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Clough A, Pitt E, Nelder C, Benson R, McDaid L, Whiteside L, Davies L, Bridge J, Freear L, Chuter R, Berresford J, McPartlin A, Crockett C, Cobben D, Salem A, Faivre-Finn C, Huddart R, Eccles CL. Simultaneous implementation of unrelated tumour sites on the MR Linac: A review of the commissioning process from a radiographer perspective and lessons learned. J Med Imaging Radiat Sci 2024; 55:101728. [PMID: 39153404 DOI: 10.1016/j.jmir.2024.101728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/29/2024] [Accepted: 07/10/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION This work reports on a systematic approach to select MRI sequences, quantify inter-observer image registration variation and determine patient positioning for the clinical implementation of MR-guided adaptive radiotherapy (MRgRT) in patients with oropharyngeal (H&N) and lung cancer. METHODS A total of 30 participants (N=10 H&N and N=10 lung cancer patients and N=10 healthy participants) were scanned on the Elekta Unity Magnetic Resonance Linear Accelerator (MRL). Participant experience questionnaires were used to determine the most appropriate positioning device for lung treatments and tolerability of H&N immobilization devices within the confined MR Linac environment. Visual guided assessments (VGAs) completed by three observers (one oncologist and two radiographers) were used to determine the most suitable tissue weighting (using vendor-provided 3D T1w and T2w sequences) for online image registration. Offline MRI to CT and MRI to MRI rigid registrations were undertaken by nine radiographers using bony and soft tissue matching. Single-factor ANOVA and paired t-tests were utilized to determine the interobserver variation. RESULTS Based on oncologist and patient feedback, lung cancer patients would be treated in a vac-bag with their arms by their sides, while H&N cancer patients would be immobilized using a 5-point fixation device and 5-point personalized thermoplastic shell. There was no clear preference for T1w or T2w images in the H&N cohort. However, observers preferred T2w sequences for tumour and organ at risk (OAR) visualization in the lung images. When a bony match was conducted, single-factor ANOVA tests showed no statistically significant differences between all H&N image registration types (p=0.09). For the soft-tissue registrations, T1w-CT and T1w-T1w registrations showed a statistically significant (p=0.01) reduction in inter-observer variability over T2w-CT registrations. Paired t-tests showed no statistically significant differences for bony or soft tissue matches using T1w or T2w sequences to the planning CT in the lung cohorts (p=0.63 and p=0.52, respectively). CONCLUSION We describe the systematic approach to the selection of strategies for imaging, immobilization, and online image registration we used for H&N and lung cancer treatments on the MRL. This has facilitated the selection of the most appropriate adaptive MRgRT strategies for treating these sites at our institution.
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Affiliation(s)
- A Clough
- The Christie NHSFT, Manchester, United Kingdom
| | - E Pitt
- The Christie NHSFT, Manchester, United Kingdom
| | - C Nelder
- The Christie NHSFT, Manchester, United Kingdom
| | - R Benson
- The Christie NHSFT, Manchester, United Kingdom
| | - L McDaid
- The Christie NHSFT, Manchester, United Kingdom
| | - L Whiteside
- The Christie NHSFT, Manchester, United Kingdom
| | - L Davies
- The Christie NHSFT, Manchester, United Kingdom
| | - J Bridge
- The Christie NHSFT, Manchester, United Kingdom
| | - L Freear
- The Christie NHSFT, Manchester, United Kingdom
| | - R Chuter
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | | | - A McPartlin
- The Christie NHSFT, Manchester, United Kingdom
| | - C Crockett
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - D Cobben
- Clatterbridge Cancer Centre, Department of Clinical Oncology; Department of Health Data Science, Institute of Population Health, University of Liverpool
| | - A Salem
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - C Faivre-Finn
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - R Huddart
- The Royal Marsden NHSFT, London, United Kingdom; The Institute for Cancer Research
| | - C L Eccles
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
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Musa J, Parvinian A, Huber N, Ferrero A, Favazza C, Kurup A, Atwell T. Conventional and spectral- CT for renal cell carcinoma thermal ablation: A case report. Radiol Case Rep 2024; 19:3517-3521. [PMID: 38881625 PMCID: PMC11179570 DOI: 10.1016/j.radcr.2024.05.024] [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: 01/10/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/18/2024] Open
Abstract
Dual-energy or spectral computed tomography (CT) information may be obtained by either sending X-ray beams of different energy spectra through the patient or by discriminating the energy of the X-rays that reach the detector. The spectral signal is then used to generate multiple results: conventional, virtual monoenergetic (MonoE), effective atomic number, electron density, and other material specific (e.g., iodine, calcium, or uric acid). This report demonstrates the potential benefits of spectral CT imaging during percutaneous tumor ablation procedures, specifically regarding visualization of inconspicuous tumors, accurate probe placement, and assessment of treatment efficacy.
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Affiliation(s)
- Juna Musa
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Andrea Ferrero
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Anil Kurup
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Thomas Atwell
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Leech M, Abdalqader A, Alexander S, Anderson N, Barbosa B, Callens D, Chapman V, Coffey M, Cox M, Curic I, Dean J, Denney E, Kearney M, Leung VW, Mortsiefer M, Nirgianaki E, Povilaitis J, Strikou D, Thompson K, van den Bosch M, Velec M, Woodford K, Buijs M. The Radiation Therapist profession through the lens of new technology: A practice development paper based on the ESTRO Radiation Therapist Workshops. Tech Innov Patient Support Radiat Oncol 2024; 30:100243. [PMID: 38831996 PMCID: PMC11145757 DOI: 10.1016/j.tipsro.2024.100243] [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: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 06/05/2024] Open
Abstract
Technological advances in radiation therapy impact on the role and scope of practice of the radiation therapist. The European Society of Radiotherapy and Oncology (ESTRO) recently held two workshops on this topic and this position paper reflects the outcome of this workshop, which included radiation therapists from all global regions. Workflows, quality assurance, research, IGRT and ART as well as clinical decision making are the areas of radiation therapist practice that will be highly influenced by advancing technology in the near future. This position paper captures the opportunities that this will bring to the radiation therapist profession, to the practice of radiation therapy and ultimately to patient care.
