1
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Villegas F, Dal Bello R, Alvarez-Andres E, Dhont J, Janssen T, Milan L, Robert C, Salagean GAM, Tejedor N, Trnková P, Fusella M, Placidi L, Cusumano D. Challenges and opportunities in the development and clinical implementation of artificial intelligence based synthetic computed tomography for magnetic resonance only radiotherapy. Radiother Oncol 2024; 198:110387. [PMID: 38885905 DOI: 10.1016/j.radonc.2024.110387] [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: 10/29/2023] [Revised: 06/13/2024] [Accepted: 06/13/2024] [Indexed: 06/20/2024]
Abstract
Synthetic computed tomography (sCT) generated from magnetic resonance imaging (MRI) can serve as a substitute for planning CT in radiation therapy (RT), thereby removing registration uncertainties associated with multi-modality imaging pairing, reducing costs and patient radiation exposure. CE/FDA-approved sCT solutions are nowadays available for pelvis, brain, and head and neck, while more complex deep learning (DL) algorithms are under investigation for other anatomic sites. The main challenge in achieving a widespread clinical implementation of sCT lies in the absence of consensus on sCT commissioning and quality assurance (QA), resulting in variation of sCT approaches across different hospitals. To address this issue, a group of experts gathered at the ESTRO Physics Workshop 2022 to discuss the integration of sCT solutions into clinics and report the process and its outcomes. This position paper focuses on aspects of sCT development and commissioning, outlining key elements crucial for the safe implementation of an MRI-only RT workflow.
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Affiliation(s)
- Fernanda Villegas
- Department of Oncology-Pathology, Karolinska Institute, Solna, Sweden; Radiotherapy Physics and Engineering, Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Solna, Sweden
| | - Riccardo Dal Bello
- Department of Radiation Oncology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Emilie Alvarez-Andres
- OncoRay - National Center for Radiation Research in Oncology, Medical Faculty and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Faculty of Medicine Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Jennifer Dhont
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium; Université Libre De Bruxelles (ULB), Radiophysics and MRI Physics Laboratory, Brussels, Belgium
| | - Tomas Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lisa Milan
- Medical Physics Unit, Imaging Institute of Southern Switzerland (IIMSI), Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Charlotte Robert
- UMR 1030 Molecular Radiotherapy and Therapeutic Innovations, ImmunoRadAI, Paris-Saclay University, Institut Gustave Roussy, Inserm, Villejuif, France; Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Ghizela-Ana-Maria Salagean
- Faculty of Physics, Babes-Bolyai University, Cluj-Napoca, Romania; Department of Radiation Oncology, TopMed Medical Centre, Targu Mures, Romania
| | - Natalia Tejedor
- Department of Medical Physics and Radiation Protection, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Petra Trnková
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Marco Fusella
- Department of Radiation Oncology, Abano Terme Hospital, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Rome, Italy.
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, Olbia, Sassari, Italy
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2
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Lombardo E, Dhont J, Page D, Garibaldi C, Künzel LA, Hurkmans C, Tijssen RHN, Paganelli C, Liu PZY, Keall PJ, Riboldi M, Kurz C, Landry G, Cusumano D, Fusella M, Placidi L. Real-time motion management in MRI-guided radiotherapy: Current status and AI-enabled prospects. Radiother Oncol 2024; 190:109970. [PMID: 37898437 DOI: 10.1016/j.radonc.2023.109970] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
MRI-guided radiotherapy (MRIgRT) is a highly complex treatment modality, allowing adaptation to anatomical changes occurring from one treatment day to the other (inter-fractional), but also to motion occurring during a treatment fraction (intra-fractional). In this vision paper, we describe the different steps of intra-fractional motion management during MRIgRT, from imaging to beam adaptation, and the solutions currently available both clinically and at a research level. Furthermore, considering the latest developments in the literature, a workflow is foreseen in which motion-induced over- and/or under-dosage is compensated in 3D, with minimal impact to the radiotherapy treatment time. Considering the time constraints of real-time adaptation, a particular focus is put on artificial intelligence (AI) solutions as a fast and accurate alternative to conventional algorithms.
