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Siddiq S, Murray V, Tyagi N, Borman P, Gui C, Crane C, Wu C, Otazo R. MR signature matching (MRSIGMA) implementation for true real-time free-breathing volumetric imaging with sub-200 ms latency on an MR-Linac. Magn Reson Med 2024; 92:1162-1176. [PMID: 38576131 PMCID: PMC11209806 DOI: 10.1002/mrm.30097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/20/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Develop a true real-time implementation of MR signature matching (MRSIGMA) for free-breathing 3D MRI with sub-200 ms latency on the Elekta Unity 1.5T MR-Linac. METHODS MRSIGMA was implemented on an external computer with a network connection to the MR-Linac. Stack-of-stars with partial kz sampling was used to accelerate data acquisition and ReconSocket was employed for simultaneous data transmission. Movienet network computed the 4D MRI motion dictionary and correlation analysis was used for signature matching. A programmable 4D MRI phantom was utilized to evaluate MRSIGMA with respect to a ground-truth translational motion reference. In vivo validation was performed on patients with pancreatic cancer, where 15 patients were employed to train Movienet and 7 patients to test the real-time implementation of MRSIGMA. Dice coefficients between real-time MRSIGMA and a retrospectively computed 4D reference were used to evaluate motion tracking performance. RESULTS Motion dictionary was computed in under 5 s. Signature acquisition and matching presented 173 ms latency on the phantom and 193 ms on patients. MRSIGMA presented a mean error of 1.3-1.6 mm for all phantom experiments, which was below the 2 mm acquisition resolution along the motion direction. The Dice coefficient over time between MRSIGMA and reference contours was 0.88 ± 0.02 (GTV), 0.87 ± 0.02(duodenum-stomach), and 0.78 ± 0.02(small bowel), demonstrating high motion tracking performance for both tumor and organs at risk. CONCLUSION The real-time implementation of MRSIGMA enabled true real-time free-breathing 3D MRI with sub-200 ms imaging latency on a clinical MR-Linac system, which can be used for treatment monitoring, adaptive radiotherapy and dose accumulation mapping in tumors affected by respiratory motion.
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Affiliation(s)
- Saad Siddiq
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Victor Murray
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pim Borman
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chengcheng Gui
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Can Wu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ricardo Otazo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Zaidi F, Calame P, Chevalier C, Henriques J, Vernerey D, Vuitton L, Heyd B, Borg C, Boustani J. A comparison of target volumes drawn on arterial and venous phase scans during radiation therapy planning for patients with pancreatic cancer: the PANCRINJ study. Radiat Oncol 2024; 19:90. [PMID: 39010133 PMCID: PMC11251351 DOI: 10.1186/s13014-024-02477-8] [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: 01/06/2024] [Accepted: 06/18/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND The planification of radiation therapy (RT) for pancreatic cancer (PC) requires a dosimetric computed tomography (CT) scan to define the gross tumor volume (GTV). The main objective of this study was to compare the inter-observer variability in RT planning between the arterial and the venous phases following intravenous contrast. METHODS PANCRINJ was a prospective monocentric study that included twenty patients with non-metastatic PC. Patients underwent a pre-therapeutic CT scan at the arterial and venous phases. The delineation of the GTV was performed by one radiologist (gold standard) and two senior radiation oncologists (operators). The primary objective was to compare the Jaccard conformity index (JCI) for the GTVs computed between the GS (gold standard) and the operators between the arterial and the venous phases with a Wilcoxon signed rank test for paired samples. The secondary endpoints were the geographical miss index (GMI), the kappa index, the intra-operator variability, and the dose-volume histograms between the arterial and venous phases. RESULTS The median JCI for the arterial and venous phases were 0.50 (range, 0.17-0.64) and 0.41 (range, 0.23-0.61) (p = 0.10) respectively. The median GS-GTV was statistically significantly smaller compared to the operators at the arterial (p < 0.0001) and venous phases (p < 0.001), respectively. The GMI were low with few tumors missed for all patients with a median GMI of 0.07 (range, 0-0.79) and 0.05 (range, 0-0.39) at the arterial and venous phases, respectively (p = 0.15). There was a moderate agreement between the radiation oncologists with a median kappa index of 0.52 (range 0.38-0.57) on the arterial phase, and 0.52 (range 0.36-0.57) on the venous phase (p = 0.08). The intra-observer variability for GTV delineation was lower at the venous phase than at the arterial phase for the two operators. There was no significant difference between the arterial and the venous phases regarding the dose-volume histogram for the operators. CONCLUSIONS Our results showed inter- and intra-observer variability in delineating GTV for PC without significant differences between the arterial and the venous phases. The use of both phases should be encouraged. Our findings suggest the need to provide training for radiation oncologists in pancreatic imaging and to collaborate within a multidisciplinary team.
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Affiliation(s)
- Fabien Zaidi
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France
| | - Paul Calame
- Department of Radiology, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Cédric Chevalier
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France
| | - Julie Henriques
- Methodology and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France
| | - Dewi Vernerey
- Methodology and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France
| | - Lucine Vuitton
- Department of Gastroenteroly, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Bruno Heyd
- Department of Digestive surgery, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Christophe Borg
- Department of Oncology, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Jihane Boustani
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France.
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France.
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Tobe T, Terakawa T, Ueno Y, Sofue K, Hara T, Furukawa J, Teishima J, Nakano Y, Harada K, Fujisawa M. Cine magnetic resonance imaging in evaluating retroperitoneal leiomyosarcoma arising from the inferior vena cava. IJU Case Rep 2024; 7:30-33. [PMID: 38173447 PMCID: PMC10758901 DOI: 10.1002/iju5.12660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/13/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction Leiomyosarcoma of the inferior vena cava is associated with poor prognosis. Complete resection is the only curative treatment. We present a patient with this disease in whom cine magnetic resonance imaging was valuable in selecting the surgical strategy and mitigating invasiveness. Case presentation A 68-year-old woman presented with right-sided abdominal pain. Computed tomography revealed an 86 mm tumor in the right retroperitoneal space that extended into the inferior vena cava and reached superiorly to the right atrium. Percutaneous needle biopsy confirmed leiomyosarcoma. Cine magnetic resonance imaging demonstrated no adhesions between the tumor and the upper segment of inferior vena cava wall, nor with the right atrial wall, indicating resectability. Radical tumor resection was successfully performed without requiring thoracotomy. Conclusion Cine magnetic resonance imaging appears to be useful in inferior vena cava leiomyosarcoma for evaluating adhesions between the tumor and vessel wall.
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Affiliation(s)
- Taisuke Tobe
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Tomoaki Terakawa
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Yoshiko Ueno
- Department of RadiologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Keitaro Sofue
- Department of RadiologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Takuto Hara
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Junya Furukawa
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Jun Teishima
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Yuzo Nakano
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
| | - Kenichi Harada
- Department of UrologyUniversity of Occupational and Environmental HealthFukuokaJapan
| | - Masato Fujisawa
- Department of UrologyKobe University Graduate School of MedicineKobeHyogoJapan
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Fast MF, Cao M, Parikh P, Sonke JJ. Intrafraction Motion Management With MR-Guided Radiation Therapy. Semin Radiat Oncol 2024; 34:92-106. [PMID: 38105098 DOI: 10.1016/j.semradonc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
High quality radiation therapy requires highly accurate and precise dose delivery. MR-guided radiotherapy (MRgRT), integrating an MRI scanner with a linear accelerator, offers excellent quality images in the treatment room without subjecting patient to ionizing radiation. MRgRT therefore provides a powerful tool for intrafraction motion management. This paper summarizes different sources of intrafraction motion for different disease sites and describes the MR imaging techniques available to visualize and quantify intrafraction motion. It provides an overview of MR guided motion management strategies and of the current technical capabilities of the commercially available MRgRT systems. It describes how these motion management capabilities are currently being used in clinical studies, protocols and provides a future outlook.
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Affiliation(s)
- Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Parag Parikh
- Department of Radiation Oncology, Henry Ford Health - Cancer, Detroit, MI
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Young T, Lee M, Johnston M, Nguyen T, Ko R, Arumugam S. Assessment of interfraction dose variation in pancreas SBRT using daily simulation MR images. Phys Eng Sci Med 2023; 46:1619-1627. [PMID: 37747645 DOI: 10.1007/s13246-023-01324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
Pancreatic Cancer is associated with poor treatment outcomes compared to other cancers. High local control rates have been achieved by using hypofractionated stereotactic body radiotherapy (SBRT) to treat pancreatic cancer. Challenges in delivering SBRT include close proximity of several organs at risk (OARs) and target volume inter and intra fraction positional variations. Magnetic resonance image (MRI) guided radiotherapy has shown potential for online adaptive radiotherapy for pancreatic cancer, with superior soft tissue contrast compared to CT. The aim of this study was to investigate the variability of target and OAR volumes for different treatment approaches for pancreatic cancer, and to assess the suitability of utilizing a treatment-day MRI for treatment planning purposes. Ten healthy volunteers were scanned on a Siemens Skyra 3 T MRI scanner over two sessions (approximately 3 h apart), per day over 5 days to simulate an SBRT daily simulation scan for treatment planning. A pretreatment scan was also done to simulate patient setup and treatment. A 4D MRI scan was taken at each session for internal target volume (ITV) generation and assessment. For each volunteer a treatment plan was generated in the Raystation treatment planning system (TPS) following departmental protocols on the day one, first session dataset (D1S1), with bulk density overrides applied to enable dose calculation. This treatment plan was propagated through other imaging sessions, and the dose calculated. An additional treatment plan was generated on each first session of each day (S1) to simulate a daily replan process, with this plan propagated to the second session of the day. These accumulated mock treatment doses were assessed against the original treatment plan through DVH comparison of the PTV and OAR volumes. The generated ITV showed large variations when compared to both the first session ITV and daily ITV, with an average magnitude of 22.44% ± 13.28% and 25.83% ± 37.48% respectively. The PTV D95 was reduced by approximately 23.3% for both plan comparisons considered. Surrounding OARs had large variations in dose, with the small bowel V30 increasing by 128.87% when compared to the D1S1 plan, and 43.11% when compared to each daily S1 plan. Daily online adaptive radiotherapy is required for accurate dose delivery for pancreas cancer in the absence of additional motion management and tumour tracking techniques.
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Affiliation(s)
- Tony Young
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.
- Ingham Institute, Sydney, Australia.
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia.
| | - Mark Lee
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | | | - Theresa Nguyen
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Rebecca Ko
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
- Ingham Institute, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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6
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Lombardo E, Liu PZY, Waddington DEJ, Grover J, Whelan B, Wong E, Reiner M, Corradini S, Belka C, Riboldi M, Kurz C, Landry G, Keall PJ. Experimental comparison of linear regression and LSTM motion prediction models for MLC-tracking on an MRI-linac. Med Phys 2023; 50:7083-7092. [PMID: 37782077 DOI: 10.1002/mp.16770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/30/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided radiotherapy with multileaf collimator (MLC)-tracking is a promising technique for intra-fractional motion management, achieving high dose conformality without prolonging treatment times. To improve beam-target alignment, the geometric error due to system latency should be reduced by using temporal prediction. PURPOSE To experimentally compare linear regression (LR) and long-short-term memory (LSTM) motion prediction models for MLC-tracking on an MRI-linac using multiple patient-derived traces with different complexities. METHODS Experiments were performed on a prototype 1.0 T MRI-linac capable of MLC-tracking. A motion phantom was programmed to move a target in superior-inferior (SI) direction according to eight lung cancer patient respiratory motion traces. Target centroid positions were localized from sagittal 2D cine MRIs acquired at 4 Hz using a template matching algorithm. The centroid positions were input to one of four motion prediction models. We used (1) a LSTM network which had been optimized in a previous study on patient data from another cohort (offline LSTM). We also used (2) the same LSTM model as a starting point for continuous re-optimization of its weights during the experiment based on recent motion (offline+online LSTM). Furthermore, we implemented (3) a continuously updated LR model, which was solely based on recent motion (online LR). Finally, we used (4) the last available target centroid without any changes as a baseline (no-predictor). The predictions of the models were used to shift the MLC aperture in real-time. An electronic portal imaging device (EPID) was used to visualize the target and MLC aperture during the experiments. Based on the EPID frames, the root-mean-square error (RMSE) between the target and the MLC aperture positions was used to assess the performance of the different motion predictors. Each combination of motion trace and prediction model was repeated twice to test stability, for a total of 64 experiments. RESULTS The end-to-end latency of the system was measured to be (389 ± 15) ms and was successfully mitigated by both LR and LSTM models. The offline+online LSTM was found to outperform the other models for all investigated motion traces. It obtained a median RMSE over all traces of (2.8 ± 1.3) mm, compared to the (3.2 ± 1.9) mm of the offline LSTM, the (3.3 ± 1.4) mm of the online LR and the (4.4 ± 2.4) mm when using the no-predictor. According to statistical tests, differences were significant (p-value <0.05) among all models in a pair-wise comparison, but for the offline LSTM and online LR pair. The offline+online LSTM was found to be more reproducible than the offline LSTM and the online LR with a maximum deviation in RMSE between two measurements of 10%. CONCLUSIONS This study represents the first experimental comparison of different prediction models for MRI-guided MLC-tracking using several patient-derived respiratory motion traces. We have shown that among the investigated models, continuously re-optimized LSTM networks are the most promising to account for the end-to-end system latency in MRI-guided radiotherapy with MLC-tracking.