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Affiliation(s)
- Michelle Leech
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Ireland
- Trinity St. James’s Cancer Institute, Dublin, Ireland
| | | | - Sophie Alexander
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, United Kingdom
| | - Nigel Anderson
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre - Austin Health, Heidelberg, Australia
| | - Barbara Barbosa
- Escola Internacional de Doutoramento, Universidad de Vigo, Spain
- Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center (CI-IPOP), Porto Comprehensive Cancer Center (Porto.CCC) & Rise@CI-IPOP (Health Research Network), Porto, Portugal
| | - Dylan Callens
- University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium
- KU Leuven, Laboratory of Experimental Radiotherapy, Leuven, Belgium
| | | | - Mary Coffey
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Ireland
| | - Maya Cox
- Auckland City Hospital, Auckland, New Zealand
| | - Ilija Curic
- Radiosurgery and Stereotactic Radiotherapy Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jenna Dean
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre - Austin Health, Heidelberg, Australia
| | | | - Maeve Kearney
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Ireland
- Trinity St. James’s Cancer Institute, Dublin, Ireland
| | - Vincent W.S. Leung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong
| | | | | | - Justas Povilaitis
- The Hospital of Lithuanian University of Health Sciences Kauno klinikos, Kaunas, Lithuania
| | - Dimitra Strikou
- Radiation Oncology Unit, University and General Attikon Hospital, Athens, Greece
| | - Kenton Thompson
- Department of Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Michael Velec
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Katrina Woodford
- Department of Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Monica Buijs
- InHolland Haarlem, University of Applied Science, Haarlem, the Netherlands
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Clough A, Chuter R, Hales RB, Parker J, McMahon J, Whiteside L, McHugh L, Davies L, Sanders J, Benson R, Nelder C, McDaid L, Choudhury A, Eccles CL. Impact of a contouring atlas on radiographer inter-observer variation in male pelvis radiotherapy. J Med Imaging Radiat Sci 2024; 55:281-288. [PMID: 38609834 DOI: 10.1016/j.jmir.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/26/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE/OBJECTIVE To determine the impact of a MR-based contouring atlas for male pelvis radiotherapy delineation on inter-observer variation to support radiographer led real-time magnetic resonance image guided adaptive radiotherapy (MRgART). MATERIAL/METHODS Eight RTTs contoured 25 MR images in the Monaco treatment planning system (Monaco 5.40.01), from 5 patients. The prostate, seminal vesicles, bladder, and rectum were delineated before and after the introduction of an atlas developed through multi-disciplinary consensus. Inter-observer contour variations (volume), time to contour and observer contouring confidence were determined at both time-points using a 5-point Likert scale. Descriptive statistics were used to analyse both continuous and categorical variables. Dice similarity coefficient (DSC), Dice-Jaccard coefficient (DJC) and Hausdorff distance were used to calculate similarity between observers. RESULTS Although variation in volume definition decreased for all structures among all observers post intervention, the change was not statistically significant. DSC and DJC measurements remained consistent following the introduction of the atlas for all observers. The highest similarity was found in the bladder and prostate whilst the lowest was the seminal vesicles. The mean contouring time for all observers was reduced by 50% following the introduction of the atlas (53 to 27 minutes, p=0.01). For all structures across all observers, the mean contouring confidence increased significantly from 2.3 to 3.5 out of 5 (p=0.02). CONCLUSION Although no significant improvements were observed in contour variation amongst observers, the introduction of the consensus-based contouring atlas improved contouring confidence and speed; key factors for a real-time RTT-led MRgART.
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Affiliation(s)
- Abigael Clough
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Chuter
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Rosie B Hales
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jacqui Parker
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - John McMahon
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lee Whiteside
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Louise McHugh
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lucy Davies
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Rebecca Benson
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Claire Nelder
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lisa McDaid
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ananya Choudhury
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
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Oliveira C, Barbosa B, Couto JG, Bravo I, Hughes C, McFadden S, Khine R, McNair HA. Advanced practice in radiotherapy across Europe: stakeholders' perceptions of implementation and evolution. Radiography (Lond) 2024; 30:896-907. [PMID: 38608565 DOI: 10.1016/j.radi.2024.03.013] [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: 11/03/2023] [Revised: 03/09/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Adapting radiotherapy services with workforce innovation using skills-mix or task-shifting optimises resources, supporting current and future demands. Advanced practitioners (APs) work at a different level of practice (beyond initial registration) across four pillars: clinical practice, leadership and management, education, and research. There is limited cross-country research on the advanced therapeutic radiographers/radiation therapists (TR/RTTs), particularly in Europe. This study aimed to investigate European radiotherapy stakeholders' perceptions regarding current and future advanced practice (AP). METHODS From June to September 2022, one-to-one online semi-structured interviews were conducted in English, and audio and video were recorded. Full verbatim audio files were independently transcribed and checked by interviewer and interviewees. Braun and Clarke's seven steps guided the thematic analysis (using NVivo). RESULTS Thirty-three interviewees working or studying in 16 European countries represented practitioners (n=14), managers (n=6), educators (n=4), professional bodies (n=4), students (n=3), and regulators (n=2). Four overarching themes emerged: "AP drivers and outcomes", "AP challenges vs enablers", "Current vs future AP", "Becoming and being advanced practitioner". Participants identified research as the neglected AP pillar due to a lack of protected time, limited staff skills, no research culture, no funding, workload, and clinical priorities. Interviewees highlighted the importance of consistency in job titles, harmonisation of education models and curricula, definition of AP requirements, and support for all AP pillars through job plans and workforce planning. CONCLUSION Neither the profession nor education of TR/RTTs are harmonised across Europe, which is highly reflected in advanced-level practice. Advanced TR/RTTs should work across all pillars, including research, and these should be embedded in master's programmes, including leadership. IMPLICATIONS FOR PRACTICE This study highlights a policy gap in the education and practice of APs in radiotherapy.
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Affiliation(s)
- C Oliveira
- Radiotherapy Department, Instituto Português de Oncologia do Porto (IPO Porto), Portugal; Escola Internacional de Doutoramento, Universidad de Vigo, Spain.
| | - B Barbosa
- Radiotherapy Department, Instituto Português de Oncologia do Porto (IPO Porto), Portugal; Escola Internacional de Doutoramento, Universidad de Vigo, Spain; Medical Physics, Radiobiology Group and Radiation Protection Group, IPO Porto Research Centre (CI-IPOP), Instituto Português de Oncologia do Porto (IPO Porto), Portugal.
| | - J G Couto
- Radiography Department, Faculty of Health Sciences, University of Malta, Malta.
| | - I Bravo
- Medical Physics, Radiobiology Group and Radiation Protection Group, IPO Porto Research Centre (CI-IPOP), Instituto Português de Oncologia do Porto (IPO Porto), Portugal.
| | - C Hughes
- School of Health Sciences, Ulster University, United Kingdom.
| | - S McFadden
- School of Health Sciences, Ulster University, United Kingdom.
| | - R Khine
- European Federation of Radiographer Societies, Utrecht, Netherlands; Institute of Health Sciences Education, Faculty of Medicine & Dentistry, Queen Mary, University of London, United Kingdom.
| | - H A McNair
- European Federation of Radiographer Societies, Utrecht, Netherlands; The Royal Marsden NHS Foundation Trust, Radiotherapy and the Institute of Cancer Research, Surrey, United Kingdom.
