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Lai J, Luo Z, Jiang L, Hu H, Gao C, Zhang C, Chen L, Wu J, Wu Z. Skin marker combined with surface-guided auto-positioning for breast DIBH radiotherapy daily initial patient setup: An optimal schedule for both accuracy and efficiency. J Appl Clin Med Phys 2024; 25:e14319. [PMID: 38522035 DOI: 10.1002/acm2.14319] [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: 07/23/2023] [Revised: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND AND PURPOSE By employing three surface-guided radiotherapy (SGRT)-assisted positioning methods, we conducted a prospective study of patients undergoing SGRT-based deep inspiration breath-hold (DIBH) radiotherapy using a Sentine/Catalys system. The aim of this study was to optimize the initial positioning workflow of SGRT-DIBH radiotherapy for breast cancer. MATERIALS AND METHODS A total of 124 patients were divided into three groups to conduct a prospective comparative study of the setup accuracy and efficiency for the daily initial setup of SGRT-DIBH breast radiotherapy. Group A was subjected to skin marker plus SGRT verification, Group B underwent SGRT optical feedback plus auto-positioning, and Group C was subjected to skin marker plus SGRT auto-positioning. We evaluated setup accuracy and efficiency using cone-beam computed tomography (CBCT) verification data and the total setup time. RESULTS In groups A, B, and C, the mean and standard deviation of the translational setup-error vectors were small, with the highest values of the three directions observed in group A (2.4 ± 1.6, 2.9 ± 1.8, and 2.8 ± 2.1 mm). The rotational vectors in group B (1.8 ± 0.7°, 2.1 ± 0.8°, and 1.8 ± 0.7°) were significantly larger than those in groups A and C, and the Group C setup required the shortest amount of time, at 1.5 ± 0.3 min, while that of Group B took the longest time, at 2.6 ± 0.9 min. CONCLUSION SGRT one-key calibration was found to be more suitable when followed by skin marker/tattoo and in-room laser positioning, establishing it as an optimal daily initial set-up protocol for breast DIBH radiotherapy. This modality also proved to be suitable for free-breathing breast cancer radiotherapy, and its widespread clinical use is recommended.
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Affiliation(s)
- Jianjun Lai
- Instiute of Intelligent Control and Robotics, Hangzhou Dianzi University, Hangzhou, China
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Zhizeng Luo
- Instiute of Intelligent Control and Robotics, Hangzhou Dianzi University, Hangzhou, China
| | - Lu Jiang
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Haili Hu
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Chang Gao
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Chuanfeng Zhang
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Liting Chen
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Jing Wu
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
| | - Zhibing Wu
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, China
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Pires AM, Carvalho L, Santos AC, Vilaça AM, Coelho AR, Oliveira C, Costa C, Fernandes F, Moreira L, Lima J, Vieira R, Ferraz MJ, Silva M, Silva P, Matias R, Zorro S, Costa S, Sarandão S, Barros AF. Radiation Therapy Skin Marking with Lancets Versus Electric Marking Pen (COMFORTATTOO)-6 Months Results on Cosmesis, Fading, and Patients' Satisfaction From a Randomized, Double-Blind Trial. Adv Radiat Oncol 2024; 9:101404. [PMID: 38292889 PMCID: PMC10823085 DOI: 10.1016/j.adro.2023.101404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 10/05/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose Most of radiation oncology centers rely on set-up skin markings for patient setup during treatment delivery. Permanent dark-ink tattooing is the most popular marking method. COMFORTATTOO is a unicentric, randomized trial testing 2 permanent methods: lancets against an electric marking pen (Comfort Marker 2.0, CM). One substudy was undertaken to test if using the CM translates into a cosmesis, fading, or satisfaction benefit compared with the lancets. Methods and Materials Patients aged 18 years or older referred to our department to receive RT were recruited. They were randomly assigned, in a 1:1 ratio, to receive set-up markings using lancets or CM. This substudy aimed to recruit all the living participants included in the main study. The primary endpoints were tattoos cosmesis, tattoos fading, and patients' satisfaction 6 months after finishing the RT. Cosmetic and fading assessments were scored on a 5-point ascending scale and patients' satisfaction on a 10-point ascending scale. The trial is registered at ClinicalTrials.gov (number NCT05371795). Results Between April and September 2022, 92 patients were enrolled (45 assigned to lancets and 47 to CM) and assessed for the outcomes. Patients receiving CM had significantly better cosmetic markings, with a median score of 4.4 (vs 3.7 for lancets, P<.001). On the fading assessment, the CM was associated with lower scores compared with the lancets (median score of 1.3 and 3.3, respectively; P<.001). No differences in patients' satisfaction were observed with either method (median score of 10 for both arms, P=.952). Conclusions Our substudy results demonstrated that, 6 months after the end of RT, the CM produces better cosmetic markings with less fading compared with the lancets. These differences didn't translate into patients' satisfaction superiority toward any method.