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Affiliation(s)
- Elia Lombardo
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Paul Z Y Liu
- Image X Institute, University of Sydney Central Clinical School, Sydney, New South Wales, Australia
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - David E J Waddington
- Image X Institute, University of Sydney Central Clinical School, Sydney, New South Wales, Australia
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - James Grover
- Image X Institute, University of Sydney Central Clinical School, Sydney, New South Wales, Australia
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Brendan Whelan
- Image X Institute, University of Sydney Central Clinical School, Sydney, New South Wales, Australia
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Esther Wong
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Michael Reiner
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, a partnership between DKFZ and LMU University Hospital Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Marco Riboldi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Paul J Keall
- Image X Institute, University of Sydney Central Clinical School, Sydney, New South Wales, Australia
- Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
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Terpstra ML, Maspero M, Verhoeff JJC, van den Berg CAT. Accelerated respiratory-resolved 4D-MRI with separable spatio-temporal neural networks. Med Phys 2023; 50:5331-5342. [PMID: 37527331 DOI: 10.1002/mp.16643] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Respiratory-resolved four-dimensional magnetic resonance imaging (4D-MRI) provides essential motion information for accurate radiation treatments of mobile tumors. However, obtaining high-quality 4D-MRI suffers from long acquisition and reconstruction times. PURPOSE To develop a deep learning architecture to quickly acquire and reconstruct high-quality 4D-MRI, enabling accurate motion quantification for MRI-guided radiotherapy (MRIgRT). METHODS A small convolutional neural network called MODEST is proposed to reconstruct 4D-MRI by performing a spatial and temporal decomposition, omitting the need for 4D convolutions to use all the spatio-temporal information present in 4D-MRI. This network is trained on undersampled 4D-MRI after respiratory binning to reconstruct high-quality 4D-MRI obtained by compressed sensing reconstruction. The network is trained, validated, and tested on 4D-MRI of 28 lung cancer patients acquired with a T1-weighted golden-angle radial stack-of-stars (GA-SOS) sequence. The 4D-MRI of 18, 5, and 5 patients were used for training, validation, and testing. Network performances are evaluated on image quality measured by the structural similarity index (SSIM) and motion consistency by comparing the position of the lung-liver interface on undersampled 4D-MRI before and after respiratory binning. The network is compared to conventional architectures such as a U-Net, which has 30 times more trainable parameters. RESULTS MODEST can reconstruct high-quality 4D-MRI with higher image quality than a U-Net, despite a thirty-fold reduction in trainable parameters. High-quality 4D-MRI can be obtained using MODEST in approximately 2.5 min, including acquisition, processing, and reconstruction. CONCLUSION High-quality accelerated 4D-MRI can be obtained using MODEST, which is particularly interesting for MRIgRT.
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Affiliation(s)
- Maarten L Terpstra
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matteo Maspero
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cornelis A T van den Berg
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
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Han Z, Sudhyadhom A, Hsu SH, Hu YH, Mak RH, Huynh MA, van Dams RR, Tanguturi S, Venkatachalam V, Mancias JD, Mamon HJ, Martin NE, Lam MB, Leeman JE. Comparison of MR-soft tissue based versus biliary stent based alignment for image guidance in pancreatic SBRT. J Appl Clin Med Phys 2023:e13965. [PMID: 36924220 DOI: 10.1002/acm2.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/27/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE The role of biliary stents in image-guided localization for pancreatic cancer has been inconclusive. To date, stent accuracy has been largely evaluated against implanted fiducials on cone beam computed tomography. We aim to use magnetic resonance (MR) soft tissue as a direct reference to examine the geometric and dosimetric impacts of stent-based localization on the newly available MR linear accelerator. METHODS Thirty pancreatic cancer patients (132 fractions) treated on our MR linear accelerator were identified to have a biliary stent. In our standard adaptive workflow, patients were set up to the target using soft tissue for image registration and structures were re-contoured on daily MR images. The original plan was then projected on treatment anatomy and dose predicted, followed by plan re-optimization and treatment delivery. These online predicted plans were soft tissue-based and served as reference plans. Retrospective image registration to the stent was performed offline to simulate stent-based localization and the magnitude of shifts was taken as the geometric accuracy of stent localization. New predicted plans were generated based on stent-alignment for dosimetric comparison. RESULTS Shifts were within 3 mm for 90% of the cases (mean = 1.5 mm); however, larger shifts up to 7.2 mm were observed. Average PTV coverage dropped by 1.1% with a maximum drop of 26.8%. The mean increase in V35Gy was 0.15, 0.05, 0.02, and 0.02 cc for duodenum, stomach, small bowel and large bowel, respectively. Stent alignment was significantly worse for all metrics except for small bowel (p = 0.07). CONCLUSIONS Overall discrepancy between stent- and soft tissue-alignment was modest; however, large discrepancies were observed for select cases. While PTV coverage loss may be compensated for by using a larger margin, the increase in dose to gastrointestinal organs at risk may limit the role of biliary stents in image-guided localization.
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Affiliation(s)
- Zhaohui Han
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Atchar Sudhyadhom
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Shu-Hui Hsu
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Yue-Houng Hu
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Mai Anh Huynh
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Ritchell R van Dams
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Shyam Tanguturi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Veena Venkatachalam
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Mancias
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil E Martin
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Lombardo E, Rabe M, Xiong Y, Nierer L, Cusumano D, Placidi L, Boldrini L, Corradini S, Niyazi M, Reiner M, Belka C, Kurz C, Riboldi M, Landry G. Evaluation of real-time tumor contour prediction using LSTM networks for MR-guided radiotherapy. Radiother Oncol 2023; 182:109555. [PMID: 36813166 DOI: 10.1016/j.radonc.2023.109555] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND PURPOSE Magnetic resonance imaging guided radiotherapy (MRgRT) with deformable multileaf collimator (MLC) tracking would allow to tackle both rigid displacement and tumor deformation without prolonging treatment. However, the system latency must be accounted for by predicting future tumor contours in real-time. We compared the performance of three artificial intelligence (AI) algorithms based on long short-term memory (LSTM) modules for the prediction of 2D-contours 500ms into the future. MATERIALS AND METHODS Models were trained (52 patients, 3.1h of motion), validated (18 patients, 0.6h) and tested (18 patients, 1.1h) with cine MRs from patients treated at one institution. Additionally, we used three patients (2.9h) treated at another institution as second testing set. We implemented 1) a classical LSTM network (LSTM-shift) predicting tumor centroid positions in superior-inferior and anterior-posterior direction which are used to shift the last observed tumor contour. The LSTM-shift model was optimized both in an offline and online fashion. We also implemented 2) a convolutional LSTM model (ConvLSTM) to directly predict future tumor contours and 3) a convolutional LSTM combined with spatial transformer layers (ConvLSTM-STL) to predict displacement fields used to warp the last tumor contour. RESULTS The online LSTM-shift model was found to perform slightly better than the offline LSTM-shift and significantly better than the ConvLSTM and ConvLSTM-STL. It achieved a 50% Hausdorff distance of 1.2mm and 1.0mm for the two testing sets, respectively. Larger motion ranges were found to lead to more substantial performance differences across the models. CONCLUSION LSTM networks predicting future centroids and shifting the last tumor contour are the most suitable for tumor contour prediction. The obtained accuracy would allow to reduce residual tracking errors during MRgRT with deformable MLC-tracking.
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Affiliation(s)
- Elia Lombardo
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Moritz Rabe
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Yuqing Xiong
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Lukas Nierer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Davide Cusumano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany; German Cancer Consortium (DKTK), Munich 81377, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany
| | - Marco Riboldi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching b. München 85748, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich 81377, Germany.
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10
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Arumugam S, Young T, Johnston M, Pavey D, Lee M. The delivered dose assessment in pancreas SBRT with the target position determined using an in-house position monitoring system. Front Oncol 2022; 12:1009916. [PMID: 36518308 PMCID: PMC9743991 DOI: 10.3389/fonc.2022.1009916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/01/2022] [Indexed: 08/01/2023] Open
Abstract
PURPOSE This study assessed the delivered dose accuracy in pancreas SBRT by incorporating the real-time target position determined using an in-house position monitoring system. METHODS AND MATERIALS An online image-based position monitoring system, SeedTracker, was developed to monitor radiopaque marker positions using monoscopic x-ray images, available from the Elekta XVI imaging system. This system was applied to patients receiving SBRT for pancreatic cancer on the MASTERPLAN Pilot trial (ACTRN 12617001642370). All patients were implanted pre-treatment with at least three peri-tumoral radiopaque markers for target localisation. During treatment delivery, marker positions were compared to expected positions delineated from the planning CT. The position tolerance of ±3mm from the expected position of the markers was set to trigger a gating event (GE) during treatment. The dosimetric impact of position deviations and actual dose delivered with position corrections was assessed by convolving the plan control point dose matrices with temporal target positions determined during treatment. RESULTS Eight patients were treated within this study. At least one GE was observed in 38% of the treatment fractions and more than one GE was observed in 10% of the fractions. The position deviations resulted in the mean(range) difference of -0.1(-1.1 - 0.4)Gy in minimum dose to tumour and 1.9(-0.1- 4.6)Gy increase to Dmax to duodenum compared to planned dose. In actual treatment delivery with the patient realignment, the mean difference of tumour min dose and duodenal Dmax was reduced to 0.1(-1.0 - 1.1)Gy and 1.1 (-0.7 - 3.3)Gy respectively compared to the planned dose. CONCLUSIONS The in-house real-time position monitoring system improved the treatment accuracy of pancreatic SBRT in a general-purpose linac and enabled assessment of delivered dose by incorporating the temporal target position during delivery. The intrafraction motion impacts the dose to tumour even if target position is maintained within a 3mm position tolerance.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Young
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Meredith Johnston
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Darren Pavey
- Department of Radiology, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
| | - Mark Lee
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
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11
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Schneider S, Stefanowicz S, Jentsch C, Lohaus F, Thiele J, Haak D, Valentini C, Platzek I, G. C. Troost E, Hoffmann AL. Reduction of intrafraction pancreas motion using an abdominal corset compatible with proton therapy and MRI. Clin Transl Radiat Oncol 2022; 38:111-116. [DOI: 10.1016/j.ctro.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
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12
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Burkoň P, Trna J, Slávik M, Němeček R, Kazda T, Pospíšil P, Dastych M, Eid M, Novotný I, Procházka T, Vrzal M. Stereotactic Body Radiotherapy (SBRT) of Pancreatic Cancer-A Critical Review and Practical Consideration. Biomedicines 2022; 10:biomedicines10102480. [PMID: 36289742 PMCID: PMC9599229 DOI: 10.3390/biomedicines10102480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Pancreatic cancer is the third leading cause of cancer death in the developed world and is predicted to become the second by 2030. A cure may be achieved only with surgical resection of an early diagnosed disease. Surgery for more advanced disease is challenging and can be contraindicated for many reasons. Neoadjuvant therapy may improve the probability of achieving R0 resection. It consists of systemic treatment followed by radiation therapy applied concurrently or sequentially with cytostatics. A novel approach to irradiation, stereotactic body radiotherapy (SBRT), has the potential to improve treatment results. SBRT can deliver higher doses of radiation to the tumor in only a few treatment fractions. It has attracted significant interest for pancreatic cancer patients, as it is completed quickly, requires less time away from full-dose chemotherapy, and is well-tolerated than conventional radiotherapy. In this review, we aim to provide the reader with a basic overview of current evidence for SBRT indications in the treatment of pancreatic tumors. In the second part of the review, we focus on practical information with respect to SBRT treatment plan preparation the performance of such therapy. Finally, we discuss future directions related to the use of magnetic resonance linear accelerators.