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Votta C, Iacovone S, Turco G, Carrozzo V, Vagni M, Scalia A, Chiloiro G, Meffe G, Nardini M, Panza G, Placidi L, Romano A, Cornacchione P, Gambacorta MA, Boldrini L. Evaluation of clinical parallel workflow in online adaptive MR-guided Radiotherapy: A detailed assessment of treatment session times. Tech Innov Patient Support Radiat Oncol 2024; 29:100239. [PMID: 38405058 PMCID: PMC10883837 DOI: 10.1016/j.tipsro.2024.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/11/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Advancements in MRI-guided radiotherapy (MRgRT) enable clinical parallel workflows (CPW) for online adaptive planning (oART), allowing medical physicists (MPs), physicians (MDs), and radiation therapists (RTTs) to perform their tasks simultaneously. This study evaluates the impact of this upgrade on the total treatment time by analyzing each step of the current 0.35T-MRgRT workflow. Methods The time process of the workflow steps for 254 treatment fractions in 0.35 MRgRT was examined. Patients have been grouped based on disease site, breathing modality (BM) (BHI or FB), and fractionation (stereotactic body RT [SBRT] or standard fractionated long course [LC]). The time spent for the following workflow steps in Adaptive Treatment (ADP) was analyzed: Patient Setup Time (PSt), MRI Acquisition and Matching (MRt), MR Re-contouring Time (RCt), Re-Planning Time (RPt), Treatment Delivery Time (TDt). Also analyzed was the timing of treatments that followed a Simple workflow (SMP), without the online re-planning (PSt + MRt + TDt.). Results The time analysis revealed that the ADP workflow (median: 34 min) is significantly (p < 0.05) longer than the SMP workflow (19 min). The time required for ADP treatments is significantly influenced by TDt, constituting 40 % of the total time. The oART steps (RCt + RPt) took 11 min (median), representing 27 % of the entire procedure. Overall, 79.2 % of oART fractions were completed in less than 45 min, and 30.6 % were completed in less than 30 min. Conclusion This preliminary analysis, along with the comparative assessment against existing literature, underscores the potential of CPW to diminish the overall treatment duration in MRgRT-oART. Additionally, it suggests the potential for CPW to promote a more integrated multidisciplinary approach in the execution of oART.
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Affiliation(s)
- Claudio Votta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Sara Iacovone
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Gabriele Turco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Valerio Carrozzo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Marica Vagni
- Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Giuditta Chiloiro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Guenda Meffe
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Matteo Nardini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Giulia Panza
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Lorenzo Placidi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Patrizia Cornacchione
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
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Oar B, Brown A, Newman G, Boles A, Rumley CN, Doyle R, Baines J, Tan A. Improvement in male pelvis magnetic resonance image contouring following radiologist-delivered training. J Med Radiat Sci 2024; 71:114-122. [PMID: 37740640 PMCID: PMC10920942 DOI: 10.1002/jmrs.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 09/07/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION The magnetic resonance linear accelerator (MRL) combines both magnetic resonance imaging and a linear accelerator, allowing for daily treatment adaptation. This study aimed to assess the impact of radiologist-delivered training in magnetic resonance (MR) contouring of relevant structures within the male pelvis. METHODS Two radiation oncologists, two radiation oncology registrars and seven radiation therapists completed contouring on 10 male pelvis MR datasets both pre- and post-training. A 2-hour MR anatomy training session was delivered by a radiologist, who also provided the 'gold standard' contours. The pre- and post-training contours were compared against the gold standard with Dice similarity coefficient (DSC) and Hausdorff distances calculated; and the pre- and post-confidence scores and timing were compared. RESULTS The improvement in DSC were significant in prostate, rectum and seminal vesicles, with a post-training median DSC of 0.87 ± 0.06, 0.92 ± 0.04 and 0.80 ± 0.14, respectively. The median Hausdorff improved with a median of 1.46 ± 0.78 mm, 0.52 ± 0.32 mm and 1.11 ± 0.86 mm for prostate, rectum and seminal vesicles, respectively. Bladder concordance was high both pre- and post-training. Urethra contours improved post-training, however, remained difficult to contour with a median post-DSC of 0.51 ± 0.24. Overall, confidence scoring improved (P < 0.001) and timing decreased by an average of 4.4 ± 16.4 min post-training. CONCLUSION Radiologist-delivered training improved concordance of male pelvis contouring on MR datasets. Further work is required in the identification of urethra on MRs. These findings are of importance in the MRL adaptive workflow.
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Affiliation(s)
- Bronwyn Oar
- Townsville University HospitalTownsvilleQueenslandAustralia
| | - Amy Brown
- Townsville University HospitalTownsvilleQueenslandAustralia
- Queensland University of TechnologyBrisbaneQueenslandAustralia
- James Cook UniversityTownsvilleQueenslandAustralia
| | - Glen Newman
- Townsville University HospitalTownsvilleQueenslandAustralia
| | - Alan Boles
- Queensland XRayTownsvilleQueenslandAustralia
| | - Christopher N. Rumley
- Townsville University HospitalTownsvilleQueenslandAustralia
- James Cook UniversityTownsvilleQueenslandAustralia
| | - Rachel Doyle
- Townsville University HospitalTownsvilleQueenslandAustralia
| | - John Baines
- Townsville University HospitalTownsvilleQueenslandAustralia
- James Cook UniversityTownsvilleQueenslandAustralia
| | - Alex Tan
- Townsville University HospitalTownsvilleQueenslandAustralia
- James Cook UniversityTownsvilleQueenslandAustralia
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de Leon J, Twentyman T, Carr M, Jameson M, Batumalai V. Optimising the MR-Linac as a standard treatment modality. J Med Radiat Sci 2023; 70:491-497. [PMID: 37540059 PMCID: PMC10715353 DOI: 10.1002/jmrs.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
The magnetic resonance linear accelerator (MR-Linac) offers a new treatment paradigm, providing improved visualisation of targets and organs at risk while allowing for daily adaptation of treatment plans in real time. Online MR-guided adaptive treatment has reduced treatment uncertainties; however, the additional treatment time and resource requirements may be a concern. We present our experience of integrating an MR-Linac into a busy department and provide recommendations for improved clinical and resource efficiency. Furthermore, we discuss potential future technological innovations that can further optimise clinical productivity in a busy department.
