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Sarihan S, Tunc SG, Kahraman A, Irem ZK. Dosimetric comparison of free-breathing versus respiratory motion-managed radiotherapy via four-dimensional computed tomography-based volumetric-modulated arctherapy for lung cancer. Cancer Radiother 2023; 27:698-704. [PMID: 37925346 DOI: 10.1016/j.canrad.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/09/2022] [Accepted: 05/20/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE The aim of this study is to use respiratory motion-managed radiotherapy (RT) to reduce side effects and to compare dosimetric factors with free-breathing planning in patients with lung cancer. MATERIALS AND METHODS Simulation images were obtained in 10 respiratory phases with free breathing using four-dimensional computed tomography (4D-CT) scanner. Planning target volume (PTV) was created with 5mm margins in each direction of the internal target volume delineated using the maximum intensity projection. A volumetric arc treatment (VMAT) plan was created so that the prescribed dose would cover 98% of the PTV. Target volumes for the free-breathing VMAT plan were created according to ICRU Reports 62 and the same prescribed dose was used. RESULTS Patients were evaluated during January 2020. Median 63Gy (59.4-64) RT was administered. Median PTV volumes were 173.53 and 494.50cm3 (P=0.008) and dose covering 95% of PTV volume was 62.97 and 60.51Gy (P=0.13) in 4D-CT based and free-breathing VMAT plans, respectively. The mean and V50 heart dose was 6.03Gy (vs. 10.36Gy, P=0.043) and 8.2% (vs. 33.9%, P=0.007), and significantly lower in 4D-CT based VMAT plans and there was also found a non-significant reduction for other risky organ doses. CONCLUSION Ten patients treated with respiratory motion-managed RT with 4D-CT based VMAT technique. It was observed that PTV did not increase, the target was covered with 95% accuracy, and with statistical significance in heart doses, all risky organ doses were found to be less.
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Affiliation(s)
- S Sarihan
- Department of Radiation Oncology, Faculty of Medicine, Bursa Uludag University, 16059 Bursa, Turkey.
| | - S G Tunc
- Department of Radiation Oncology, Faculty of Medicine, Bursa Uludag University, 16059 Bursa, Turkey.
| | - A Kahraman
- Department of Radiation Oncology, Faculty of Medicine, Bursa Uludag University, 16059 Bursa, Turkey.
| | - Z K Irem
- Department of Radiation Oncology, Faculty of Medicine, Bursa Uludag University, 16059 Bursa, Turkey.
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Davey A, Thor M, van Herk M, Faivre-Finn C, Rimner A, Deasy JO, McWilliam A. Predicting cancer relapse following lung stereotactic radiotherapy: an external validation study using real-world evidence. Front Oncol 2023; 13:1156389. [PMID: 37503315 PMCID: PMC10369005 DOI: 10.3389/fonc.2023.1156389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Purpose For patients receiving lung stereotactic ablative radiotherapy (SABR), evidence suggests that high peritumor density predicts an increased risk of microscopic disease (MDE) and local-regional failure, but only if there is low or heterogenous incidental dose surrounding the tumor (GTV). A data-mining method (Cox-per-radius) has been developed to investigate this dose-density interaction. We apply the method to predict local relapse (LR) and regional failure (RF) in patients with non-small cell lung cancer. Methods 199 patients treated in a routine setting were collated from a single institution for training, and 76 patients from an external institution for validation. Three density metrics (mean, 90th percentile, standard deviation (SD)) were studied in 1mm annuli between 0.5cm inside and 2cm outside the GTV boundary. Dose SD and fraction of volume receiving less than 30Gy were studied in annuli 0.5-2cm outside the GTV to describe incidental MDE dosage. Heat-maps were created that correlate with changes in LR and RF rates due to the interaction between dose heterogeneity and density at each distance combination. Regions of significant improvement were studied in Cox proportional hazards models, and explored with and without re-fitting in external data. Correlations between the dose component of the interaction and common dose metrics were reported. Results Local relapse occurred at a rate of 6.5% in the training cohort, and 18% in the validation cohort, which included larger and more centrally located tumors. High peritumor density in combination with high dose variability (0.5 - 1.6cm) predicts LR. No interactions predicted RF. The LR interaction improved the predictive ability compared to using clinical variables alone (optimism-adjusted C-index; 0.82 vs 0.76). Re-fitting model coefficients in external data confirmed the importance of this interaction (C-index; 0.86 vs 0.76). Dose variability in the 0.5-1.6 cm annular region strongly correlates with heterogeneity inside the target volume (SD; ρ = 0.53 training, ρ = 0.65 validation). Conclusion In these real-world cohorts, the combination of relatively high peritumor density and high dose variability predicts increase in LR, but not RF, following lung SABR. This external validation justifies potential use of the model to increase low-dose CTV margins for high-risk patients.
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Affiliation(s)
- Angela Davey
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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Cui T, Zhang A, Cui J, Chen L, Chen G, Dai H, Qin X, Li G, Sun J. Feasibility of omitting the clinical target volume under PET-CT guidance in unresectable stage III non-small-cell lung cancer: A phase II clinical trial. Radiother Oncol 2023; 181:109505. [PMID: 36764460 DOI: 10.1016/j.radonc.2023.109505] [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: 09/26/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND This clinical trial aims at investigate the feasibility of CTV-omitted, positron-emission tomography computed tomography (PET-CT) combined with intensity-modulated radiation therapy (IMRT) for unresectable stage III NSCLC. METHODS AND MATERIALS This was a single-center, phase II clinical trial initiated in July 2016. Patients with unresectable stage III NSCLC undergoing routine IMRT were randomly enrolled into the study group (CTV-omitted under PET-CT guidance) and the control group (CTV-delineated). Patients received platinum-based dual-drug concurrent chemoradio therapy. In the study group, the PGTV dose was 60 Gy given in 30 daily 2 Gy fractions; in the control group, the PCTV dose was 54 Gy given in 30 daily 1.8 Gy fractions, and the PGTV dose was 60 Gy given in 30 daily 2 Gy fractions. The primary endpoint was the incidence of radiation respiratory events or esophagitis with grade 3 or higher. The secondary endpoints included objective response rate (ORR), locate control rate, progression-free survival (PFS), failure pattern and overall survival (OS). RESULTS A total of 90 patients were enrolled between July 2016 and March 2019. The incidence of radiation respiratory events or esophagitis with grade 3 or higher was 11.1 % in the study group, significantly lower than the rate of 28.9 % in the control group (P = 0.035), basically due to the reduced irradiated volumes of the lungs and esophagus in the study group. The median PFS was 9.0 months versus 10.0 months (P = 0.597), and the median OS 31.0 months versus 26.0 months (P = 0.489) in the study group and the control group, respectively. The failure pattern was not significantly different between the two groups (P = 0.826). CONCLUSION Omitting the CTV under PET-CT guidance has high feasibility to reduce severe radiation associated toxicity in IMRT for unresectable stage III NSCLC, without compromising the efficacy.
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Affiliation(s)
- Tianxiang Cui
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China.
| | - Anmei Zhang
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jianxiong Cui
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China; Department of Oncology, Sichuan Provincial Crops Hospital of Chinese People's Armed Police Forces, Leshan, China
| | - Lu Chen
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Guangpeng Chen
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hongya Dai
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xianli Qin
- Department of Nuclear Medicine, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Guanghui Li
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China.
| | - Jianguo Sun
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China.
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Yang K, Sun C, Yin R. Letter to the editor of radiotherapy and oncology regarding of the article "Dosimetric parameters related to occurrence of distant metastases and regional nodal relapse after SBRT for early-stage non-small cell lung cancer" by Lalonde et al. Radiother Oncol 2022; 177:240-241. [PMID: 35716839 DOI: 10.1016/j.radonc.2022.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Kaixuan Yang
- Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuntang Sun
- Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Rutie Yin
- Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China.
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Novel Harmonization Method for Multi-Centric Radiomic Studies in Non-Small Cell Lung Cancer. Curr Oncol 2022; 29:5179-5194. [PMID: 35892979 PMCID: PMC9332210 DOI: 10.3390/curroncol29080410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 01/06/2023] Open
Abstract
The purpose of this multi-centric work was to investigate the relationship between radiomic features extracted from pre-treatment computed tomography (CT), positron emission tomography (PET) imaging, and clinical outcomes for stereotactic body radiation therapy (SBRT) in early-stage non-small cell lung cancer (NSCLC). One-hundred and seventeen patients who received SBRT for early-stage NSCLC were retrospectively identified from seven Italian centers. The tumor was identified on pre-treatment free-breathing CT and PET images, from which we extracted 3004 quantitative radiomic features. The primary outcome was 24-month progression-free-survival (PFS) based on cancer recurrence (local/non-local) following SBRT. A harmonization technique was proposed for CT features considering lesion and contralateral healthy lung tissues using the LASSO algorithm as a feature selector. Models with harmonized CT features (B models) demonstrated better performances compared to the ones using only original CT features (C models). A linear support vector machine (SVM) with harmonized CT and PET features (A1 model) showed an area under the curve (AUC) of 0.77 (0.63–0.85) for predicting the primary outcome in an external validation cohort. The addition of clinical features did not enhance the model performance. This study provided the basis for validating our novel CT data harmonization strategy, involving delta radiomics. The harmonized radiomic models demonstrated the capability to properly predict patient prognosis.
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Falahatpour Z, Geramifar P, Mahdavi SR, Abdollahi H, Salimi Y, Nikoofar A, Ay MR. Potential advantages of FDG-PET radiomic feature map for target volume delineation in lung cancer radiotherapy. J Appl Clin Med Phys 2022; 23:e13696. [PMID: 35699200 PMCID: PMC9512354 DOI: 10.1002/acm2.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/20/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To investigate the potential benefits of FDG PET radiomic feature maps (RFMs) for target delineation in non-small cell lung cancer (NSCLC) radiotherapy. METHODS Thirty-two NSCLC patients undergoing FDG PET/CT imaging were included. For each patient, nine grey-level co-occurrence matrix (GLCM) RFMs were generated. gross target volume (GTV) and clinical target volume (CTV) were contoured on CT (GTVCT , CTVCT ), PET (GTVPET40 , CTVPET40 ), and RFMs (GTVRFM , CTVRFM ,). Intratumoral heterogeneity areas were segmented as GTVPET50-Boost and radiomic boost target volume (RTVBoost ) on PET and RFMs, respectively. GTVCT in homogenous tumors and GTVPET40 in heterogeneous tumors were considered as GTVgold standard (GTVGS ). One-way analysis of variance was conducted to determine the threshold that finds the best conformity for GTVRFM with GTVGS . Dice similarity coefficient (DSC) and mean absolute percent error (MAPE) were calculated. Linear regression analysis was employed to report the correlations between the gold standard and RFM-derived target volumes. RESULTS Entropy, contrast, and Haralick correlation (H-correlation) were selected for tumor segmentation. The threshold values of 80%, 50%, and 10% have the best conformity of GTVRFM-entropy , GTVRFM-contrast , and GTVRFM-H-correlation with GTVGS , respectively. The linear regression results showed a positive correlation between GTVGS and GTVRFM-entropy (r = 0.98, p < 0.001), between GTVGS and GTVRFM-contrast (r = 0.93, p < 0.001), and between GTVGS and GTVRFM-H-correlation (r = 0.91, p < 0.001). The average threshold values of 45% and 15% were resulted in the best segmentation matching between CTVRFM-entropy and CTVRFM-contrast with CTVGS , respectively. Moreover, we used RFM to determine RTVBoost in the heterogeneous tumors. Comparison of RTVBoost with GTVPET50-Boost MAPE showed the volume error differences of 31.7%, 36%, and 34.7% in RTVBoost-entropy , RTVBoost-contrast , and RTVBoost-H-correlation , respectively. CONCLUSIONS FDG PET-based radiomics features in NSCLC demonstrated a promising potential for decision support in radiotherapy, helping radiation oncologists delineate tumors and generate accurate segmentation for heterogeneous region of tumors.
