areas requiring further research.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pablo Botas
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Foundation 29 of February, Pozuelo de Alarcón, Madrid, Spain
| | - Gregory C Sharp
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian Winey
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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12
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Moteabbed M, Smeets J, Hong TS, Janssens G, Labarbe R, Wolfgang JA, Bortfeld TR. Toward MR-integrated proton therapy: modeling the potential benefits for liver tumors. Phys Med Biol 2021; 66. [PMID: 34407528 DOI: 10.1088/1361-6560/ac1ef2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/18/2021] [Indexed: 12/25/2022]
Abstract
Magnetic resonance imaging (MRI)-integrated proton therapy (MRiPT) is envisioned to improve treatment quality for many cancer patients. However, given the availability of alternative image-guided strategies, its clinical need is yet to be justified. This study aims to compare the expected clinical outcomes of MRiPT with standard of practice cone-beam CT (CBCT)-guided PT, and other MR-guided methods, i.e. offline MR-guided PT and MR-linac, for treatment of liver tumors. Clinical outcomes were assessed by quantifying the dosimetric and biological impact of target margin reduction enabled by each image-guided approach. Planning target volume (PTV) margins were calculated using random and systematic setup, delineation and motion uncertainties, which were quantified by analyzing longitudinal MRI data for 10 patients with liver tumors. Proton treatment plans were created using appropriate PTV margins for each image-guided PT method. Photon plans with margins equivalent to MRiPT were generated to represent MR-linac. Normal tissue complication probabilities (NTCP) of the uninvolved liver were compared. We found that PTV margin can be reduced by 20% and 40% for offline MR-guided PT and MRiPT, respectively, compared with CBCT-guided PT. Furthermore, clinical target volume expansion could be largely alleviated when delineating on MRI rather than CT. Dosimetric implications included decreased equivalent mean dose of the uninvolved liver, i.e. up to 24.4 Gy and 27.3 Gy for offline MR-guided PT and MRiPT compared to CBCT-guided PT, respectively. Considering Child-Pugh score increase as endpoint, NTCP of the uninvolved liver was significantly decreased for MRiPT compared to CBCT-guided PT (up to 48.4%,p < 0.01), offline MR-guided PT (up to 12.9%,p < 0.01) and MR-linac (up to 30.8%,p < 0.05). Target underdose was possible in the absence of MRI-guidance (D90 reduction up to 4.2 Gy in 20% of cases). In conclusion, MRiPT has the potential to significantly reduce healthy liver toxicities in patients with liver tumors. It is superior to other image-guided techniques currently available.
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Affiliation(s)
- Maryam Moteabbed
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | | | - Rudi Labarbe
- Ion Beam Applications, Louvain-La-Neuve, Belguim
| | - John A Wolfgang
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Thomas R Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
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13
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Khalifa J, Supiot S, Pignot G, Hennequin C, Blanchard P, Pasquier D, Magné N, de Crevoisier R, Graff-Cailleaud P, Riou O, Cabaillé M, Azria D, Latorzeff I, Créhange G, Chapet O, Rouprêt M, Belhomme S, Mejean A, Culine S, Sargos P. Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder. Radiother Oncol 2021; 161:95-114. [PMID: 34118357 DOI: 10.1016/j.radonc.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations. METHODS AND MATERIALS In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy. RESULTS A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence. CONCLUSION The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France
| | - Géraldine Pignot
- Department of Urology, Institut Paoli Calmettes, Marseille, France
| | | | - Pierre Blanchard
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, Lille, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | | | - Pierre Graff-Cailleaud
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Olivier Riou
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | | | - David Azria
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | | | - Olivier Chapet
- Department of Radiotherapy, Hospices Civils de Lyon, France
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpétrière, APHP Sorbonne Université, Paris, France
| | - Sarah Belhomme
- Department of Medical Physics, Institut Bergonié, Bordeaux, France
| | - Arnaud Mejean
- Department of Urology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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14
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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15
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Hijab A, Tocco B, Hanson I, Meijer H, Nyborg CJ, Bertelsen AS, Smeenk RJ, Smith G, Michalski J, Baumann BC, Hafeez S. MR-Guided Adaptive Radiotherapy for Bladder Cancer. Front Oncol 2021; 11:637591. [PMID: 33718230 PMCID: PMC7947660 DOI: 10.3389/fonc.2021.637591] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
Radiotherapy has an important role in the curative and palliative treatment settings for bladder cancer. As a target for radiotherapy the bladder presents a number of technical challenges. These include poor tumor visualization and the variability in bladder size and position both between and during treatment delivery. Evidence favors the use of magnetic resonance imaging (MRI) as an important means of tumor visualization and local staging. The availability of hybrid systems incorporating both MRI scanning capabilities with the linear accelerator (MR-Linac) offers opportunity for in-room and real-time MRI scanning with ability of plan adaption at each fraction while the patient is on the treatment couch. This has a number of potential advantages for bladder cancer patients. In this article, we examine the technical challenges of bladder radiotherapy and explore how magnetic resonance (MR) guided radiotherapy (MRgRT) could be leveraged with the aim of improving bladder cancer patient outcomes. However, before routine clinical implementation robust evidence base to establish whether MRgRT translates into improved patient outcomes should be ascertained.
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Affiliation(s)
- Adham Hijab
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Boris Tocco
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ian Hanson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Hanneke Meijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gillian Smith
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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16
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Cabaillé M, Gaston R, Belhomme S, Giraud A, Rouffilange J, Roubaud G, Sargos P. [Plan of the day adaptive radiotherapy for bladder cancer: Dosimetric and clinical results]. Cancer Radiother 2021; 25:308-315. [PMID: 33422418 DOI: 10.1016/j.canrad.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To account of individual intra-pelvic anatomical variations in muscle invasive bladder cancer (MIBC) irradiation, adaptive radiotherapy (ART) using a personalized plan library may have dosimetric and clinical benefits. MATERIAL AND METHODS The data from ten patients treated for localized MIBC according to the "plan of the day" (P0oD) individualized ART technique were collected and retrospectively analysed. Target volumes and organs at risk (OAR) were delineated at different bladder fill rates, resulting in two or three treatment plans. Daily Cone-Beam CT (CBCT) was used for the selection of PoD at each fraction. Retrospectively, we delineated rectal, intestinal and target volumes on each CBCT, to assess target volume coverage and dose sparing to healthy tissues. A comparison with the conventional radiotherapy technique was performed. The secondary objectives were toxicity and efficacy. RESULTS The target coverage was respected with the adaptive treatment: 97.3% for the bladder Clinical Target Volume (CTV) (99.5; [60.1-100]) and 98% for the bladder+lymph nodes CTV (98.6; [85.4-100]). Concerning OAR, the volume of healthy tissue spared was 43.7% on average and the V45Gy for the small bowel was 43,4cc (35; [0-129]) (versus 57,6cc). The rectal D50 was on average 18,7Gy for the adaptive treatment (15.9; [2.4-44.1]) versus 17Gy with the conventional approach. With a median follow-up of 2.94 years (95% CI: [0.92-4.02]), we observed three grade 3 toxicities (30%). No grade 4 toxicity was observed. The 2-year overall survival and progression-free survival rates were 65.6% (95% CI: [26-87.6]) and 45.7% (95% CI: [14.3-73]), respectively. CONCLUSION The ART technique using a PoD strategy showed a reduction of the irradiated healthy tissue volume while maintaining a similar bladder coverage, with an acceptable rate of toxicity.