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Affiliation(s)
| | | | - Madeline Carr
- GenesisCareAlexandriaNew South WalesAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongWollongongNew South WalesAustralia
| | - Michael Jameson
- GenesisCareAlexandriaNew South WalesAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongWollongongNew South WalesAustralia
- School of Clinical Medicine, Faculty of Medicine and HealthUNSW SydneySydneyNew South WalesAustralia
| | - Vikneswary Batumalai
- GenesisCareAlexandriaNew South WalesAustralia
- School of Clinical Medicine, Faculty of Medicine and HealthUNSW SydneySydneyNew South WalesAustralia
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9
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Li W, Padayachee J, Navarro I, Winter J, Dang J, Raman S, Kong V, Berlin A, Catton C, Glicksman R, Malkov V, McPartlin A, Kataki K, Lindsay P, Chung P. Practice-based training strategy for therapist-driven prostate MR-Linac adaptive radiotherapy. Tech Innov Patient Support Radiat Oncol 2023; 27:100212. [PMID: 37265510 PMCID: PMC10230256 DOI: 10.1016/j.tipsro.2023.100212] [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: 02/03/2023] [Revised: 04/19/2023] [Accepted: 05/09/2023] [Indexed: 06/03/2023] Open
Abstract
Purpose To develop a practice-based training strategy to transition from radiation oncologist to therapist-driven prostate MR-Linac adaptive radiotherapy. Methods and materials In phase 1, 7 therapists independently contoured the prostate and organs-at-risk on T2-weighted MR images from 11 previously treated MR-Linac prostate patients. Contours were evaluated quantitatively (i.e. Dice similarity coefficient [DSC] calculated against oncologist generated online contours) and qualitatively (i.e. oncologist using a 5-point Likert scale; a score ≥ 4 was deemed a pass, a 90% pass rate was required to proceed to the next phase). Phase 2 consisted of supervised online workflow with therapists required no intervention from the oncologist on 10 total cases to advance. Phase 3 involved unsupervised therapist-driven workflow, with offline support from oncologists prior to the next fraction. Results In phase 1, the mean DSC was 0.92 (range 0.85-0.97), and mean Likert score was 3.7 for the prostate. Five therapists did not attain a pass rate (3-5 cases with prostate contour score < 4), underwent follow-up one-on-one review, and performed contours on a further training set (n = 5). Each participant completed a median of 12 (range 10-13) cases in phase 2; of 82 cases, minor direction were required from the oncologist on 5 regarding target contouring. Radiation oncologists reviewed 179 treatment fractions in phase 3, and deemed 5 cases acceptable but with suggestions for next fraction; all other cases were accepted without suggestions. Conclusion A training stepwise program was developed and successfully implemented to enable a therapist-driven workflow for online prostate MR-Linac adaptive radiotherapy.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jerusha Padayachee
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Inmaculada Navarro
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jeff Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jennifer Dang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Vickie Kong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Charles Catton
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Rachel Glicksman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Victor Malkov
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrew McPartlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Kaushik Kataki
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Patricia Lindsay
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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10
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Joyce E, Jackson M, Skok J, Rock B, McNair HA. What do we want? Training! When do we want it? Now? A training needs analysis for adaptive radiotherapy for therapeutic radiographers. Radiography (Lond) 2023; 29:818-826. [PMID: 37331130 DOI: 10.1016/j.radi.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/14/2023] [Accepted: 05/24/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Therapeutic radiographers (TRs) have adapted to the changing requirements and demands of the oncology service and in response to advanced techniques such as on-line adaptive MRI-guided radiotherapy (MRIgRT). The skills required for MRIgRT would benefit many TRs not just those involved in this technique. This study presents the results of a training needs analysis (TNA) for the required MRIgRT skills in readiness for training TRs for current and future practice. METHODS A UK-based TNA was used to ask TRs about their knowledge and experience with essential skills required for MRIgRT based on previous investigations into the topic. A five-point Likert scale was used for each of the skills and the difference in values were used to calculate the training need for current and future practice. RESULTS 261 responses were received (n = 261). The skill rated the most important to current practice was CBCT/CT matching and/or fusion. The current highest priority needs were radiotherapy planning and radiotherapy dosimetry. The skill rated the most important to future practice was CBCT/CT matching and/or fusion. The future highest priority needs were MRI acquisition and MRI Contouring. Over 50% of participants wanted training or additional training in all skills. There was an increase in all values for skills investigated from current to future roles. CONCLUSION Although the examined skills were viewed as important to current roles, the future training needs, both overall and high priority, were different compared to current roles. As the 'future' of radiotherapy can arrive rapidly, it is essential that training is delivered appropriately and timely. Before this can occur, there must be investigations into the method and delivery of this training. IMPLICATIONS FOR PRACTICE Role development. Education changes for therapeutic radiographers.
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Affiliation(s)
- E Joyce
- Royal Marsden NHS Foundation Trust, London, UK.
| | - M Jackson
- St George's University of London, UK
| | - J Skok
- St George's University of London, UK
| | - B Rock
- Royal Marsden NHS Foundation Trust, London, UK
| | - H A McNair
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, UK.
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11
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Picton M, Crawford D, Jameson M, Alvares S, Hogan L, Loo C, Moutrie Z, Jelen U, Pagulayan C, Dunkerley N, Twentyman T, de Leon J, Batumalai V. Introduction of radiation therapist‐led adaptive treatments on a 1.5 T
MR
‐Linac. J Med Radiat Sci 2022; 70 Suppl 2:94-98. [PMID: 36572532 PMCID: PMC10122921 DOI: 10.1002/jmrs.643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022] Open
Abstract
The introduction of magnetic resonance (MR) linear accelerators (MR-Linac) marks the beginning of a new era in radiotherapy. MR-Linac systems are currently being operated by teams of radiation therapists (RTs), radiation oncology medical physicists (ROMPs) and radiation oncologists (ROs) due to the diverse and complex tasks required to deliver treatment. This is resource-intensive and logistically challenging. RT-led service delivery at the treatment console is paramount to simplify the process and make the best use of this technology for suitable patients with commonly treated anatomical sites. This article will discuss the experiences of our department in developing and implementing an RT-led workflow on the 1.5 T MR-Linac.
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Affiliation(s)
| | | | - Michael Jameson
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Kensington New South Wales Australia
| | | | - Louise Hogan
- GenesisCare Alexandria New South Wales Australia
| | - Conrad Loo
- GenesisCare Alexandria New South Wales Australia
| | - Zoe Moutrie
- GenesisCare Alexandria New South Wales Australia
- Department of Radiation Oncology South West Sydney Local Health District Sydney New South Wales Australia
| | | | | | | | | | | | - Vikneswary Batumalai
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Kensington New South Wales Australia
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12
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Hogan L, Jameson M, Crawford D, Alvares S, Loo C, Picton M, Moutrie Z, Pagulayan C, Jelen U, Dunkerley N, Twentyman T, de Leon J, Batumalai V. Old dogs, new tricks:
MR‐Linac
training and credentialing of radiation oncologists, radiation therapists and medical physicists. J Med Radiat Sci 2022; 70 Suppl 2:99-106. [PMID: 36502538 PMCID: PMC10122927 DOI: 10.1002/jmrs.640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
The introduction of magnetic resonance (MR) linear accelerators (MR-Linacs) into radiotherapy departments has increased in recent years owing to its unique advantages including the ability to deliver online adaptive radiotherapy. However, most radiation oncology professionals are not accustomed to working with MR technology. The integration of an MR-Linac into routine practice requires many considerations including MR safety, MR image acquisition and optimisation, image interpretation and adaptive radiotherapy strategies. This article provides an overview of training and credentialing requirements for radiation oncology professionals to develop competency and efficiency in delivering treatment safely on an MR-Linac.