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Affiliation(s)
- Zahra Falahatpour
- Department of Medical Physics, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Geramifar
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Rabie Mahdavi
- Department of Medical Physics, Faculty of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Abdollahi
- Department of Radiology Technology, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Yazdan Salimi
- Department of Biomedical Engineering and Medical Physics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Nikoofar
- Department of Radiation Oncology, Faculty of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ay
- Department of Medical Physics, Tehran University of Medical Sciences, Tehran, Iran
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Optimal Clinical Target Volume of Radiotherapy Based on Microscopic Extension around the Primary Gross Tumor in Non-Small-Cell Lung Cancer: A Systematic Review. Cancers (Basel) 2022; 14:cancers14092318. [PMID: 35565447 PMCID: PMC9103011 DOI: 10.3390/cancers14092318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 12/10/2022] Open
Abstract
A crucial issue in radical radiation therapy for non-small-cell lung cancer is how to define the clinical target volume (CTV). Although the scope of microscopic extension (ME) and microscopic proximal bronchial extension (PBE) from a primary tumor should be considered when defining the CTV, there has been limited research on ME and PBE. Therefore, we conducted this systematic review. The PubMed, ICHUSHI (Japanese database), and Cochrane Library databases were searched, and 816 articles were initially retrieved. After primary and secondary screenings, eight articles were ultimately selected. The results of this systematic review suggest the importance of a 0 mm margin in stereotactic radiotherapy for early-stage cancer and a 5–8 mm margin in curative irradiation for locally advanced cancer. Regarding PBE, this review yielded the conclusion that it is appropriate to consider the addition of an approximately 15 mm margin from the bronchial vasculature. Although there were few articles with a high level of evidence, this systematic review enabled us to collate results from previous studies and to provide recommendations, to some extent, regarding the CTV margin in the current clinical environment, where high-precision radiation therapy, such as image-guided radiotherapy and intensity-modulated radiotherapy, is predominant.
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Davey A, van Herk M, Faivre-Finn C, McWilliam A. Radial Data Mining to Identify Density-Dose Interactions That Predict Distant Failure Following SABR. Front Oncol 2022; 12:838155. [PMID: 35356210 PMCID: PMC8959483 DOI: 10.3389/fonc.2022.838155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Lower dose outside the planned treatment area in lung stereotactic radiotherapy has been linked to increased risk of distant metastasis (DM) possibly due to underdosage of microscopic disease (MDE). Independently, tumour density on pretreatment computed tomography (CT) has been linked to risk of MDE. No studies have investigated the interaction between imaging biomarkers and incidental dose. The interaction would showcase whether the impact of dose on outcome is dependent on imaging and, hence, if imaging could inform which patients require dose escalation outside the gross tumour volume (GTV). We propose an image-based data mining methodology to investigate density-dose interactions radially from the GTV to predict DM with no a priori assumption on location. Methods Dose and density were quantified in 1-mm annuli around the GTV for 199 patients with early-stage lung cancer treated with 60 Gy in 5 fractions. Each annulus was summarised by three density and three dose parameters. For parameter combinations, Cox regressions were performed including a dose-density interaction in independent annuli. Heatmaps were created that described improvement in DM prediction due to the interaction. Regions of significant improvement were identified and studied in overall outcome models. Results Dose-density interactions were identified that significantly improved prediction for over 50% of bootstrap resamples. Dose and density parameters were not significant when the interaction was omitted. Tumour density variance and high peritumour density were associated with DM for patients with more cold spots (less than 30-Gy EQD2) and non-uniform dose about 3 cm outside of the GTV. Associations identified were independent of the mean GTV dose. Conclusions Patients with high tumour variance and peritumour density have increased risk of DM if there is a low and non-uniform dose outside the GTV. The dose regions are independent of tumour dose, suggesting that incidental dose may play an important role in controlling occult disease. Understanding such interactions is key to identifying patients who will benefit from dose-escalation. The methodology presented allowed spatial dose-density interactions to be studied at the exploratory stage for the first time. This could accelerate the clinical implementation of imaging biomarkers by demonstrating the impact of incidental dose for tumours of varying characteristics in routine data.
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Affiliation(s)
- Angela Davey
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.,Department of Clinical Oncology, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
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Evaluation of Microscopic Tumour Extension in Localized Stage Non-Small-Cell Lung Cancer for Stereotactic Radiotherapy Planning. Cancers (Basel) 2022; 14:cancers14051282. [PMID: 35267589 PMCID: PMC8909894 DOI: 10.3390/cancers14051282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Stereotactic radiotherapy for localised stage non-small-cell lung carcinoma (NSCLC) is an alternative indication for patients who are inoperable or refuse surgery. A study showed that the microscopic tumour extension (ME) of NSCLC varied according to the histological type, which allowed us to deduce adapted margins for the clinical target volume (CTV). However, to date, no study has been able to define the most relevant margins for patients with stage 1 tumours. Methods: We performed a retrospective analysis including patients with adenocarcinoma (ADC) or squamous cell carcinoma (SCC) of localised stage T1N0 or T2aN0 who underwent surgery. The ME was measured from this boundary. The profile of the type of tumour spread was also evaluated. Results: The margin required to cover the ME of a localised NSCLC with a 95% probability is 4.4 mm and 2.9 mm for SCC and ADC, respectively. A significant difference in the maximum distance of the ME between the tumour-infiltrating lymphocytes (TILs), 0−10% and 50−90% (p < 0.05), was noted for SCC. There was a significant difference in the maximum ME distance based on whether the patient had chronic obstructive pulmonary disease (COPD) (p = 0.011) for ADC. Multivariate analysis showed a statistically significant relationship between the maximum microextension distance and size with the shrinkage coefficient. Conclusion: This study definitively demonstrated that the ME depends on the pathology subtype of NSCLC. According to International Commission on Radiation Units and Measurements (ICRU) reports, 50, 62 and 83 CTV margins, proposed by these results, should be added to the GTV (Gross tumour volume). When stereotactic body radiation therapy is used, this approach should be considered in conjunction with the dataset and other margins to be applied.
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Katz MS, Mihai A, Milano MT. A Dose of Reality: Embracing the Unseen to Improve Stereotactic Radiotherapy. Clin Oncol (R Coll Radiol) 2022; 34:395-397. [PMID: 35094939 DOI: 10.1016/j.clon.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- M S Katz
- Department of Radiation Medicine, Lowell General Hospital, Lowell, MA, USA.
| | - A Mihai
- Department of Radiation Oncology, Beacon Hospital, Sandyford, Dublin, Ireland
| | - M T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Falay O, Selçukbiricik F, Tanju S, Erus S, Kapdağli M, Cesur E, Yavuz Ö, Bulutay P, Firat P, Mandel NM, Dilege Ş. The prediction of spread through air spaces with preoperative 18F-FDG PET/CT in cases with primary lung adenocarcinoma, its effect on the decision for an adjuvant treatment and its prognostic role. Nucl Med Commun 2021; 42:922-927. [PMID: 33795612 DOI: 10.1097/mnm.0000000000001414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE In lung adenocarcinoma cases, 'spread through air spaces' (STAS) is a new indicator of invasion and directly related to disease survival. The aim of our study is to establish whether a preoperatively performed 18F-Fluorodeoxyglucose (FDG) PET/computed tomography (CT) imaging data can predict the presence of STAS in cases with lung adenocarcinoma and thus predict the decision for the type of surgery and adjuvant chemotherapy. MATERIALS AND METHODS Between 2000 and 2019, we retrospectively analyzed 63 patients with lung adenocarcinoma cases that had undergone lobectomy or pneumonectomy. Semiquantitative parameters were calculated and metabolic tumor volume (MTV)/CT volume (CTV) ratio was recorded from FDG PET/CT data. The pathological samples from these patients were evaluated for STAS. All these values were evaluated for their correlation with the alveolar spread. RESULTS There was no statistically significant correlation to be found between CTV, MTV, total lesion glycolysis (TLG), standardized uptake value (SUV)max, SUVmean and STAS (P > 0.05). However, MTV/CTV ratio above 1 had statistically more alveolar spread. In the group with an MTV ratio above 1, STAS positivity was 27 (75%), and 9 (25%) did not have STAS, whereas these were 6 (22.2%) patients who had STAS, and 21 (77.8%) did not have STAS in the group with below 1 (P < 0.001). CONCLUSIONS In the preoperative PET study inoperable lung adenocarcinoma cases, MTV/CTV ratio higher than 1 was found to predict STAS positivity. As a result, it was found that it provided significant clinical additional information regarding the need for a surgical approach (lobar resection instead of sublobar) and adjuvant chemotherapy.
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Affiliation(s)
| | | | - Serhan Tanju
- Department of General Thoracic Surgery, Koç University School of Medicine
| | - Suat Erus
- Department of General Thoracic Surgery, Koç University School of Medicine
| | - Murat Kapdağli
- Department of General Thoracic Surgery, VKF American Hospital
| | - Ezgi Cesur
- Department of General Thoracic Surgery, VKF American Hospital
| | - Ömer Yavuz
- Department of General Thoracic Surgery, Koç University School of Medicine
| | - Pinar Bulutay
- Department of Pathology, Koç University School of Medicine, Istanbul, Turkey
| | - Pinar Firat
- Department of Pathology, Koç University School of Medicine, Istanbul, Turkey
| | | | - Şükrü Dilege
- Department of General Thoracic Surgery, Koç University School of Medicine
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Meynard C, Mansuet-Lupo A, Giraud N, Boulle G, Imbault P, Guénégou-Arnoux A, Bobbio A, Durdux C, Damotte D, Giraud P. Size and Predictive Factors of Microscopic Tumor Extension in Locally Advanced Non-Small Cell Lung Cancer. Pract Radiat Oncol 2021; 11:491-501. [PMID: 34126295 DOI: 10.1016/j.prro.2021.05.006] [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: 12/28/2020] [Revised: 05/21/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation therapy for locally advanced non-small cell lung cancer (NSCLC) should treat the whole tumor, including its microscopic extensions, and protect adjacent organs at risk as much as possible. The aim of our study is to evaluate the size of microscopic tumor extension (MEmax) in NSCLC, and search for potential predictive factors. METHODS AND MATERIALS We retrospectively selected 70 patients treated with postoperative radiation therapy for a NSCLC with N2 nodal status, then 34 additional patients operated for a squamous cell lung cancer with N1 or N2 nodal status. On the digitized slides originating from the resected tumors of these 104 patients, we outlined the border of the tumor, as seen with the naked eye. We then searched for microscopic tumor extension outside of these borders with a magnification as high as 40 × and measured the maximum size of MEmax. RESULTS The median MEmax in the whole cohort was 0.85 mm (0-9.95). The MEmax was <5.3 mm in 95% of adenocarcinomas (6.5 mm in the subgroup without neoadjuvant chemotherapy) and <3.5 mm in 95% of squamous cell carcinomas (3.7 mm in the subgroup without neoadjuvant chemotherapy). After multivariate analysis, the factors associated with the size of MEmax were vascular invasion (P = .0002), histologic type, with a wider MEmax for adenocarcinomas in comparison with squamous cell carcinomas (P = .002), tumor size, which was inversely related with the size of MEmax (P = .024), and high blood pressure (P = .03). Macroscopic histologic tumor size was well correlated with both radiologic tumor size on a mediastinal setting computed tomography (correlation coefficient of 0.845) and on a parenchymal setting computed tomography (correlation coefficient of 0.836). CONCLUSIONS The clinical target volume margin, accounting for microscopic tumoral extension, could be reduced to 7 mm for adenocarcinomas and 4 mm for squamous cell carcinomas.