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Affiliation(s)
- Elia Lombardo
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jennifer Dhont
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium; Université Libre De Bruxelles (ULB), Radiophysics and MRI Physics Laboratory, Brussels, Belgium
| | - Denis Page
- University of Manchester, Division of Cancer Sciences, Manchester, United Kingdom
| | - Cristina Garibaldi
- IEO, Unit of Radiation Research, European Institute of Oncology IRCCS, Milan, Italy
| | - Luise A Künzel
- National Center for Tumor Diseases (NCT), Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Rob H N Tijssen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Paul Z Y Liu
- Image X Institute, University of Sydney Central Clinical School, Sydney, NSW, Australia; Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Paul J Keall
- Image X Institute, University of Sydney Central Clinical School, Sydney, NSW, Australia; Department of Medical Physics, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Marco Riboldi
- Department of Medical Physics, Faculty of Physics, LMU Munich, Munich, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, a Partnership between DKFZ and LMU University Hospital Munich, Germany; Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany
| | | | - Marco Fusella
- Department of Radiation Oncology, Abano Terme Hospital, Italy.
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
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3
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Klavsen MF, Ankjærgaard C, Boye K, Behrens CP, Vogelius IR, Ehrbar S, Baumgartl M, Rippke C, Buchele C, Renkamp CK, Santurio GV, Andersen CE. Accumulated dose implications from systematic dose-rate transients in gated treatments with Viewray MRIdian accelerators. Biomed Phys Eng Express 2023; 9:065001. [PMID: 37591227 DOI: 10.1088/2057-1976/acf138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023]
Abstract
The combination of magnetic resonance (MR) imaging and linear accelerators (linacs) into MR-Linacs enables continuous MR imaging and advanced gated treatments of patients. Previously, a dose-rate transient (∼8% reduced dose rate during the initial 0.5 s of each beam) was identified for a Viewray MRIdian MR-Linac (Klavsenet al2022Radiation Measurement106759). Here, the dose-rate transient is studied in more detail at four linacs of the same type at different hospitals. The implications of dose-rate transients were examined for gated treatments. The dose-rate transients were investigated using dose-per pulse measurements with organic plastic scintillators in three experiments: (i) A gated treatment with the scintillator placed in a moving target in a dynamic phantom, (ii) a gated treatment with the same dynamic conditions but with the scintillator placed in a stationary target, and (iii) measurements in a water-equivalent material to examine beam quality deviations at a dose-per-pulse basis. Gated treatments (i) compared with non-gated treatments with a static target in the same setup showed a broadening of accumulated dose profiles due to motion (dose smearing). The linac with the largest dose-rate transient had a reduced accumulated dose of up to (3.1 ± 0.65) % in the center of the PTV due to the combined dose smearing and dose-rate transient effect. Dose-rate transients were found to vary between different machines. Two MR-Linacs showed initial dose-rate transients that could not be identified from conventional linearity tests. The source of the transients includes an initial change in photon fluence rate and an initial change in x-ray beam quality. For gated treatments, this caused a reduction of more than 1% dose delivered at the central part of the beam for the studied, cyclic-motion treatment plan. Quality assurance of this effect should be considered when gated treatment with the Viewray MRIdian is implemented clinically.