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Affiliation(s)
- Louise Hogan
- GenesisCare Alexandria New South Wales Australia
| | - Michael Jameson
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Australia
| | | | | | - Conrad Loo
- GenesisCare Alexandria New South Wales Australia
| | | | - Zoe Moutrie
- GenesisCare Alexandria New South Wales Australia
- Department of Radiation Oncology South West Sydney Local Health District Warwick Farm New South Wales Australia
| | | | - Ursula Jelen
- GenesisCare Alexandria New South Wales Australia
| | | | | | | | - Vikneswary Batumalai
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Australia
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13
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Benson R, Rodgers J, Nelder C, Clough A, Pitt E, Parker J, Whiteside L, Davies L, Bailey R, McMahon J, Kolbe H, Cree A, Dubec M, Van Herk M, Choudhury A, Hoskin P, Eccles C. The impact of an educational tool in cervix image registration across three imaging modalities. Br J Radiol 2022; 95:20211402. [PMID: 35616660 PMCID: PMC10996960 DOI: 10.1259/bjr.20211402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/21/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Accurate image registration is vital in cervical cancer where changes in both planning target volume (PTV) and organs at risk (OARs) can make decisions regarding image registration complicated. This work aims to determine the impact of a dedicated educational tool compared with experience gained in MR-guided radiotherapy (MRgRT). METHODS 10 therapeutic radiographers acted as observers and were split into two groups based on previous experience with MRgRT and Monaco treatment planning system. Three CBCT-CT, three MR-CT and two MR-MR registrations were completed per patient by each observer. Observers recorded translations, time to complete image registration and confidence. Data were collected in two phases; prior to and following the introduction of a cervix registration guide. RESULTS No statistically significant differences were noted between imaging modalities. Each group was assessed independently pre- and post-education, no statistically significant differences were noted in either CBCT-CT or MR-CT imaging. Group 1 MR-MR imaging showed a statistically significant reduction in interobserver variability (p=0.04), in Group 2, the result was not statistically significant (p=0.06). Statistically significant increases in confidence were seen in all three modalities (p≤0.05). CONCLUSIONS At The Christie NHS Foundation Trust, radiographers consistently registered images across three different imaging modalities regardless of their previous experience. The implementation of an image registration guide had limited impact on inter- and intraobserver variability. Radiographers' confidence showed statistically significant improvements following the use of the registration manual. ADVANCES IN KNOWLEDGE This work helps evaluate training methods for novel roles that are developing in MRgRT.
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Affiliation(s)
- Rebecca Benson
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - John Rodgers
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Claire Nelder
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Abigael Clough
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Eleanor Pitt
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Jacqui Parker
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Lee Whiteside
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Lucy Davies
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Rachael Bailey
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - John McMahon
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Hope Kolbe
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
| | - Anthea Cree
- Department of Clinical Oncology, The Clatterbridge Cancer
Centre, Liverpool,
UK
| | - Michael Dubec
- Department of Medical Physics and Engineering, The Christie NHS
Foundation Trust, Manchester,
UK
| | - Marcel Van Herk
- Department of Clinical Oncology, The Christie NHS Foundation
Trust, Manchester,
UK
- Division of Cancer Sciences, School of Medical Sciences,
Faculty of Biology, Medicine and Health, University of Manchester,
Manchester Academic Health Science Centre,
Manchester, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation
Trust, Manchester,
UK
- Division of Cancer Sciences, School of Medical Sciences,
Faculty of Biology, Medicine and Health, University of Manchester,
Manchester Academic Health Science Centre,
Manchester, UK
| | - Peter Hoskin
- Department of Clinical Oncology, The Christie NHS Foundation
Trust, Manchester,
UK
- Division of Cancer Sciences, School of Medical Sciences,
Faculty of Biology, Medicine and Health, University of Manchester,
Manchester Academic Health Science Centre,
Manchester, UK
| | - Cynthia Eccles
- Department of Radiotherapy, The Christie Hospital NHS
Trust, Manchester,
UK
- Division of Cancer Sciences, School of Medical Sciences,
Faculty of Biology, Medicine and Health, University of Manchester,
Manchester Academic Health Science Centre,
Manchester, UK
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14
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Whiteside L, McDaid L, Hales RB, Rodgers J, Dubec M, Huddart RA, Choudhury A, Eccles CL. To see or not to see: Evaluation of magnetic resonance imaging sequences for use in MR Linac-based radiotherapy treatment. J Med Imaging Radiat Sci 2022; 53:362-373. [PMID: 35850925 DOI: 10.1016/j.jmir.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE This work evaluated the suitability of MR derived sequences for use in online adaptive RT workflows on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac). MATERIALS/METHODS Non-patient volunteers were recruited to an ethics approved MR Linac imaging study. Participants attended 1-3 imaging sessions in which a combination of DIXON, 2D and 3D volumetric T1 and T2 weighted images were acquired axially, with volunteers positioned using immobilisation devices typical for radiotherapy to the anatomical region being scanned. Images from each session were appraised by three independent reviewers to determine optimal sequences over six anatomical regions: head and neck, female and male pelvis, thorax (lung), thorax (breast/chest wall) and abdomen. Site specific anatomical structures were graded by the perceived ability to accurately contour a typical organ at risk. Each structure was independently graded on a 4-point Likert scale as 'Very Clear', 'Clear', 'Unclear' or 'Not visible' by observers, consisting of radiographers (therapeutic and diagnostic) and clinicians. RESULTS From July 2019 to September 2019, 18 non-patient volunteers underwent 24 imaging sessions in the following anatomical regions: head and neck (n=3), male pelvis (n=4), female pelvis (n=5), lung/oesophagus (n=5) abdomen (n=4) and chest wall/breast (n=3). T2 sequences were the most preferred for perceived ability to contour anatomy in both male and female pelvis. For all other sites T1 weighted DIXON sequences were most favourable. CONCLUSION This study has determined the preferential sequence selection for organ visualisation, as a pre-requisite to our institution adopting MR-guided radiotherapy for a more diverse range of disease sites.
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Affiliation(s)
- Lee Whiteside
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom.
| | - Lisa McDaid
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - Rosie B Hales
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - John Rodgers
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - Michael Dubec
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, United Kingdom
| | - Robert A Huddart
- The Institute of Cancer Research, London UK; The Royal Marsden, London, United Kingdom
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Clinical Oncology, The Christie NHS Foundation Trust, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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15
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Online adaptive MR-guided radiotherapy: Conformity of contour adaptation for prostate cancer, rectal cancer and lymph node oligometastases among radiation therapists and radiation oncologists. Tech Innov Patient Support Radiat Oncol 2022; 23:33-40. [PMID: 36090011 PMCID: PMC9460551 DOI: 10.1016/j.tipsro.2022.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Contour adaptation conformity analyzed for LN-metastases, rectal- + prostate cancer. Contour adaptation conformity among RTTs and radiation oncologists is comparable. Role expansion of RTTs with daily contour adaptation impacts workflow efficiency.
Background and purpose Online adaptive MR-guided treatment planning workflows facilitate daily contour adaptation to the actual anatomy. Allocating contour adaptation to radiation therapists (RTTs) instead of radiation oncologists (ROs) might allow for increasing workflow efficiency. This study investigates conformity of adapted target contours provided by dedicated RTTs and ROs. Materials and methods In a simulated online procedure, 6 RTTs and 6 ROs recontoured targets and organs at risk (OAR) in prostate cancer (n = 2), rectal cancer (n = 2) and lymph node-oligometastases (n = 2) cases. RTTs gained contouring competence beforehand by following a specific in-house training program. For all target contours and the reference delineations volumetric differences were determined and Dice similarity coefficient (DSC), conformity index (CI) and generalized CI were calculated. Delineation time and –confidence were registered for targets and OAR. Impact of contour adaptation on treatment plan quality was investigated. Results Delineation conformity was generally high with DSC, CI and generalized CI values in the range of 0.81–0.94, 0.87–0.95 and 0.63–0.85 for prostate cancer, rectal cancer and LN-oligometastasis, respectively. Target volumes were comparable for both, RTTs and ROs. Time needed and confidence in contour adaptation was comparable as well. Treatment plans derived with adapted contours did not violate dose volume constrains as used in clinical routine. Conclusion After tumor site specific training, daily contour adaptations as needed in adaptive online radiotherapy workflows can be accurately performed by RTTs. Conformity of the derived contours is high and comparable to contours as provided by ROs.