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Affiliation(s)
- Claire Meynard
- Radiation Oncology unit, Assistance Publique-Hôpitaux de Paris, Georges Pompidou European Hospital, Paris University, Paris, France.
| | - Audrey Mansuet-Lupo
- Department of Pathology, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Paris University, Paris, France; Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Nicolas Giraud
- Radiation Oncology Department, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | - Geoffroy Boulle
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Paul Imbault
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, Georges Pompidou European Hospital, Paris University, Paris, France
| | - Armelle Guénégou-Arnoux
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, Georges Pompidou European Hospital, Paris University, Paris, France; INSERM CIC1418-EC, Georges Pompidou European Hospital, Paris, France
| | - Antonio Bobbio
- Department of Thoracic Surgery, Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Paris University, Paris, France
| | - Catherine Durdux
- Radiation Oncology unit, Assistance Publique-Hôpitaux de Paris, Georges Pompidou European Hospital, Paris University, Paris, France
| | - Diane Damotte
- Department of Pathology, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Paris University, Paris, France; Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Philippe Giraud
- Radiation Oncology unit, Assistance Publique-Hôpitaux de Paris, Georges Pompidou European Hospital, Paris University, Paris, France
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Hughes RT, Steber CR, Jacobson TJ, Farris MK. Impact of dose to lung outside the planning target volume on distant metastasis or progression after SBRT for early-stage non-small cell lung cancer. Radiother Oncol 2021; 159:28-32. [PMID: 33711410 PMCID: PMC8292923 DOI: 10.1016/j.radonc.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/09/2021] [Accepted: 03/02/2021] [Indexed: 12/25/2022]
Abstract
Mean dose (EQD2) to 3-cm shell of lung surrounding the PTV was evaluated for association with distant metastasis and PFS after SBRT for stage I NSCLC. Dose was uniformly above previously determined threshold and metastasis was uncommon. An association between outcomes and mean EQD2 could not be confirmed or refuted.
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Affiliation(s)
- Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, United States.
| | - Cole R Steber
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, United States
| | - Travis J Jacobson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, United States
| | - Michael K Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, United States
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Nestle U, Le Pechoux C, De Ruysscher D. Evolving target volume concepts in locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1999-2010. [PMID: 34012809 PMCID: PMC8107754 DOI: 10.21037/tlcr-20-805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiotherapy (RT) target volume concepts for locally advanced lung cancer have been under discussion for years. Although they may be as important as treatment doses, many aspects of them are still based on conventions, which, due to the paucity of prospective data, rely on long-term practice or on clinical knowledge and experience (e.g., on patterns of spread or recurrence). However, in recent years, large improvements have been made in medical imaging and molecular imaging methods have been implemented, which are of great interest in RT. For lung cancer, in recent years, 18F-fluoro-desoxy-glucose (FDG)-positron-emission tomography (PET)/computed tomography (CT) has shown a superior diagnostic accuracy as compare to conventional imaging and has become an indispensable standard tool for diagnostic workup, staging and response assessment. This offers the chance to optimize target volume concepts in relation to modern imaging. While actual recommendations as the EORTC or ESTRO-ACROP guidelines already include imaging standards, the recently published PET-Plan trial prospectively investigated conventional versus imaging guided target volumes in relation to patient outcome. The results of this trial may help to further refine standards. The current review gives a practical overview on procedures for pre-treatment imaging and target volume delineation in locally advanced non-small cell lung cancer (NSCLC) in synopsis of the procedures established by the PET-Plan trial with the actual EORTC and ACROP guidelines.
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Affiliation(s)
- Ursula Nestle
- Department of Radiation Oncology, University of Freiburg, Medical Center Faculty of Medicine, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), Villejuif, France
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center+, GROW Research Institute, Maastricht, The Netherlands
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15
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Saha A, Beasley M, Hatton N, Dickinson P, Franks K, Clarke K, Jain P, Teo M, Murray P, Lilley J. Can dosimetry affect local control and survival in patients with early-stage lung cancer treated with Stereotactic Ablative Radiotherapy (SABR)? An analysis of the UK's largest cohort of lung SABR patients. Acta Oncol 2021; 60:505-512. [PMID: 33491521 DOI: 10.1080/0284186x.2021.1874617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE/OBJECTIVES A recent study has shown that tight conformity of lung Stereotactic Ablative Radiotherapy (SABR) plans might worsen loco-regional control and can predict distant metastases. The study aims to report overall survival (OS), progression-free survival (PFS), local recurrence free survival (LRFS), and dosimetry of early-stage lung cancer patients treated with SABR and to try to explore any dosimetric predictor of outcomes. MATERIAL AND METHODS Patients treated in our institute (May 2009-August 2018) were included. Electronic medical records were reviewed for baseline characteristics, treatment details, and outcomes. Dosimetric data were extracted from Xio and Monaco software. Patients were treated according to the United Kingdom (UK) SABR consortium guidelines. Kaplan-Meier's analysis with log-rank test was used for survival analysis. The univariate and multivariable Cox regression model was used for correlating dosimetric variables and outcomes. RESULTS We treated 1266 patients with median age of 75 years and 47.4% were male. Median follow up was 56 months. Median OS was 36 months with 1, 2, and 5 years OS of 84.2%, 64.5%, and 31.5%, respectively. Median for PFS and LRFS was not reached. One, 2, and 5 years PFS were 87.4%, 78.4%, and 72.5%, respectively. One, 2, and 5 years LRFS were 98.2%, 95.1%, and 92.5%, respectively. Planning target volume (PTV), dose to 99% volume of PTV (D99), and R50 (volume receiving the 50% dose/volume (PTV)) were significantly associated with OS. PTV, mean lung dose (MLD), V20 (volume of lung minus gross tumour volume (GTV) receiving 20 Gy), V12.5 (volume of lung minus GTV receiving 12.5 Gy), and dose fractionation were significantly associated with PFS. Nothing was associated with LRFS on univariate analysis. R100 of >1.1 was associated with better OS, PFS, and LRFS compared to R100 ≤ 1.1. CONCLUSION SABR achieves good clinical outcomes in patients with early-stage lung cancer; even in elderly patients with multiple comorbidities. In the largest UK early lung cancer cohort treated with SABR, we found that dosimetry correlates with clinical outcomes. Further validation of these results is needed to guide future optimisation of SABR delivery.
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Affiliation(s)
- Animesh Saha
- Department of Oncology, Apollo Gleneagles Cancer Hospital, Kolkata, India
| | - Matthew Beasley
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Nathaniel Hatton
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Peter Dickinson
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Kevin Franks
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Katy Clarke
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Pooja Jain
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Mark Teo
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - Patrick Murray
- Department of Oncology, Leeds Teaching Hospitals, NHS trust, Leeds, UK
| | - John Lilley
- Department of Medical Physics, Leeds Teaching Hospitals, NHS trust, Leeds, UK
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Tibdewal A, Patil M, Misra S, Purandare N, Rangarajan V, Mummudi N, Karimundackal G, Jiwnani S, Agarwal J. Optimal Standardized Uptake Value Threshold for Auto contouring of Gross Tumor Volume using Positron Emission Tomography/Computed Tomography in Patients with Operable Nonsmall-Cell Lung Cancer: Comparison with Pathological Tumor Size. Indian J Nucl Med 2021; 36:7-13. [PMID: 34040289 PMCID: PMC8130683 DOI: 10.4103/ijnm.ijnm_134_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose: Incorporating 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) for gross tumor volume (GTV) delineation is challenging due to varying tumor edge based on the set threshold of the standardized uptake value (SUV). This study aims to determine an optimal SUV threshold that correlates best with the pathological tumor size. Materials and Methods: From January 2013 to July 2014, 25 consecutive patients of operable nonsmall-cell lung cancer (NSCLC) who underwent staging18F-FDG-PET/CT before surgical resection were included in the test cohort and 12 patients in the validation cohort. GTVs were delineated on the staging PET/CT by automatic delineation using various percentage threshold of maximum SUV (SUVmax) and absolute SUV. The maximum pathological tumor diameter was then matched with the maximum auto-delineated tumor diameter with varying SUV thresholds. First-order linear regression and Bland–Altman plots were used to obtain an optimal SUV threshold for each patient. Three radiation oncologists with varying degrees of experiences also delineated GTVs with the visual aid of PET/CT to assess interobserver variation in delineation. Results: In the test set, the mean optimal percentage threshold for GTV was SUVmax of 35.6%±18.6% and absolute SUV of 4.35 ± 1.7. In the validation set, the mean optimal percentage threshold SUV and absolute SUV were 36.9 ± 16.9 and 4.1 ± 1.6, respectively. After a combined analysis of all 37 patients, the mean optimal threshold was 36% ± 17.9% and 4.27 ± 1.7, respectively. Using Bland–Altman plots, auto-contouring with 40% SUVmax and SUV 4 was in greater agreement with the pathological tumor diameter. Conclusion: Automatic GTV delineation on PETCT in NSCLC with percentage threshold SUV of 40% and absolute SUV of 4 correlated best with pathological tumor size. Auto-contouring using these thresholds will increase the precision of radiotherapy contouring of GTV and will save time.