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Affiliation(s)
- M Cabaillé
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France
| | - R Gaston
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - S Belhomme
- Département de Physique Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - A Giraud
- Unité de Recherche Épidémiologique et Clinique, Institut Bergonié, 33076 Bordeaux cedex, France
| | - J Rouffilange
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - G Roubaud
- Département d'Oncologie Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - P Sargos
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France.
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17
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Cabaillé M, Khalifa J, Tessier AM, Belhomme S, Créhange G, Sargos P. [A review of adaptive radiotherapy for bladder cancer]. Cancer Radiother 2021; 25:271-278. [PMID: 33402293 DOI: 10.1016/j.canrad.2020.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Radiation therapy (RT) for muscle invasive bladder cancer (MIBC) is challenging, with observed variations in bladder shape and size resulting in inappropriate coverage of the target volumes (CTV). Large margins were historically applied around the CTV, increasing the dose delivered to organs at risk (OAR). With repositioning imaging and visualization of soft tissues during image guided RT, an opportunity to consider these movements and deformations appeared possible with an adaptive RT approach (ART). MATERIALS AND METHODS A bibliographic search on the PubMed database has been done in January 2019. Studies focusing on patients with MIBC, treating on ART, with the objectives of feasibility, clinical and/or dosimetric evaluation and comparison with a standard irradiation technique were eligible. The purpose of this review was to define the different ART techniques used in clinical practice, to discuss their advantages compared to conventional RT in terms of target volume's coverage and OAR dose and to describe their feasibility in clinical practice. RESULTS A total of 30 studies were selected. The strategies known as "composite offline", "plan of the day" not individualized or individualized, and "re-optimization" have been identified. All the studies have shown a significant benefit of ART in target coverage and dose of OAR, especially the rectum and small bowel. All ART plans produced are not used during RT sessions. Inter-observer variability for the selection of these plans can be observed. The practical implementation within a department required staff education and training, and increases the duration of treatment preparation. The "A-POLO" approach seems to be the most suitable for practice. CONCLUSION ART is the technique of choice for bladder cancer RT. The "plan of the day" approach, individualized according to the A-POLO methodology, seems to be the most effective. The emergence of daily re-optimization, especially using MRI-Linac, is promising. The correlation between dosimetric benefits and clinical efficacy and safety results should be demonstrated into future trials.
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Affiliation(s)
- M Cabaillé
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - J Khalifa
- Département de radiothérapie, Institut universitaire du Cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - A M Tessier
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - G Créhange
- Département de radiothérapie, Institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - P Sargos
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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18
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Hafeez S, Lewis R, Griffin C, Hall E, Huddart R. Failing to Close the Gap Between Evidence and Clinical Practice in Radical Bladder Cancer Radiotherapy. Clin Oncol (R Coll Radiol) 2021; 33:46-49. [PMID: 32762980 DOI: 10.1016/j.clon.2020.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/12/2020] [Accepted: 07/01/2020] [Indexed: 12/18/2022]
Affiliation(s)
- S Hafeez
- Department of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
| | - R Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - C Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - E Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - R Huddart
- Department of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
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Sibolt P, Andersson LM, Calmels L, Sjöström D, Bjelkengren U, Geertsen P, Behrens CF. Clinical implementation of artificial intelligence-driven cone-beam computed tomography-guided online adaptive radiotherapy in the pelvic region. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 17:1-7. [PMID: 33898770 PMCID: PMC8057957 DOI: 10.1016/j.phro.2020.12.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 12/31/2022]
Abstract
Background and purpose Studies have demonstrated the potential of online adaptive radiotherapy (oART). However, routine use has been limited due to resource demanding solutions. This study reports on experiences with oART in the pelvic region using a novel cone-beam computed tomography (CBCT)-based, artificial intelligence (AI)-driven solution. Material and methods Automated pre-treatment planning for thirty-nine pelvic cases (bladder, rectum, anal, and prostate), and one hundred oART simulations were conducted in a pre-clinical release of Ethos (Varian Medical Systems, Palo Alto, CA). Plan quality, AI-segmentation accuracy, oART feasibility and an integrated calculation-based quality assurance solution were evaluated. Experiences from the first five clinical oART patients (three bladder, one rectum and one sarcoma) are reported. Results Auto-generated pre-treatment plans demonstrated similar planning target volume (PTV) coverage and organs at risk doses, compared to institution reference. More than 75% of AI-segmentations during simulated oART required none or minor editing and the adapted plan was superior in 88% of cases. Limitations in AI-segmentation correlated to cases where AI model training was lacking. The five first treated patients complied well with the median adaptive procedure duration of 17.6 min (from CBCT acceptance to treatment delivery start). The treated bladder patients demonstrated a 42% median primary PTV reduction, indicating a 24%-30% reduction in V45Gy to the bowel cavity, compared to non-ART. Conclusions A novel commercial oART solution was demonstrated feasible for various pelvic sites. Clinically acceptable AI-segmentation and auto-planning enabled adaptation within reasonable timeslots. Possibilities for reduced PTVs observed for bladder cancer indicated potential for toxicity reductions.
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Affiliation(s)
- Patrik Sibolt
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lina M Andersson
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lucie Calmels
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - David Sjöström
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Ulf Bjelkengren
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Poul Geertsen
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Claus F Behrens
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
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20
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Webster A, Appelt A, Eminowicz G. Image-Guided Radiotherapy for Pelvic Cancers: A Review of Current Evidence and Clinical Utilisation. Clin Oncol (R Coll Radiol) 2020; 32:805-816. [DOI: 10.1016/j.clon.2020.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
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21
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Dos Reis RB, Muglia VF, Rodrigues AA, Viani G. Editorial Comment: Endoclips as novel fiducial markers in trimodality bladder preserving therapy of muscle-invasive bladder carcinoma: feasibility and patient out-comes. Int Braz J Urol 2020; 47:100-102. [PMID: 33047915 PMCID: PMC7712691 DOI: 10.1590/s1677-5538.ibju.2019.0713.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rodolfo Borges Dos Reis
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Valdair Francisco Muglia
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
| | - Antônio Antunes Rodrigues
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Gustavo Viani
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
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22
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Outaggarts Z, Wegener D, Berger B, Zips D, Paulsen F, Bleif M, Thorwarth D, Alber M, Dohm O, Müller AC. Target miss using PTV-based IMRT compared to robust optimization via coverage probability concept in prostate cancer. Acta Oncol 2020; 59:911-917. [PMID: 32436467 DOI: 10.1080/0284186x.2020.1760349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: Cure- and toxicity rates of prostate IGRT can both be affected by ill-chosen planning target volume (PTV) margins. For dose-escalated prostate radiotherapy, we studied the potential for organ at risk (OAR) sparing and compensation of prostate motion with robust plan optimization using the coverage probability (CovP) concept compared to conventional PTV-based IMRT.Material and methods: We evaluated plan quality of CovP-plans for 27 intermediate risk prostate cancer patients treated in a prospective study (78 Gy/39 fractions). Clinical target volume (CTV) and OARs were contoured on three separate CTs to capture movement and deformation. To define the internal target volume (ITV), the union of CTV1-3 was encompassed by an isotropic margin of 7 mm for the planning process. CovP-dose distribution is optimized considering weight factors for IMRT constraints derived from probabilities of systematic organ displacement in the three CTs. CovP-dose volume histograms (DVHs) were compared with additionally calculated conventional PTV-based IMRT plans. PTV-based IMRT was planned on one-single CT with an isotropically expanded CTV to generate the PTV (i.e., CTV1 + 7mm) and was evaluated on the two other CTs.Results: The CovP-concept showed higher robustness in target volume coverage. Target miss was frequently observed with PTV-based IMRT, resulting in cold spots until 70 Gy with the CovP-concept. The target dose at 74 Gy was comparable, while further the dose-escalation (75-78 Gy) was improved with PTV-based IMRT. However, dose-escalation with PTV-based IMRT was associated with increased OAR-doses, especially in high-dose areas.Conclusions: Probabilistic dose-escalated IMRT was feasible in this prospective study. Comparison of the CovP-concept with PTV-based IMRT revealed superiority with regard to target-coverage and sparing of OARs. The CovP-concept implements a robust plan optimization strategy for organ deformation and motions and could, therefore, serve as a less demanding compromise on the way to adaptive IGRT avoiding daily time-consuming re-planning. SUMMARYWe evaluated the robustness of coverage probability (CovP)-based IMRT plans within a prospective study for prostate cancer radiotherapy. The treatment plans were compared with newly calculated conventional PTV-based IMRT plans. We were able to show that CovP led to a clearly more robust target coverage by avoiding hot spots at OARs compared to conventional PTV-based IMRT. In addition, negative consequences of an inflated PTV can be ameliorated by a more relaxed CovP-based dose prescription.