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16
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MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges. Int J Radiat Oncol Biol Phys 2022; 114:950-967. [PMID: 35901978 DOI: 10.1016/j.ijrobp.2022.07.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting. METHODS AND MATERIALS We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT. RESULTS Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered. CONCLUSIONS The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.
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17
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Oliveira C, Barbosa B, Couto JG, Bravo I, Khine R, McNair H. Advanced practice roles of therapeutic radiographers/radiation therapists: A systematic literature review. Radiography (Lond) 2022; 28:605-619. [PMID: 35550932 DOI: 10.1016/j.radi.2022.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/06/2022] [Accepted: 04/19/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Advances in Radiotherapy (RT) technology and increase of complexity in cancer care have enabled the implementation of new treatment techniques. Subsequently, a greater level of autonomy, responsibility, and accountability in the practice of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) has led to Advanced Practice (AP) roles. The published evidence of this role is scattered with confusing terminology and divergence regarding the perception of whether a specific role represents AP internationally. This study aims to establish an international baseline of evidence on AP roles in RT to identify roles and activities performed by TR/RTTs at advanced level practice and to summarise the impact. METHODS A systematic PRISMA review of the literature was undertaken. Thematic analysis was used to synthesise the roles and associated activities. Six RT external experts validated the list. The impact was scrutinised in terms of clinical, organisational, and professional outcomes. RESULTS Studies (n = 87) were included and categorised into four groups. AP roles were listed by clinical area, site-specific, and scope of practice, and advanced activities were organised into seven dimensions and 27 sub-dimensions. Three most-reported outcomes were: enhanced service capacity, higher patient satisfaction, and safety maintenance. CONCLUSION Evidence-based AP amongst TR/RTTs show how AP roles were conceptualised, implemented, and evaluated. Congruence studies have shown that TR/RTTs are at par with the gold-standard across the various AP roles. IMPLICATIONS FOR PRACTICE This is the first systematic literature review synthetisising AP roles and activities of TR/RTTs. This study also identified the main areas of AP that can be used to develop professional frameworks and education guiding policy by professional bodies, educators and other stakeholders.
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Affiliation(s)
- C Oliveira
- Radiotherapy Department, Instituto Português de Oncologia do Porto (IPO Porto), R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal; Escola Internacional de Doutoramento, Universidad de Vigo, Circunvalación Ao Campus Universitario, 36310, Vigo, Pontevedra, Spain.
| | - B Barbosa
- Radiotherapy Department, Instituto Português de Oncologia do Porto (IPO Porto), R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal; Escola Internacional de Doutoramento, Universidad de Vigo, Circunvalación Ao Campus Universitario, 36310, Vigo, Pontevedra, Spain; Medical Physics, Radiobiology Group and Radiation Protection Group, IPO Porto Research Centre (CI-IPOP), Instituto Português de Oncologia do Porto (IPO Porto), R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal.
| | - J G Couto
- Radiography Department, Faculty of Health Sciences, University of Malta, Msida, MSD2080, Malta.
| | - I Bravo
- Medical Physics, Radiobiology Group and Radiation Protection Group, IPO Porto Research Centre (CI-IPOP), Instituto Português de Oncologia do Porto (IPO Porto), R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal.
| | - R Khine
- European Federation of Radiographer Societies, PO Box 30511, Utrecht, 3503, AH, Netherlands; School of Health Care and Social Work, Buckinghamshire New University, Buckinghamshire, United Kingdom.
| | - H McNair
- European Federation of Radiographer Societies, PO Box 30511, Utrecht, 3503, AH, Netherlands; The Royal Marsden NHS Foundation Trust, Radiotherapy and the Institute of Cancer Research, Surrey, SM2 5PT, United Kingdom.
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18
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Li W, Winter J, Padayachee J, Dang J, Kong V, Chung P. Case Report: MR-Guided Adaptive Radiotherapy, Some Room to Maneuver. Front Oncol 2022; 12:877452. [PMID: 35494044 PMCID: PMC9047540 DOI: 10.3389/fonc.2022.877452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
Abstract
Background A magnetic resonance linear accelerator (MR-Linac) provides superior soft tissue contrast to evaluate inter- and intra-fraction motion and facilitate online adaptive radiation therapy (ART). We present here an unusual case of locally advanced castrate-resistant prostate cancer treated with high-dose palliative ultra-hypofractionated radiation therapy on the MR-Linac with significant inter-fraction tumor regression. Case Presentation The patient was a 65-year-old man diagnosed with metastatic prostate cancer to bone and pelvic lymph nodes 7 years prior. At diagnosis, he presented with a PSA of 23 ng/ml and was commenced on a luteinizing hormone-releasing hormone agonist, achieving a PSA nadir of 4.68 ng/ml at 12 months. The patient subsequently had progressive lower urinary tract symptoms, his PSA increased to 47 ng/ml, and there was a markedly enlarged pelvic mass involving the prostate with gross extra-capsular disease and invasion into the posterior bladder wall. The patient was referred for palliative radiation to the pelvic mass due to urinary symptoms, pain, and lower limb paraesthesia. Treatment was planned to be delivered on the MR-Linac with a schedule of 36 Gy over 6 weekly factions allowing for maximal target dose delivery while minimizing surrounding organs at risk (OARs) radiation exposure. Unexpectedly, the target volume had a marked 49% (453 cc to 233 cc) reduction that was accounted for in the online adaptive process. A new reference plan was generated after 3 fractions to add sacral plexus as an OAR, previously not visible due to mass encroachment. The patient reported ongoing reduction in urinary symptoms, pelvic pain, and lower limb paresthesia by the end of treatment. Conclusion Using daily MR-guided ART, improved visualization of the changing target and OARs ensured safe dose escalation. The unexpected positive response of the target and improved patient outcomes demonstrated the added value of the MR-Linac for online adaptive radiotherapy in this setting.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- *Correspondence: Winnie Li,
| | - Jeff Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jerusha Padayachee
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jennifer Dang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vickie Kong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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19
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Sritharan K, Tree A. MR-guided radiotherapy for prostate cancer: state of the art and future perspectives. Br J Radiol 2022; 95:20210800. [PMID: 35073158 PMCID: PMC8978250 DOI: 10.1259/bjr.20210800] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/16/2021] [Accepted: 12/22/2021] [Indexed: 12/25/2022] Open
Abstract
Advances in radiotherapy technology have increased precision of treatment delivery and in some tumour types, improved cure rates and decreased side effects. A new generation of radiotherapy machines, hybrids of an MRI scanner and a linear accelerator, has the potential to further transform the practice of radiation therapy in some cancers. Facilitating superior image quality and the ability to change the dose distribution online on a daily basis (termed "daily adaptive replanning"), MRI-guided radiotherapy machines allow for new possibilities including increasing dose, for hard to treat cancers, and more selective sparing of healthy tissues, where toxicity reduction is the key priority.These machines have already been used to treat most types of cancer, although experience is still in its infancy. This review summarises the potential and current evidence for MRI-guided radiotherapy, with a predominant focus on prostate cancer. Current advantages and disadvantages are discussed including a realistic appraisal of the likely potential to improve patient outcomes. In addition, horizon scanning for near-term possibilities for research and development will hopefully delineate the potential role for this technology over the next decade.