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Affiliation(s)
- Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mangesh Patil
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shagun Misra
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nilendu Purandare
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Mummudi
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - George Karimundackal
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sabita Jiwnani
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jaiprakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Bortfeld T, Shusharina N, Craft D. Probabilistic definition of the clinical target volume-implications for tumor control probability modeling and optimization. Phys Med Biol 2021; 66:01NT01. [PMID: 33197905 DOI: 10.1088/1361-6560/abcad8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Evidence has been presented that moving beyond the binary definition of clinical target volume (CTV) towards a probabilistic CTV can result in better treatment plans. The probabilistic CTV takes the likelihood of disease spread outside of the gross tumor into account. An open question is: how to optimize tumor control probability (TCP) based on the probabilistic CTV. We derive expressions for TCP under the assumptions of voxel independence and dependence. For the dependent case, we make the assumption that tumors grow outward from the gross tumor volume. We maximize the (non-convex) TCP under convex dose constraints for all models. For small numbers of voxels, and when a dose-influence matrix is not used, we use exhaustive search or Lagrange multiplier theory to compute optimal dose distributions. For larger cases we present (1) a multi-start strategy using linear programming with a random cost vector to provide random feasible starting solutions, followed by a local search, and (2) a heuristic strategy that greedily selects which subvolumes to dose, and then for each subvolume assignment runs a convex approximation of the optimization problem. The optimal dose distributions are in general different for the independent and dependent models even though the probabilities of each voxel being tumorous are set to the same in both cases. We observe phase transitions, where a subvolume is either dosed to a high level, or it gets 'sacrificed' by not dosing it at all. The greedy strategy often yields solutions indistinguishable from the multi-start solutions, but for the 2D case involving organs-at-risk and the dependent TCP model, discrepancies of around 5% (absolute) for TCP are observed. For realistic geometries, although correlated voxels is a more reasonable assumption, the correlation function is in general unknown. We demonstrate a tractable heuristic that works very well for the independent models and reasonably well for the dependent models. All data are provided.
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Affiliation(s)
- Thomas Bortfeld
- Massachusetts General Hospital and Harvard Medical School, Department of Radiation Oncology, Division of Radiation Biophysics, 100 Blossom St, Boston, MA 02114, United States of America
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18
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Witte M, Pos F, Incrocci L, Heemsbergen W. Association between incidental dose outside the prostate and tumor control after modern image-guided radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 17:25-31. [PMID: 33898774 PMCID: PMC8057954 DOI: 10.1016/j.phro.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 01/06/2023]
Abstract
Background and purpose External beam radiotherapy for prostate cancer deposits incidental dose to a region surrounding the target volume. Previously, an association was identified between tumor control and incidental dose for patients treated with conventional radiotherapy. We investigated whether such an association exists for patients treated using intensity modulated radiotherapy (IMRT) and tighter margins. Materials and methods Computed tomography scans and three-dimensional treatment planning dose distributions were available from the Dutch randomized HYPRO trial for 397 patients in the standard fractionation arm (39 × 2 Gy) and 407 patients in the hypofractionation arm (19 × 3.4 Gy), mainly delivered using online image-guided IMRT. Endpoint was any treatment failure within 5 years. A mapping of 3D dose distributions between anatomies was performed based on distance to the surface of the prostate delineation. Mean mapped dose distributions were computed for patient groups with and without failure, obtaining dose difference distributions. Random patient permutations were performed to derive p values and to identify relevant regions. Results For high-risk patients treated in the conventional arm, higher incidental dose was significantly associated with a higher probability of tumor control in both univariate and multivariate analysis. The locations of the excess dose mainly overlapped with the position of obturator internus muscles at about 2.5 cm from the prostate surface. No such relationship could be established for intermediate-risk patients. Conclusions An association was established between reduced treatment failure and the delivery of incidental dose outside the prostate for high-risk patients treated using conventionally fractionated IMRT.
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Affiliation(s)
- Marnix Witte
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilma Heemsbergen
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
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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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20
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Diamant A, Heng VJ, Chatterjee A, Faria S, Bahig H, Filion E, Doucet R, Khosrow-Khavar F, Naqa IE, Seuntjens J. Comparing local control and distant metastasis in NSCLC patients between CyberKnife and conventional SBRT. Radiother Oncol 2020; 144:201-208. [PMID: 32044418 DOI: 10.1016/j.radonc.2020.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/01/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous literature suggests that the dose proximally outside the PTV could have an impact on the incidence of distant metastasis (DM) after SBRT in stage I NSCLC patients. We investigated this observation (along with local failure) in deliveries made by different treatment modalities: robotic mounted linac SBRT (CyberKnife) vs conventional SBRT (VMAT/CRT). MATERIALS AND METHODS This study included 422 stage I NSCLC patients from 2 institutions who received SBRT: 217 treated conventionally and 205 with CyberKnife. The dose behavior outside the PTV of both sub-cohorts were compared by analyzing the mean dose in continuous shells extending 1, 2, 3, …, 100 mm from the PTV. Kaplan-Meier analysis was performed between the two sub-cohorts with respect to DM-free survival and local progression-free survival. A multivariable Cox proportional hazards model was fitted to the combined cohort (n = 422) with respect to DM incidence and local failure. RESULTS The shell-averaged dose fall-off beyond the PTV was found to be significantly more modest in CyberKnife plans than in conventional SBRT plans. In a 30 mm shell around the PTV, the mean dose delivered with CyberKnife (38.1 Gy) is significantly larger than with VMAT/CRT (22.8 Gy, p<10-8). For 95% of CyberKnife plans, this region receives a mean dose larger than the 21 Gy threshold dose discovered in our previous study. In contrast, this occurs for only 75% of VMAT/CRT plans. The DM-free survival of the entire CyberKnife cohort is superior to that of the 25% of VMAT/CRT patients receiving less than the threshold dose (VMAT/CRT<21Gy), with a hazard ratio of 5.3 (95% CI: 3.0-9.3, p<10-8). The 2 year DM-free survival rates were 87% (95% CI: 81%-91%) and 44% (95% CI: 28%-58%) for CyberKnife and the below-threshold dose conventional cohorts, respectively. A multivariable analysis of the combined cohort resulted in the confirmation that threshold dose was a significant predictor of DM(HR = 0.28, 95% CI: 0.15-0.55, p<10-3) when adjusted for other clinical factors. CyberKnife was also found to be superior to the entire VMAT/CRT with respect to local control (HR = 3.44, CI: 1.6-7.3). The 2-year local progression-free survival rates for the CyberKnife cohort and the VMAT/CRT cohort were 96% (95% CI: 92%-98%) and 88% (95% CI: 82%-92%) respectively. CONCLUSIONS In standard-of-care CyberKnife treatments, dose distributions that aid distant control are achieved 95% of the time. Although similar doses could be physically achieved by conventional SBRT, this is not always the case with current prescription practices, resulting in worse DM outcomes for 25% of conventional SBRT patients. Furthermore, CyberKnife was found to provide superior local control compared to VMAT/CRT.
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Affiliation(s)
- André Diamant
- Medical Physics Unit, McGill University and Cedars Cancer Center, Montréal, Canada.
| | - Veng Jean Heng
- Medical Physics Unit, McGill University and Cedars Cancer Center, Montréal, Canada
| | - Avishek Chatterjee
- Medical Physics Unit, McGill University and Cedars Cancer Center, Montréal, Canada
| | - Sergio Faria
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Canada
| | - Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Canada
| | - Edith Filion
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Canada
| | - Robert Doucet
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Canada
| | | | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Jan Seuntjens
- Medical Physics Unit, McGill University and Cedars Cancer Center, Montréal, Canada
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Filice A, Casali M, Ciammella P, Galaverni M, Fioroni F, Iotti C, Versari A. Radiotherapy Planning and Molecular Imaging in Lung Cancer. Curr Radiopharm 2020; 13:204-217. [PMID: 32186275 PMCID: PMC8206193 DOI: 10.2174/1874471013666200318144154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/11/2019] [Accepted: 11/11/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients suitable for radical chemoradiotherapy for lung cancer, 18F-FDGPET/ CT is a proposed management to improve the accuracy of high dose radiotherapy. However, there is a high rate of locoregional failure in patients with locally advanced non-small cell lung cancer (NSCLC), probably due to the fact that standard dosing may not be effective in all patients. The aim of the present review was to address some criticisms associated with the radiotherapy image-guided in NSCLC. MATERIALS AND METHODS A systematic literature search was conducted. Only published articles that met the following criteria were included: articles, only original papers, radiopharmaceutical ([18F]FDG and any tracer other than [18F]FDG), target, only specific for lung cancer radiotherapy planning, and experimental design (eventually "in vitro" studies were excluded). Peer-reviewed indexed journals, regardless of publication status (published, ahead of print, in press, etc.) were included. Reviews, case reports, abstracts, editorials, poster presentations, and publications in languages other than English were excluded. The decision to include or exclude an article was made by consensus and any disagreement was resolved through discussion. RESULTS Hundred eligible full-text articles were assessed. Diverse information is now available in the literature about the role of FDG and new alternative radiopharmaceuticals for the planning of radiotherapy in NSCLC. In particular, the role of alternative technologies for the segmentation of FDG uptake is essential, although indeterminate for RT planning. The pros and cons of the available techniques have been extensively reported. CONCLUSION PET/CT has a central place in the planning of radiotherapy for lung cancer and, in particular, for NSCLC assuming a substantial role in the delineation of tumor volume. The development of new radiopharmaceuticals can help overcome the problems related to the disadvantage of FDG to accumulate also in activated inflammatory cells, thus improving tumor characterization and providing new prognostic biomarkers.
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Affiliation(s)
- Angelina Filice
- Address correspondence to this author at the Nuclear Medicine Unit, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; E-mail:
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Apolle R, Appold S, Bijl HP, Blanchard P, Bussink J, Faivre-Finn C, Khalifa J, Laprie A, Lievens Y, Madani I, Ruffier A, de Ruysscher D, van Elmpt W, Troost EGC. Inter-observer variability in target delineation increases during adaptive treatment of head-and-neck and lung cancer. Acta Oncol 2019; 58:1378-1385. [PMID: 31271079 DOI: 10.1080/0284186x.2019.1629017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Inter-observer variability (IOV) in target volume delineation is a well-documented source of geometric uncertainty in radiotherapy. Such variability has not yet been explored in the context of adaptive re-delineation based on imaging data acquired during treatment. We compared IOV in the pre- and mid-treatment setting using expert primary gross tumour volume (GTV) and clinical target volume (CTV) delineations in locoregionally advanced head-and-neck squamous cell carcinoma (HNSCC) and (non-)small cell lung cancer [(N)SCLC]. Material and methods: Five and six observers participated in the HNSCC and (N)SCLC arm, respectively, and provided delineations for five cases each. Imaging data consisted of CT studies partly complemented by FDG-PET and was provided in two separate phases for pre- and mid-treatment. Global delineation compatibility was assessed with a volume overlap metric (the Generalised Conformity Index), while local extremes of IOV were identified through the standard deviation of surface distances from observer delineations to a median consensus delineation. Details of delineation procedures, in particular, GTV to CTV expansion and adaptation strategies, were collected through a questionnaire. Results: Volume overlap analysis revealed a worsening of IOV in all but one case per disease site, which failed to reach significance in this small sample (p-value range .063-.125). Changes in agreement were propagated from GTV to CTV delineations, but correlation could not be formally demonstrated. Surface distance based analysis identified longitudinal target extent as a pervasive source of disagreement for HNSCC. High variability in (N)SCLC was often associated with tumours abutting consolidated lung tissue or potentially invading the mediastinum. Adaptation practices were variable between observers with fewer than half stating that they consistently adapted pre-treatment delineations during treatment. Conclusion: IOV in target volume delineation increases during treatment, where a disparity in institutional adaptation practices adds to the conventional causes of IOV. Consensus guidelines are urgently needed.
