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Muecke J, Reitz D, Huang L, da Silva Mendes V, Landry G, Reiner M, Belka C, Freislederer P, Corradini S, Niyazi M. Intrafractional motion detection for spine SBRT via X-ray imaging using ExacTrac Dynamic. Clin Transl Radiat Oncol 2024; 46:100765. [PMID: 38560512 PMCID: PMC10979138 DOI: 10.1016/j.ctro.2024.100765] [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: 07/21/2023] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose Due to its close vicinity to critical structures, especially the spinal cord, standards for safety for spine stereotactic body radiotherapy (SBRT) should be high. This study was conducted, to evaluate intrafractional motion during spine SBRT for patients without individualized immobilization (e.g., vacuum cushions) using high accuracy patient monitoring via orthogonal X-ray imaging. Methods Intrafractional X-ray data were collected from 29 patients receiving 79 fractions of spine SBRT. No individualized immobilization devices were used during the treatment. Intrafractional motion was monitored using the ExacTrac Dynamic (ETD) System (Brainlab AG, Munich, Germany). Deviations were detected in six degrees of freedom (6 DOF). Tolerances for repositioning were 0.7 mm for translational and 0.5° for rotational deviations. Patients were repositioned when the tolerance levels were exceeded. Results Out of the 925 pairs of stereoscopic X-ray images examined, 138 (15 %) showed at least one deviation exceeding the predefined tolerance values. In all 6 DOF together, a total of 191 deviations out of tolerance were recorded. The frequency of deviations exceeding the tolerance levels varied among patients but occurred in all but one patient. Deviations out of tolerance could be seen in all 6 DOF. Maximum translational deviations were 2.6 mm, 2.3 mm and 2.8 mm in the lateral, longitudinal and vertical direction. Maximum rotational deviations were 1.8°, 2.6° and 1.6° for pitch, roll and yaw, respectively. Translational deviations were more frequent than rotational ones, and frequency and magnitude of deviations showed an inverse correlation. Conclusion Intrafractional motion detection and patient repositioning during spine SBRT using X-ray imaging via the ETD System can lead to improved safety during the application of high BED in critical locations. When using intrafractional imaging with low thresholds for re-positioning individualized immobilization devices (e.g. vacuum cushions) may be omitted.
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Affiliation(s)
- Johannes Muecke
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Strahlentherapie Nymphenburg/Fürstenfeldbruck, Munich, Germany
| | - Lili Huang
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | | | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | | | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
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Remmerts de Vries IF, Verbakel WFAR, Adema M, Slotman BJ, Dahele M. Spine Stereotactic Body Radiation Therapy Without Immobilization: Detailed Analysis of Intrafraction Motion Using High-Frequency kV Imaging During Irradiation. Int J Radiat Oncol Biol Phys 2024; 118:525-532. [PMID: 37652305 DOI: 10.1016/j.ijrobp.2023.08.054] [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: 04/13/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Spine stereotactic body radiation therapy (SBRT) requires high positioning accuracy and a stable patient to maximize target coverage and reduce excessive irradiation to organs at risk. Positional verification during spine SBRT delivery helps to ensure accurate positioning for all patients. We report our experience with noninvasive 3-dimensional target position monitoring during volumetric modulated arc therapy of spine metastases in nonimmobilized patients positioned using only a thin mattress and simple arm and knee supports. METHODS AND MATERIALS Fluoroscopic planar kV images were acquired at 7 frames/s using the on-board imaging system during volumetric modulated arc therapy spine SBRT. Template matching and triangulation were used to track the target in vertical, longitudinal, and lateral directions. If the tracking trace deviated >1 mm from the planned position in ≥1 direction, treatment was manually interrupted and 6-dimensional cone beam computed tomography (CBCT)-based couch correction was performed. Tracking data were used to retrospectively analyze the target position. Positional data, agreement with CBCT, correlation between position of the couch and direction of any positional correction, and treatment times were analyzed. RESULTS In total, 175 fractions were analyzed. Delivery was interrupted 83 times in 66 fractions for a deviation >1 mm. In 97% of cases the difference between tracking data and subsequent clinical shift performed after the CBCT match was ≤0.5 mm. Lateral/longitudinal shift performed after intervention correlated with the couch roll/pitch at the start of treatment (correlation coefficient, -0.63/0.53). Mean (SD; range) time between start of first imaging and end of the last arc was 15.2 minutes (5.1; 7.6-36.3). CONCLUSIONS Spine tracking during irradiation can be used to prompt an intervention CBCT scan and repositioning so that a spine SBRT target deviates by ≤1 mm from the planned position, even in nonimmobilized patients. kV tracking and CBCT are in good agreement. The data support verification CBCT after all 6 degrees-of-freedom positional corrections in nonimmobilized spine SBRT patients.