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Affiliation(s)
- Zoulikha Outaggarts
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Bernhard Berger
- Clinic for Radiation Oncology, Oberschwaben Hospital Group, Ravensburg, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Martin Bleif
- Clinic for Radiology and Radiation Oncology, ALB FILS Clinics Hospital on the Eichert, Goppingen, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section Medical Physics, University Hospital Tübingen, Tübingen, Germany
| | - Markus Alber
- Clinic for Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Oliver Dohm
- Department of Radiation Oncology, Section Medical Physics, University Hospital Tübingen, Tübingen, Germany
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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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Lim SN, Ahunbay EE, Nasief H, Zheng C, Lawton C, Li XA. Indications of Online Adaptive Replanning Based On Organ Deformation. Pract Radiat Oncol 2019; 10:e95-e102. [PMID: 31446149 DOI: 10.1016/j.prro.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/24/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Although vital to account for interfractional variations during radiation therapy, online adaptive replanning (OLAR) is time-consuming and labor-intensive compared with the repositioning method. Repositioning is enough for minimal interfractional deformations. Therefore, determining indications for OLAR is desirable. We introduce a method to rapidly determine the need for OLAR by analyzing the Jacobian determinant histogram (JDH) obtained from deformable image registration between reference (planning) and daily images. METHODS AND MATERIALS The proposed method was developed and tested based on daily computed tomography (CT) scans acquired during image guided radiation therapy for prostate cancer using an in-room CT scanner. Deformable image registration between daily and reference CT scans was performed. JDHs were extracted from the prostate and a uniform surrounding 10-mm expansion. A classification tree was trained to determine JDH metrics to predict the need for OLAR for a daily CT set. Sixty daily CT scans from 12 randomly selected prostate cases were used as the training data set, with dosimetric plans for both OLAR and repositioning used to determine their class. The resulting classification tree was tested using an independent data set of 45 daily CT scans from 9 other patients with 5 CT scans each. RESULTS Of a total of 27 JDH metrics tested, 5 were identified predicted whether OLAR was substantially superior to repositioning for a given fraction. A decision tree was constructed using the obtained metrics from the training set. This tree correctly identified all cases in the test set where benefits of OLAR were obvious. CONCLUSIONS A decision tree based on JDH metrics to quickly determine the necessity of online replanning based on the image of the day without segmentation was determined using a machine learning process. The process can be automated and completed within a minute, allowing users to quickly decide which fractions require OLAR.
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Affiliation(s)
- Sara N Lim
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ergun E Ahunbay
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Haidy Nasief
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cheng Zheng
- Department of Biostatistics, University of Wisconsin Milwaukee, Milwaukee, Wisconsin
| | - Colleen Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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25
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Murthy V, Gupta P, Baruah K, Krishnatry R, Joshi A, Prabhash K, Noronha V, Menon S, Pal M, Prakash G, Bakshi G. Adaptive Radiotherapy for Carcinoma of the Urinary Bladder: Long-term Outcomes With Dose Escalation. Clin Oncol (R Coll Radiol) 2019; 31:646-652. [PMID: 31301959 DOI: 10.1016/j.clon.2019.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 12/22/2022]
Abstract
AIMS To report long-term outcomes with dose-escalated, image-guided adaptive radiotherapy (ART) for bladder preservation in muscle-invasive bladder cancer (MIBC). MATERIALS AND METHODS All MIBC patients receiving bladder-preserving ART at our institute from 2009 to 2018 were analysed. For ART, three anisotropic planning target volumes (PTV) were concentrically grown around the simulation bladder volume. A library of intensity-modulated radiotherapy plans was created for each patient. A total dose of 64 Gy in 32 fractions to the entire bladder and 55 Gy to pelvic nodes was planned, with 68 Gy to the tumour bed (2 Gy equivalent dose = 68.7 Gy, α/β = 10) as simultaneous integrated boost for solitary tumours. The most appropriate PTV encompassing the bladder ('plan-of-the-day') was chosen daily using on-board megavoltage imaging. Neoadjuvant and concurrent chemotherapy was prescribed for medically fit patients. RESULTS Of a total of 106 patients, most had T2 (68%) or T3 (19%) disease. Ninety-two patients (87%) completed 64 Gy to the whole bladder. Sixty-three patients (59%) received 68 Gy as tumour bed boost. Seventy-six per cent received concurrent weekly chemotherapy. At a median follow-up of 26 months, 3-year locoregional control, disease-free survival and overall survival were 74.3, 62.9 and 67.7%, respectively. Eighty-two per cent of patients retained disease-free bladder. Radiation Therapy Oncology Group grade III/IV acute genitourinary and gastrointestinal toxicities were 7.5% and 0%, respectively, and late genitourinary/gastrointestinal toxicities were 6.5% and 3.8%, respectively. Overall survival, disease-free survival, locoregional control and grade III/IV genitourinary/gastrointestinal toxicities did not differ significantly with dose escalation. CONCLUSION Plan-of-the-day ART is clinically safe and effective for bladder preservation and can be implemented in routine clinical practice. A high bladder preservation rate is achievable without compromising on survival or toxicities. Dose escalation does not seem to affect outcomes.