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Affiliation(s)
- Rudi Apolle
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Steffen Appold
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Henk P. Bijl
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corinne Faivre-Finn
- The Christie NHS Foundation Trust, Division of Cancer Science, The University of Manchester, Manchester, UK
| | - Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Anne Laprie
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Indira Madani
- Department of Radiation Oncology, University Hospital Zürich, Zürich, Switzerland
| | - Amandine Ruffier
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Dirk de Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Esther G. C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center DKFZ, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany
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Taasti VT, Jeong J, Jackson A, Deasy JO. A theoretical investigation of adequate range uncertainty margins in proton treatment planning to preserve tumor control probability. Acta Oncol 2019; 58:1446-1450. [PMID: 31241385 DOI: 10.1080/0284186x.2019.1627415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Proton dose distributions are sensitive to range uncertainties, resulting in margins added to ensure adequate tumor control probability (TCP). We investigated the required margin and dose shape needed to ensure adequate TCP, for representative tumor cell distributions in the clinical target volume (CTV). Material and methods: A mechanistic tumor response model, validated for lung tumors, was used to estimate TCP. The tumor cell distribution ( ρ ) was assumed to decrease exponentially in the CTV with decay parameter λ toward the outer border ( xCTVmax ). It was investigated if a gradual dose fall-off could reduce the dose to normal tissues outside the CTV, while achieving adequate TCP. For various values of xCTVmax and λ, we derived adequate uniform dose margins ( m ), coupled to linear dose fall-off regions ( Δx, Δxnom=Δx-0.9 cm), that ensured TCP>TCPlimit, while delivering the least mean dose outside the CTV. To account for variabilities in patients and tumor types, variable probabilities ( p ) of finding tumor cells in the non-GTV part of the CTV for a given patient were also tested. Dose from a single beam or two opposing beams was simulated under the influence of a typical stopping power ratio uncertainty of 3.5%. Results: For large λ and xCTVmax, a dose distribution with a shallower dose fall-off ( Δx>0 ) was advantageous, and m could be smaller than xCTVmax. In the case of small xCTVmax values, however, a conventional dose distribution ( Δx=0 ) would generally perform better. For no CTV, m=0.4 cm in the case of two opposing beams, while it was 0.7 cm for a single beam, however, for two opposing beams Δx=1.2 cm ( Δxnom=0.3 cm), while it was zero for a single beam. Conclusion: The details of the underlying cancer cell distribution characteristics do impact the adequate dose arrangements, and for opposing beams a non-conventional dose distribution shape is often advantageous.
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Affiliation(s)
- Vicki T. Taasti
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jeho Jeong
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Is tumour sphericity an important prognostic factor in patients with lung cancer? Radiother Oncol 2019; 143:73-80. [PMID: 31472998 DOI: 10.1016/j.radonc.2019.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/05/2019] [Accepted: 08/05/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Quantitative tumour shape features extracted from radiotherapy planning scans have shown potential as prognostic markers. In this study, we investigated if sphericity of the gross tumour volume (GTV) on planning computed tomography (CT) is an independent predictor of overall survival (OS) in lung cancer patients treated with standard radiotherapy. In the analysis, we considered whether tumour sphericity is correlated with clinical prognostic factors or influenced by the inclusion of lymph nodes in the GTV. MATERIALS AND METHODS Sphericity of single GTV delineation was extracted for 457 lung cancer patients. Relationships between sphericity, and common patient and tumour characteristics were investigated via correlation analysis and multivariate Cox regression to assess prognostic value of GTV sphericity. A subset analysis was performed for 290 nodal stage N0 patients to determine prognostic value of primary tumour sphericity. RESULTS Sphericity is correlated with clinical variables: tumour volume, mean lung dose, N stage, and T stage. Sphericity is strongly associated with OS (p < 0.001, hazard ratio (HR) (95% confidence interval (CI)) = 0.13 (0.04-0.41)) in univariate analysis. However, this association did not remain significant in multivariate analysis (p = 0.826, HR (95% CI) = 0.83 (0.16-4.31), and inclusion of sphericity to a clinical model did not improve model performance. In addition, no significant relationship between sphericity and OS was detected in univariate (p = 0.072) or multivariate (p = 0.920) analysis of N0 subset. CONCLUSION Sphericity correlates clearly with clinical prognostic factors, which are often unaccounted for in radiomic studies. Sphericity is also influenced by the presence of nodal involvement within the GTV contour.
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25
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Konert T, van de Kamer JB, Sonke JJ, Vogel WV. The developing role of FDG PET imaging for prognostication and radiotherapy target volume delineation in non-small cell lung cancer. J Thorac Dis 2018; 10:S2508-S2521. [PMID: 30206495 DOI: 10.21037/jtd.2018.07.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Advancements in functional imaging technology have allowed new possibilities in contouring of target volumes, monitoring therapy, and predicting treatment outcome in non-small cell lung cancer (NSCLC). Consequently, the role of 18F-fluorodeoxyglucose positron emission tomography (FDG PET) has expanded in the last decades from a stand-alone diagnostic tool to a versatile instrument integrated with computed tomography (CT), with a prominent role in lung cancer radiotherapy. This review outlines the most recent literature on developments in FDG PET imaging for prognostication and radiotherapy target volume delineation (TVD) in NSCLC. We also describe the challenges facing the clinical implementation of these developments and present new ideas for future research.
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Affiliation(s)
- Tom Konert
- Nuclear Medicine Department, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jeroen B van de Kamer
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Nuclear Medicine Department, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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26
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Shusharina N, Craft D, Chen YL, Shih H, Bortfeld T. The clinical target distribution: a probabilistic alternative to the clinical target volume. ACTA ACUST UNITED AC 2018; 63:155001. [DOI: 10.1088/1361-6560/aacfb4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Comparison of SUVmax and SUVpeak based segmentation to determine primary lung tumour volume on FDG PET-CT correlated with pathology data. Radiother Oncol 2018; 129:227-233. [PMID: 29983260 DOI: 10.1016/j.radonc.2018.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/06/2018] [Accepted: 06/20/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim of the study was to compare simple SUVmax and SUVpeak based segmentation methods for calculating the lung tumour volume, compared to a pathology ground truth. METHODS Thirty patients diagnosed with early stage Non-Small Cell lung cancer (NSCLC) underwent surgical resection in the Netherlands between 2006 and 2008. FDG PET-CT scans for these patients were acquired within a median of 20 days before surgery. The tumour volume for each percentage SUVmax and SUVpeak threshold, with and without background correction, was calculated for each patient. The percentage threshold that provided the tumour volume that corresponded best with the pathology volume was considered to be the optimal threshold. The optimal thresholds were plotted as a function of tumour volume using a power law function and cross validated using the leave-one-out technique. RESULTS The mean optimal percentage threshold was 50% ± 10% and 62% ± 15% for the SUVmax and SUVpeak without background correction respectively and 47% ± 10% and 60 ± 15% for the SUVmax and SUVpeak with background correction respectively. The optimal threshold curves could be fitted well with power law function. After cross validation the correlation between the effective tumour diameter in pathology and autosegmentation was 0.900 and 0.905 for the SUVmax and SUVpeak without background correction respectively and 0.913 and 0.908 for the SUVmax and SUVpeak with background correction respectively. CONCLUSION No benefit was shown on clinical data for the SUVpeak based segmentation method over a SUVmax based one. Both methods can be used to determine the tumour volumes in resected NSCLC tumours.
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Diamant A, Chatterjee A, Faria S, Naqa IE, Bahig H, Filion E, Robinson C, Al-Halabi H, Seuntjens J. Can dose outside the PTV influence the risk of distant metastases in stage I lung cancer patients treated with stereotactic body radiotherapy (SBRT)? Radiother Oncol 2018; 128:513-519. [PMID: 29801721 DOI: 10.1016/j.radonc.2018.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE In an era where little is known about the "abscopal" (out-of-the-field) effects of lung SBRT, we investigated correlations between the radiation dose proximally outside the PTV and the risk of cancer recurrence after SBRT in patients with primary stage I non-small cell lung cancer (NSCLC). MATERIALS AND METHODS This study included 217 stage I NSCLC patients across 2 institutions who received SBRT. Correlations between clinical and dosimetric factors were investigated. The clinical factors considered were distant metastasis (DM), loco-regional control (LRC) and radiation pneumonitis (RP). The dose (converted to EQD2) delivered to regions of varying size directly outside of the PTV was computed. For each feature, area under the curve (AUC) and odds ratios with respect to the outcome parameters DM, LRC and RP were estimated; Kaplan-Meier (KM) analysis was also performed. RESULTS Thirty-seven (17%) patients developed DM after a median follow-up of 24 months. It was found that the mean dose delivered to a shell-shaped region of thickness 30 mm outside the PTV had an AUC of 0.82. Two years after treatment completion, the rate of DM in patients where the mean dose delivered to this region was higher than 20.8 Gy2 was 5% compared to 60% in those who received a dose lower than 20.8 Gy2. KM analysis resulted in a hazard ratio of 24.2 (95% CI: 10.7, 54.4); p < 10-5. No correlations were found between any factor and either LRC or RP. CONCLUSIONS The results of this study suggest that the dose received by the region close to the PTV has a significant impact on the risk of distant metastases in stage I NSCLC patients treated with SBRT. If these results are independently confirmed, caution should be taken, particularly when a treatment plan results in a steep dose gradient extending outwards from the PTV.
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Affiliation(s)
- André Diamant
- Medical Physics Unit, McGill University Health Centre, Canada.
| | | | - Sergio Faria
- Department of Radiation Oncology, McGill University Health Centre, Canada
| | - Issam El Naqa
- Department of Radiation Oncology, Michigan University, United States
| | - Houda Bahig
- Département de Radio-oncologie, Centre Hospitalier de l'Université de Montréal, Canada
| | - Edith Filion
- Département de Radio-oncologie, Centre Hospitalier de l'Université de Montréal, Canada
| | - Cliff Robinson
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Hani Al-Halabi
- Department of Radiation Oncology, McGill University Health Centre, Canada
| | - Jan Seuntjens
- Medical Physics Unit, McGill University Health Centre, Canada
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29
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Lada MJ, Milano MT, Jones CE. Pulmonary metastectomy: impact of tumor histology and size. J Thorac Dis 2018; 10:644-647. [PMID: 29607129 DOI: 10.21037/jtd.2018.01.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michal J Lada
- Department of Surgery, University of Rochester, Rochester, NY 14642, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY 14642, USA
| | - Carolyn E Jones
- Department of Surgery, University of Rochester, Rochester, NY 14642, USA
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30
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Johnson C, Price G, Khalifa J, Faivre-Finn C, Dekker A, Moore C, van Herk M. A method to combine target volume data from 3D and 4D planned thoracic radiotherapy patient cohorts for machine learning applications. Radiother Oncol 2018; 126:355-361. [PMID: 29223683 DOI: 10.1016/j.radonc.2017.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/14/2017] [Accepted: 11/19/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE The gross tumour volume (GTV) is predictive of clinical outcome and consequently features in many machine-learned models. 4D-planning, however, has prompted substitution of the GTV with the internal gross target volume (iGTV). We present and validate a method to synthesise GTV data from the iGTV, allowing the combination of 3D and 4D planned patient cohorts for modelling. MATERIAL AND METHODS Expert delineations in 40 non-small cell lung cancer patients were used to develop linear fit and erosion methods to synthesise the GTV volume and shape. Quality was assessed using Dice Similarity Coefficients (DSC) and closest point measurements; by calculating dosimetric features; and by assessing the quality of random forest models built on patient populations with and without synthetic GTVs. RESULTS Volume estimates were within the magnitudes of inter-observer delineation variability. Shape comparisons produced mean DSCs of 0.8817 and 0.8584 for upper and lower lobe cases, respectively. A model trained on combined true and synthetic data performed significantly better than models trained on GTV alone, or combined GTV and iGTV data. CONCLUSIONS Accurate synthesis of GTV size from the iGTV permits the combination of lung cancer patient cohorts, facilitating machine learning applications in thoracic radiotherapy.