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Affiliation(s)
- M F Klavsen
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
| | - C Ankjærgaard
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
| | - K Boye
- Dept. of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - C P Behrens
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
- Dept. of Oncology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - I R Vogelius
- Dept. of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen- Copenhagen, Denmark
| | - S Ehrbar
- Dept. of Radiation Oncology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - M Baumgartl
- Dept. of Radiation Oncology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - C Rippke
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - C Buchele
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - C K Renkamp
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - G V Santurio
- Dept. of Oncology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - C E Andersen
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
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4
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Waddington DEJ, Hindley N, Koonjoo N, Chiu C, Reynolds T, Liu PZY, Zhu B, Bhutto D, Paganelli C, Keall PJ, Rosen MS. Real-time radial reconstruction with domain transform manifold learning for MRI-guided radiotherapy. Med Phys 2023; 50:1962-1974. [PMID: 36646444 PMCID: PMC10809819 DOI: 10.1002/mp.16224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND MRI-guidance techniques that dynamically adapt radiation beams to follow tumor motion in real time will lead to more accurate cancer treatments and reduced collateral healthy tissue damage. The gold-standard for reconstruction of undersampled MR data is compressed sensing (CS) which is computationally slow and limits the rate that images can be available for real-time adaptation. PURPOSE Once trained, neural networks can be used to accurately reconstruct raw MRI data with minimal latency. Here, we test the suitability of deep-learning-based image reconstruction for real-time tracking applications on MRI-Linacs. METHODS We use automated transform by manifold approximation (AUTOMAP), a generalized framework that maps raw MR signal to the target image domain, to rapidly reconstruct images from undersampled radial k-space data. The AUTOMAP neural network was trained to reconstruct images from a golden-angle radial acquisition, a benchmark for motion-sensitive imaging, on lung cancer patient data and generic images from ImageNet. Model training was subsequently augmented with motion-encoded k-space data derived from videos in the YouTube-8M dataset to encourage motion robust reconstruction. RESULTS AUTOMAP models fine-tuned on retrospectively acquired lung cancer patient data reconstructed radial k-space with equivalent accuracy to CS but with much shorter processing times. Validation of motion-trained models with a virtual dynamic lung tumor phantom showed that the generalized motion properties learned from YouTube lead to improved target tracking accuracy. CONCLUSION AUTOMAP can achieve real-time, accurate reconstruction of radial data. These findings imply that neural-network-based reconstruction is potentially superior to alternative approaches for real-time image guidance applications.
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Affiliation(s)
- David E. J. Waddington
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Department of Medical PhysicsIngham Institute for Applied Medical ResearchLiverpoolNSWAustralia
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
| | - Nicholas Hindley
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
| | - Neha Koonjoo
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
| | - Christopher Chiu
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Tess Reynolds
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Paul Z. Y. Liu
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Department of Medical PhysicsIngham Institute for Applied Medical ResearchLiverpoolNSWAustralia
| | - Bo Zhu
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
| | - Danyal Bhutto
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
- Department of Biomedical EngineeringBoston UniversityBostonMassachusettsUSA
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e BioingegneriaPolitecnico di MilanoMilanItaly
| | - Paul J. Keall
- Image X Institute, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Department of Medical PhysicsIngham Institute for Applied Medical ResearchLiverpoolNSWAustralia
| | - Matthew S. Rosen
- A. A. Martinos Center for Biomedical ImagingMassachusetts General HospitalCharlestownMassachusettsUSA
- Department of PhysicsHarvard UniversityCambridgeMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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5
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Kisling K, Keiper TD, Branco D, Kim GG, Moore KL, Ray X. Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations. J Appl Clin Med Phys 2022; 23:e13801. [PMID: 36316805 PMCID: PMC9797177 DOI: 10.1002/acm2.13801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 12/29/2022] Open
Abstract
Online adaptive radiotherapy platforms present a unique challenge for commissioning as guidance is lacking and specialized adaptive equipment, such as deformable phantoms, are rare. We designed a novel adaptive commissioning process consisting of end-to-end tests using standard clinical resources. These tests were designed to simulate anatomical changes regularly observed at patient treatments. The test results will inform users of the magnitude of uncertainty from on-treatment changes during the adaptive workflow and the limitations of their systems. We implemented these tests for the cone-beam computed tomography (CT)-based Varian Ethos online adaptive platform. Many adaptive platforms perform online dose calculation on a synthetic CT (synCT). To assess the impact of the synCT generation and online dose calculation on dosimetric accuracy, we conducted end-to-end tests using commonly available equipment: a CIRS IMRT Thorax phantom, PinPoint ionization chamber, Gafchromic film, and bolus. Four clinical scenarios were evaluated: weight gain and weight loss were simulated by adding and removing bolus, internal target shifts were simulated by editing the CTV during the adaptive workflow to displace it, and changes in gas were simulated by removing and reinserting rods in varying phantom locations. The effect of overriding gas pockets during planning was also assessed. All point dose measurements agreed within 2.7% of the calculated dose, with one exception: a scenario simulating gas present in the planning CT, not overridden during planning, and dissipating at treatment. Relative film measurements passed gamma analysis (3%/3 mm criteria) for all scenarios. Our process validated the Ethos dose calculation for online adapted treatment plans. Based on our results, we made several recommendations for our clinical adaptive workflow. This commissioning process used commonly available equipment and, therefore, can be applied in other clinics for their respective online adaptive platforms.