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Affiliation(s)
- V Murthy
- Department of Radiation Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India.
| | - P Gupta
- Department of Radiation Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - K Baruah
- Department of Radiation Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - R Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Joshi
- Department of Medical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Noronha
- Department of Medical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - S Menon
- Department of Pathology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - M Pal
- Department of Surgical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - G Prakash
- Department of Surgical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - G Bakshi
- Department of Surgical Oncology, Tata Memorial Centre and Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
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26
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Cai B, Laugeman E, Mazur TR, Park JC, Henke LE, Kim H, Hugo GD, Mutic S, Li H. Characterization of a prototype rapid kilovoltage x-ray image guidance system designed for a ring shape radiation therapy unit. Med Phys 2019; 46:1355-1370. [PMID: 30675902 DOI: 10.1002/mp.13396] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/03/2018] [Accepted: 12/21/2018] [Indexed: 01/15/2023] Open
Abstract
PURPOSE This study aims to characterize the performance of a prototype rapid kilovoltage (kV) x-ray image guidance system onboard the newly released Halcyon 2.0 linear accelerator (Varian Medical Systems, Palo Alto, CA) by use of conventional and innovatively designed testing procedures. METHODS Basic imaging system performance tests and radiation dose measurements were performed for all eleven kV-cone beam computed tomography (CBCT) imaging protocols available on a preclinical Halcyon 2.0 LINAC. Both conventional CBCT reconstruction using the Feldkamp-Davis-Kress (FDK) algorithm and a novel, advanced iterative reconstruction (iCBCT) available on this platform were evaluated. Standard image quality metrics, including slice thickness accuracy, high-contrast resolution, low-contrast resolution, regional uniformity and noise, and CT Hounsfield unit (HU) number accuracy and linearity were evaluated using a manufacturer-supplied QUART phantom (GmbH, Zorneding, Germany) and an independent image quality phantom (Catphan 500, The Phantom Laboratory, New York, NY). Due to the simplified design of the QUART phantom, we developed surrogate and clinically feasible strategies for measuring slice thickness and high- and low-contrast resolution. Imaging dose delivered by these eleven protocols was measured using a computed tomography dose index phantom and pencil chamber with commonly accepted methods and procedures. A subset of measurements were repeated on a conventional C-arm LINAC (TrueBeam and Trilogy, Varian Medical System) for comparison. Clinical patient images of pelvic and abdominal regions are also presented for qualitative assessment as part of a feasibility study for clinical implementation. RESULTS Image acquisition time was 17-42 s on the Halcyon system compared with 60 s on the C-arm LINAC systems. The kV imager projection offset, imaging and treatment isocenter coincidence and the couch three-dimensional match movement all achieved less than1 mm mechanical accuracy. All major image quality metrics were within either the national guideline or vendor-recommended tolerances. The designed surrogate approach with the QUART phantom showed a range of 0.24-0.35 cycles/mm for spatial resolution, a contrast-to-noise ratio (CNR) of 2-20 for FDK reconstruction and a tolerance of 0.5 mm for slice thickness. Other metrics derived from the Catphan images obtained on the Halcyon and C-arm LINACs showed comparable values for the FDK reconstruction. The iterative reconstruction tended to reduce noise, as evidenced by a higher CNR ratio. The fast scan pelvis protocols for Halcyon resulted in 50% lower dose compared to the standard scans, and the thorax fast protocol similarly delivered 10% lower dose than the standard thoracic scan. Preliminary patient images indicated that rapid kV CBCT with breath-hold is feasible, with improved imaging quality compared to free-breathing scans. CONCLUSION Independent and comprehensive characterization of the kV imaging guidance system on the Halcyon 2.0 system demonstrated acceptable image quality for clinical use. The imaging unit onboard the Halcyon meets vendor specifications and satisfies requirements for routine clinical use. The fast kV imaging system enables the potential for volumetric CBCT acquisition during a single breath-hold and the iterative reconstruction tends to reduce the noise therefore has the potential to improve the CNR for normal size patient.
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Affiliation(s)
- Bin Cai
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Thomas R Mazur
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Justin C Park
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
| | - Hua Li
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
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27
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Comparison of 3 image-guided adaptive strategies for bladder locoregional radiotherapy. Med Dosim 2019; 44:111-116. [DOI: 10.1016/j.meddos.2018.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 11/22/2022]
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28
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Efficient and Effective Personalization of PTV Margins During Radiation Therapy for Bladder Cancer. J Med Imaging Radiat Sci 2018; 49:420-427. [DOI: 10.1016/j.jmir.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/20/2022]
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Zhang B, Lee SW, Chen S, Zhou J, Prado K, D'Souza W, Yi B. Action Levels on Dose and Anatomic Variation for Adaptive Radiation Therapy Using Daily Offline Plan Evaluation: Preliminary Results. Pract Radiat Oncol 2018; 9:49-54. [PMID: 30142442 DOI: 10.1016/j.prro.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 07/05/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE This study aimed to develop action levels for replanning to accommodate dosimetric variations resulting from anatomic changes during the course of treatments, using daily cone beam computed tomography (CBCT). METHODS AND MATERIALS Daily or weekly CBCT images of 20 patients (10 head and neck, 5 lung, and 5 prostate cancers) who underwent resimulation per physicians' clinical decisions, mainly from the comparison of CBCT scans, were used to determine action levels. The first CBCT image acquired before the first treatment was used as the reference image to rule out effects of dose inaccuracy from the CBCT. The Pearson correlation of clinical target volume (CTV) was used as a parameter of anatomic variation. Parameters for action levels on dose and anatomic variation were deduced by comparing the parameters and clinical decisions made for replanning. A software tool was developed to automatically perform all procedures, including dose calculations, using the CBCT and plan evaluations. RESULTS Replans were clinically decided based on either significant dose or anatomic changes in 13 cases. The 7 cases that did not require replanning showed dose differences <5%, and the Pearson correlation of the CTV was >75% for all fractions. A difference in planning target volume dose >5% or a difference in the image correlation coefficient of the CTV <0.75 proved to be indicators for replanning. Once the results of the CBCT plan met the replanning criteria, the software tool automatically alerted the attending physician and physicist by both e-mail and pager so that the case could be examined closely. CONCLUSIONS Our study shows that a dose difference of 5% and/or anatomy variation at 0.75 Pearson correlations are practical action levels on dose and anatomic variation for replanning for the given data sets.
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Affiliation(s)
- Baoshe Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Sung-Woo Lee
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jinghao Zhou
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Karl Prado
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Warren D'Souza
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Byongyong Yi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
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30
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Collins SD, Leech MM. A review of plan library approaches in adaptive radiotherapy of bladder cancer. Acta Oncol 2018; 57:566-573. [PMID: 29299945 DOI: 10.1080/0284186x.2017.1420908] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Large variations in the shape and size of the bladder volume are commonly observed in bladder cancer radiotherapy (RT). The clinical target volume (CTV) is therefore frequently inadequately treated and large isotropic margins are inappropriate in terms of dose to organs at risk (OAR); thereby making adaptive radiotherapy (ART) attractive for this tumour site. There are various methods of ART delivery, however, for bladder cancer, plan libraries are frequently used. MATERIAL AND METHODS A review of published studies on plan libraries for bladder cancer using four databases (Pubmed, Science Direct, Embase and Cochrane Library) was conducted. The endpoints selected were accuracy and feasibility of initiation of a plan library strategy into a RT department. RESULTS Twenty-four articles were included in this review. The majority of studies reported improvement in accuracy with 10 studies showing an improvement in planning target volume (PTV) and CTV coverage with plan libraries, some by up to 24%. Seventeen studies showed a dose reduction to OARs, particularly the small bowel V45Gy, V40Gy, V30Gy and V10Gy, and the rectal V30Gy. However, the occurrence of no suitable plan was reported in six studies, with three studies showing no significant difference between adaptive and non-adaptive strategies in terms of target coverage. In addition, inter-observer variability in plan selection appears to remain problematic. The additional resources, education and technology required for the initiation of plan library selection for bladder cancer may hinder its routine clinical implementation, with eight studies illustrating increased treatment time required. CONCLUSIONS While there is a growing body of evidence in support of plan libraries for bladder RT, many studies differed in their delivery approach. The advent of the clinical use of the MRI-linear accelerator will provide RT departments with the opportunity to consider daily online adaption for bladder cancer as an alternate to plan library approaches.