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20
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Proposal and Evaluation of a Physician-Free, Real-Time On-Table Adaptive Radiotherapy (PF-ROAR) Workflow for the MRIdian MR-Guided LINAC. J Clin Med 2022; 11:jcm11051189. [PMID: 35268279 PMCID: PMC8911471 DOI: 10.3390/jcm11051189] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
With the implementation of MR-LINACs, real-time adaptive radiotherapy has become a possibility within the clinic. However, the process of adapting a patient’s plan is time consuming and often requires input from the entire clinical team, which translates to decreased throughput and limited patient access. In this study, the authors propose and simulate a workflow to address these inefficiencies in staffing and patient throughput. Two physicians, three radiation therapists (RTT), and a research fellow each adapted bladder and bowel contours for 20 fractions from 10 representative patient plans. Contouring ability was compared via calculation of a Dice Similarity Index (DSI). The DSI for bladder and bowel based on each potential physician–therapist pair, as well as an inter-physician comparison, exhibited good overlap amongst all comparisons (p = 0.868). Plan quality was compared through calculation of the conformity index (CI), as well as an evaluation of the plan’s dose to a ‘gold standard’ set of structures. Overall, non-physician plans passed 91.2% of the time. Of the eight non-physician plans that failed their clinical evaluation, six also failed their evaluation against the ‘gold standard’. Another two plans that passed their clinical evaluation subsequently failed in their evaluation against the ‘gold standard’. Thus, the PF-ROAR process has a success rate of 97.5%, with 78/80 plans correctly adapted to the gold standard or halted at treatment. These findings suggest that a physician-free workflow can be well tolerated provided RTTs continue to develop knowledge of MR anatomy and careful attention is given to understanding the complexity of the plan prior to treatment.
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21
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Shepherd M, Graham S, Ward A, Zwart L, Cai B, Shelley C, Booth J. Pathway for radiation therapists online advanced adapter training and credentialing. Tech Innov Patient Support Radiat Oncol 2021; 20:54-60. [PMID: 34917781 PMCID: PMC8665404 DOI: 10.1016/j.tipsro.2021.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/15/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Online Adaptive Radiation Therapy (oART) provides a solution to account for daily patient variations, but wide spread implementation is hindered by human resources and training. Physicians can mentor Radiation Therapists (RTTs) through traditional tasks such as contouring and plan approval. With evidence-based credentialing activities, decision support aids and ‘on-call’ caveats, RTTs can lead the oART workflow and a ‘Clinician-Lite’ approach. Compliance with legislative, regulatory and medico-legal governing bodies can be addressed through post-graduate study, advanced practice pathways, exemptions and delegation of task.
Online adaptive radiotherapy (oART) is an emerging advanced treatment option for cancer patients worldwide. Current oART practices using magnetic resonance (MR) and cone beam computed tomography (CBCT) based imaging are resource intensive and require physician presence, which is a barrier to widespread implementation. Global evidence demonstrates Radiation Therapists (RTTs) can lead the oART workflow with decision support tools and on ‘on-call’ caveats in a ‘clinician-lite’ approach without significantly compromising on treatment accuracy, speed or patient outcomes. With careful consideration of jurisdictional regulations and guidance from the multi-disciplinary team, RTTs can elevate beyond traditional scopes of practice. By implementing robust and evidence-based credentialing activities, they enable service sustainability and expand the real-world gains of adaptive radiotherapy to a greater number of cancer patients worldwide. This work summarises the evidence for RTT-led oART treatments and proposes a pathway for training and credentialing.
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Affiliation(s)
- Meegan Shepherd
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonard, NSW 2065, Australia
| | - Siobhan Graham
- Queen's Hospital, BHRUT NHS Trust, Rom Valley Way, Romford RM1 0AG, UK
| | - Amy Ward
- Queen's Hospital, BHRUT NHS Trust, Rom Valley Way, Romford RM1 0AG, UK
| | - Lissane Zwart
- Medisch Spectrum Twente (MST), Koningstraat 1, 7512 KZ Enschede, Netherlands
| | - Bin Cai
- UT Southwestern Medical Center, Harry Hines Blvd, Dallas, TX 75390, USA
| | | | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonard, NSW 2065, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Camperdown, NSW 2004, Australia
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22
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McNair HA, Joyce E, O'Gara G, Jackson M, Peet B, Huddart RA, Wiseman T. Radiographer-led online image guided adaptive radiotherapy: A qualitative investigation of the therapeutic radiographer role. Radiography (Lond) 2021; 27:1085-1093. [PMID: 34006442 PMCID: PMC8497277 DOI: 10.1016/j.radi.2021.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/06/2021] [Accepted: 04/25/2021] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Online MRI guided adaptive radiotherapy (MRIgRT) is resource intensive. To maintain and increase uptake traditional roles and responsibilities may need refining. This novel study aims to provide an in-depth understanding and subsequent impact of the roles required to deliver on-line adaptive MRIgRT by exploring the current skills and knowledge of radiographers. METHOD A purposive sampling approach was used to invite radiographers, clinicians and physicists from centres with experience of MRIgRT to participate. Focus Group Interviews were conducted with two facilitators using a semi-structure interview guide (Appendix 1). Four researchers independently familiarised themselves and coded the data using framework analysis. A consensus thematic framework of ptive Radiotherapy codes and categories was agreed and systematically applied. RESULTS Thirty participants took part (Radiographers: N = 18, Physicists: N = 9 and Clinicians: N = 3). Three key themes were identified: 'Current MRIgRT', 'Training' and 'Future Practice'. Current MRIgRT identified a variation in radiographers' roles and responsibilities with pathways ranging from radiographer-led, clinician-light-led and MDT-led. The consensus was to move towards radiographer-led with the need to have a robust on-call service heavily emphasised. Training highlighted the breadth of knowledge required by radiographers including MRI, contouring, planning and dosimetry, and treatment experience. Debate was presented over timing and length of training required. Future Practice identified the need to have radiographers solely deliver MRIgRT, to reduce staff present which was seen as a main driver, and time and resources to train radiographers seen as the main barriers. CONCLUSION Radiographer-led MRIgRT is an exciting development because of the potential radiographer role development. A national training framework created collaboratively with all stakeholders and professions involved would ensure consistency in skills and knowledge. IMPLICATIONS FOR PRACTICE Role development and changes in education for therapeutic radiographers.