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Affiliation(s)
- Petr Burkoň
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Jan Trna
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Marek Slávik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Radim Němeček
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Petr Pospíšil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Milan Dastych
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Michal Eid
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Ivo Novotný
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Procházka
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
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Ji T, Feng Z, Sun E, Ng SK, Su L, Zhang Y, Han D, Han-Oh S, Iordachita I, Lee J, Kazanzides P, Bell MAL, Wong J, Ding K. A phantom-based analysis for tracking intra-fraction pancreatic tumor motion by ultrasound imaging during radiation therapy. Front Oncol 2022; 12:996537. [PMID: 36237341 PMCID: PMC9552199 DOI: 10.3389/fonc.2022.996537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeIn this study, we aim to further evaluate the accuracy of ultrasound tracking for intra-fraction pancreatic tumor motion during radiotherapy by a phantom-based study.MethodsTwelve patients with pancreatic cancer who were treated with stereotactic body radiation therapy were enrolled in this study. The displacement points of the respiratory cycle were acquired from 4DCT and transferred to a motion platform to mimic realistic breathing movements in our phantom study. An ultrasound abdominal phantom was placed and fixed in the motion platform. The ground truth of phantom movement was recorded by tracking an optical tracker attached to this phantom. One tumor inside the phantom was the tracking target. In the evaluation of the results, the monitoring results from the ultrasound system were compared with the phantom motion results from the infrared camera. Differences between infrared monitoring motion and ultrasound tracking motion were analyzed by calculating the root-mean-square error.ResultsThe 82.2% ultrasound tracking motion was within a 0.5 mm difference value between ultrasound tracking displacement and infrared monitoring motion. 0.7% ultrasound tracking failed to track accurately (a difference value > 2.5 mm). These differences between ultrasound tracking motion and infrared monitored motion do not correlate with respiratory displacements, respiratory velocity, or respiratory acceleration by linear regression analysis.ConclusionsThe highly accurate monitoring results of this phantom study prove that the ultrasound tracking system may be a potential method for real-time monitoring targets, allowing more accurate delivery of radiation doses.
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Affiliation(s)
- Tianlong Ji
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Ziwei Feng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Edward Sun
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Sook Kien Ng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Lin Su
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Yin Zhang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dong Han
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Iulian Iordachita
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Junghoon Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Peter Kazanzides
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
| | - Muyinatu A. Lediju Bell
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - John Wong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
- *Correspondence: Kai Ding,
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14
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Grimbergen G, Eijkelenkamp H, Heerkens HD, Raaymakers BW, Intven MPW, Meijer GJ. Dosimetric impact of intrafraction motion under abdominal compression during MR-guided SBRT for (Peri-) pancreatic tumors. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8ddd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. Intrafraction motion is a major concern for the safety and effectiveness of high dose stereotactic body radiotherapy (SBRT) in the upper abdomen. In this study, the impact of the intrafraction motion on the delivered dose was assessed in a patient group that underwent MR-guided radiotherapy for upper abdominal malignancies with an abdominal corset. Approach. Fast online 2D cine MRI was used to extract tumor motion during beam-on time. These tumor motion profiles were combined with linac log files to reconstruct the delivered dose in 89 fractions of MR-guided SBRT in twenty patients. Aside the measured tumor motion, motion profiles were also simulated for a wide range of respiratory amplitudes and drifts, and their subsequent dosimetric impact was calculated in every fraction. Main results. The average (SD) D
99% of the gross tumor volume (GTV), relative to the planned D
99%, was 0.98 (0.03). The average (SD) relative D
0.5cc
of the duodenum, small bowel and stomach was 0.99 (0.03), 1.00 (0.03), and 0.97 (0.05), respectively. No correlation of respiratory amplitude with dosimetric impact was observed. Fractions with larger baseline drifts generally led to a larger uncertainty of dosimetric impact on the GTV and organs at risk (OAR). The simulations yielded that the delivered dose is highly dependent on the direction of on baseline drift. Especially in anatomies where the OARs are closely abutting the GTV, even modest LR or AP drifts can lead to substantial deviations from the planned dose. Significance. The vast majority of the fractions was only modestly impacted by intrafraction motion, increasing our confidence that MR-guided SBRT with abdominal compression can be safely executed for patients with abdominal tumors, without the use of gating or tracking strategies.
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15
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Zeng C, Lu W, Reyngold M, Cuaron JJ, Li X, Cerviño L, Li T. Intrafractional accuracy and efficiency of a surface imaging system for deep inspiration breath hold during ablative gastrointestinal cancer treatment. J Appl Clin Med Phys 2022; 23:e13740. [PMID: 35906884 PMCID: PMC9680575 DOI: 10.1002/acm2.13740] [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: 01/12/2022] [Revised: 07/18/2022] [Accepted: 07/15/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Beam gating with deep inspiration breath hold (DIBH) usually depends on some external surrogate to infer internal target movement, and the exact internal movement is unknown. In this study, we tracked internal targets and characterized residual motion during DIBH treatment, guided by a surface imaging system, for gastrointestinal cancer. We also report statistics on treatment time. METHODS AND MATERIALS We included 14 gastrointestinal cancer patients treated with surface imaging-guided DIBH volumetrically modulated arc therapy, each with at least one radiopaque marker implanted near or within the target. They were treated in 25, 15, or 10 fractions. Thirteen patients received treatment for pancreatic cancer, and one underwent separate treatments for two liver metastases. The surface imaging system monitored a three-dimensional surface with ± 3 mm translation and ± 3° rotation threshold. During delivery, a kilovolt image was automatically taken every 20° or 40° gantry rotation, and the internal marker was identified from the image. The displacement and residual motion of the markers were calculated. To analyze the treatment efficiency, the treatment time of each fraction was obtained from the imaging and treatment timestamps in the record and verify system. RESULTS Although the external surface was monitored and limited to ± 3 mm and ± 3°, significant residual internal target movement was observed in some patients. The range of residual motion was 3-21 mm. The average displacement for this cohort was 0-3 mm. In 19% of the analyzed images, the magnitude of the instantaneous displacement was > 5 mm. The mean treatment time was 17 min with a standard deviation of 4 min. CONCLUSIONS Precaution is needed when applying surface image guidance for gastrointestinal cancer treatment. Using it as a solo DIBH technique is discouraged when the correlation between internal anatomy and patient surface is limited. Real-time radiographic verification is critical for safe treatments.
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Affiliation(s)
- Chuan Zeng
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Wei Lu
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Marsha Reyngold
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - John J. Cuaron
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Laura Cerviño
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Tianfang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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16
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Pham TT, Whelan B, Oborn BM, Delaney GP, Vinod S, Brighi C, Barton M, Keall P. Magnetic resonance imaging (MRI) guided proton therapy: A review of the clinical challenges, potential benefits and pathway to implementation. Radiother Oncol 2022; 170:37-47. [DOI: 10.1016/j.radonc.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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Grimbergen G, Eijkelenkamp H, Heerkens HD, Raaymakers BW, Intven MPW, Meijer GJ. Intrafraction pancreatic tumor motion patterns during ungated magnetic resonance guided radiotherapy with an abdominal corset. Phys Imaging Radiat Oncol 2022; 21:1-5. [PMID: 35005257 PMCID: PMC8715205 DOI: 10.1016/j.phro.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) has been shown to be a promising therapy for unresectable pancreatic tumors. However, intrafraction motion, caused by respiratory motion and organ drift, is one of the main concerns for efficient dose delivery in ungated upper abdominal radiotherapy. The aim of this study was to analyze the intrafraction gross tumor volume (GTV) motion in a clinical cohort. Materials and methods We included 13 patients that underwent online adaptive magnetic resonance (MR)-guided SBRT for malignancies in the pancreatic region (5 × 8 Gy). An abdominal corset was fitted in order to reduce the abdominal respiratory motion. Coronal and sagittal cine magnetic resonance images of the tumor region were made at 2 Hz during the entire beam-on time of each fraction. We used deformable image registration to obtain GTV motion profiles in all three directions, which were subsequently high-pass and low-pass filtered to isolate the motion caused by respiratory motion and baseline drift, respectively. Results The mean (SD) respiratory amplitudes were 4.2 (1.9) mm cranio-caudal (CC), 2.3 (1.1) mm ventral-dorsal (AP) and 1.4 (0.6) mm left–right (LR), with low variability within patients. The mean (SD) maximum baseline drifts were 1.2 (1.1) mm CC, 0.5 (0.4) mm AP and 0.5 (0.3) mm LR. The mean (SD) minimum baseline drifts were −0.7 (0.5) mm CC, −0.6 (0.5) mm AP and −0.5 (0.4) mm LR. Conclusion Overall tumor motion during treatment was small and interfractionally stable. These findings show that high-precision ungated MR-guided SBRT is feasible with an abdominal corset.
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Affiliation(s)
- Guus Grimbergen
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Hanne D Heerkens
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Bas W Raaymakers
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
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Shao HC, Huang X, Folkert MR, Wang J, Zhang Y. Automatic liver tumor localization using deep learning-based liver boundary motion estimation and biomechanical modeling (DL-Bio). Med Phys 2021; 48:7790-7805. [PMID: 34632589 DOI: 10.1002/mp.15275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Recently, two-dimensional-to-three-dimensional (2D-3D) deformable registration has been applied to deform liver tumor contours from prior reference images onto estimated cone-beam computed tomography (CBCT) target images to automate on-board tumor localizations. Biomechanical modeling has also been introduced to fine-tune the intra-liver deformation-vector-fields (DVFs) solved by 2D-3D deformable registration, especially at low-contrast regions, using tissue elasticity information and liver boundary DVFs. However, the caudal liver boundary shows low contrast from surrounding tissues in the cone-beam projections, which degrades the accuracy of the intensity-based 2D-3D deformable registration there and results in less accurate boundary conditions for biomechanical modeling. We developed a deep-learning (DL)-based method to optimize the liver boundary DVFs after 2D-3D deformable registration to further improve the accuracy of subsequent biomechanical modeling and liver tumor localization. METHODS The DL-based network was built based on the U-Net architecture. The network was trained in a supervised fashion to learn motion correlation between cranial and caudal liver boundaries to optimize the liver boundary DVFs. Inputs of the network had three channels, and each channel featured the 3D DVFs estimated by the 2D-3D deformable registration along one Cartesian direction (x, y, z). To incorporate patient-specific liver boundary information into the DVFs, the DVFs were masked by a liver boundary ring structure generated from the liver contour of the prior reference image. The network outputs were the optimized DVFs along the liver boundary with higher accuracy. From these optimized DVFs, boundary conditions were extracted for biomechanical modeling to further optimize the solution of intra-liver tumor motion. We evaluated the method using 34 liver cancer patient cases, with 24 for training and 10 for testing. We evaluated and compared the performance of three methods: 2D-3D deformable registration, 2D-3D-Bio (2D-3D deformable registration with biomechanical modeling), and DL-Bio (DL model prediction with biomechanical modeling). The tumor localization errors were quantified through calculating the center-of-mass-errors (COMEs), DICE coefficients, and Hausdorff distance between deformed liver tumor contours and manually segmented "gold-standard" contours. RESULTS The predicted DVFs by the DL model showed improved accuracy at the liver boundary, which translated into more accurate liver tumor localizations through biomechanical modeling. On a total of 90 evaluated images and tumor contours, the average (± sd) liver tumor COMEs of the 2D-3D, 2D-3D-Bio, and DL-Bio techniques were 4.7 ± 1.9 mm, 2.9 ± 1.0 mm, and 1.7 ± 0.4 mm. The corresponding average (± sd) DICE coefficients were 0.60 ± 0.12, 0.71 ± 0.07, and 0.78 ± 0.03; and the average (± sd) Hausdorff distances were 7.0 ± 2.6 mm, 5.4 ± 1.5 mm, and 4.5 ± 1.3 mm, respectively. CONCLUSION DL-Bio solves a general correlation model to improve the accuracy of the DVFs at the liver boundary. With improved boundary conditions, the accuracy of biomechanical modeling can be further increased for accurate intra-liver low-contrast tumor localization.