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Affiliation(s)
- Kelly Kisling
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Timothy D. Keiper
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Daniela Branco
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Grace Gwe‐Ya Kim
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Kevin L Moore
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Xenia Ray
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
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6
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Nierer L, Kamp F, Reiner M, Corradini S, Rabe M, Dietrich O, Parodi K, Belka C, Kurz C, Landry G. Evaluation of an anthropomorphic ion chamber and 3D gel dosimetry head phantom at a 0.35 T MR-linac using separate 1.5 T MR-scanners for gel readout. Z Med Phys 2022; 32:312-325. [PMID: 35305857 PMCID: PMC9948847 DOI: 10.1016/j.zemedi.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE To date, no universally accepted technique for the evaluation of the overall dosimetric performance of hybrid integrated magnetic resonance imaging (MR) - linear accelerators (linacs) is available. We report on the suitability and reliability of a novel phantom with modular inserts for combined polymer gel (PG) and ionisation chamber (IC) measurements at a 0.35 T MR-linac. METHODS Three 3D-printed, modular head phantoms, based on real patient anatomy, were used for repeated (2 times) PG irradiations of cranial treatment plans on a 0.35 T MR-linac. The PG readout was performed on two 1.5 T diagnostic MR-scanners to reduce scanning time. The PG dose volumes were normalised to the IC dose (normalised dose N1) and to the median planning target volume dose (normalised dose N2). Linearity of the PG dose response was validated and dose profiles, centres of mass (COM) of the 95% isodoses and dose volume histograms (DVH) were compared between planned and measured dose distributions and a 3D gamma analysis was performed. RESULTS Dose linearity of the PG was good (R2> 0.99 for all linear fit functions). High agreement was found between planned and measured dose volumes in the dose profiles and DVHs. The largest dose deviation was found in the intermediate dose region (mean dose deviation 0.2Gy; 5.6%). A mean COM offset of 1.2mm indicated high spatial accuracy. Mean 3D gamma passing rates (2%, 2mm) of 83.3% for N1 and 91.6% for N2 dose distributions were determined. When comparing repeated PG measurements to each other, a mean gamma passing rate of 95.7% was found. CONCLUSION The new modular phantom was found practical for use at a 0.35 T MR-linac. In contrast to the high dose region, larger mean deviations were found in the mid dose range. The PG measurements showed high reproducibility. The MR-linac performed well in a non-adaptive setting in terms of spatial and dosimetric accuracy.
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Affiliation(s)
- Lukas Nierer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Florian Kamp
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Department of Radiation Oncology, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Moritz Rabe
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Olaf Dietrich
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, 85748 Garching, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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7
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Rippke C, Schrenk O, Renkamp CK, Buchele C, Hörner-Rieber J, Debus J, Alber M, Klüter S. Quality assurance for on-table adaptive magnetic resonance guided radiation therapy: A software tool to complement secondary dose calculation and failure modes discovered in clinical routine. J Appl Clin Med Phys 2022; 23:e13523. [PMID: 35019212 PMCID: PMC8906229 DOI: 10.1002/acm2.13523] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/14/2021] [Accepted: 12/19/2021] [Indexed: 11/16/2022] Open
Abstract
Online adaption of treatment plans on a magnetic resonance (MR)‐Linac enables the daily creation of new (adapted) treatment plans using current anatomical information of the patient as seen on MR images. Plan quality assurance (QA) relies on a secondary dose calculation (SDC) that is required because a pretreatment measurement is impossible during the adaptive workflow. However, failure mode and effect analysis of the adaptive planning process shows a large number of error sources, and not all of them are covered by SDC. As the complex multidisciplinary adaption process takes place under time pressure, additional software solutions for pretreatment per‐fraction QA need to be used. It is essential to double‐check SDC input to ensure a safe treatment delivery. Here, we present an automated treatment plan check tool for adaptive radiotherapy (APART) at a 0.35 T MR‐Linac. It is designed to complement the manufacturer‐provided adaptive QA tool comprising SDC. Checks performed by APART include contour analysis, electron density map examinations, and fluence modulation complexity controls. For nine of 362 adapted fractions (2.5%), irregularities regarding missing slices in target volumes and organs at risks as well as in margin expansion of target volumes have been found. This demonstrates that mistakes occur and can be detected by additional QA measures, especially contour analysis. Therefore, it is recommended to implement further QA tools additional to what the manufacturer provides to facilitate an informed decision about the quality of the treatment plan.