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Affiliation(s)
- H A McNair
- Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom.
| | - E Joyce
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - G O'Gara
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - M Jackson
- St George's University of London, United Kingdom
| | - B Peet
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - R A Huddart
- Institute of Cancer Research, United Kingdom
| | - T Wiseman
- Royal Marsden NHS Foundation Trust, United Kingdom
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23
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Wegener D, Zips D, Gani C, Boeke S, Nikolaou K, Othman AE, Almansour H, Paulsen F, Müller AC. [Primary treatment of prostate cancer using 1.5 T MR-linear accelerator]. Radiologe 2021; 61:839-845. [PMID: 34297139 PMCID: PMC8410708 DOI: 10.1007/s00117-021-00882-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Hintergrund Der potenzielle Nutzen des verbesserten Weichteilkontrastes von MR-Sequenzen gegenüber der Computertomographie (CT) für die Radiotherapie des Prostatakarzinoms ist bekannt und führt zu konsistenteren und kleineren Zielvolumina sowie verbesserter Risikoorganschonung. Hybridgeräte aus Magnetresonanztomographie (MRT) und Linearbeschleuniger (MR-Linac) stellen eine neue vielversprechende Erweiterung der radioonkologischen Therapieoptionen dar. Material und Methoden Dieser Artikel gibt eine Übersicht über bisherige Erfahrungen, Indikationen, Vorteile und Herausforderungen für die Radiotherapie des primären Prostatakarzinoms mit dem 1,5-T-MR-Linac. Ergebnisse Alle strahlentherapeutischen Therapieindikationen für das primäre Prostatakarzinom können mit dem 1,5-T-MR-Linac abgedeckt werden. Die potenziellen Vorteile umfassen die tägliche MR-basierte Lagekontrolle in Bestrahlungsposition und die Möglichkeit der täglichen Echtzeitanpassung des Bestrahlungsplans an die aktuelle Anatomie der Beckenorgane (adaptive Strahlentherapie). Zusätzlich werden am 1,5-T-MR-Linac funktionelle MRT-Sequenzen für individuelles Response-Assessment für die Therapieanpassung untersucht. Dadurch soll das therapeutische Fenster weiter optimiert werden. Herausforderungen stellen u. a. die technische Komplexität und die Dauer der Behandlungssitzung dar. Schlussfolgerung Der 1,5-T-MR-Linac erweitert das radioonkologische Spektrum in der Therapie des Prostatakarzinoms und bietet Vorteile durch tagesaktuelle MRT-basierte Zielvolumendefinition und Planadaptation. Weitere klinische Untersuchungen sind notwendig, um die Patienten zu identifizieren, die von der Behandlung am MR-Linac gegenüber anderen strahlentherapeutischen Methoden besonders profitieren.
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Affiliation(s)
- Daniel Wegener
- Universitätsklinik für Radioonkologie, Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
| | - Daniel Zips
- Universitätsklinik für Radioonkologie, Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - Cihan Gani
- Universitätsklinik für Radioonkologie, Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - Simon Boeke
- Universitätsklinik für Radioonkologie, Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - Konstantin Nikolaou
- Universitätsklinik für Radiologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Ahmed E Othman
- Universitätsklinik für Radiologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
- Universitätsklink für Neuroradiologie, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Haidara Almansour
- Universitätsklinik für Radiologie, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Frank Paulsen
- Universitätsklinik für Radioonkologie, Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
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24
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Shelley CE, Barraclough LH, Nelder CL, Otter SJ, Stewart AJ. Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation. Clin Oncol (R Coll Radiol) 2021; 33:579-590. [PMID: 34247890 DOI: 10.1016/j.clon.2021.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.
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Affiliation(s)
- C E Shelley
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | - L H Barraclough
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - C L Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Otter
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - A J Stewart
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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25
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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26
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Mee T, Vickers AJ, Jena R, Kirkby KJ, Choudhury A, Kirkby NF. Variations in Demand across England for the Magnetic Resonance-Linac Technology, Simulated Utilising Local-level Demographic and Cancer Data in the Malthus Project. Clin Oncol (R Coll Radiol) 2021; 33:e285-e294. [PMID: 33775495 PMCID: PMC8217906 DOI: 10.1016/j.clon.2021.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/14/2021] [Accepted: 03/05/2021] [Indexed: 11/26/2022]
Abstract
AIMS Cancer incidence varies across England, which affects the local-level demand for treatments. The magnetic resonance-linac (MR-linac) is a new radiotherapy technology that combines imaging and treatment. Here we model the demand and demand variations for the MR-linac across England. MATERIALS AND METHODS Initial clinical indications were provided by the MR-linac consortium and introduced into the Malthus radiotherapy clinical decision trees. The Malthus model contains Clinical Commissioning Group (CCG) population, cancer incidence and stage presentation data (for lung and prostate) and simulated the demand for the MR-linac for all CCGs and Radiotherapy Operational Delivery Networks (RODN) across England. RESULTS Based on the initial target clinical indications, the MR-linac could service 16% of England's fraction burden. The simulated fractions/million population demand/annum varies between 3000 and 10 600 fractions/million at the CCG level. Focussing only on the cancer population, the simulated fractions/1000 cancer cases demand/annum ranges from 1028 to 1195 fractions/1000 cases. If a national average for fractions/million demand was then used, at the RODN level, the variation from actual annual demand ranges from an overestimation of 8400 fractions to an underestimation of 5800 fractions. When using the national average fractions/1000 cases, the RODN demand varies from an overestimation of 3200 fractions to an underestimation of 3000 fractions. CONCLUSIONS Planning cancer services is complex due to regional variations in cancer burden. The variations in simulated demand of the MR-linac highlight the requirement to use local-level data when planning to introduce a new technology.
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Affiliation(s)
- T Mee
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - A J Vickers
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R Jena
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
| | - K J Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A Choudhury
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - N F Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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27
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Glide-Hurst CK, Lee P, Yock AD, Olsen JR, Cao M, Siddiqui F, Parker W, Doemer A, Rong Y, Kishan AU, Benedict SH, Li XA, Erickson BA, Sohn JW, Xiao Y, Wuthrick E. Adaptive Radiation Therapy (ART) Strategies and Technical Considerations: A State of the ART Review From NRG Oncology. Int J Radiat Oncol Biol Phys 2020; 109:1054-1075. [PMID: 33470210 DOI: 10.1016/j.ijrobp.2020.10.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022]
Abstract
The integration of adaptive radiation therapy (ART), or modifying the treatment plan during the treatment course, is becoming more widely available in clinical practice. ART offers strong potential for minimizing treatment-related toxicity while escalating or de-escalating target doses based on the dose to organs at risk. Yet, ART workflows add complexity into the radiation therapy planning and delivery process that may introduce additional uncertainties. This work sought to review presently available ART workflows and technological considerations such as image quality, deformable image registration, and dose accumulation. Quality assurance considerations for ART components and minimum recommendations are described. Personnel and workflow efficiency recommendations are provided, as is a summary of currently available clinical evidence supporting the implementation of ART. Finally, to guide future clinical trial protocols, an example ART physician directive and a physics template following standard NRG Oncology protocol is provided.
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Affiliation(s)
- Carri K Glide-Hurst
- Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam D Yock
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado- Denver, Denver, Colorado
| | - Minsong Cao
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - William Parker
- Department of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | - Anthony Doemer
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Yi Rong
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason W Sohn
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Evan Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
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