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Affiliation(s)
- Hua-Chieh Shao
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Xiaokun Huang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jing Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - You Zhang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Olberg S, Chun J, Su Choi B, Park I, Kim H, Kim T, Sung Kim J, Green O, Park JC. Abdominal synthetic CT reconstruction with intensity projection prior for MRI-only adaptive radiotherapy. Phys Med Biol 2021; 66. [PMID: 34530421 DOI: 10.1088/1361-6560/ac279e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/16/2021] [Indexed: 11/11/2022]
Abstract
Objective. Owing to the superior soft tissue contrast of MRI, MRI-guided adaptive radiotherapy (ART) is well-suited to managing interfractional changes in anatomy. An MRI-only workflow is desirable, but producing synthetic CT (sCT) data through paired data-driven deep learning (DL) for abdominal dose calculations remains a challenge due to the highly variable presence of intestinal gas. We present the preliminary dosimetric evaluation of our novel approach to sCT reconstruction that is well suited to handling intestinal gas in abdominal MRI-only ART.Approach. We utilize a paired data DL approach enabled by the intensity projection prior, in which well-matching training pairs are created by propagating air from MRI to corresponding CT scans. Evaluations focus on two classes: patients with (1) little involvement of intestinal gas, and (2) notable differences in intestinal gas presence between corresponding scans. Comparisons between sCT-based plans and CT-based clinical plans for both classes are made at the first treatment fraction to highlight the dosimetric impact of the variable presence of intestinal gas.Main results. Class 1 patients (n= 13) demonstrate differences in prescribed dose coverage of the PTV of 1.3 ± 2.1% between clinical plans and sCT-based plans. Mean DVH differences in all structures for Class 1 patients are found to be statistically insignificant. In Class 2 (n= 20), target coverage is 13.3 ± 11.0% higher in the clinical plans and mean DVH differences are found to be statistically significant.Significance. Significant deviations in calculated doses arising from the variable presence of intestinal gas in corresponding CT and MRI scans result in uncertainty in high-dose regions that may limit the effectiveness of adaptive dose escalation efforts. We have proposed a paired data-driven DL approach to sCT reconstruction for accurate dose calculations in abdominal ART enabled by the creation of a clinically unavailable training data set with well-matching representations of intestinal gas.
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Affiliation(s)
- Sven Olberg
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States of America.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63110, United States of America
| | - Jaehee Chun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byong Su Choi
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States of America.,Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Inkyung Park
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States of America.,Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Kim
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63110, United States of America
| | - Taeho Kim
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63110, United States of America
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Olga Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63110, United States of America
| | - Justin C Park
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States of America
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20
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Park SJ, Kim JH, Joo I, Han JK. Predictors of conversion surgery in patients with pancreatic cancer who underwent neoadjuvant or palliative FOLFIRINOX treatment using baseline and follow-up CT. Abdom Radiol (NY) 2021; 46:4765-4778. [PMID: 34085090 DOI: 10.1007/s00261-021-03127-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/11/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE We aimed to evaluate the predictive factors of conversion surgery in pancreatic adenocarcinoma (PAC) after neoadjuvant or palliative FOLFIRINOX using baseline and follow-up CT. METHODS We retrospectively included 189 patients who had undergone more than 4 cycles of FOLFIRINOX. We reviewed baseline CT (B-CT), 1st follow-up CT (1st-CT), and the preoperative or last follow-up CT (L-CT) and determined tumor size changes according to the Response Evaluation Criteria in Solid Tumors (RECIST 1.1). Extra-pancreatic perineural invasion (EPNI) and resectability using NCCN 2019 guideline were evaluated. Subgroup analysis by baseline resectability was performed. RESULTS B-CT included resectable (n = 25, 23.2%), borderline (n = 55, 29.1%), locally advanced (n = 44, 23.3%), and metastatic (n = 65, 34.4%) PAC. Seventy-four patients had undergone surgery (39.2%) with an 83.8% (62/74) R0 resection. For operability, resectable status at L-CT (hazard ratio (HR) 65.5; 95% confidence interval (CI) 5.0-865; P = 0.002), RECIST (partial response) at 1st-CT (HR 3.6; 95% CI 1.1-11.7; P = 0.032), and baseline borderline resectability (HR 8.6; 95% CI 1.6-46.4; P = 0.013) were important predictors. Based on a size reduction cut-off of 22.2%, the area under the receiver operating characteristic (ROC) curve (Az) was 0.761 (sensitivity = 70.3%, specificity = 74.8%). In subgroup analysis, RECIST (partial response) at 1st-CT was a significant predictor of locally advanced PAC (HR 32; 95% CI 4.5-227, P 0.001), and the optimal cut-off was 22.2% (Az = 0.914; sensitivity = 100%, specificity = 75%). Baseline tumor size ([Formula: see text] 4 cm) (HR 5.6, 95% CI 1.3-24.3, P = 0.022) and unresectable status at 1st-CT (HR 4.8, 95% CI 1.1-20.6, P = 0.035) were significantly associated with margin-positive resection. CONCLUSION Both baseline and follow-up CT findings are useful to predict conversion surgery for PAC after FOLFIRINOX.
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Affiliation(s)
- Sae-Jin Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, SMG-SNU Boramae Medical Cencer, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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21
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Elamir AM, Stanescu T, Shessel A, Tadic T, Yeung I, Letourneau D, Kim J, Lukovic J, Dawson LA, Wong R, Barry A, Brierley J, Gallinger S, Knox J, O'Kane G, Dhani N, Hosni A, Taylor E. Simulated dose painting of hypoxic sub-volumes in pancreatic cancer stereotactic body radiotherapy. Phys Med Biol 2021; 66. [PMID: 34438383 DOI: 10.1088/1361-6560/ac215c] [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: 04/28/2021] [Accepted: 08/26/2021] [Indexed: 12/26/2022]
Abstract
Dose painting of hypoxic tumour sub-volumes using positron-emission tomography (PET) has been shown to improve tumour controlin silicoin several sites, predominantly head and neck and lung cancers. Pancreatic cancer presents a more stringent challenge, given its proximity to critical gastro-intestinal organs-at-risk (OARs), anatomic motion, and impediments to reliable PET hypoxia quantification. A radiobiological model was developed to estimate clonogen survival fraction (SF), using18F-fluoroazomycin arabinoside PET (FAZA PET) images from ten patients with unresectable pancreatic ductal adenocarcinoma to quantify oxygen enhancement effects. For each patient, four simulated five-fraction stereotactic body radiotherapy (SBRT) plans were generated: (1) a standard SBRT plan aiming to cover the planning target volume with 40 Gy, (2) dose painting plans delivering escalated doses to a maximum of three FAZA-avid hypoxic sub-volumes, (3) dose painting plans with simulated spacer separating the duodenum and pancreatic head, and (4), plans with integrated boosts to geometric contractions of the gross tumour volume (GTV). All plans saturated at least one OAR dose limit. SF was calculated for each plan and sensitivity of SF to simulated hypoxia quantification errors was evaluated. Dose painting resulted in a 55% reduction in SF as compared to standard SBRT; 78% with spacer. Integrated boosts to hypoxia-blind geometric contractions resulted in a 41% reduction in SF. The reduction in SF for dose-painting plans persisted for all hypoxia quantification parameters studied, including registration and rigid motion errors that resulted in shifts and rotations of the GTV and hypoxic sub-volumes by as much as 1 cm and 10 degrees. Although proximity to OARs ultimately limited dose escalation, with estimated SFs (∼10-5) well above levels required to completely ablate a ∼10 cm3tumour, dose painting robustly reduced clonogen survival when accounting for expected treatment and imaging uncertainties and thus, may improve local response and associated morbidity.
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Affiliation(s)
- Ahmed M Elamir
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Teodor Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrea Shessel
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ivan Yeung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Canada
| | - Daniel Letourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jelena Lukovic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Steven Gallinger
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Jennifer Knox
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Grainne O'Kane
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Neesha Dhani
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Edward Taylor
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
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22
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Bednarz BP, Jupitz S, Lee W, Mills D, Chan H, Fiorillo T, Sabitini J, Shoudy D, Patel A, Mitra J, Sarcar S, Wang B, Shepard A, Matrosic C, Holmes J, Culberson W, Bassetti M, Hill P, McMillan A, Zagzebski J, Smith LS, Foo TK. First-in-human imaging using a MR-compatible e4D ultrasound probe for motion management of radiotherapy. Phys Med 2021; 88:104-110. [PMID: 34218199 DOI: 10.1016/j.ejmp.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Respiration-induced tumor or organ positional changes can impact the accuracy of external beam radiotherapy. Motion management strategies are used to account for these changes during treatment. The authors report on the development, testing, and first-in-human evaluation of an electronic 4D (e4D) MR-compatible ultrasound probe that was designed for hands-free operation in a MR and linear accelerator (LINAC) environment. METHODS Ultrasound components were evaluated for MR compatibility. Electromagnetic interference (EMI) shielding was used to enclose the entire probe and a factory-fabricated cable shielded with copper braids was integrated into the probe. A series of simultaneous ultrasound and MR scans were acquired and analyzed in five healthy volunteers. RESULTS The ultrasound probe led to minor susceptibility artifacts in the MR images immediately proximal to the ultrasound probe at a depth of <10 mm. Ultrasound and MR-based motion traces that were derived by tracking the salient motion of endogenous target structures in the superior-inferior (SI) direction demonstrated good concordance (Pearson correlation coefficients of 0.95-0.98) between the ultrasound and MRI datasets. CONCLUSION We have demonstrated that our hands-free, e4D probe can acquire ultrasound images during a MR acquisition at frame rates of approximately 4 frames per second (fps) without impacting either the MR or ultrasound image quality. This use of this technology for interventional procedures (e.g. biopsies and drug delivery) and motion compensation during imaging are also being explored.
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Affiliation(s)
- Bryan P Bednarz
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States.
| | - Sydney Jupitz
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Warren Lee
- GE Global Research, Niskayuna, NY 12309, United States
| | - David Mills
- GE Global Research, Niskayuna, NY 12309, United States
| | - Heather Chan
- GE Global Research, Niskayuna, NY 12309, United States
| | | | | | - David Shoudy
- GE Global Research, Niskayuna, NY 12309, United States
| | - Aqsa Patel
- GE Global Research, Niskayuna, NY 12309, United States
| | - Jhimli Mitra
- GE Global Research, Niskayuna, NY 12309, United States
| | | | - Bo Wang
- GE Global Research, Niskayuna, NY 12309, United States
| | - Andrew Shepard
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States; Department of Radiation Oncology, University of Iowa, Iowa City, IA 52242, United States
| | - Charles Matrosic
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States
| | - James Holmes
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Wesley Culberson
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Patrick Hill
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Alan McMillan
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - James Zagzebski
- Medical Physics, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - L Scott Smith
- GE Global Research, Niskayuna, NY 12309, United States
| | - Thomas K Foo
- GE Global Research, Niskayuna, NY 12309, United States
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23
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The first real-time intrafraction target position monitoring in pancreas SBRT on an Elekta linear accelerator. Phys Eng Sci Med 2021; 44:625-638. [PMID: 34019228 DOI: 10.1007/s13246-021-01007-0] [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: 09/22/2020] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
To perform implanted fiducial based real-time target position monitoring in pancreas stereotactic body radiotherapy (SBRT) using the x-ray imaging system available in a Elekta linear accelerator. An in-house system was developed and clinically utilised for real-time target position monitoring of pancreas SBRT delivery. The developed system was used for the target position monitoring of a pancreas cancer patient treated in free breathing treatment within the study entitled 'Mfolfirinox And STEreotactic Radiotherapy for Patients with Locally Advanced paNcreas cancer (MASTERPLAN): a feasibility study' (ACTRN 12617001642370) consisting of five treatment fractions. The clinical efficacy of the system was studied by performing a retrospective cumulative dose assessment of delivered dose using observed position deviations. The developed system identified two events of baseline shifts in target position that exceeded the accepted tolerance level of ± 3 mm from reference planned position. The retrospective dose assessment study showed that if the position deviations were not detected and corrected for, the maximum dose to duodenum would have increased from 34.6 to 38.8 Gy. The first real-time position monitoring in pancreas SBRT on an Elekta linear accelerator was successfully performed. The developed system was shown to improve the safety and accuracy of SBRT delivery.