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Affiliation(s)
- Isabel F Remmerts de Vries
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Wilko F A R Verbakel
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marrit Adema
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Ohira S, Ikawa T, Inui S, Kanayama N, Ueda Y, Miyazaki M, Nishio T, Koizumi M, Konishi K. Improvement of target coverage using automated non-coplanar volumetric modulated arc therapy planning in stereotactic radiotherapy for cervical metastatic spinal tumors. Med Dosim 2023:S0958-3947(23)00039-0. [PMID: 37202230 DOI: 10.1016/j.meddos.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023]
Abstract
This study aimed to compare dosimetric parameters for targets and organs at risk (OARs) between volumetric modulated arc therapy (VMAT) and automated VMAT (HyperArc, HA) plans in stereotactic radiotherapy for patients with cervical metastatic spine tumors. VMAT plans were generated for 11 metastases using the simultaneous integrated boost technique to deliver 35 to 40 and 20 to 25 Gy for high dose and elective dose planning target volume (PTVHD and PTVED), respectively. The HA plans were retrospectively generated using 1 coplanar and 2 noncoplanar arcs. Subsequently, the doses to the targets and OARs were compared. The HA plans provided significantly higher (p < 0.05) Dmin (77.4 ± 13.1%), D99% (89.3 ± 8.9%), and D98% (92.5 ± 7.7%) for gross tumor volume (GTV) than those of the VMAT plans (73.4 ± 12.2%, 84.2 ± 9.6 and 87.3 ± 8.8% for Dmin, D99% and D98%, respectively). In addition, D99% and D98% for PTVHD were significantly higher in the HA plans, whereas dosimetric parameters were comparable between the HA and VMAT plans for PTVED. The Dmax values for the brachial plexus, esophagus, and spinal cord were comparable, and no significant difference was observed in the Dmean for the larynx, pharyngeal constrictor, thyroid, parotid grand (left and right), and Submandibular gland (left and right). The HA plans provided significantly higher target coverage of GTV and PTVHD, with a comparable dose for OARs with VMAT plans. The results of this study may contribute to the improvement of local control in clinical practice.
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Affiliation(s)
- Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Teiji Nishio
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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Iramina H, Nakamura M, Nakamura K, Fujimoto T, Mizowaki T. Quantification of six-degree-of-freedom motion during beam delivery in spine stereotactic body radiotherapy using intra-irradiation cone-beam computed tomography imaging technique. Phys Med 2023; 110:102605. [PMID: 37167776 DOI: 10.1016/j.ejmp.2023.102605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Quantifying intra-fractional six-degree-of-freedom (6DoF) residual errors or motion from approved patient setups is necessary for accurate beam delivery in spine stereotactic body radiotherapy. However, previously reported errors were not acquired during beam delivery. Therefore, we aimed to quantify the 6DoF residual errors and motions during arc beam delivery using a concurrent cone-beam computed tomography (CBCT) imaging technique, intra-irradiation CBCT. METHODS Consecutive 15 patients, 19 plans for various treatment sites, and 199 CBCT images were analyzed. Pre-irradiation CBCT was performed to verify shifts from the initial patient setup using the ExacTrac system. During beam delivery by two or three co-planar full-arc rotations, CBCT imaging was performed concurrently. Subsequently, an intra-irradiation CBCT image was reconstructed. Pre- and intra-irradiation CBCT images were rigidly registered to a planning CT image based on the bone to quantify 6DoF residual errors. RESULTS 6DoF residual errors quantified using pre- and intra-irradiation CBCTs were within 2.0 mm/2.0°, except for one measurement. The mean elapsed time (mean ± standard deviation [min:sec]) after pre-irradiation CBCT to the end of the last arc beam delivery was 6:08 ± 1:25 and 7:54 ± 2:14 for the 2- and 3-arc plans, respectively. Root mean squares of residual errors for several directions showed significant differences; however, they were within 1.0 mm/1.0°. Time-dependent analysis revealed that the residual errors tended to increase with elapsed time. CONCLUSION The errors represent the optimal intra-fractional error compared with those acquired using the pre-, inter-beam, and post-6DoF image guidance and can be acquired within a standard treatment timeslot.