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Affiliation(s)
- André M. Pires
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Luísa Carvalho
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Ana C. Santos
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Ana M. Vilaça
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Ana R. Coelho
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Celeste Oliveira
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Céline Costa
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Flávia Fernandes
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Liliana Moreira
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - João Lima
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Rafaela Vieira
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Maria J. Ferraz
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Marta Silva
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Pedro Silva
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Rafael Matias
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Sara Zorro
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Susana Costa
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Susana Sarandão
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
| | - Ana F. Barros
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr António Bernardino de Almeida, Porto, Portugal
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Bellala R, Kuppusamy A, Bellala VM, Tyagi T, Manoharan S, Gangarapu G, Bellala R. Review of clinical applications and challenges with surface-guided radiation therapy. J Cancer Res Ther 2023; 19:1160-1169. [PMID: 37787279 DOI: 10.4103/jcrt.jcrt_1147_21] [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] [Indexed: 10/04/2023]
Abstract
Aim To evaluate the use of this new technique, surface-guided radiotherapy (SGRT), for patient setup and motion management in various cancers. Materials and Methods Data was collected from 533 patients, who received treatment in our hospital for various malignancies using SGRT from October 2019 to April 2021. We studied patient setup, interfraction position, and patient position during the breath-hold (BH) technique. The main advantage of SGRT is that, it is completely non-invasive and uses visible light to compare the patient's skin surface in the treatment room and planned treatment position. In this analysis, Monaco 5.51.10 (Elekta) treatment planning system, Versa HD Linear Accelerator, and AlignRT 6.2 (Vision RT) SGRT system were used. Results With SGRT, treatment setup time can be reduced with more precision and techniques like Deep inspiration breathhold (DIBH) can be done with very good compliance. Conclusion SGRT has shown improved accuracy in patient setup compared to conventional laser setup. The daily kilo voltage imaging frequency can be reduced; it helps in reducing additional radiation exposure due to imaging. SGRT has demonstrated reproducibility with adequate accuracy in BH treatments in DIBH for breast and SBRT.
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Affiliation(s)
- Ravishankar Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Anandakrishnan Kuppusamy
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Venkat Madhavi Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Tulika Tyagi
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Surendhiran Manoharan
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Gunasekhar Gangarapu
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Rishik Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
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Mueller B, Song Y, Chia-Ko W, Hsu HY, Zhai X, Tamas P, Powell S, Cahlon O, McCormick B, Khan A, Gillespie E, Cervino L, Zhao B, Hong L, Braunstein LZ. Accuracy and Efficiency of Patient Setup Using Surface Imaging versus Skin Tattoos for Accelerated Partial Breast Irradiation. Adv Radiat Oncol 2023; 8:101183. [PMID: 36896216 PMCID: PMC9991531 DOI: 10.1016/j.adro.2023.101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 01/11/2023] [Indexed: 01/27/2023] Open
Abstract
Purpose Skin tattoos represent the standard approach for surface alignment and setup of breast cancer radiation therapy, yet permanent skin markings contribute to adverse cosmesis and patient dissatisfaction. With the advent of contemporary surface-imaging technology, we evaluated setup accuracy and timing between "tattoo-less" and traditional tattoo-based setup techniques. Methods and Materials Patients receiving accelerated partial breast irradiation (APBI) underwent traditional tattoo-based setup (TTB), alternating daily with a tattoo-less setup via surface imaging using AlignRT (ART). Following initial setup, position was verified via daily kV imaging, with matching on surgical clips representing ground truth. Translational shifts (TS) and rotational shifts (RS) were ascertained, as were setup time and total in-room time. Statistical analyses used the Wilcoxon signed rank test and Pitman-Morgan variance test. Results A total of 43 patients receiving APBI and 356 treatment fractions were analyzed (174 TTB fractions and 182 using ART). For tattoo-less setup via ART, the median absolute TS were 0.31 cm in the vertical (range, 0.08-0.82), 0.23 cm in the lateral (0.05-0.86), and 0.26 cm in the longitudinal (0.02-0.72) axes. For TTB setup, the corresponding median TS were 0.34 cm (0.05-1.98), 0.31 cm (0.09-1.84), and 0.34 cm (0.08-1.25), respectively. The median magnitude shifts