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24
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Placidi L, Nardini M, Cusumano D, Boldrini L, Chiloiro G, Romano A, Votta C, Antonelli MV, Valentini V, Indovina L. VMAT-like plans for magnetic resonance guided radiotherapy: Addressing unmet needs. Phys Med 2021; 85:72-78. [PMID: 33979726 DOI: 10.1016/j.ejmp.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/29/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE VMAT delivery technique is currently not applicable to Magnetic Resonance-guided radiotherapy (MRgRT) hybrid systems. Aim of this study is to evaluate an innovative VMAT-like (VML) delivery technique. MATERIAL AND METHODS First, planning and dosimetric evaluation of the MRgRT VML treatment have been performed on 10 different disease sites and the results have been compared with the corresponding IMRT plans. Then, in the second phase, 10 of the most dosimetrically challenging locally advanced pancreas treatment plans have been retrospectively re-planned using the VML approach to explore the potentiality of this new delivery technique. Finally, VML robustness was evaluated and compared with the IMRT plans, considering a lateral positioning error of ± 5 mm. RESULTS In phase one, all VML plans were within constraint for all OARs. When PTV coverage is considered, in the 50% of the cases VML PTV coverage is equal or higher than in IMRT plan. In the remaining 50%, the highest target under coverage difference in comparison with IMRT plan is -1.71%. The mean and maximum treatment time differences (VML-IMRT) is 0.2 min and 3.1 min respectively. In phase two, the treatment time variation (VML-IMRT), shows a mean, maximum and minimum variations of 1.3, 4.6 and -0.6 min respectively. All VML plans have a better target coverage if compared with IMRT plans, keeping in any case the OARs constraints within tolerance. VML doesn't increase plan robustness. CONCLUSION VMAT-like treatment approach appeared to be an efficient planning solution and it was decided to clinically implement it in daily practice, especially in the frame of hypo fractionated treatments.
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Affiliation(s)
- L Placidi
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - M Nardini
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - D Cusumano
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy.
| | - L Boldrini
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - G Chiloiro
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - A Romano
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - C Votta
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - M V Antonelli
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - V Valentini
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Indovina
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
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25
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Remy C, Ahumada D, Labine A, Côté JC, Lachaine M, Bouchard H. Potential of a probabilistic framework for target prediction from surrogate respiratory motion during lung radiotherapy. Phys Med Biol 2021; 66. [PMID: 33761479 DOI: 10.1088/1361-6560/abf1b8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 03/23/2021] [Indexed: 12/25/2022]
Abstract
Purpose.Respiration-induced motion introduces significant positioning uncertainties in radiotherapy treatments for thoracic sites. Accounting for this motion is a non-trivial task commonly addressed with surrogate-based strategies and latency compensating techniques. This study investigates the potential of a new unified probabilistic framework to predict both future target motion in real-time from a surrogate signal and associated uncertainty.Method.A Bayesian approach is developed, based on a Kalman filter theory adapted specifically for surrogate measurements. Breathing motions are collected simultaneously from a lung target, two external surrogates (abdominal and thoracic markers) and an internal surrogate (liver structure) for 9 volunteers during 4 min, in which severe breathing changes occur to assess the robustness of the method. A comparison with an artificial non-linear neural network (NN) is performed, although no confidence interval prediction is provided. A static worst-case scenario and a simple static design are investigated.Results.Although the NN can reduce the prediction errors from thoracic surrogate in some cases, the Bayesian framework outperforms in most cases the NN when using the other surrogates: bias on predictions is reduced by 38% and 16% on average when using respectively the liver and the abdomen for the simple scenario, and by respectively 40% and 31% for the worst-case scenario. The standard deviation of residuals is reduced on average by up to 42%. The Bayesian method is also found to be more robust to increasing latencies. The thoracic marker appears to be less reliable to predict the target position, while the liver shows to be a better surrogate. A statistical test confirms the significance of both observations.Conclusion.The proposed framework predicts both the future target position and the associated uncertainty, which can be valuably used to further assist motion management decisions. Further investigation is required to improve the predictions by using an adaptive version of the proposed framework.
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Affiliation(s)
- Charlotte Remy
- Département de physique, Université de Montréal, Complexe des sciences, 1375 Avenue Thérèse-Lavoie-Roux, Montréal, Québec H2V 0B3, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 Rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Daniel Ahumada
- Département de physique, Université de Montréal, Complexe des sciences, 1375 Avenue Thérèse-Lavoie-Roux, Montréal, Québec H2V 0B3, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 Rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Alexandre Labine
- Département de physique, Université de Montréal, Complexe des sciences, 1375 Avenue Thérèse-Lavoie-Roux, Montréal, Québec H2V 0B3, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 Rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Jean-Charles Côté
- Département de radio-oncologie, Centre hospitalier de l'Université de Montréal (CHUM), 1560 rue Sherbrooke est, Montréal, Québec H2L 4M1, Canada
| | - Martin Lachaine
- Elekta Ltd., 2050 de Bleury, Suite 200, Montréal, Québec H3A2J5, Canada
| | - Hugo Bouchard
- Département de physique, Université de Montréal, Complexe des sciences, 1375 Avenue Thérèse-Lavoie-Roux, Montréal, Québec H2V 0B3, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 Rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.,Département de radio-oncologie, Centre hospitalier de l'Université de Montréal (CHUM), 1560 rue Sherbrooke est, Montréal, Québec H2L 4M1, Canada
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26
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Liu L, Johansson A, Cao Y, Kashani R, Lawrence TS, Balter JM. Modeling intra-fractional abdominal configuration changes using breathing motion-corrected radial MRI. Phys Med Biol 2021; 66. [PMID: 33725676 DOI: 10.1088/1361-6560/abef42] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/16/2021] [Indexed: 12/11/2022]
Abstract
Abdominal organ motions introduce geometric uncertainties to gastrointestinal radiotherapy. This study investigated slow drifting motion induced by changes of internal anatomic organ arrangements using a 3D radial MRI sequence with a scan length of 20 min. Breathing motion and cyclic GI motion were first removed through multi-temporal resolution image reconstruction. Slow drifting motion analysis was performed using an image time series consisting of 72 image volumes with a temporal sampling rate of 17 s. B-spline deformable registration was performed to align image volumes of the time series to a reference volume. The resulting deformation fields were used for motion velocity evaluation and patient-specific motion model construction through principal component analysis (PCA). Geometric uncertainties introduced by slow drifting motion were assessed by Hausdorff distances between unions of organs at risk (OARs) at different motion states and reference OAR contours as well as probabilistic distributions of OARs predicted using the PCA model. Thirteen examinations from 11 patients were included in this study. The averaged motion velocities ranged from 0.8 to 1.9 mm min-1, 0.7 to 1.6 mm min-1, 0.6 to 2.0 mm min-1and 0.7 to 1.4 mm min-1for the small bowel, colon, duodenum and stomach respectively; the averaged Hausdorff distances were 5.6 mm, 5.3 mm, 5.1 mm and 4.6 mm. On average, a margin larger than 4.5 mm was needed to cover a space with OAR occupancy probability higher than 55%. Temporal variations of geometric uncertainties were evaluated by comparing across four 5 min sub-scans extracted from the full scan. Standard deviations of Hausdorff distances across sub-scans were less than 1 mm for most examinations, indicating stability of relative margin estimates from separate time windows. These results suggested slow drifting motion of GI organs is significant and geometric uncertainties introduced by such motion should be accounted for during radiotherapy planning and delivery.
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Affiliation(s)
- Lianli Liu
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America.,Department of Radiation Oncology, Stanford University, Palo Alto, CA 94304, United States of America
| | - Adam Johansson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America.,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, SE 75185, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, SE 75185, Sweden
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America.,Department of Radiology, University of Michigan, Ann Arbor, MI 48109, United States of America.,Department of biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, United States of America
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Johansson A, Balter JM, Cao Y. Gastrointestinal 4D MRI with respiratory motion correction. Med Phys 2021; 48:2521-2527. [PMID: 33595909 DOI: 10.1002/mp.14786] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/12/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Gastrointestinal motion patterns such as peristalsis and segmental contractions can alter the shape and position of the stomach and intestines with respect to other irradiated organs during radiation therapy. Unfortunately, these deformations are concealed by conventional four-dimensional (4D)-MRI techniques, which were developed to visualize respiratory motion by binning acquired data into respiratory motion states without considering the phases of GI motion. We present a method to reconstruct breathing-compensated images showing the phases of periodic gastric motion and study the effect of this motion on regional anatomical structures. METHODS Sixty-seven DCE-MRI examinations were performed on patients undergoing MRI simulation for hepatocellular carcinoma using a golden-angle stack-of-stars sequence that collected 2000 radial spokes over 5 min. The collected data were reconstructed using a method with integrated respiratory motion correction into a time series of 3D image volumes without visible breathing motion. From this series, a gastric motion signal was extracted by temporal filtering of time-intensity curves in the stomach. Using this motion signal, breathing-corrected back-projection images were sorted according to the gastric phase and reconstructed into 21 gastric motion state images showing the phases of gastric motion. RESULTS Reconstructed image volumes showed gastric motion states clearly with no visible breathing motion or related artifacts. The mean frequency of the gastric motion signal was 3 cycles/min with a standard deviation of 0.27 cycles/min. CONCLUSIONS Periodic gastrointestinal motion can be visualized without confounding respiratory motion using the presented GI 4D MRI technique. GI 4D MRIs may help define internal target volumes for treatment planning, aid in planning organ at risk volume definition, or support motion model development for gastrointestinal motion tracking algorithms for real-time MR-guided radiation therapy.
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Affiliation(s)
- Adam Johansson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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Zhang Y, Kashani R, Cao Y, Lawrence TS, Johansson A, Balter JM. A hierarchical model of abdominal configuration changes extracted from golden angle radial magnetic resonance imaging. Phys Med Biol 2021; 66:045018. [PMID: 33361579 PMCID: PMC7993537 DOI: 10.1088/1361-6560/abd66e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abdominal organs are subject to a variety of physiological forces that superimpose their effects to influence local motion and configuration. These forces not only include breathing, but can also arise from cyclic antral contractions and a range of slow configuration changes. To elucidate each individual motion pattern as well as their combined effects, a hierarchical motion model was built for characterization of these 3 motion modes (characterized as deformation maps between states) using golden angle radial MR signals. Breathing motions are characterized first. Antral contraction states are then reconstructed after breathing motion-induced deformation are corrected; slow configuration change states are further extracted from breathing motion-corrected image reconstructions. The hierarchical model is established based on these multimodal states, which can be either individually shown or combined to demonstrate any arbitrary composited motion patterns. The model was evaluated using 20 MR scans acquired from 9 subjects. Poor reproducibility of breathing motions both within as well as between scan sessions was observed, with an average intra-subject difference of 1.6 cycles min-1 for average breathing frequencies of 12.0 cycles min-1. Antral contraction frequency distributions were more stable than breathing, but also presented poor reproducibility between scans with an average difference of 0.3 cycles min-1 for average frequencies of 3.2 cycles min-1. The magnitudes of motions beyond breathing were found to be significant, with 14.4 and 33.8 mm maximal motions measured from antral contraction and slow configuration changes, respectively. Hierarchical motion models have potential in multiple applications in radiotherapy, including improving the accuracy of dose delivery estimation, providing guidance for margin creation, and supporting advanced decisions and strategies for immobilization, treatment monitoring and gating.