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Affiliation(s)
- Shane D. Collins
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
| | - Michelle M. Leech
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
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31
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Cai B, Green OL, Kashani R, Rodriguez VL, Mutic S, Yang D. A practical implementation of physics quality assurance for photon adaptive radiotherapy. Z Med Phys 2018; 28:211-223. [PMID: 29550014 DOI: 10.1016/j.zemedi.2018.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 11/26/2022]
Abstract
The fast evolution of technology in radiotherapy (RT) enabled the realization of adaptive radiotherapy (ART). However, the new characteristics of ART pose unique challenges for efficiencies and effectiveness of quality assurance (QA) strategies. In this paper, we discuss the necessary QAs for ART and introduce a practical implementation. A previously published work on failure modes and effects analysis (FMEA) of ART is introduced first to explain the risks associated with ART sub-processes. After a brief discussion of QA challenges, we review the existing QA strategies and tools that might be suitable for each ART step. By introducing the MR-guided online ART QA processes developed at our institute, we demonstrate a practical implementation. The limitations and future works to develop more robust and efficient QA strategies are discussed at the end.
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Affiliation(s)
- Bin Cai
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Abor, MI, 48109, USA
| | - Vivian L Rodriguez
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Deshan Yang
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA.
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10 - Nuove Tecnologie in Radioterapia E Prospettive Future. TUMORI JOURNAL 2018; 104:S39-S41. [DOI: 10.1177/0300891618766114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Lim-Reinders S, Keller BM, Al-Ward S, Sahgal A, Kim A. Online Adaptive Radiation Therapy. Int J Radiat Oncol Biol Phys 2017; 99:994-1003. [DOI: 10.1016/j.ijrobp.2017.04.023] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 04/14/2017] [Indexed: 10/19/2022]
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Korpics M, Block AM, Altoos B, Martin B, Carey K, Welsh J, Harkenrider MM, Solanki AA. Maximizing survival in patients with muscle-invasive bladder cancer undergoing curative bladder-preserving radiotherapy: the impact of radiotherapy dose escalation. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s13566-017-0319-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adaptive Radiotherapy for Bladder Cancer—A Systematic Review. J Med Imaging Radiat Sci 2017; 48:199-206. [DOI: 10.1016/j.jmir.2016.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/20/2022]
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Hafeez S, McDonald F, Lalondrelle S, McNair H, Warren-Oseni K, Jones K, Harris V, Taylor H, Khoo V, Thomas K, Hansen V, Dearnaley D, Horwich A, Huddart R. Clinical Outcomes of Image Guided Adaptive Hypofractionated Weekly Radiation Therapy for Bladder Cancer in Patients Unsuitable for Radical Treatment. Int J Radiat Oncol Biol Phys 2017; 98:115-122. [PMID: 28586948 PMCID: PMC5392498 DOI: 10.1016/j.ijrobp.2017.01.239] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/23/2017] [Accepted: 01/31/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE AND OBJECTIVES We report on the clinical outcomes of a phase 2 study assessing image guided hypofractionated weekly radiation therapy in bladder cancer patients unsuitable for radical treatment. METHODS AND MATERIALS Fifty-five patients with T2-T4aNx-2M0-1 bladder cancer not suitable for cystectomy or daily radiation therapy treatment were recruited. A "plan of the day" radiation therapy approach was used, treating the whole (empty) bladder to 36 Gy in 6 weekly fractions. Acute toxicity was assessed weekly during radiation therapy, at 6 and 12 weeks using the Common Terminology Criteria for Adverse Events version 3.0. Late toxicity was assessed at 6 months and 12 months using Radiation Therapy Oncology Group grading. Cystoscopy was used to assess local control at 3 months. Cumulative incidence function was used to determine local progression at 1 at 2 years. Death without local progression was treated as a competing risk. Overall survival was estimated using the Kaplan-Meier method. RESULTS Median age was 86 years (range, 68-97 years). Eighty-seven percent of patients completed their prescribed course of radiation therapy. Genitourinary and gastrointestinal grade 3 acute toxicity was seen in 18% (10/55) and 4% (2/55) of patients, respectively. No grade 4 genitourinary or gastrointestinal toxicity was seen. Grade ≥3 late toxicity (any) at 6 and 12 months was seen in 6.5% (2/31) and 4.3% (1/23) of patients, respectively. Local control after radiation therapy was 92% of assessed patients (60% total population). Cumulative incidence of local progression at 1 year and 2 years for all patients was 7% (95% confidence interval [CI] 2%-17%) and 17% (95% CI 8%-29%), respectively. Overall survival at 1 year was 63% (95% CI 48%-74%). CONCLUSION Hypofractionated radiation therapy delivered weekly with a plan of the day approach offers good local control with acceptable toxicity in a patient population not suitable for radical bladder treatment.
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MESH Headings
- Aged
- Aged, 80 and over
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Transitional Cell/mortality
- Carcinoma, Transitional Cell/pathology
- Carcinoma, Transitional Cell/radiotherapy
- Cystectomy
- Disease Progression
- Female
- Gastrointestinal Diseases/etiology
- Humans
- Kaplan-Meier Estimate
- Male
- Prospective Studies
- Radiation Dose Hypofractionation
- Radiation Injuries/pathology
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Image-Guided/adverse effects
- Radiotherapy, Image-Guided/methods
- Time Factors
- Treatment Outcome
- Urinary Bladder/radiation effects
- Urinary Bladder Neoplasms/mortality
- Urinary Bladder Neoplasms/pathology
- Urinary Bladder Neoplasms/radiotherapy
- Urination Disorders/etiology
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey.
| | | | | | - Helen McNair
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Karole Warren-Oseni
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Kelly Jones
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | | | | | | | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Vibeke Hansen
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - David Dearnaley
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Alan Horwich
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Robert Huddart
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
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Nishioka K, Shimizu S, Shinohara N, Ito YM, Abe T, Maruyama S, Katoh N, Kinoshita R, Hashimoto T, Miyamoto N, Onimaru R, Shirato H. Analysis of inter- and intra fractional partial bladder wall movement using implanted fiducial markers. Radiat Oncol 2017; 12:44. [PMID: 28249609 PMCID: PMC5333467 DOI: 10.1186/s13014-017-0778-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/08/2017] [Indexed: 11/13/2022] Open
Abstract
Background Current adaptive and dose escalating radiotherapy for muscle invasive bladder cancer requires knowledge of both inter-fractional and intra-fractional motion of the bladder wall involved. The purpose of this study is to characterize inter- and intra-fractional movement of the partial bladder wall using implanted fiducial markers and a real-time tumor-tracking radiotherapy system. Methods Two hundred fifty one sessions with 29 patients were analysed. After maximal transurethral bladder tumor resection and 40 Gy of whole bladder irradiation, up to six gold markers were implanted transurethrally into the bladder wall around the tumor bed and used for positional registration. We compared the systematic and random uncertainty of positions between cranial vs. caudal, left vs. right, and anterior vs. posterior tumor groups. The variance in intrafractional movement and the percentage of sessions where 3 mm and 5 mm or more of intrafractional wall movement occurring at 2, 4, 6, 8, 10, and at more than 10 min until the end of a session were determined. Results The cranial and anterior tumor group showed larger interfractional uncertainties in the position than the opposite side tumor group in the CC and AP directions respectively, but these differences did not reach significance. Among the intrafractional uncertainty of position, the cranial and anterior tumor group showed significantly larger systematic uncertainty of position than the groups on the opposite side in the CC direction. The variance of intrafractional movement increased over time; the percentage of sessions where intrafractional wall movement was larger than 3 mm within 2 min of the start of a radiation session or larger than 5 mm within 10 min was less than 5%, but this percentage was increasing further during the session, especially in the cranial and anterior tumor group. Conclusions More attention for intrafractional uncertainty of position is required in the treatment of cranial and anterior bladder tumors especially in the CC direction. The optimal internal margins in each direction should be chosen or a precise intrafractional target localization system is required depending on the tumor location and treatment delivery time in the setting of partial bladder radiotherapy.