were 0.59 (0.30-1.31) for ART and 0.80 (0.27-2.13) for TTB. ART was not statistically distinguishable from TTB in terms of TS, except in the longitudinal direction (P = .154, .059, and .021, respectively), and was superior to TTB for magnitude shift (P < .001). The variance of each TS variable was significantly narrower for ART compared with TTB (P ≤ .001 vertical, P = .001 lateral, P = .005 longitudinal). The median absolute RS for ART was 0.64° rotation (range, 0.00-1.90), 0.65° roll (0.05-2.90), and 0.30° pitch (0.00-1.50). The corresponding median RS for TTB were 0.80° (0.00-2.50), 0.64° (0.00-3.00), and 0.46° (0.00-2.90), respectively. ART setup was not statistically different from TTB in terms of RS (P = .868, .236, and .079, respectively). ART showed lower variance than TTB in terms of pitch (P = .009). The median total in-room time was shorter for ART than TTB (15.42 vs 17.25 minutes; P = .008), as was the median setup time (11.12 vs 13.00 minutes; P = .001). Moreover, ART had a narrower distribution of setup time with fewer lengthy outliers versus TTB. Conclusions These findings suggest that a tattoo-less setup approach with AlignRT may be sufficiently accurate and expeditious to supplant surface tattoos for patients receiving APBI. Further analyses with larger cohorts will determine whether tattoo-based approaches can be replaced by noninvasive surface imaging.
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Affiliation(s)
- Boris Mueller
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yulin Song
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wang Chia-Ko
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hao-Yun Hsu
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Xingchen Zhai
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Tamas
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon Powell
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif Khan
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin Gillespie
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura Cervino
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bo Zhao
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Hong
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z Braunstein
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Zhang G, Jiang Z, Zhu J, Dai T, He X, Liu X, Chang Y, Wang L. Innovative integration of augmented reality and optical surface imaging: A coarse-to-precise system for radiotherapy positioning. Med Phys 2023. [PMID: 37060328 DOI: 10.1002/mp.16417] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 04/01/2023] [Accepted: 04/02/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Traditional methods of radiotherapy positioning have shortcomings such as fragile skin-markers, additional doses, and lack of information integration. Emerging technologies may provide alternatives for the relevant clinical practice. PURPOSE To propose a noninvasive radiotherapy positioning system integrating augmented reality (AR) and optical surface, and to evaluate its feasibility in clinical workflow. METHODS AR and structured light-based surface were integrated to implement the coarse-to-precise positioning through two coherent steps, the AR-based coarse guidance and the optical surface-based precise verification. To implement quality assurance, recognition of face and pattern was used for patient authentication, case association, and accessory validation in AR scenes. The holographic images reconstructed from simulation computed tomography (CT) images, guided the initial posture correction by virtual-real alignment. The point clouds of body surface were fused, with the calibration and pose estimation of structured light cameras, and segmented according to the preset regions of interest (ROIs). The global-to-local registration for cross-source point clouds was achieved to calculate couch shifts in six degrees-of-freedom (DoF), which were ultimately transmitted to AR scenes. The evaluation based on phantom and human-body (4 volunteers) included, (i) quality assurance workflow, (ii) errors of both steps and correlation analysis, (iii) receiver operating characteristic (ROC), (iv) distance characteristics of accuracy, and (v) clinical positioning efficiency. RESULTS The maximum errors in phantom evaluation were 3.4 ± 2.5 mm in Vrt and 1.4 ± 1.0° in Pitch for the coarse guidance step, while 1.6 ± 0.9 mm in Vrt and 0.6 ± 0.4° in Pitch for the precise verification step. The Pearson correlation coefficients between precise verification and cone beam CT (CBCT) results were distributed in the interval [0.81, 0.85]. In ROC analysis, the areas under the curve (AUC) were 0.87 and 0.89 for translation and rotation, respectively. In human body-based evaluation, the errors of thorax and abdomen (T&A) were significantly greater than those of head and neck (H&N) in Vrt (2.6 ± 1.1 vs. 1.7 ± 0.8, p < 0.01), Lng (2.3 ± 1.1 vs. 1.4 ± 0.9, p < 0.01), and Rtn (0.8 ± 0.4 vs. 0.6 ± 0.3, p = 0.01) while relatively similar in Lat (1.8 ± 0.9 vs. 1.7 ± 0.8, p = 0.07). The translation displacement range, after coarse guidance step, required for high accuracy of the optical surface component of the integrated system was 0-42 mm, and the average positioning duration of the integrated system was significantly less than that of conventional workflow (355.7 ± 21.7 vs. 387.7 ± 26.6 s, p < 0.01). CONCLUSIONS The combination of AR and optical surface has utility and feasibility for patient positioning, in terms of both safety and accuracy.