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Affiliation(s)
- Carolin Rippke
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany.,Medical Faculty, University of Heidelberg, Heidelberg, Baden-Wurttemberg, Germany
| | - Oliver Schrenk
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany.,PTW-Freiburg, Freiburg, Baden-Wurttemberg, Germany
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany
| | - Carolin Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany.,Medical Faculty, University of Heidelberg, Heidelberg, Baden-Wurttemberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Baden-Wurttemberg, Germany.,German Cancer Consortium (DKTK), Core-center Heidelberg, Heidelberg, Baden-Wurttemberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Baden-Wurttemberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany.,Medical Faculty, University of Heidelberg, Heidelberg, Baden-Wurttemberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Baden-Wurttemberg, Germany.,German Cancer Consortium (DKTK), Core-center Heidelberg, Heidelberg, Baden-Wurttemberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Baden-Wurttemberg, Germany
| | - Markus Alber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany.,Medical Faculty, University of Heidelberg, Heidelberg, Baden-Wurttemberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Baden-Wurttemberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Baden-Wurttemberg, Germany
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8
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Elter A, Rippke C, Johnen W, Mann P, Hellwich E, Schwahofer A, Dorsch S, Buchele C, Klüter S, Karger CP. End-to-end test for fractionated online adaptive MR-guided radiotherapy using a deformable anthropomorphic pelvis phantom. Phys Med Biol 2021; 66. [PMID: 34845991 DOI: 10.1088/1361-6560/ac3e0c] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022]
Abstract
Objective.In MR-guided radiotherapy (MRgRT) for prostate cancer treatments inter-fractional anatomy changes such as bladder and rectum fillings may be corrected by an online adaption of the treatment plan. To clinically implement such complex treatment procedures, however, specific end-to-end tests are required that are able to validate the overall accuracy of all treatment steps from pre-treatment imaging to dose delivery.Approach.In this study, an end-to-end test of a fractionated and online adapted MRgRT prostate irradiation was performed using the so-called ADAM-PETer phantom. The phantom was adapted to perform 3D polymer gel (PG) dosimetry in the prostate and rectum. Furthermore, thermoluminescence detectors (TLDs) were placed at the center and on the surface of the prostate for additional dose measurements as well as for an external dose renormalization of the PG. For the end-to-end test, a total of five online adapted irradiations were applied in sequence with different bladder and rectum fillings, respectively.Main results.A good agreement of measured and planned dose was found represented by highγ-index passing rates (3%/3mmcriterion) of the PG evaluation of98.9%in the prostate and93.7%in the rectum. TLDs used for PG renormalization at the center of the prostate showed a deviation of-2.3%.Significance.The presented end-to-end test, which allows for 3D dose verification in the prostate and rectum, demonstrates the feasibility and accuracy of fractionated and online-adapted prostate irradiations in presence of inter-fractional anatomy changes. Such tests are of high clinical importance for the commissioning of new image-guided treatment procedures such as online adaptive MRgRT.
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Affiliation(s)
- A Elter
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Physics and Astronomy, Heidelberg University, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - C Rippke
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - W Johnen
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - P Mann
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - E Hellwich
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - A Schwahofer
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - S Dorsch
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - C Buchele
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - S Klüter
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - C P Karger
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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Thorwarth D, Low DA. Technical Challenges of Real-Time Adaptive MR-Guided Radiotherapy. Front Oncol 2021; 11:634507. [PMID: 33763369 PMCID: PMC7982516 DOI: 10.3389/fonc.2021.634507] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/26/2021] [Indexed: 12/18/2022] Open
Abstract
In the past few years, radiotherapy (RT) has experienced a major technological innovation with the development of hybrid machines combining magnetic resonance (MR) imaging and linear accelerators. This new technology for MR-guided cancer treatment has the potential to revolutionize the field of adaptive RT due to the opportunity to provide high-resolution, real-time MR imaging before and during treatment application. However, from a technical point of view, several challenges remain which need to be tackled to ensure safe and robust real-time adaptive MR-guided RT delivery. In this manuscript, several technical challenges to MR-guided RT are discussed. Starting with magnetic field strength tradeoffs, the potential and limitations for purely MR-based RT workflows are discussed. Furthermore, the current status of real-time 3D MR imaging and its potential for real-time RT are summarized. Finally, the potential of quantitative MR imaging for future biological RT adaptation is highlighted.