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Affiliation(s)
- Yuhang Zhang
- Department of Radiation Oncology, University of Michigan, United States of America
- Department of Biomedical Engineering, University of Michigan, United States of America
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, United States of America
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, United States of America
- Department of Biomedical Engineering, University of Michigan, United States of America
- Department of Radiology, University of Michigan, United States of America
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, United States of America
| | - Adam Johansson
- Department of Surgical Sciences, Uppsala University, Sweden
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, United States of America
- Department of Biomedical Engineering, University of Michigan, United States of America
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29
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Brunner TB, Haustermans K, Huguet F, Morganti AG, Mukherjee S, Belka C, Krempien R, Hawkins MA, Valentini V, Roeder F. ESTRO ACROP guidelines for target volume definition in pancreatic cancer. Radiother Oncol 2021; 154:60-69. [DOI: 10.1016/j.radonc.2020.07.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/08/2023]
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30
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Zeng C, Li X, Lu W, Reyngold M, Gewanter RM, Cuaron JJ, Yorke E, Li T. Accuracy and efficiency of respiratory gating comparable to deep inspiration breath hold for pancreatic cancer treatment. J Appl Clin Med Phys 2020; 22:218-225. [PMID: 33378792 PMCID: PMC7856516 DOI: 10.1002/acm2.13137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/06/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Deep inspiration breath hold (DIBH) and respiratory gating (RG) are widely used to reduce movement of target and healthy organs caused by breathing during irradiation. We hypothesized that accuracy and efficiency comparable to DIBH can be achieved with RG for pancreas treatment. Methods and Materials Twenty consecutive patients with pancreatic cancer treated with DIBH (eight) or RG (twelve) volumetric modulated arc therapy during 2017–2019 were included in this study, with radiopaque markers implanted near or in the targets. Seventeen patients received 25 fractions, while the other three received 15 fractions. Only patients who could not tolerate DIBH received RG treatment. While both techniques relied on respiratory signals from external markers, internal target motions were monitored with kV X‐ray imaging during treatment. A 3‐mm external gating window was used for DIBH treatment; RG treatment was centered on end‐expiration with a duty cycle of 40%, corresponding to an external gating window of 2–3 mm. During dose delivery, kV images were automatically taken every 20◦ or 40◦ gantry rotation, from which internal markers were identified. The marker displacement from their initial positions and the residual motion amplitudes were calculated. For the analysis of treatment efficiency, the treatment time of every session was calculated from the motion management waveform files recorded at the treatment console. Results Within one fraction, the displacement was 0–5 mm for DIBH and 0–6 mm for RG. The average magnitude of displacement for each patient during the entire course of treatment ranged 0–3 mm for both techniques. No statistically significant difference in displacement or residual motion was observed between the two techniques. The average treatment time was 15 min for DIBH and 17 min for RG, with no statistical significance. Conclusions The accuracy and efficiency were comparable between RG and DIBH treatment for pancreas irradiation. RG is a feasible alternative strategy to DIBH.
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Affiliation(s)
- Chuan Zeng
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wei Lu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard M Gewanter
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tianfang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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31
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Liauw SL, Ni L, Wu T, Arif F, Cloutier D, Posner MC, Kozloff M, Kindler HL. A prospective trial of stereotactic body radiation therapy for unresectable pancreatic cancer testing ablative doses. J Gastrointest Oncol 2020; 11:1399-1407. [PMID: 33457009 DOI: 10.21037/jgo-20-187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We explored the safety and efficacy of ablative doses of stereotactic body radiation therapy (SBRT) for unresectable pancreatic cancer. Methods This phase I/II trial included patients with unresectable pancreatic cancer previously treated with any number of cycles of induction chemotherapy. Patients were enrolled according to a 3+3 dose escalation design at 10, 12.5, and 15 Gy ×3, with subsequent patients at the maximally tolerated dose (MTD). Treatment was delivered to gross tumor delineated with MRI fusion using image-guidance to fiducial markers. Dose-limiting toxicity (DLT) was defined as grade 3+ toxicity within 30 days. Secondary endpoints included late gastrointestinal (GI) toxicity, freedom from local failure (FFLF), and survival. Results Fifteen patients received a median 10 cycles of chemotherapy. There were no DLTs, and the MTD was 15 Gy ×3. Thirty-day toxicity included grade 2 nausea (46%) and grade 2 diarrhea (7%). Median survival after SBRT was 12.8 months (23 months after diagnosis) and median relapse-free survival was 7 months. At 1-year, FFLF was 80%. Four patients had grade 3+ GI bleeding after 30 days (median 6 months). Grade 3+ GI bleeding was associated with tumor volume (P=0.01), heterogeneity of dose within the planning target volume (PTV) (V120, P=0.03), and duodenal dose (V26-30 Gy, P<0.2). Conclusions This aggressive SBRT regimen demonstrated limited 30-day morbidity, a moderate degree of local control, and a moderate risk for late GI bleeding. Further work is necessary to define the most appropriate hypofractionated radiation therapy (RT) regimen in the ablative dose range.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Tianming Wu
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Fauzia Arif
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Denise Cloutier
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mitchell C Posner
- Department of Surgical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mark Kozloff
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Hedy L Kindler
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
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Vergalasova I, Cai J. A modern review of the uncertainties in volumetric imaging of respiratory-induced target motion in lung radiotherapy. Med Phys 2020; 47:e988-e1008. [PMID: 32506452 DOI: 10.1002/mp.14312] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy has become a critical component for the treatment of all stages and types of lung cancer, often times being the primary gateway to a cure. However, given that radiation can cause harmful side effects depending on how much surrounding healthy tissue is exposed, treatment of the lung can be particularly challenging due to the presence of moving targets. Careful implementation of every step in the radiotherapy process is absolutely integral for attaining optimal clinical outcomes. With the advent and now widespread use of stereotactic body radiation therapy (SBRT), where extremely large doses are delivered, accurate, and precise dose targeting is especially vital to achieve an optimal risk to benefit ratio. This has largely become possible due to the rapid development of image-guided technology. Although imaging is critical to the success of radiotherapy, it can often be plagued with uncertainties due to respiratory-induced target motion. There has and continues to be an immense research effort aimed at acknowledging and addressing these uncertainties to further our abilities to more precisely target radiation treatment. Thus, the goal of this article is to provide a detailed review of the prevailing uncertainties that remain to be investigated across the different imaging modalities, as well as to highlight the more modern solutions to imaging motion and their role in addressing the current challenges.
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Affiliation(s)
- Irina Vergalasova
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Jing Cai
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
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Jupitz SA, Shepard AJ, Hill PM, Bednarz BP. Investigation of tumor and vessel motion correlation in the liver. J Appl Clin Med Phys 2020; 21:183-190. [PMID: 32533758 PMCID: PMC7484818 DOI: 10.1002/acm2.12943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/29/2020] [Accepted: 05/06/2020] [Indexed: 12/24/2022] Open
Abstract
Intrafraction imaging‐based motion management systems for external beam radiotherapy can rely on internal surrogate structures when the target is not easily visualized. This work evaluated the validity of using liver vessels as internal surrogates for the estimation of liver tumor motion. Vessel and tumor motion were assessed using ten two‐dimensional sagittal MR cine datasets collected on the ViewRay MRIdian. For each case, a liver tumor and at least one vessel were tracked for 175 s. A tracking approach utilizing block matching and multiple simultaneous templates was applied. Accuracy of the tracked motion was calculated from the error between the tracked centroid position and manually defined ground truth annotations. The patient’s abdomen surface and diaphragm were manually annotated in all frames. The Pearson correlation coefficient (CC) was used to compare the motion of the features and tumor in the anterior–posterior (AP) and superior–inferior (SI) directions. The distance between the centroids of the features and the tumors was calculated to assess if feature proximity affects relative correlation, and the tumor range of motion was determined. Intra‐ and interfraction motion amplitude variabilities were evaluated to further assess the relationship between tumor and feature motion. The mean CC between the motion of the vessel and the tumor were 0.85 ± 0.11 (AP) and 0.92 ± 0.04 (SI), 0.83 ± 0.11 (AP) and −0.89 ± 0.06 (SI) for the surface and tumor, and 0.80 ± 0.17 (AP) and 0.94 ± 0.03 (SI) for the diaphragm and tumor. For intrafraction analysis, the average amplitude variability was 2.47 ± 0.77 mm (AP) and 3.14 ± 1.49 mm (SI) for the vessels, 2.70 ± 1.08 mm (AP) and 3.43 ± 1.73 mm (SI) for the surface, and 2.76 ± 1.41 mm (AP) and 2.91 ± 1.38 mm (SI) for the diaphragm. No relationship between distance and motion correlation was observed. The motion of liver tumors and liver vessels was well correlated, making vessels a suitable surrogate for tumor motion in the liver.
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Affiliation(s)
- Sydney A Jupitz
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
| | - Andrew J Shepard
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, USA
| | - Patrick M Hill
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, USA
| | - Bryan P Bednarz
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
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Tryggestad EJ, Liu W, Pepin MD, Hallemeier CL, Sio TT. Managing treatment-related uncertainties in proton beam radiotherapy for gastrointestinal cancers. J Gastrointest Oncol 2020; 11:212-224. [PMID: 32175124 DOI: 10.21037/jgo.2019.11.07] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years, there has been rapid adaption of proton beam radiotherapy (RT) for treatment of various malignancies in the gastrointestinal (GI) tract, with increasing number of institutions implementing intensity modulated proton therapy (IMPT). We review the progress and existing literature regarding the technical aspects of RT planning for IMPT, and the existing tools that can help with the management of uncertainties which may impact the daily delivery of proton therapy. We provide an in-depth discussion regarding range uncertainties, dose calculations, image guidance requirements, organ and body cavity filling consideration, implanted devices and hardware, use of fiducials, breathing motion evaluations and both active and passive motion management methods, interplay effect, general IMPT treatment planning considerations including robustness plan evaluation and optimization, and finally plan monitoring and adaptation. These advances have improved confidence in delivery of IMPT for patients with GI malignancies under various scenarios.
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Affiliation(s)
- Erik J Tryggestad
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Phoenix, Phoenix, AZ, USA
| | - Mark D Pepin
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Phoenix, Phoenix, AZ, USA
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35
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Navest RJM, Mandija S, Bruijnen T, Stemkens B, Tijssen RHN, Andreychenko A, Lagendijk JJW, van den Berg CAT. The noise navigator: a surrogate for respiratory-correlated 4D-MRI for motion characterization in radiotherapy. Phys Med Biol 2020; 65:01NT02. [PMID: 31775130 DOI: 10.1088/1361-6560/ab5c62] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Respiratory-correlated 4D-MRI can characterize respiratory-induced motion of tumors and organs-at-risk for radiotherapy treatment planning and is a necessity for image guidance of moving tumors treated on an MRI-linac. Essential for 4D-MRI generation is a robust respiratory surrogate signal. We investigated the feasibility of the noise navigator as respiratory surrogate signal for 4D-MRI generation. The noise navigator is based on the respiratory-induced modulation of the thermal noise variance measured by the receive coils during MR acquisition and thus is inherently present and synchronized with MRI data acquisition. Additionally, the noise navigator can be combined with any rectilinear readout strategy (e.g. radial and cartesian) and is independent of MR image contrast and imaging orientation. For radiotherapy applications, the noise navigator provides a robust respiratory signal for patients scanned with an elevated coil setup. This is particularly attractive for widely used cartesian sequences where currently a non-interfering self-navigation means is lacking for MRI-based simulation and MRI-guided radiotherapy. The feasibility of 4D-MRI generation with the noise navigator as respiratory surrogate signal was demonstrated for both cartesian and radial readout strategies in radiotherapy setup on four healthy volunteers and two radiotherapy patients on a dedicated 1.5 T MRI scanner and two radiotherapy patients on a 1.5 T MRI-linac system. Moreover, the respiratory-correlated 4D-MR images showed liver motion comparable to a reference 2D cine MRI series for the volunteers. For 2D cartesian cine MRI acquisitions, both the noise navigator and respiratory bellows were benchmarked against an image navigator. Respiratory phase detection based on the noise navigator agreed 1.4 times better with the image navigator than the respiratory bellows did. For a 3D Stack-of-Stars acquisitions, the noise navigator was compared to radial self-navigation and a 1.7 times higher respiratory phase detection agreement was observed than for the respiratory bellows compared to radial self-navigation.