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Affiliation(s)
- Gongsen Zhang
- Artificial Intelligence Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Zejun Jiang
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Jian Zhu
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Tianyuan Dai
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Xiaolong He
- Artificial Intelligence Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Xinchao Liu
- Cheeloo College of Medicine, Shandong University, Ji'nan, Shandong, China
| | - Yankui Chang
- School of Nuclear Science and Technology, University of Science and Technology of China, Hefei, China
| | - Linlin Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
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Gorecki A, Sorgato V, Mazzara C, Clément S, Fric D, Farah J. SurVolT: Surface to Volume conversion Tool. A proof of concept. Phys Med 2023; 108:102566. [PMID: 36989979 DOI: 10.1016/j.ejmp.2023.102566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
PURPOSE To develop SurVolT, a conversion tool able to apply volumetric changes to DICOM Computed Tomography (CT) data using daily surface (obj) data acquired with AlignRT® (VisionRT Ltd.), primarily designed and validated for breast treatments. MATERIALS AND METHODS SurVolT proceeds in 4 steps: 1. AlignRT .obj files extraction, 2. Contour deformation where the surface data points are matched to the initial external contour on a Region Of Interest, ROImatch, on which the anatomy is supposed to be unchanged. Then, external contour substitution is performed on the ROIttt covering the treated breast area. This is validated on a female torso phantom with a tissue-equivalent bolus mimicking an edema. The Planning Treatment Volume (PTV) contour from the initial CT is also deformed according to the new external contour in the ROIttt. 3. Volumetric data estimation according to the new external contour, validated on an anthropomorphic pelvis phantom. 4. Import of new DICOM data into the Treatment Planning System (TPS). Finally, the workflow is applied on a first patient presenting an anatomical change during the treatment. RESULTS The validation of step 2 and 3 shows a bolus thickness estimation of 5.8±1.2mm (expected 5 mm) and the non-rigid deformation of initial CT images follows the new external contour at the ROIttt bolus site while revealing negligible deformation elsewhere. CONCLUSION This first proof of concept introducing a Surface Guided Radiotherapy (SGRT) tool allowing daily surface data to volume conversion is a fundamental step toward SGRT-based adaptive radiotherapy.