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Affiliation(s)
- Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Daniel A Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
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10
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Axford A, Dikaios N, Roberts DA, Clark CH, Evans PM. An end-to-end assessment on the accuracy of adaptive radiotherapy in an MR-linac. Phys Med Biol 2021; 66:055021. [PMID: 33503604 DOI: 10.1088/1361-6560/abe053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To develop and demonstrate an end-to-end assessment procedure for adaptive radiotherapy (ART) within an MR-guided system. METHODS AND MATERIALS A 3D printed pelvic phantom was designed and constructed for use in this study. The phantom was put through the complete radiotherapy treatment chain, with planned internal changes made to model prostate translations and shape changes, allowing an investigation into three ART techniques commonly used. Absolute dosimetry measurements were made within the phantom using both gafchromic film and alanine. Comparisons between treatment planning system (TPS) calculations and measured dose values were made using the gamma evaluation with criteria of 3 mm/3% and 2 mm/2%. RESULTS Gamma analysis evaluations for each type of treatment plan adaptation investigated showed a very high agreement with pass rates for each experiment ranging from 98.10% to 99.70% and 92.60% to 97.55%, for criteria of 3%/3 mm and 2%/2 mm respectively. These pass rates were consistent for both shape and position changes. Alanine measurements further supported the results, showing an average difference of 1.98% from the TPS. CONCLUSION The end-to-end assessment procedure provided demanding challenges for treatment plan adaptations to demonstrate the capabilities and achieved high consistency in all findings.
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Affiliation(s)
- A Axford
- The Centre for Vision Speech and Signal Processing (CVSSP), University of Surrey, Guildford, Surrey, United Kingdom. Metrology for Medical Physics (MEMPHYS), National Physical Laboratory, Teddington, United Kingdom
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11
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Perkins T, Lee D, Simpson J, Greer P, Goodwin J. Experimental evaluation of four-dimensional Magnetic Resonance Imaging for radiotherapy planning of lung cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 17:32-35. [PMID: 33898775 PMCID: PMC8058028 DOI: 10.1016/j.phro.2020.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 12/25/2022]
Abstract
Radiotherapy planning for lung cancer typically requires both 3D and 4D Computed Tomography (CT) to account for respiratory related movement. 4D Magnetic Resonance Imaging (MRI) with self-navigation offers a potential alternative with greater reliability in patients with irregular breathing patterns and improved soft tissue contrast. In this study 4D-CT and a 4D-MRI Radial Volumetric Interpolated Breath-hold Examination (VIBE) sequence was evaluated with a 4D phantom and 13 patient respiratory patterns, simulating tumour motion. Quantification of motion related tumour displacement in 4D-MRI and 4D-CT found no statistically significant difference in mean motion range. The results demonstrated the potential viability of 4D-MRI for lung cancer treatment planning.
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Affiliation(s)
- Terry Perkins
- Blacktown Cancer & Haematology Centre, Blacktown Hospital, NSW, Australia.,School of Physics, University of Sydney, Australia
| | - Danny Lee
- School of Mathematical and Physical Science, University of Newcastle, Australia
| | - John Simpson
- Radiation Oncology, Calvary Mater Newcastle, Australia.,School of Mathematical and Physical Science, University of Newcastle, Australia
| | - Peter Greer
- Radiation Oncology, Calvary Mater Newcastle, Australia.,School of Mathematical and Physical Science, University of Newcastle, Australia
| | - Jonathan Goodwin
- Radiation Oncology, Calvary Mater Newcastle, Australia.,School of Mathematical and Physical Science, University of Newcastle, Australia
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