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Affiliation(s)
- Corinne Johnson
- Manchester Cancer Research Centre, Division of Molecular and Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, UK; The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK.
| | - Gareth Price
- Manchester Cancer Research Centre, Division of Molecular and Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, UK; The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK
| | - Jonathan Khalifa
- The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK; Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse - Oncopole, France
| | - Corinne Faivre-Finn
- Manchester Cancer Research Centre, Division of Molecular and Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, UK; The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK
| | - Andre Dekker
- The MAASTRO Clinic, Maastricht University Medical Centre+, The Netherlands
| | - Christopher Moore
- Manchester Cancer Research Centre, Division of Molecular and Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, UK; The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK
| | - Marcel van Herk
- Manchester Cancer Research Centre, Division of Molecular and Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, UK; The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK
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The potential for increased tumor control probability in non-small cell lung cancer with a hypofractionated integrated boost to the gross tumor volume. Med Dosim 2018; 43:352-357. [PMID: 29289456 DOI: 10.1016/j.meddos.2017.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/08/2017] [Accepted: 11/21/2017] [Indexed: 12/25/2022]
Abstract
Treatment outcomes in locally advanced non-small cell lung cancer (NSCLC) to date have been poor, with normal tissue toxicity often limiting the dose that can be delivered to the tumor. Treatment intensification in NSCLC via targeted dose escalation with modern delivery techniques may offer the potential for a significant increase in tumor control probability (TCP) without a clinically significant increase in organ-at-risk (OAR) toxicity. In this planning study, 20 patients were re-planned with a volumetric modulated arc therapy (VMAT) and an inhomogeneous dose distribution with iteratively escalated doses to the gross tumor volume (iGTV) (composite GTV across multiple 4-dimensional computed tomography [4DCT] phases) in a series of 20 fraction regimes. For each plan OAR doses, target coverage and predicted TCPs were collected and compared with homogenous 3-dimensional (3D) and VMAT plans, as well as with each other. In 70% of patients, it was possible to escalate to 75 Gy in 20 fractions within OAR tolerances, opening the possibility of treating these patients to a biological effective dose (BED) of 103.1 Gy10. This planning study forms the basis of a clinical trial INTENSE (Inhomogeneous Targeted Dose Escalation in Non-Small CEll Lung Cancer), CTRIAL 15-47.
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De Ruysscher D, Faivre-Finn C, Moeller D, Nestle U, Hurkmans CW, Le Péchoux C, Belderbos J, Guckenberger M, Senan S. European Organization for Research and Treatment of Cancer (EORTC) recommendations for planning and delivery of high-dose, high precision radiotherapy for lung cancer. Radiother Oncol 2017; 124:1-10. [PMID: 28666551 DOI: 10.1016/j.radonc.2017.06.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 04/25/2017] [Accepted: 06/05/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To update literature-based recommendations for techniques used in high-precision thoracic radiotherapy for lung cancer, in both routine practice and clinical trials. METHODS A literature search was performed to identify published articles that were considered clinically relevant and practical to use. Recommendations were categorised under the following headings: patient positioning and immobilisation, Tumour and nodal changes, CT and FDG-PET imaging, target volumes definition, radiotherapy treatment planning and treatment delivery. An adapted grading of evidence from the Infectious Disease Society of America, and for models the TRIPOD criteria, were used. RESULTS Recommendations were identified for each of the above categories. CONCLUSION Recommendations for the clinical implementation of high-precision conformal radiotherapy and stereotactic body radiotherapy for lung tumours were identified from the literature. Techniques that were considered investigational at present are highlighted.
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Affiliation(s)
- Dirk De Ruysscher
- Maastricht University Medical Center+, Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, The Netherlands; KU Leuven, Radiation Oncology, Belgium.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences University of Manchester, Christie NHS Foundation Trust, UK
| | - Ditte Moeller
- Aarhus University Hospital, Department of Oncology, Denmark
| | - Ursula Nestle
- Freiburg University Medical Center (DKTK partner site), Department of Radiation Oncology, Germany; Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Coen W Hurkmans
- Catharina Hospital, Department of Radiation Oncology, Eindhoven, The Netherlands
| | | | - José Belderbos
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | | | - Suresh Senan
- VU University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
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Hatt M, Lee JA, Schmidtlein CR, Naqa IE, Caldwell C, De Bernardi E, Lu W, Das S, Geets X, Gregoire V, Jeraj R, MacManus MP, Mawlawi OR, Nestle U, Pugachev AB, Schöder H, Shepherd T, Spezi E, Visvikis D, Zaidi H, Kirov AS. Classification and evaluation strategies of auto-segmentation approaches for PET: Report of AAPM task group No. 211. Med Phys 2017; 44:e1-e42. [PMID: 28120467 DOI: 10.1002/mp.12124] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 12/09/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The purpose of this educational report is to provide an overview of the present state-of-the-art PET auto-segmentation (PET-AS) algorithms and their respective validation, with an emphasis on providing the user with help in understanding the challenges and pitfalls associated with selecting and implementing a PET-AS algorithm for a particular application. APPROACH A brief description of the different types of PET-AS algorithms is provided using a classification based on method complexity and type. The advantages and the limitations of the current PET-AS algorithms are highlighted based on current publications and existing comparison studies. A review of the available image datasets and contour evaluation metrics in terms of their applicability for establishing a standardized evaluation of PET-AS algorithms is provided. The performance requirements for the algorithms and their dependence on the application, the radiotracer used and the evaluation criteria are described and discussed. Finally, a procedure for algorithm acceptance and implementation, as well as the complementary role of manual and auto-segmentation are addressed. FINDINGS A large number of PET-AS algorithms have been developed within the last 20 years. Many of the proposed algorithms are based on either fixed or adaptively selected thresholds. More recently, numerous papers have proposed the use of more advanced image analysis paradigms to perform semi-automated delineation of the PET images. However, the level of algorithm validation is variable and for most published algorithms is either insufficient or inconsistent which prevents recommending a single algorithm. This is compounded by the fact that realistic image configurations with low signal-to-noise ratios (SNR) and heterogeneous tracer distributions have rarely been used. Large variations in the evaluation methods used in the literature point to the need for a standardized evaluation protocol. CONCLUSIONS Available comparison studies suggest that PET-AS algorithms relying on advanced image analysis paradigms provide generally more accurate segmentation than approaches based on PET activity thresholds, particularly for realistic configurations. However, this may not be the case for simple shape lesions in situations with a narrower range of parameters, where simpler methods may also perform well. Recent algorithms which employ some type of consensus or automatic selection between several PET-AS methods have potential to overcome the limitations of the individual methods when appropriately trained. In either case, accuracy evaluation is required for each different PET scanner and scanning and image reconstruction protocol. For the simpler, less robust approaches, adaptation to scanning conditions, tumor type, and tumor location by optimization of parameters is necessary. The results from the method evaluation stage can be used to estimate the contouring uncertainty. All PET-AS contours should be critically verified by a physician. A standard test, i.e., a benchmark dedicated to evaluating both existing and future PET-AS algorithms needs to be designed, to aid clinicians in evaluating and selecting PET-AS algorithms and to establish performance limits for their acceptance for clinical use. The initial steps toward designing and building such a standard are undertaken by the task group members.
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Affiliation(s)
- Mathieu Hatt
- INSERM, UMR 1101, LaTIM, University of Brest, IBSAM, Brest, France
| | - John A Lee
- Université catholique de Louvain (IREC/MIRO) & FNRS, Brussels, 1200, Belgium
| | | | | | - Curtis Caldwell
- Sunnybrook Health Sciences Center, Toronto, ON, M4N 3M5, Canada
| | | | - Wei Lu
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Shiva Das
- University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Xavier Geets
- Université catholique de Louvain (IREC/MIRO) & FNRS, Brussels, 1200, Belgium
| | - Vincent Gregoire
- Université catholique de Louvain (IREC/MIRO) & FNRS, Brussels, 1200, Belgium
| | - Robert Jeraj
- University of Wisconsin, Madison, WI, 53705, USA
| | | | | | - Ursula Nestle
- Universitätsklinikum Freiburg, Freiburg, 79106, Germany
| | - Andrei B Pugachev
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Heiko Schöder
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | | | - Emiliano Spezi
- School of Engineering, Cardiff University, Cardiff, Wales, United Kingdom
| | | | - Habib Zaidi
- Geneva University Hospital, Geneva, CH-1211, Switzerland
| | - Assen S Kirov
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Apolle R, Rehm M, Bortfeld T, Baumann M, Troost EGC. The clinical target volume in lung, head-and-neck, and esophageal cancer: Lessons from pathological measurement and recurrence analysis. Clin Transl Radiat Oncol 2017; 3:1-8. [PMID: 29658006 PMCID: PMC5893525 DOI: 10.1016/j.ctro.2017.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy research has achieved remarkable progress in target volume definition. Advances in medical imaging facilitate more precise localization of the gross tumor volume, alongside a more detailed understanding of the geometric uncertainties associated with treatment delivery that has enabled robust safety margins to be customized to the specific treatment scenario at hand. By contrast, the clinical target volume, meant to encompass gross tumor, as well as, adjacent sub-clinical disease, has evolved very little. It is more often defined by clinician experience and institutional convention than on a patient-specific basis. This disparity arises from the inherent invisibility of sub-clinical disease in current medical imaging. Its incidence and expanse can only be ascertained via indirect means. This article reviews two such strategies: histopathological measurements on resection specimen and analyses of locoregional recurrences after radiotherapy.