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Parsons D, Joo M, Iqbal Z, Godley A, Kim N, Spangler A, Albuquerque K, Sawant A, Zhao B, Gu X, Rahimi A. Stability and reproducibility comparisons between deep inspiration breath-hold techniques for left-sided breast cancer patients: A prospective study. J Appl Clin Med Phys 2023; 24:e13906. [PMID: 36691339 PMCID: PMC10161105 DOI: 10.1002/acm2.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/06/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Deep inspiration breath-hold (DIBH) is crucial in reducing the lung and cardiac dose for treatment of left-sided breast cancer. We compared the stability and reproducibility of two DIBH techniques: Active Breathing Coordinator (ABC) and VisionRT (VRT). MATERIALS AND METHODS We examined intra- and inter-fraction positional variation of the left lung. Eight left-sided breast cancer patients were monitored with electronic portal imaging during breath-hold (BH) at every fraction. For each patient, half of the fractions were treated using ABC and the other half with VRT, with an equal amount starting with either ABC or VRT. The lung in each portal image was delineated, and the variation of its area was evaluated. Intrafraction stability was evaluated as the mean coefficient of variation (CV) of the lung area for the supraclavicular (SCV) and left lateral (LLat) field over the course of treatment. Reproducibility was the CV for the first image of each fraction. Daily session time and total imaging monitor units (MU) used in patient positioning were recorded. RESULTS The mean intrafraction stability across all patients for the LLat field was 1.3 ± 0.7% and 1.5 ± 0.9% for VRT and ABC, respectively. Similarly, this was 1.5 ± 0.7% and 1.6 ± 0.8% for VRT and ABC, respectively, for the SCV field. The mean interfraction reproducibility for the LLat field was 11.0 ± 3.4% and 14.9 ± 6.0% for VRT and ABC, respectively. Similarly, this was 13.0 ± 2.5% and 14.8 ± 9% for VRT and ABC, respectively, for the SCV. No difference was observed in the number of verification images required for either technique. CONCLUSIONS The stability and reproducibility were found to be comparable between ABC and VRT. ABC can have larger interfractional variation with less feedback to the treating therapist compared to VRT as shown in the increase in geometric misses at the matchline.
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Affiliation(s)
- David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mindy Joo
- Department of Radiation Oncology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Zohaib Iqbal
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew Godley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nathan Kim
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ann Spangler
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Amit Sawant
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bo Zhao
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Xuejun Gu
- Department of Radiation Oncology, Stanford University, Palo Alto, California, USA
| | - Asal Rahimi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Pires AM, Carvalho L, Santos AC, Vilaça AM, Coelho AR, Fernandes F, Moreira L, Lima J, Vieira R, Ferraz MJ, Silva M, Silva P, Matias R, Zorro S, Costa S, Sarandão S, Barros AF. Radiotherapy skin marking with lancets versus electric marking pen - Comfort, satisfaction, effectiveness and cosmesis results from the randomized, double-blind COMFORTATTOO trial. Radiography (Lond) 2023; 29:171-177. [PMID: 36410128 DOI: 10.1016/j.radi.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/13/2022] [Accepted: 10/28/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Set-up skin markings are performed, in several centers, for radiotherapy (RT) treatments. This study aimed to compare two permanent methods: lancets and an electric marking pen, the Comfort Marker 2.0® (CM). METHODS This was a prospective, unicentric, randomized study. Patients aged 18 years or older referred to our department to receive RT were recruited. Patients were randomly assigned, in a 1:1 ratio, to receive set-up markings using lancets or CM. The markings arrangement followed our departmental protocols. The coprimary endpoints were patients' comfort and effectiveness. Secondary endpoints included radiation therapists (RTTs) satisfaction and cosmesis. RESULTS Between October 2021 and January 2022, 100 patients were enrolled (50 received lancets and 50 CM) and assessed for the comfort and satisfaction outcomes. CM was significantly less painful than the lancets, with 44% and 16% of the patients, respectively, considering the tattooing process painless (RR = 2.75; 95% IC: 1.36 - 5.58). On the RTT-reported satisfaction, CM had significantly easier processes than lancets (98.0% vs. 78.0%, respectively; RR = 1.26; 95% CI: 1.08 - 1.46). For effectiveness and cosmesis assessment, 98 patients were analyzed (48 received lancets and 50 CM). Patients receiving CM had a significantly higher proportion of markings graded as good and excellent compared to those receiving lancets (98.0% and 50.0%, respectively, had ≥75% of the tattoos assessed as good/excellent, RR = 1.96; 95% CI: 1.47 - 2.61). On the cosmetic evaluation, patients receiving CM had significantly better cosmetic markings, with a median score of 4.4 (vs. 3.5 for lancets, p <0.001). CONCLUSION The trial results demonstrated that tattooing with the CM is significantly less painful, more effective, easier to apply, and cosmetically superior to tattooing with lancets. IMPLICATIONS FOR PRACTICE Tattooing with CM allows for better results regarding pain, quality, ease and cosmesis.