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Affiliation(s)
- Kentaro Nishioka
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Shinichi Shimizu
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan. .,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan.
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashige Abe
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Satoru Maruyama
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Norio Katoh
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Takayuki Hashimoto
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Rikiya Onimaru
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Hiroki Shirato
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan.,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
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Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
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Thörnqvist S, Hysing LB, Tuomikoski L, Vestergaard A, Tanderup K, Muren LP, Heijmen BJM. Adaptive radiotherapy strategies for pelvic tumors - a systematic review of clinical implementations. Acta Oncol 2016; 55:943-58. [PMID: 27055486 DOI: 10.3109/0284186x.2016.1156738] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Introdution: Variation in shape, position and treatment response of both tumor and organs at risk are major challenges for accurate dose delivery in radiotherapy. Adaptive radiotherapy (ART) has been proposed to customize the treatment to these motion/response patterns of the individual patients, but increases workload and thereby challenges clinical implementation. This paper reviews strategies and workflows for clinical and in silico implemented ART for prostate, bladder, gynecological (gyne) and ano-rectal cancers. MATERIAL AND METHODS Initial identification of papers was based on searches in PubMed. For each tumor site, the identified papers were screened independently by two researches for selection of studies describing all processes of an ART workflow: treatment monitoring and evaluation, decision and execution of adaptations. Both brachytherapy and external beam studies were eligible for review. RESULTS The review consisted of 43 clinical studies and 51 in silico studies. For prostate, 1219 patients were treated with offline re-planning, mainly to adapt prostate motion relative to bony anatomy. For gyne 1155 patients were treated with online brachytherapy re-planning while 25 ano-rectal cancer patients were treated with offline re-planning, all to account for tumor regression detected by magnetic resonance imaging (MRI)/computed tomography (CT). For bladder and gyne, 161 and 64 patients, respectively, were treated with library-based online plan selection to account for target volume and shape variations. The studies reported sparing of rectum (prostate and bladder cancer), bladder (ano-rectal cancer) and bowel cavity (gyne and bladder cancer) as compared to non-ART. CONCLUSION Implementations of ART were dominated by offline re-planning and online brachytherapy re-planning strategies, although recently online plan selection workflows have increased with the availability of cone-beam CT. Advantageous dosimetric and outcome patterns using ART was documented by the studies of this review. Despite this, clinical implementations were scarce due to challenges in target/organ re-contouring and suboptimal patient selection in the ART workflows.
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Affiliation(s)
- Sara Thörnqvist
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Nolan CP, Forde EJ. A review of the use of fiducial markers for image-guided bladder radiotherapy. Acta Oncol 2016; 55:533-8. [PMID: 26588169 DOI: 10.3109/0284186x.2015.1110250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Enhancing target visualization and reducing set-up errors in image-guided radiotherapy (IGRT) are issues faced when trying to implement more conformal and partial bladder techniques. This review examines the evidence available pertaining to the clinical use of Lipiodol and gold fiducials for IGRT for bladder cancer. MATERIAL AND METHODS Nine published articles relating to the feasibility of using Lipiodol injections or gold fiducial markers in IGRT for bladder patients were recruited from a database search strategy. Set-up errors were evaluated in addition to the stability and visibility of each on verification imaging. Adverse reactions from the insertion of each method were also assessed. RESULTS Both Lipiodol and gold fiducials have the potential to remain stable and visible in the bladder, however, fading, washout and seed loss was also reported. Set-up errors can be reduced by using Lipiodol or fiducial registration when compared to other registration techniques. Adverse reactions reported were minimal for each. CONCLUSION Current evidence suggests that Lipiodol injections and gold fiducial markers present as promising and highly accurate methods of overcoming interfraction bladder motion in IGRT.
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Affiliation(s)
- Conor P. Nolan
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
| | - Elizabeth J. Forde
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
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Hafeez S, Warren-Oseni K, McNair HA, Hansen VN, Jones K, Tan M, Khan A, Harris V, McDonald F, Lalondrelle S, Mohammed K, Thomas K, Thompson A, Kumar P, Dearnaley D, Horwich A, Huddart R. Prospective Study Delivering Simultaneous Integrated High-dose Tumor Boost (≤70 Gy) With Image Guided Adaptive Radiation Therapy for Radical Treatment of Localized Muscle-Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2016; 94:1022-30. [PMID: 27026308 DOI: 10.1016/j.ijrobp.2015.12.379] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Image guided adaptive radiation therapy offers individualized solutions to improve target coverage and reduce normal tissue irradiation, allowing the opportunity to increase the radiation tumor dose and spare normal bladder tissue. METHODS AND MATERIALS A library of 3 intensity modulated radiation therapy plans were created (small, medium, and large) from planning computed tomography (CT) scans performed at 30 and 60 minutes; treating the whole bladder to 52 Gy and the tumor to 70 Gy in 32 fractions. A "plan of the day" approach was used for treatment delivery. A post-treatment cone beam CT (CBCT) scan was acquired weekly to assess intrafraction filling and coverage. RESULTS A total of 18 patients completed treatment to 70 Gy. The plan and treatment for 1 patient was to 68 Gy. Also, 1 patient's plan was to 70 Gy but the patient was treated to a total dose of 65.6 Gy because dose-limiting toxicity occurred before dose escalation. A total of 734 CBCT scans were evaluated. Small, medium, and large plans were used in 36%, 48%, and 16% of cases, respectively. The mean ± standard deviation rate of intrafraction filling at the start of treatment (ie, week 1) was 4.0 ± 4.8 mL/min (range 0.1-19.4) and at end of radiation therapy (ie, week 5 or 6) was 1.1 ± 1.6 mL/min (range 0.01-7.5; P=.002). The mean D98 (dose received by 98% volume) of the tumor boost and bladder as assessed on the post-treatment CBCT scan was 97.07% ± 2.10% (range 89.0%-104%) and 99.97% ± 2.62% (range 96.4%-112.0%). At a median follow-up period of 19 months (range 4-33), no muscle-invasive recurrences had developed. Two patients experienced late toxicity (both grade 3 cystitis) at 5.3 months (now resolved) and 18 months after radiation therapy. CONCLUSIONS Image guided adaptive radiation therapy using intensity modulated radiation therapy to deliver a simultaneous integrated tumor boost to 70 Gy is feasible, with acceptable toxicity, and will be evaluated in a randomized trial.