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Affiliation(s)
- R J M Navest
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands. Computational Imaging Group for MRI Diagnostics & Therapy, Centre for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands. Author to whom any correspondence should be addressed
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Mickevicius NJ, Nencka AS, Paulson ES. Generalized simultaneous multi-orientation 2D imaging. Magn Reson Med 2019; 84:847-856. [PMID: 31872496 DOI: 10.1002/mrm.28150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 11/09/2022]
Abstract
PURPOSE Flexibility in slice prescription is critical for precise motion monitoring during MR-guided therapies. Adding more slices to improve spatial coverage during rapid 2D cine imaging often hampers temporal resolution. This work describes a framework to simultaneously acquire multiple arbitrarily oriented slices which share a common frequency encoding axis. This framework allows for higher frame rates for a given number of slices compared to conventional interleaved-slice multi-orientation cine imaging. THEORY AND METHODS A framework to calculate zeroth gradient moments to be played out between sequentially excited slices with multiple orientations is described here. Experiments were performed in phantom, and in vivo in the head/neck and abdomen of patients. RESULTS Images arbitrarily rotated relative to one another were successfully obtained in phantom and in vivo. Simultaneous multi-orientation (SMO) images were also acquired with additional in-plane acceleration to demonstrate the capability of this method to rapidly image objects moving with physiological motion. CONCLUSIONS The technical feasibility of the generalized SMO imaging framework was tested in this study. It shows promise for continued development for motion monitoring during MR-guided therapies.
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Affiliation(s)
| | - Andrew S Nencka
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eric S Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Oar A, Lee M, Le H, Hruby G, Dalfsen R, Pryor D, Lee D, Chu J, Holloway L, Briggs A, Barbour A, Chander S, Ng SP, Samra J, Shakeshaft J, Goldstein D, Nguyen N, Goodman KA, Chang DT, Kneebone A. Australasian Gastrointestinal Trials Group (AGITG) and Trans-Tasman Radiation Oncology Group (TROG) Guidelines for Pancreatic Stereotactic Body Radiation Therapy (SBRT). Pract Radiat Oncol 2019; 10:e136-e146. [PMID: 31761541 DOI: 10.1016/j.prro.2019.07.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Nonrandomized data exploring pancreas stereotactic body radiation therapy (SBRT) has demonstrated excellent local control rates and low toxicity. Before commencing a randomized trial investigating pancreas SBRT, standardization of prescription dose, dose constraints, simulation technique, and clinical target volume delineation are required. METHODS AND MATERIALS Specialists in radiation oncology, medical oncology, hepatobiliary surgery, and gastroenterology attended 2 consecutive Australasian Gastrointestinal Trials Group workshops in 2017 and 2018. Sample cases were discussed during workshop contact with specifically invited international speakers highly experienced in pancreas SBRT. Furthermore, sample cases were contoured and planned between workshop contact to finalize dose constraints and clinical target volume delineation. RESULTS Over 2 separate workshops, consensus was reached on dose and simulation technique. The working group recommended a dose prescription of 40 Gy in 5 fractions. Treatment delivery during end-expiratory breath hold with triple-phase contrast enhanced computed tomography was recommended. In addition, dose constraints, stepwise contouring guidelines, and an anatomic atlas for pancreatic SBRT were developed. CONCLUSIONS Pancreas SBRT is emerging as a promising treatment modality requiring prospective evaluation in randomized studies. This work attempts to standardize dose, simulation technique, and volume delineation to support the delivery of high quality SBRT in a multicenter study.
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Affiliation(s)
- Andrew Oar
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast; Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.
| | - Mark Lee
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - George Hruby
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Raymond Dalfsen
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Australia
| | | | - Julie Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lois Holloway
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia; South Western Clinical School, University of New South Wales, Sydney, Australia; Institute of Medical Physics, University of Sydney, Sydney, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Adam Briggs
- Royal North Shore Hospital, Sydney, Australia
| | - Andrew Barbour
- Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Diamantina Institute, Translational Research Institute, Woolloongabba, Australia
| | - Sarat Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jas Samra
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - John Shakeshaft
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - David Goldstein
- Department of Medical Oncology, Nelune Cancer Centre, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Nam Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Andrew Kneebone
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
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Knowles BR, Friedrich F, Fischer C, Paech D, Ladd ME. Beyond T2 and 3T: New MRI techniques for clinicians. Clin Transl Radiat Oncol 2019; 18:87-97. [PMID: 31341982 PMCID: PMC6630188 DOI: 10.1016/j.ctro.2019.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 12/12/2022] Open
Abstract
Technological advances in Magnetic Resonance Imaging (MRI) in terms of field strength and hybrid MR systems have led to improvements in tumor imaging in terms of anatomy and functionality. This review paper discusses the applications of such advances in the field of radiation oncology with regards to treatment planning, therapy guidance and monitoring tumor response and predicting outcome.
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Affiliation(s)
- Benjamin R. Knowles
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Florian Friedrich
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Physics and Astronomy, University of Heidelberg, Heidelberg, Germany
| | - Carola Fischer
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Physics and Astronomy, University of Heidelberg, Heidelberg, Germany
| | - Daniel Paech
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mark E. Ladd
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Physics and Astronomy, University of Heidelberg, Heidelberg, Germany
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Fujimoto K, Shiinoki T, Yuasa Y, Onizuka R, Yamane M. Evaluation of the effects of motion mitigation strategies on respiration-induced motion in each pancreatic region using cine-magnetic resonance imaging. J Appl Clin Med Phys 2019; 20:42-50. [PMID: 31385418 PMCID: PMC6753735 DOI: 10.1002/acm2.12693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/28/2019] [Accepted: 07/19/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose This study aimed to quantify the respiration‐induced motion in each pancreatic region during motion mitigation strategies and to characterize the correlations between this motion and that of the surrogate signals in cine‐magnetic resonance imaging (MRI). We also aimed to evaluate the effects of these motion mitigation strategies in each pancreatic region. Methods Sagittal and coronal two‐dimensional cine‐MR images were obtained in 11 healthy volunteers, eight of whom also underwent imaging with abdominal compression (AC). For each pancreatic region, the magnitude of pancreatic motion with and without motion mitigation and the positional error between the actual and predicted pancreas motion based on surrogate signals were evaluated. Results The magnitude of pancreatic motion with and without AC in the left–right (LR) and superior–inferior (SI) directions varied depending on the pancreatic region. In respiratory gating (RG) assessments based on a surrogate signal, although the correlation was reasonable, the positional error was large in the pancreatic tail region. Furthermore, motion mitigation in the anterior‐posterior and SI directions with RG was more effective than was that with AC in the head region. Conclusions This study revealed pancreatic region‐dependent variations in respiration‐induced motion and their effects on motion mitigation outcomes during AC or RG. The magnitude of pancreatic motion with or without AC and the magnitude of the positional error with RG varied depending on the pancreatic region. Therefore, during radiation therapy for pancreatic cancer, it is important to consider that the effects of motion mitigation during AC or RG may differ depending on the pancreatic region.
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Affiliation(s)
- Koya Fujimoto
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Takehiro Shiinoki
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Yuki Yuasa
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Ryota Onizuka
- Department of Radiological Technology, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Masatoshi Yamane
- Department of Radiological Technology, Yamaguchi University Hospital, Yamaguchi, Japan
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Ding Y, Campbell WG, Miften M, Vinogradskiy Y, Goodman KA, Schefter T, Jones BL. Quantifying Allowable Motion to Achieve Safe Dose Escalation in Pancreatic SBRT. Pract Radiat Oncol 2019; 9:e432-e442. [PMID: 30951868 PMCID: PMC6592725 DOI: 10.1016/j.prro.2019.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/04/2019] [Accepted: 03/23/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Tumor motion plays a key role in the safe delivery of stereotactic body radiation therapy (SBRT) for pancreatic cancer. The purpose of this study was to use tumor motion measured in patients to establish limits on motion magnitude for safe delivery of pancreatic SBRT and to help guide motion-management decisions in potential dose-escalation scenarios. METHODS AND MATERIALS Using 91 sets of pancreatic tumor motion data, we calculated the motion-convolved dose of the gross tumor volume, duodenum, and stomach for 25 patients with pancreatic cancer. We derived simple linear or quadratic models relating motion to changes in dose and used these models to establish the maximum amount of motion allowable while satisfying error thresholds on key dose metrics. In the same way, we studied the effects of dose escalation and tumor volume on allowable motion. RESULTS In our patient cohort, the mean (range) allowable motion for 33, 40, and 50 Gy to the planning target volume was 11.9 (6.3-22.4), 10.4 (5.2-19.1), and 9.0 (4.2-16.0) mm, respectively. The maximum allowable motion decreased as the dose was escalated and was smaller in patients with larger tumors. We found significant differences in allowable motion between the different plans, suggesting a patient-specific approach to motion management is possible. CONCLUSIONS The effects of motion on pancreatic SBRT are highly variable among patients, and there is potential to allow more motion in certain patients, even in dose-escalated scenarios. In our dataset, a conservative limit of 6.3 mm would ensure safe treatment of all patients treated to 33 Gy in 5 fractions.
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Affiliation(s)
- Yijun Ding
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Warren G Campbell
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | | | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Tracey Schefter
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Bernard L Jones
- Department of Radiation Oncology, University of Colorado, Denver, Colorado.
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Ding Y, Barrett HH, Kupinski MA, Vinogradskiy Y, Miften M, Jones BL. Objective assessment of the effects of tumor motion in radiation therapy. Med Phys 2019; 46:3311-3323. [PMID: 31111961 DOI: 10.1002/mp.13601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Internal organ motion reduces the accuracy and efficacy of radiation therapy. However, there is a lack of tools to objectively (based on a medical or scientific task) assess the dosimetric consequences of motion, especially on an individual basis. We propose to use therapy operating characteristic (TOC) analysis to quantify the effects of motion on treatment efficacy for individual patients. We demonstrate the application of this tool with pancreatic stereotactic body radiation therapy (SBRT) clinical data and explore the origin of motion sensitivity. METHODS The technique is described as follows. (a) Use tumor-motion data measured from patients to calculate the motion-convolved dose of the gross tumor volume (GTV) and the organs at risk (OARs). (b) Calculate tumor control probability (TCP) and normal tissue complication probability (NTCP) from the motion-convolved dose-volume histograms. (c) Construct TOC curves from TCP and NTCP models. (d) Calculate the area under the TOC curve (AUTOC) and use it as a figure of merit for treatment efficacy. We used tumor motion data measured from patients to calculate the relation between AUTOC and motion magnitude for 25 pancreatic SBRT treatment plans. Furthermore, to explore the driving factor of motion sensitivity of a given plan, we compared the dose distribution of motion-sensitive plans and motion-robust plans and studied the dependence of motion sensitivity to motion directions. RESULTS Our technique is able to recognize treatment plans that are sensitive to motion. Under the presence of motion, the treatment efficacy of some plans changes from providing high tumor control and low risks of complications to providing no tumor control and high risks of side effects. Several treatment plans experience falloffs in AUTOC at a smaller magnitude of motion than other plans. In our dataset, a potential indicator of a motion-sensitive treatment plan is that the duodenum is in proximity to the tumor in the SI direction. CONCLUSIONS The TOC framework can serve as a tool to quantify the effects of internal organ motion in radiation therapy. With pancreatic SBRT clinical data, we applied this tool to study the change in treatment efficacy induced by motion for individual treatment plans. This framework could potentially be used clinically to understand the effects of motion in an individual patient and to design a patient-specific motion management plan. This framework could also be used in research to evaluate different components of the treatment process, such as motion-management techniques, treatment-planning algorithms, and treatment margins.