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Affiliation(s)
- Rudi Apolle
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany
| | - Maximilian Rehm
- OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Baumann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Esther G C Troost
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
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Basaula D, Quinn A, Walker A, Batumalai V, Kumar S, Delaney GP, Holloway L. Risks and benefits of reducing target volume margins in breast tangent radiotherapy. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:305-315. [PMID: 28243923 DOI: 10.1007/s13246-017-0529-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 01/27/2017] [Indexed: 12/25/2022]
Abstract
This study investigates the potential benefits of planning target volume (PTV) margin reduction for whole breast radiotherapy in relation to dose received by organs at risk (OARs), as well as reductions in radiation-induced secondary cancer risk. Such benefits were compared to the increased radiation-induced secondary cancer risk attributed from increased ionizing radiation imaging doses. Ten retrospective patients' computed tomography datasets were considered. Three computerized treatment plans with varied PTV margins (0, 5 and 10 mm) were created for each patient complying with the Radiation Therapy Oncology Group (RTOG) 1005 protocol requirements. The BEIR VII lifetime attributable risk (LAR) model was used to estimate secondary cancer risk to OARs. The LAR was assessed for all treatment plans considering (a) doses from PTV margin variation and (b) doses from two (daily and weekly) kilovoltage cone beam computed tomography (kV CBCT) imaging protocols during the course of treatment. We found PTV margins from largest to smallest resulted in a mean OAR relative dose reduction of 31% (heart), 28% (lung) and 23% (contralateral breast) and the risk of radiation-induced secondary cancer by a relative 23% (contralateral breast) and 22% (contralateral lung). Daily image-guidance using kV CBCT increased the risk of radiation induced secondary cancer to the contralateral breast and contralateral lung by a relative 1.6-1.9% and 1.9-2.5% respectively. Despite the additional dose from kV CBCT for the two considered imaging protocols, smaller PTV margins would still result in an overall reduction in secondary cancer risk.
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Affiliation(s)
- Deepak Basaula
- Department of Medical Physics and Radiation Engineering, The Canberra Hospital, Garran, Australia. .,Ingham Institute of Applied Medical Research, Sydney, Australia.
| | - Alexandra Quinn
- Northern Sydney Cancer Therapy Centre, Royal North Shore Hospital, Sydney, Australia
| | - Amy Walker
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Vikneswary Batumalai
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Shivani Kumar
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Geoff P Delaney
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Lois Holloway
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia.,Institute of Medical Physics, University of Sydney, Sydney, Australia
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Vinod SK, Jameson MG, Min M, Holloway LC. Uncertainties in volume delineation in radiation oncology: A systematic review and recommendations for future studies. Radiother Oncol 2016; 121:169-179. [PMID: 27729166 DOI: 10.1016/j.radonc.2016.09.009] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/27/2016] [Accepted: 09/25/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Volume delineation is a well-recognised potential source of error in radiotherapy. Whilst it is important to quantify the degree of interobserver variability (IOV) in volume delineation, the resulting impact on dosimetry and clinical outcomes is a more relevant endpoint. We performed a literature review of studies evaluating IOV in target volume and organ-at-risk (OAR) delineation in order to analyse these with respect to the metrics used, reporting of dosimetric consequences, and use of statistical tests. METHODS AND MATERIALS Medline and Pubmed databases were queried for relevant articles using keywords. We included studies published in English between 2000 and 2014 with more than two observers. RESULTS 119 studies were identified covering all major tumour sites. CTV (n=47) and GTV (n=38) were most commonly contoured. Median number of participants and data sets were 7 (3-50) and 9 (1-132) respectively. There was considerable heterogeneity in the use of metrics and methods of analysis. Statistical analysis of results was reported in 68% (n=81) and dosimetric consequences in 21% (n=25) of studies. CONCLUSION There is a lack of consistency in conducting and reporting analyses from IOV studies. We suggest a framework to use for future studies evaluating IOV.
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Affiliation(s)
- Shalini K Vinod
- Cancer Therapy Centre, Liverpool Hospital, Australia; South Western Sydney Clinical School, University of New South Wales, Australia; Western Sydney University, Australia.
| | - Michael G Jameson
- Cancer Therapy Centre, Liverpool Hospital, Australia; Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia
| | - Myo Min
- Cancer Therapy Centre, Liverpool Hospital, Australia; South Western Sydney Clinical School, University of New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia
| | - Lois C Holloway
- Cancer Therapy Centre, Liverpool Hospital, Australia; South Western Sydney Clinical School, University of New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia
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Leeman JE, Rimner A, Montecalvo J, Hsu M, Zhang Z, von Reibnitz D, Panchoo K, Yorke E, Adusumilli PS, Travis W, Wu AJ. Histologic Subtype in Core Lung Biopsies of Early-Stage Lung Adenocarcinoma is a Prognostic Factor for Treatment Response and Failure Patterns After Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 97:138-145. [PMID: 27839909 DOI: 10.1016/j.ijrobp.2016.09.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/12/2016] [Accepted: 09/22/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) has emerged as an effective treatment for early-stage lung cancer. The histologic subtype of surgically resected lung adenocarcinoma is recognized as a prognostic factor, with the presence of solid or micropapillary patterns predicting poor outcomes. We describe the outcomes after SBRT for early-stage lung adenocarcinoma stratified by histologic subtype. METHODS AND MATERIALS We identified 119 consecutive patients (124 lesions) with stage I to IIA lung adenocarcinoma who had undergone definitive SBRT at our institution from August 2008 to August 2015 and had undergone core biopsy. Histologic subtyping was performed according to the 2015 World Health Organization classification. Of the 124 tumors, 37 (30%) were a high-risk subtype, defined as containing a component of solid and/or micropapillary pattern. The cumulative incidences of local, nodal, regional, and distant failure were compared between the high-risk and non-high-risk adenocarcinoma subtypes using Gray's test, and multivariable-adjusted hazard ratios (HRs) were estimated from propensity score-weighted Cox regression models. RESULTS The median follow-up for the entire cohort was 17 months and for surviving patients was 21 months. The 1-year cumulative incidence of and adjusted HR for local, nodal, regional, and distant failure in high-risk versus non-high-risk lesions was 7.3% versus 2.7% (HR 16.8; 95% confidence interval [CI] 3.5-81.4), 14.8% versus 2.6% (HR 3.8; 95% CI 0.95-15.0), 4.0% versus 1.2% (HR 20.9; 95% CI 2.3-192.3), and 22.7% versus 3.6% (HR 6.9; 95% CI 2.2-21.1), respectively. No significant difference was seen with regard to overall survival. CONCLUSIONS The outcomes after SBRT for early-stage adenocarcinoma of the lung correlate highly with histologic subtype, with micropapillary and solid tumors portending significantly higher rates of locoregional and metastatic progression. In this context, the histologic subtype determined from core biopsies is a prognostic factor and could have important implications for patient selection, adjuvant treatment, biopsy methods, and clinical trial design.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Montecalvo
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kelly Panchoo
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Prasad S Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Multiple training interventions significantly improve reproducibility of PET/CT-based lung cancer radiotherapy target volume delineation using an IAEA study protocol. Radiother Oncol 2016; 121:39-45. [PMID: 27663950 DOI: 10.1016/j.radonc.2016.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/01/2016] [Accepted: 09/04/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE To assess the impact of a standardized delineation protocol and training interventions on PET/CT-based target volume delineation (TVD) in NSCLC in a multicenter setting. MATERIAL AND METHODS Over a one-year period, 11 pairs, comprised each of a radiation oncologist and nuclear medicine physician with limited experience in PET/CT-based TVD for NSCLC from nine different countries took part in a training program through an International Atomic Energy Agency (IAEA) study (NCT02247713). Teams delineated gross tumor volume of the primary tumor, during and after training interventions, according to a provided delineation protocol. In-house developed software recorded the performed delineations, to allow visual inspection of strategies and to assess delineation accuracy. RESULTS Following the first training, overall concordance indices for 3 repetitive cases increased from 0.57±0.07 to 0.66±0.07. The overall mean surface distance between observer and expert contours decreased from -0.40±0.03cm to -0.01±0.33cm. After further training overall concordance indices for another 3 repetitive cases further increased from 0.64±0.06 to 0.80±0.05 (p=0.01). Mean surface distances decreased from -0.34±0.16cm to -0.05±0.20cm (p=0.01). CONCLUSION Multiple training interventions improve PET/CT-based TVD delineation accuracy in NSCLC and reduce interobserver variation.
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Impact of microscopic disease extension, extra-CTV tumour islets, incidental dose and dose conformity on tumour control probability. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2016; 39:493-500. [PMID: 27168065 DOI: 10.1007/s13246-016-0446-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
Abstract
The impact of microscopic disease extension (MDE), extra-CTV tumour islets (TIs), incidental dose and dose conformity on tumour control probability (TCP) is analyzed using insilico simulations in this study. MDE in the region in between GTV and CTV is simulated inclusive of geometric uncertainties (GE) using spherical targets and spherical dose distribution. To study the effect of incidental dose on TIs and the effect of dose-response curve (DRC) on tumour control, islets were randomly distributed and TCP was calculated for various dose levels by rescaling the dose. Further, the impact of dose conformity on required PTV margins is also studied. The required PTV margins are ~2 mm lesser than assuming a uniform clonogen density if an exponential clonogen density fall off in the GTV-CTV is assumed. However, margins are almost equal if GE is higher in both cases. This shows that GE has a profound impact on margins. The effect of TIs showed a bi-phasic relation with increasing dose, indicating that patients with islets not in the beam paths do not benefit from dose escalation. Increasing dose conformity is also found to have considerable effect on TCP loss especially for larger GE. Further, smaller margins in IGRT should be used with caution where uncertainty in CTV definition is of concern.
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40
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Kadota K, Nitadori JI, Sima CS, Ujiie H, Rizk NP, Jones DR, Adusumilli PS, Travis WD. Tumor Spread through Air Spaces is an Important Pattern of Invasion and Impacts the Frequency and Location of Recurrences after Limited Resection for Small Stage I Lung Adenocarcinomas. J Thorac Oncol 2016; 10:806-814. [PMID: 25629637 DOI: 10.1097/jto.0000000000000486] [Citation(s) in RCA: 399] [Impact Index Per Article: 49.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Tumor invasion in lung adenocarcinoma is defined as infiltration of stroma, blood vessels, or pleura. Based on observation of tumor spread through air spaces (STAS), we considered whether this could represent new patterns of invasion and investigated whether it correlated with locoregional versus distant recurrence according to limited resection versus lobectomy. METHODS We reviewed resected small (less than or equal to 2 cm) stage I lung adenocarcinomas (n = 411; 1995-2006). Tumor STAS was defined as tumor cells-micropapillary structures, solid nests, or single cells-spreading within air spaces in the lung parenchyma beyond the edge of the main tumor. Competing risks methods were used to estimate risk of disease recurrence and its associations with clinicopathological risk factors. RESULTS STAS was observed in 155 cases (38%). In the limited resection group (n = 120), the risk of any recurrence was significantly higher in patients with STAS-positive tumors than that of patients with STAS-negative tumors (5-year cumulative incidence of recurrence, 42.6% versus 10.9%; P < 0.001); the presence of STAS correlated with higher risk of distant (P = 0.035) and locoregional recurrence (P = 0.001). However, in the lobectomy group (n = 291), the presence of STAS was not associated with either any (P = 0.50) or distant recurrence (P = 0.76). In a multivariate analysis, the presence of tumor STAS remained independently associated with the risk of developing recurrence (hazard ratio, 3.08; P = 0.014). CONCLUSION The presence of STAS is a significant risk factor of recurrence in small lung adenocarcinomas treated with limited resection. These findings support our proposal that STAS should formally be recognized as a pattern of invasion in lung adenocarcinoma.