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom.
| | - Karole Warren-Oseni
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Helen A McNair
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Vibeke N Hansen
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kelly Jones
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Melissa Tan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Attia Khan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Victoria Harris
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kabir Mohammed
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Thompson
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Pardeep Kumar
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - David Dearnaley
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Horwich
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Robert Huddart
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
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Lutkenhaus LJ, van Os RM, Bel A, Hulshof MCCM. Clinical results of conformal versus intensity-modulated radiotherapy using a focal simultaneous boost for muscle-invasive bladder cancer in elderly or medically unfit patients. Radiat Oncol 2016; 11:45. [PMID: 26993980 PMCID: PMC4797227 DOI: 10.1186/s13014-016-0618-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For elderly or medically unfit patients with muscle-invasive bladder cancer, cystectomy or chemotherapy are contraindicated. This leaves radical radiotherapy as the only treatment option. It was the aim of this study to retrospectively analyze the treatment outcome and associated toxicity of conformal versus intensity-modulated radiotherapy (IMRT) using a focal simultaneous tumor boost for muscle-invasive bladder cancer in patients not suitable for cystectomy. METHODS One hundred eighteen patients with T2-4 N0-1 M0 bladder cancer were analyzed retrospectively. Median age was 80 years. Treatment consisted of either a conformal box technique or IMRT and included a simultaneous boost to the tumor. To enable an accurate boost delivery, fiducial markers were placed around the tumor. Patients were treated with 40 Gy in 20 fractions to the elective treatment volumes, and a daily tumor boost up to 55-60 Gy. RESULTS Clinical complete response was seen in 87 % of patients. Three-year overall survival was 44 %, with a locoregional control rate of 73 % at 3 years. Toxicity was low, with late urinary and intestinal toxicity rates grade ≥ 2 of 14 and 5 %, respectively. The use of IMRT reduced late intestinal toxicity, whereas fiducial markers reduced acute urinary toxicity. CONCLUSIONS Radical radiotherapy using a focal boost is feasible and effective for elderly or unfit patients, with a 3-year locoregional control of 73 %. Toxicity rates were low, and were reduced by the use of IMRT and fiducial markers.
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Affiliation(s)
- Lotte J Lutkenhaus
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Rob M van Os
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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43
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Evaluating the need for adaptive therapy when delivering conformal bladder radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396915000539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground and purposeThe purpose of this study was to audit positioning errors during bladder image-guided radiotherapy (IGRT) and quantify survival outcomes.Materials and methodsWe carried out a retrospective review of 141 patients treated between March 2007 and July 2010 with three-dimensional conformal radiotherapy. An offline imaging protocol using kV cone beam computed tomography (CBCT) was used. Positioning errors, clinical interventions and re-planning rates were quantified. Cancer outcomes and survival were collected by review of patient notes and a registry search.ResultsAmong all, 43% of the patients required no intervention. Isocentre corrections were used for systematic bony set-up error in 13% and to improve bladder coverage in 28%. Clinical interventions to improve bladder coverage were required in 16% of the patients and repeat computed tomography planning in a further 16%. Overall, 44% of the patients demonstrated some form of organ deformation that would have resulted in inadequate dose to the bladder or significant overdose to an organ at risk if not corrected for. Post-treatment check cystoscopy was undertaken in 107 patients (76%) with 72 noted to have a complete response. Overall survival was 47·8% at 3 years.ConclusionsOrgan deformation during radiotherapy for bladder cancer is a significant problem for over 40% of patients. Strategies to compensate are essential to ensure optimal plan delivery.
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Clinical Outcomes With Dose-Escalated Adaptive Radiation Therapy for Urinary Bladder Cancer: A Prospective Study. Int J Radiat Oncol Biol Phys 2016; 94:60-66. [DOI: 10.1016/j.ijrobp.2015.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/04/2015] [Accepted: 09/09/2015] [Indexed: 11/17/2022]
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Kibrom AZ, Knight KA. Adaptive radiation therapy for bladder cancer: a review of adaptive techniques used in clinical practice. J Med Radiat Sci 2015; 62:277-85. [PMID: 27512574 PMCID: PMC4968556 DOI: 10.1002/jmrs.129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/18/2022] Open
Abstract
Significant changes in the shape, size and position of the bladder during radiotherapy (RT) treatment for bladder cancer have been correlated with high local failure rates; typically due to geographical misses. To account for this, large margins are added around the target volumes in conventional RT; however, this increases the volume of healthy tissue irradiation. The availability of cone beam computed tomography (CBCT) has not only allowed in‐room volumetric imaging of the bladder, but also the development of adaptive radiotherapy (ART) for modification of plans to patient‐specific changes. The aim of this review is to: (1) identify and explain the different ART techniques being used in clinical practice and (2) compare and contrast these different ART techniques to conventional RT in terms of target coverage and dose to healthy tissue: A literature search was conducted using EMBASE, MEDLINE and Scopus with the key words ‘bladder, adaptive, radiotherapy/radiation therapy’. 11 studies were obtained that compared different adaptive RT techniques to conventional RT in terms of target volume coverage and healthy tissue sparing. All studies showed superior target volume coverage and/or healthy tissue sparing in adaptive RT compared to conventional RT. Cross‐study comparison between different adaptive techniques could not be made due to the difference in protocols used in different studies. However, one study found daily re‐optimisation of plans to be superior to plan of the day technique. The use of adaptive RT for bladder cancer is promising. Further study is required to assess adaptive RT versus conventional RT in terms of local control and long‐term toxicity.
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Affiliation(s)
- Awet Z Kibrom
- Department of Medical Imaging and Radiation Sciences Faculty of Medicine, Nursing and Health Sciences School of Biomedical Sciences Monash University Clayton Victoria Australia
| | - Kellie A Knight
- Department of Medical Imaging and Radiation Sciences Faculty of Medicine, Nursing and Health Sciences School of Biomedical Sciences Monash University Clayton Victoria Australia
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Bonnes pratiques de radiothérapie guidée par l’image. Cancer Radiother 2015; 19:489-500. [DOI: 10.1016/j.canrad.2015.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/16/2015] [Indexed: 11/22/2022]
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47
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Wood TJ, Moore CS, Horsfield CJ, Saunderson JR, Beavis AW. Accounting for patient size in the optimization of dose and image quality of pelvis cone beam CT protocols on the Varian OBI system. Br J Radiol 2015; 88:20150364. [PMID: 26419892 PMCID: PMC4743457 DOI: 10.1259/bjr.20150364] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/08/2015] [Accepted: 09/29/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The purpose of this study was to develop size-based radiotherapy kilovoltage cone beam CT (CBCT) protocols for the pelvis. METHODS Image noise was measured in an elliptical phantom of varying size for a range of exposure factors. Based on a previously defined "small pelvis" reference patient and CBCT protocol, appropriate exposure factors for small, medium, large and extra-large patients were derived which approximate the image noise behaviour observed on a Philips CT scanner (Philips Medical Systems, Best, Netherlands) with automatic exposure control (AEC). Selection criteria, based on maximum tube current-time product per rotation selected during the radiotherapy treatment planning scan, were derived based on an audit of patient size. RESULTS It has been demonstrated that 110 kVp yields acceptable image noise for reduced patient dose in pelvic CBCT scans of small, medium and large patients, when compared with manufacturer's default settings (125 kVp). Conversely, extra-large patients require increased exposure factors to give acceptable images. 57% of patients in the local population now receive much lower radiation doses, whereas 13% require higher doses (but now yield acceptable images). CONCLUSION The implementation of size-based exposure protocols has significantly reduced radiation dose to the majority of patients with no negative impact on image quality. Increased doses are required on the largest patients to give adequate image quality. ADVANCES IN KNOWLEDGE The development of size-based CBCT protocols that use the planning CT scan (with AEC) to determine which protocol is appropriate ensures adequate image quality whilst minimizing patient radiation dose.