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Affiliation(s)
- Yijun Ding
- College of Optical Sciences, University of Arizona, Tucson, AZ, 85719, USA
| | - Harrison H Barrett
- College of Optical Sciences, University of Arizona, Tucson, AZ, 85719, USA.,Department of Medical Imaging, University of Arizona, Tucson, AZ, 85719, USA
| | - Matthew A Kupinski
- College of Optical Sciences, University of Arizona, Tucson, AZ, 85719, USA
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Bernard L Jones
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
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Zeng C, Xiong W, Li X, Reyngold M, Gewanter RM, Cuaron JJ, Yorke ED, Li T. Intrafraction tumor motion during deep inspiration breath hold pancreatic cancer treatment. J Appl Clin Med Phys 2019; 20:37-43. [PMID: 30933428 PMCID: PMC6523018 DOI: 10.1002/acm2.12577] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose Beam gating with deep inspiration breath hold (DIBH) has been widely used for motion management in radiotherapy. Normally it relies on some external surrogate for estimating the internal target motion, while the exact internal motion is unknown. In this study, we used the intrafraction motion review (IMR) application to directly track an internal target and characterized the residual motion during DIBH treatment for pancreatic cancer patients through their full treatment courses. Methods and Materials Eight patients with pancreatic cancer treated with DIBH volumetric modulated arc therapy in 2017 and 2018 were selected for this study, each with some radiopaque markers (fiducial or surgical clips) implanted near or inside the target. The Varian Real‐time Position Management (RPM) system was used to monitor the breath hold, represented by the anterior‐posterior displacement of an external surrogate, namely reflective markers mounted on a plastic block placed on the patient's abdomen. Before each treatment, a cone beam computed tomography (CBCT) scan under DIBH was acquired for patient setup. For scan and treatment, the breath hold reported by RPM had to lie within a 3 mm window. IMR kV images were taken every 20° or 40° gantry rotation during dose delivery, resulting in over 5000 images for the cohort. The internal markers were manually identified in the IMR images. The residual motion amplitudes of the markers as well as the displacement from their initial positions located in the setup CBCT images were analyzed. Results Even though the external markers indicated that the respiratory motion was within 3 mm in DIBH treatment, significant residual internal target motion was observed for some patients. The range of average motion was from 3.4 to 7.9 mm, with standard deviation ranging from 1.2 to 3.5 mm. For all patients, the target residual motions seemed to be random with mean positions around their initial setup positions. Therefore, the absolute target displacement relative to the initial position was small during DIBH treatment, with the mean and the standard deviation 0.6 and 2.9 mm, respectively. Conclusions Internal target motion may differ from external surrogate motion in DIBH treatment. Radiographic verification of target position at the beginning and during each fraction is necessary for precise RT delivery. IMR can serve as a useful tool to directly monitor the internal target motion.
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Affiliation(s)
- Chuan Zeng
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Weijun Xiong
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiang Li
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - John J Cuaron
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen D Yorke
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tianfang Li
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Dolde K, Dávid C, Echner G, Floca R, Hentschke C, Maier F, Niebuhr N, Ohmstedt K, Saito N, Alimusaj M, Fluegel B, Naumann P, Dreher C, Freitag M, Pfaffenberger A. 4DMRI-based analysis of inter— and intrafractional pancreas motion and deformation with different immobilization devices. Biomed Phys Eng Express 2019. [DOI: 10.1088/2057-1976/aaf9ae] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nakamura A, Hiraoka M, Itasaka S, Nakamura M, Akimoto M, Ishihara Y, Mukumoto N, Goto Y, Kishi T, Yoshimura M, Matsuo Y, Yano S, Mizowaki T. Evaluation of Dynamic Tumor-tracking Intensity-modulated Radiotherapy for Locally Advanced Pancreatic Cancer. Sci Rep 2018; 8:17096. [PMID: 30459454 PMCID: PMC6244273 DOI: 10.1038/s41598-018-35402-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/05/2018] [Indexed: 12/25/2022] Open
Abstract
Intensity-modulated radiotherapy (IMRT) is now regarded as an important treatment option for patients with locally advanced pancreatic cancer (LAPC). To reduce the underlying tumor motions and dosimetric errors during IMRT as well as the burden of respiratory management for patients, we started to apply a new treatment platform of the dynamic tumor dynamic tumor-tracking intensity-modulated radiotherapy (DTT-IMRT) using the gimbaled linac, which can swing IMRT toward the real-time tumor position under patients' voluntary breathing. Between June 2013 and March 2015, ten patients were treated, and the tumor-tracking accuracy and the practical benefits were evaluated. The mean PTV size in DTT-IMRT was 18% smaller than a conventional ITV-based PTV. The root-mean-squared errors between the predicted and the detected tumor positions were 1.3, 1.2, and 1.5 mm in left-right, anterior-posterior, and cranio-caudal directions, respectively. The mean in-room time was 24.5 min. This high-accuracy of tumor-tracking with reasonable treatment time are promising and beneficial to patients with LAPC.
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Affiliation(s)
- Akira Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Satoshi Itasaka
- Department of Radiation Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mami Akimoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitomo Ishihara
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobutaka Mukumoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoko Goto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Kishi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinsuke Yano
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Paganelli C, Whelan B, Peroni M, Summers P, Fast M, van de Lindt T, McClelland J, Eiben B, Keall P, Lomax T, Riboldi M, Baroni G. MRI-guidance for motion management in external beam radiotherapy: current status and future challenges. Phys Med Biol 2018; 63:22TR03. [PMID: 30457121 DOI: 10.1088/1361-6560/aaebcf] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
High precision conformal radiotherapy requires sophisticated imaging techniques to aid in target localisation for planning and treatment, particularly when organ motion due to respiration is involved. X-ray based imaging is a well-established standard for radiotherapy treatments. Over the last few years, the ability of magnetic resonance imaging (MRI) to provide radiation-free images with high-resolution and superb soft tissue contrast has highlighted the potential of this imaging modality for radiotherapy treatment planning and motion management. In addition, these advantageous properties motivated several recent developments towards combined MRI radiation therapy treatment units, enabling in-room MRI-guidance and treatment adaptation. The aim of this review is to provide an overview of the state-of-the-art in MRI-based image guidance for organ motion management in external beam radiotherapy. Methodological aspects of MRI for organ motion management are reviewed and their application in treatment planning, in-room guidance and adaptive radiotherapy described. Finally, a roadmap for an optimal use of MRI-guidance is highlighted and future challenges are discussed.
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Affiliation(s)
- C Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy. Author to whom any correspondence should be addressed. www.cartcas.polimi.it
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Retrospective evaluation of decision-making for pancreatic stereotactic MR-guided adaptive radiotherapy. Radiother Oncol 2018; 129:319-325. [DOI: 10.1016/j.radonc.2018.08.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/11/2018] [Accepted: 08/09/2018] [Indexed: 01/01/2023]
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Mostafaei F, Tai A, Omari E, Song Y, Christian J, Paulson E, Hall W, Erickson B, Li XA. Variations of MRI-assessed peristaltic motions during radiation therapy. PLoS One 2018; 13:e0205917. [PMID: 30359413 PMCID: PMC6201905 DOI: 10.1371/journal.pone.0205917] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/03/2018] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Understanding complex abdominal organ motion is essential for motion management in radiation therapy (RT) of abdominal tumors. This study investigates abdominal motion induced by respiration and peristalsis, during various time durations relevant to RT, using various CT and MRI techniques acquired under free breathing (FB) and breath hold (BH). METHODS A series of CT and MRI images acquired with various techniques under free breathing and/or breath hold from 37 randomly-selected pancreatic or liver cancer patients were analyzed to assess the motion in various time frames. These data include FB 4DCT from 15 patients (for motion in time duration of 5 sec), FB 2D cine-MRI from 4 patients (time duration of 1.7 min, 1 second acquisition time per slice), FB cine-MRI acquired using MR-Linac from 6 patients in various fractions (acquisition time is less than 0.6 seconds per slice), FB 4DMRI from 2 patients (time duration of 2 min), respiration-gated T2 with gating at the end expiration (time duration of 3-5 min), and BH T1 with multiphase dynamic contrast in acquisition times of 17 seconds for each of five phases (pre-contrast, arterial, venous, portal venous and delayed post-contrast) from 10 patients. Motions of various organs including gallbladder (GB) and liver were measured based on these MRI data. The GB motion includes both respiration and peristalsis, while liver motion is primarily respiration. By subtracting liver motion (respiration) from GB motion (respiration and peristalsis), the peristaltic motion, along with small residual motion, was obtained. RESULTS From cine-MRI, the residual motion beyond the respiratory motion was found to be up to 0.6 cm in superior-inferior (SI) and 0.55 cm in anterior-posterior (AP) directions. From 2D cine-MRI acquired by the MR-Linac, different peristaltic motions were found from different fractions for each patient. The peristaltic motion was found to vary between 0.3-1 cm. From BH T1 phase images, the average motions that were primarily due to peristalsis movements were found to be 1.2 cm in SI, 0.7 cm in AP, and 0.9 cm in left-right (LR) directions. The average motions assessed from 4DCT were 1.0 cm in SI and 0.3 cm in AP directions, which were generally smaller than the motions assessed from cine-MRI, i.e., 1.8 cm in SI and 0.6 cm in AP directions, for the same patients. However, average motions from 4DMRI, which are coming from respiratory were measured to be 1.5, 0.5, and 0.4 cm in SI, AP, and LR directions, respectively. CONCLUSION The abdominal motion due to peristalsis can be similar in magnitude to respiratory motion as assessed. These motions can be irregular and persistent throughout the imaging and RT delivery procedures, and should be considered together with respiratory motion during RT for abdominal tumors.
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Affiliation(s)
- Farshad Mostafaei
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Eenas Omari
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Yingqiu Song
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Union Hospital Cancer Center, Huazhong University of Science and Technology, Wuhan, China
| | - James Christian
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail:
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Stemkens B, Paulson ES, Tijssen RHN. Nuts and bolts of 4D-MRI for radiotherapy. ACTA ACUST UNITED AC 2018; 63:21TR01. [DOI: 10.1088/1361-6560/aae56d] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Comparison of four dimensional computed tomography and magnetic resonance imaging in abdominal radiotherapy planning. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 7:70-75. [PMID: 33458408 PMCID: PMC7807635 DOI: 10.1016/j.phro.2018.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 12/25/2022]
Abstract
Background and Purpose Four-dimensional (4D) computed tomography (CT) is widely used in radiotherapy (RT) planning and remains the current standard for motion evaluation. We assess a 4D magnetic resonance imaging (MRI) sequence in terms of motion and image quality in a phantom, healthy volunteers and patients undergoing RT. Materials and Methods The 4D-MRI sequence is a prototype T1-weighted 3D gradient echo with radial acquisition with self-gating. The accuracy of the 4D-MRI respiratory sorting based method was assessed using a MRI-CT compatible respiratory simulation phantom. In volunteers, abdominal viscera were evaluated for artefact, noise, structure delineation and overall image quality using a previously published four-point scoring system. In patients undergoing abdominal RT, the tumour (or a surrogate) was utilized to assess the range of motion on both 4D-CT and 4D-MRI. Furthermore, imaging quality was evaluated for both 4D-CT and 4D-MRI. Results In phantom studies 4D-MRI demonstrated amplitude of motion error of less than 0.2 mm for five, seven and ten bins. 4D-MRI provided excellent image quality for liver, kidney and pancreas. In patients, the median amplitude of motion seen on 4D-CT and 4D-MRI was 11.2 mm (range 2.8–20.3 mm) and 10.1 mm (range 0.7–20.7 mm) respectively. The median difference in amplitude between 4D-CT and 4D-MRI was −0.6 mm (range −3.4–5.2 mm). 4D-MRI demonstrated superior edge detection (median score 3 versus 1) and overall image quality (median score 2 versus 1) compared to 4D-CT. Conclusions The prototype 4D-MRI sequence demonstrated promising results and may be used in abdominal targeting, motion gating, and towards implementing MRI-based adaptive RT.
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