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Affiliation(s)
- Kyuichi Kadota
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY; Faculty of Medicine, Department of Diagnostic Pathology, Kagawa University, Kagawa, Japan
| | - Jun-Ichi Nitadori
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Thoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Camelia S Sima
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hideki Ujiie
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nabil P Rizk
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY.
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Bains S, Adusumilli PS. Is spread through alveolar spaces, the newly recognized pattern of invasion, a potential game changer in lung adenocarcinoma? ANNALS OF TRANSLATIONAL MEDICINE 2016; 3:350. [PMID: 26807405 DOI: 10.3978/j.issn.2305-5839.2015.09.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarina Bains
- Thoracic Service, Department of Surgery, Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kilburn JM, Lucas JT, Soike MH, Ayala-Peacock DN, Blackstock AW, Hinson WH, Munley MT, Petty WJ, Urbanic JJ. Is a Clinical Target Volume (CTV) Necessary in the Treatment of Lung Cancer in the Modern Era Combining 4-D Imaging and Image-guided Radiotherapy (IGRT)? Cureus 2016; 8:e466. [PMID: 26929893 PMCID: PMC4764420 DOI: 10.7759/cureus.466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: We hypothesized that omission of clinical target volumes (CTV) in lung cancer radiotherapy would not compromise control by determining retrospectively if the addition of a CTV would encompass the site of failure. Methods: Stage II-III patients were treated from 2009-2012 with daily cone-beam imaging and a 5 mm planning target volume (PTV) without a CTV. PTVs were expanded 1 cm and termed CTVretro. Recurrences were scored as 1) within the PTV, 2) within CTVretro, or 3) outside the PTV. Locoregional control (LRC), distant control (DC), progression-free survival (PFS), and overall survival (OS) were estimated. Result: Among 110 patients, Stage IIIA 57%, IIIB 32%, IIA 4%, and IIB 7%. Eighty-six percent of Stage III patients received chemotherapy. Median dose was 70 Gy (45-74 Gy) and fraction size ranged from 1.5-2.7 Gy. Median follow-up was 12 months, median OS was 22 months (95% CI 19-30 months), and LRC at two years was 69%. Fourteen local and eight regional events were scored with two CTVretro failures equating to a two-year CTV failure-free survival of 98%. Conclusion: Omission of a 1 cm CTV expansion appears feasible based on only two events among 110 patients and should be considered in radiation planning.
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Affiliation(s)
| | - John T Lucas
- Radiation Oncology, Wake Forest School of Medicine
| | | | | | | | | | | | - William J Petty
- Medicine, Division of Hematology/Oncology, Wake Forest School of Medicine
| | - James J Urbanic
- Radiation Medicine and Applied Sciences, UCSD School of Medicine
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PET/CT imaging for target volume delineation in curative intent radiotherapy of non-small cell lung cancer: IAEA consensus report 2014. Radiother Oncol 2015; 116:27-34. [PMID: 25869338 DOI: 10.1016/j.radonc.2015.03.014] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/09/2015] [Accepted: 03/15/2015] [Indexed: 12/20/2022]
Abstract
This document describes best practice and evidence based recommendations for the use of FDG-PET/CT for the purposes of radiotherapy target volume delineation (TVD) for curative intent treatment of non-small cell lung cancer (NSCLC). These recommendations have been written by an expert advisory group, convened by the International Atomic Energy Agency (IAEA) to facilitate a Coordinated Research Project (CRP) aiming to improve the applications of PET based radiation treatment planning (RTP) in low and middle income countries. These guidelines can be applied in routine clinical practice of radiotherapy TVD, for NSCLC patients treated with concurrent chemoradiation or radiotherapy alone, where FDG is used, and where a calibrated PET camera system equipped for RTP patient positioning is available. Recommendations are provided for PET and CT image visualization and interpretation, and for tumor delineation using planning CT with and without breathing motion compensation.
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Peulen H, Belderbos J, Guckenberger M, Hope A, Grills I, van Herk M, Sonke JJ. Target delineation variability and corresponding margins of peripheral early stage NSCLC treated with stereotactic body radiotherapy. Radiother Oncol 2015; 114:361-6. [DOI: 10.1016/j.radonc.2015.02.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/12/2015] [Accepted: 02/15/2015] [Indexed: 11/29/2022]
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Depuydt T, Poels K, Verellen D, Engels B, Collen C, Buleteanu M, Van den Begin R, Boussaer M, Duchateau M, Gevaert T, Storme G, De Ridder M. Treating patients with real-time tumor tracking using the Vero gimbaled linac system: implementation and first review. Radiother Oncol 2014; 112:343-51. [PMID: 25049177 DOI: 10.1016/j.radonc.2014.05.017] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 05/14/2014] [Accepted: 05/24/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE To report on the first clinical application of a real-time tumor tracking (RTTT) solution based on the Vero SBRT gimbaled linac system for treatment of moving tumors. METHODS AND MATERIALS A first group of 10 SBRT patients diagnosed with NSCLC or oligometastatic disease in lung or liver was treated with the RTTT technique. The PTV volumes and OAR exposure were benchmarked against the widely used ITV approach. Based on data acquired during execution of RTTT treatments, a first review was performed of the process. RESULTS The 35% PTV volume reduction with RTTT of the studied single lesions SBRT irradiations of small target volumes is expected to result in a small (<1%) reduction of lung or liver NTCP. A GTV-PTV margin of 5.0mm was applied for treatment planning of RTTT. From patient data on residual geometric uncertainties, a CTV-PTV margin of 3.2mm was calculated. Reduction of the GTV-PTV margin below 5.0mm without better understanding of biological definition of tumor boundaries was discouraged. Total treatment times were reduced to 34.4 min on average. CONCLUSION A considerable PTV volume reduction was achieved applying RTTT and time efficiency for respiratory correlated SBRT was reestablished with Vero RTTT.
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Affiliation(s)
- Tom Depuydt
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels; Vrije Universiteit Brussel, Medical Imaging and Physical Sciences Group, Faculty of Medicine and Pharmacy; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - Kenneth Poels
- Vrije Universiteit Brussel, Medical Imaging and Physical Sciences Group, Faculty of Medicine and Pharmacy
| | - Dirk Verellen
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels; Vrije Universiteit Brussel, Medical Imaging and Physical Sciences Group, Faculty of Medicine and Pharmacy
| | - Benedikt Engels
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | - Christine Collen
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | - Manuela Buleteanu
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | | | - Marlies Boussaer
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | - Michael Duchateau
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | - Thierry Gevaert
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels
| | - Guy Storme
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels; Vrije Universiteit Brussel, Medical Imaging and Physical Sciences Group, Faculty of Medicine and Pharmacy
| | - Mark De Ridder
- Radiotherapy Department, UZ Brussel, Vrije Universiteit Brussel, Brussels; Vrije Universiteit Brussel, Medical Imaging and Physical Sciences Group, Faculty of Medicine and Pharmacy
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47
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van Elmpt W, Zegers CML, Das M, De Ruysscher D. Imaging techniques for tumour delineation and heterogeneity quantification of lung cancer: overview of current possibilities. J Thorac Dis 2014; 6:319-27. [PMID: 24688776 DOI: 10.3978/j.issn.2072-1439.2013.08.62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/21/2013] [Indexed: 01/05/2023]
Abstract
Imaging techniques for the characterization and delineation of primary lung tumours and lymph nodes are a prerequisite for adequate radiotherapy. Numerous imaging modalities have been proposed for this purpose, but only computed tomography (CT) and FDG-PET have been implemented in clinical routine. Hypoxia PET, dynamic contrast-enhanced CT (DCE-CT), dual energy CT (DECT) and (functional) magnetic resonance imaging (MRI) hold promise for the future. Besides information on the primary tumour, these techniques can be used for quantification of tissue heterogeneity and response. In the future, treatment strategies may be designed which are based on imaging techniques to optimize individual treatment.
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Affiliation(s)
- Wouter van Elmpt
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Catharina M L Zegers
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Marco Das
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Dirk De Ruysscher
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
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Dubray B, Thureau S, Nkhali L, Modzelewski R, Doyeux K, Ruan S, Vera P. FDG-PET imaging for radiotherapy target volume definition in lung cancer. Ing Rech Biomed 2014. [DOI: 10.1016/j.irbm.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18F-Deoxyglucose Uptake in Stage I Non–Small-Cell Lung Cancer: Time to Move to Randomized Trials. J Thorac Oncol 2014; 9:5-6. [DOI: 10.1097/jto.0000000000000059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Combined recipe for clinical target volume and planning target volume margins. Int J Radiat Oncol Biol Phys 2013; 88:708-14. [PMID: 24113058 DOI: 10.1016/j.ijrobp.2013.08.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/24/2013] [Accepted: 08/23/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE To develop a combined recipe for clinical target volume (CTV) and planning target volume (PTV) margins. METHODS AND MATERIALS A widely accepted PTV margin recipe is M(geo) = aΣ(geo) + bσ(geo), with Σ(geo) and σ(geo) standard deviations (SDs) representing systematic and random geometric uncertainties, respectively. On the basis of histopathology data of breast and lung tumors, we suggest describing the distribution of microscopic islets around the gross tumor volume (GTV) by a half-Gaussian with SD Σ(micro), yielding as possible CTV margin recipe: M(micro) = ƒ(N(i)) × Σ(micro), with N(i) the average number of microscopic islets per patient. To determine ƒ(N(i)), a computer model was developed that simulated radiation therapy of a spherical GTV with isotropic distribution of microscopic disease in a large group of virtual patients. The minimal margin that yielded D(min) <95% in maximally 10% of patients was calculated for various Σ(micro) and N(i). Because Σ(micro) is independent of Σ(geo), we propose they should be added quadratically, yielding for a combined GTV-to-PTV margin recipe: M(GTV-PTV) = √{[aΣ(geo)](2) + [ƒ(N(i))Σ(micro)](2)} + bσ(geo). This was validated by the computer model through numerous simultaneous simulations of microscopic and geometric uncertainties. RESULTS The margin factor ƒ(N(i)) in a relevant range of Σ(micro) and N(i) can be given by: ƒ(N(i)) = 1.4 + 0.8log(N(i)). Filling in the other factors found in our simulations (a = 2.1 and b = 0.8) yields for the combined recipe: M(GTV-PTV) = √({2.1Σ(geo)}(2) + {[1.4 + 0.8log(N(i))] × Σ(micro)}(2)) + 0.8σ(geo). The average margin difference between the simultaneous simulations and the above recipe was 0.2 ± 0.8 mm (1 SD). Calculating M(geo) and M(micro) separately and adding them linearly overestimated PTVs by on average 5 mm. Margin recipes based on tumor control probability (TCP) instead of D(min) criteria yielded similar results. CONCLUSIONS A general recipe for GTV-to-PTV margins is proposed, which shows that CTV and PTV margins should be added in quadrature instead of linearly.
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