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Affiliation(s)
- Tim J Wood
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
- Faculty of Science, University of Hull, Hull, UK
| | - Craig S Moore
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
- Faculty of Science, University of Hull, Hull, UK
| | - Carl J Horsfield
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - John R Saunderson
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
- Faculty of Science, University of Hull, Hull, UK
| | - Andrew W Beavis
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
- Faculty of Science, University of Hull, Hull, UK
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
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Whalley D, Caine H, McCloud P, Guo L, Kneebone A, Eade T. Promising results with image guided intensity modulated radiotherapy for muscle invasive bladder cancer. Radiat Oncol 2015; 10:205. [PMID: 26407726 PMCID: PMC4583158 DOI: 10.1186/s13014-015-0499-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 09/03/2015] [Indexed: 01/06/2023] Open
Abstract
AIM To describe the feasibility of image guided intensity modulated radiotherapy (IG-IMRT) using daily soft tissue matching in the treatment of bladder cancer. METHODS Twenty-eight patients with muscle-invasive carcinoma of the bladder were recruited to a protocol of definitive radiation using IMRT with accelerated hypofractionation with simultaneous integrated boost (SIB). Isotropic margins of .5 and 1 cm were used to generate the high risk and intermediate risk planning target volumes respectively. Cone beam CT (CBCT) was acquired daily and a soft tissue match was performed. Cystoscopy was scheduled 6 weeks post treatment. RESULTS The median age was 83 years (range 58-92). Twenty patients had stage II or III disease, and eight were stage IV. Gross disease received 66 Gy in 30 fractions in 11 patients (ten with concurrent chemotherapy) or 55 Gy in 20 fractions for those of poorer performance status or with palliative intent. All patients completed radiation treatment as planned. Three patients ceased chemotherapy early due to toxicity. Six patients (21 %) had acute Grade ≥ 2 genitourinary (GU) toxicity and six (21 %) had acute Grade ≥ 2 gastrointestinal (GI) toxicity. Five patients (18 %) developed Grade ≥2 late GU toxicity and no ≥2 late GI toxicity was observed. Nineteen patients underwent cystoscopy following radiation, with complete response (CR) in 16 cases (86 %), including all patients treated with chemoradiotherapy. Eight patients relapsed, four of which were local relapses. Of the patients with local recurrence, one underwent salvage cystectomy. For patients treated with definitive intent, freedom from locoregional recurrence (FFLR) and overall survival (OS) was 90 %/100 % for chemoradiotherapy versus 86 %/69 % for radiotherapy alone. CONCLUSION IG- IMRT using daily soft tissue matching is a feasible in the treatment of bladder cancer, enabling the delivery of accelerated synchronous integrated boost with good early local control outcomes and low toxicity.
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Affiliation(s)
- D Whalley
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia.
| | - H Caine
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia.
| | - P McCloud
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia. .,McCloud Consulting Group, 7-9 Merriwa Street, Gordon, NSW, 2072, Australia.
| | - L Guo
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia.
| | - A Kneebone
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia. .,McCloud Consulting Group, 7-9 Merriwa Street, Gordon, NSW, 2072, Australia.
| | - T Eade
- Northern Sydney Cancer Centre, Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia. .,Northern Clinical School, University of Sydney, Camperdown, NSW, 2050, Australia.
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McNair HA, Hafeez S, Taylor H, Lalondrelle S, McDonald F, Hansen VN, Huddart R. Radiographer-led plan selection for bladder cancer radiotherapy: initiating a training programme and maintaining competency. Br J Radiol 2015; 88:20140690. [PMID: 25564753 DOI: 10.1259/bjr.20140690] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The implementation of plan of the day selection for patients receiving radiotherapy (RT) for bladder cancer requires efficient and confident decision-making. This article describes the development of a training programme and maintenance of competency. METHODS Cone beam CT (CBCT) images acquired on patients receiving RT for bladder cancer were assessed to establish baseline competency and training needs. A training programme was implemented, and observers were asked to select planning target volumes (PTVs) on two groups of 20 patients' images. After clinical implementation, the PTVs chosen were reviewed offline, and an audit performed after 3 years. RESULTS A mean of 73% (range, 53-93%) concordance rate was achieved prior to training. Subsequent to training, the mean score decreased to 66% (Round 1), then increased to 76% (Round 2). Six radiographers and two clinicians successfully completed the training programme. An independent observer reviewed the images offline after clinical implementation, and a 91% (126/139) concordance rate was achieved. During the audit, 125 CBCT images from 13 patients were reviewed by a single observer and concordance was 92%. CONCLUSION Radiographer-led selection of plan of the day was implemented successfully with the use of a training programme and continual assessment. Quality has been maintained over a period of 3 years. ADVANCES IN KNOWLEDGE The training programme was successful in achieving and maintaining competency for a plan of the day technique.
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Affiliation(s)
- H A McNair
- 1 Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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Wood TJ, Moore CS, Saunderson JR, Beavis AW. Validation of a technique for estimating organ doses for kilovoltage cone-beam CT of the prostate using the PCXMC 2.0 patient dose calculator. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2015; 35:153-163. [PMID: 25634880 DOI: 10.1088/0952-4746/35/1/153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The use of cone beam CT in common radiotherapy treatments is increasing with the growth of image guided radiotherapy. Whilst the benefits that this technology offers are clear, such as improved patient positioning prior to treatment, it is always important to consider the implications of such intensive imaging regimes on the patient, especially when considering the fundamental radiation protection requirements for justification and optimisation.The purpose of this study was to develop a technique that uses readily available dose calculation software (PCXMC 2.0) to estimate the organ and effective doses that result from these types of examination in prostate treatments on the Varian OBI system. It has been shown that by separating these types of examinations into 28 different projections, with a range of x-ray beam qualities, it is possible to reproduce the complex geometry that is used on these imaging systems in PCXMC i.e. asymmetric radiation field with a half bowtie filter rotating 360° around the patient.This new technique has been validated with thermo-luminescent dosimeter measurements in the Rando anthropomorphic phantom, and has been shown to give excellent agreement with this established method (R(2) = 0.995). This technique will prove to be valuable to radiotherapy departments that are looking to optimise their CBCT imaging protocols as it allows a rapid evaluation of the impact of any changes on patient dose. It also serves to further highlight the levels of dose that these types of patient are subject to when having daily CBCT scans as part of the treatment, which further reinforces the need for optimisation of both patient dose and image quality on these systems.
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Affiliation(s)
- T J Wood
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull & East Yorkshire Hospitals NHS Trust, Castle Road, Hull, HU16 5JQ, UK. Department of Engineering, Faculty of Science, University of Hull, Cottingham Road, Hull, HU6 7RX, UK
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