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Affiliation(s)
- Hiraku Iramina
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Mitsuhiro Nakamura
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Kiyonao Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takahiro Fujimoto
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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Implementation of triggered kilovoltage imaging for stereotactic radiotherapy of the spine for patients with spinal fixation hardware. Phys Imaging Radiat Oncol 2023; 25:100422. [PMID: 36875327 PMCID: PMC9978845 DOI: 10.1016/j.phro.2023.100422] [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: 08/06/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background and purpose Mitigation of intrafraction motion (IM) is valuable in stereotactic radiotherapy (SRT) radiotherapy where submillimeter accuracy is desired. The purpose of this study was to investigate the application of triggered kilovoltage (kV) imaging for spine SRT patients with hardware by correlating kV imaging with patient motion and summarizing implications of tolerance for IM based on calculated dose. Materials and methods Ten plans (33 fractions) were studied, correlating kV imaging during treatment with pre- and post-treatment cone beam computed tomography (CBCT). Images were taken at 20-degree gantry angle intervals during the arc-based treatment. The contour of the hardware with a 1 mm expansion was displayed at the treatment console to manually pause treatment delivery if the hardware was visually detected outside the contour. The treatment CBCTs were compared using retrospective image registration to assess the validity of contour-based method for pausing treatment. Finally, plans were generated to estimate dose volume objective differences in case of 1 mm deviation. Results When kV imaging during treatment was used with the 1 mm contour, 100 % of the post-treatment CBCTs reported consistent results. One patient in the cohort exhibited motion greater than 1 mm during treatment which allowed intervention and re-setup during treatment. The average translational motion was 0.35 mm. Treatment plan comparison at 1 mm deviation showed little differences in calculated dose for the target and cord. Conclusions Utilizing kV imaging during treatment is an effective method of assessing IM for SRT spine patients with hardware without increasing treatment time.
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Gaudreault M, Yeo A, Kron T, Hanna GG, Siva S, Hardcastle N. Treatment Time Optimization in Single Fraction Stereotactic Ablative Radiation Therapy: A 10-Year Institutional Experience. Adv Radiat Oncol 2022; 7:100829. [PMID: 36148377 PMCID: PMC9486429 DOI: 10.1016/j.adro.2021.100829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/30/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Stereotactic ablative radiation therapy (SABR) delivered in a single fraction (SF) can be considered to have higher uncertainty given that the error probability is concentrated in a single session. This study aims to report the variation in technology and technique used and its effect on intrafraction motion based on a 10 years of experience in SF SABR. Methods and Materials Records of patients receiving SF SABR delivered at our instruction between 2010 and 2019 were included. Treatment parameters were extracted from the patient management database by using an in-house script. Treatment time was defined as the time difference between the first image acquisition to the last beam off of a single session. The intrafraction variation was measured from the 3-dimensional couch displacement measured after the first cone beam computed tomography (CBCT) acquired during a treatment. Results The number of SF SABR increased continuously from 2010 to 2019 and were mainly lung treatments. Treatment time was minimized by using volumetric modulated arc therapy, flattening filter-free dose rate, and coplanar field (24 ± 9 min). Treatment time increased as the number of CBCTs per session increased. The most common scenario involved both 2 and 3 CBCTs per session. On the average, a CBCT acquisition added 6 minutes to the treatment time. All treatments considered, the average intrafraction variation was 1.7 ± 1.6 mm. Conclusions SF SABR usage increased with time in our institution. The intrafraction motion was acceptable and therefore a single fraction is an efficacious treatment option when considering SABR.
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Billiet C, Vingerhoed W, Van Laere S, Joye I, Mercier C, Dirix P, Nevens D, Vermeulen P, Meijnders P, Verellen D. Precision of image-guided spinal stereotactic ablative radiotherapy and impact of positioning variables. Phys Imaging Radiat Oncol 2022; 22:73-76. [PMID: 35686020 PMCID: PMC9172170 DOI: 10.1016/j.phro.2022.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background and purpose Spinal stereotactic ablative body radiotherapy (SABR) requires high precision. We evaluate the intrafraction motion during cone-beam computed tomography (CBCT) guided SABR with different immobilization techniques. Material and methods Fifty-seven consecutive patients were treated for 62 spinal lesions with SABR with positioning corrected in six degrees of freedom. A surface monitoring system was used for patient set up and to ensure patient immobilization in 65% of patients. Intrafractional motion was defined as the difference between the last CBCT before the start of treatment and the first CT afterwards. Results For all 194 fractions, the mean intrafractional motion was 0.1 cm (0-1.1 cm) in vertical direction, 0.1 cm (0-1.1 cm) in longitudinal direction and 0.1 cm (0-0.5 cm) in lateral direction. A mean pitch of 0.6° (0-4.3°), a roll of 0.5° (0-3.4°) and a rotational motion of 0.4° (0-3.9°) was observed. 95.5% of the translational errors and 95.4% of the rotational errors were within safety range. There was a significantly higher rotational motion for patients with arms along the body (p = 0.01) and without the use of the body mask (p = 0.05). For cervical locations a higher rotational motion was seen, although not significant (p = 0.1). The acquisition of an extra CBCT was correlated with a higher rotational (pitch) motion (p = 0 < 0.01). Conclusion Very high precision in CBCT guided and surface-guided spinal SABR was observed in this cohort. The lowest intrafraction motion was seen in patients treated with arms above their head and a body mask. The use of IGRT with surface monitoring is an added value for patient monitoring leading to treatment interruption if necessary.
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Affiliation(s)
- Charlotte Billiet
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Wim Vingerhoed
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
| | - Steven Van Laere
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Ines Joye
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Carole Mercier
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Daan Nevens
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Peter Vermeulen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Paul Meijnders
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
| | - Dirk Verellen
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, Antwerp, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Belgium
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