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Affiliation(s)
- A M Pires
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal.
| | - L Carvalho
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - A C Santos
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - A M Vilaça
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - A R Coelho
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - F Fernandes
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - L Moreira
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - J Lima
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - R Vieira
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - M J Ferraz
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - M Silva
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - P Silva
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - R Matias
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - S Zorro
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - S Costa
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - S Sarandão
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
| | - A F Barros
- Radiation Oncology Department, Portuguese Institute of Oncology of Porto, R. Dr. António Bernardino de Almeida 865, 4200-072, Porto, Portugal
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9
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Sauer TO, Ott OJ, Lahmer G, Fietkau R, Bert C. Prerequisites for the clinical implementation of a markerless SGRT-only workflow for the treatment of breast cancer patients. Strahlenther Onkol 2023; 199:22-29. [PMID: 35788694 PMCID: PMC9839804 DOI: 10.1007/s00066-022-01966-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/23/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE A markerless workflow for the treatment of breast cancer patients has been introduced and evaluated retrospectively. It includes surface-guided radiation therapy (SGRT)-only positioning for patients with small cone beam CT (CBCT) position corrections during the first five fractions. Prerequisites and the frequency of its clinical application were evaluated, as well as potential benefits in terms of treatment time and dose savings, the frequency of CBCT scans, and the accuracy of the positioning. METHODS A group of 100 patients treated with the new workflow on two Versa HD linacs has been compared to a matched control group of patients treated with the former workflow, which included prepositioning with skin markings and lasers, SGRT and daily CBCT. The comparison was based on the evaluation of logfiles. RESULTS Of the patients treated with the new workflow, 40% did not receive daily CBCT scans. This resulted in mean time savings of 97 s, 166 s and 239 s per fraction for the new workflow, for patients treated without daily CBCT and for SGRT-only fractions, respectively, when compared to the old workflow. Dose savings amounted to a weighted computed tomography dose index reduction of CTDIW = 2.56 cGy on average for normofractionated treatment and weekly CBCTs, while for patients not treated with daily CBCT, SGRT-based positioning accuracy was 5.2 mm for the mean translational magnitude, as evaluated by CBCT. CONCLUSION For 40% of the patients, after five fractions with small CBCT corrections, the workflow could be changed to SGRT-only positioning with weekly CBCT. This leads to imaging dose and time savings and thus also reduced intrafraction motion, potentially increased patient throughput and patient comfort, while assuring appropriate positioning accuracy.
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Affiliation(s)
- Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany ,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Oliver J. Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany ,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Godehard Lahmer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany ,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany ,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany ,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
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10
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Svestad JG, Heydari M, Mikalsen SG, Flote VG, Nordby F, Hellebust TP. Surface-guided positioning eliminates the need for skin markers in radiotherapy of right sided breast cancer: A single center randomized crossover trial. Radiother Oncol 2022; 177:46-52. [PMID: 36309152 DOI: 10.1016/j.radonc.2022.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/20/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively investigate whether surface guided setup of right sided breast cancer patients can increase efficiency and accuracy compared to traditional skin marker/tattoo based setup. MATERIAL AND METHODS Twenty-five patients were included in this study. Each patient was positioned using skin marks and tattoos (procedure A) for half of the fractions and surface guidance using AlignRT (procedure B) for the other half of the fractions. The order of the two procedures was randomized. Pretreatment CBCT was acquired at every fraction for both setup procedures. A total of ten time points were recorded during every treatment session. Applied couch shifts after CBCT match were recorded and used for potential error calculations if no CBCT had been used. RESULTS In the vertical direction procedure B showed significant smaller population based systematic (Ʃ) and random (σ) errors. However, a significant larger systematic error on the individual patient level (M) was also shown. This was found to be due to patient relaxation between setup and CBCT matching. Procedure B also showed a significant smaller random error in the lateral direction, while no significant differences were seen in the longitudinal direction. No significant difference in setup time was found between the two procedures. CONCLUSION Setup of right sided breast cancer patients using surface guidance yields higher accuracy than setup using skin marks/tattoos and lasers with the same setup time. Patient alignment for this patient group can safely be done without the use of permanent tattoos and skin marks when utilizing surface-guided patient positioning. However, CBCT should still be used as final setup verification.
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Affiliation(s)
| | - Mojgan Heydari
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | | | - Fredrik Nordby
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Taran Paulsen Hellebust
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Norway.
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11
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Costin IC, Marcu LG. Factors impacting on patient setup analysis and error management during breast cancer radiotherapy. Crit Rev Oncol Hematol 2022; 178:103798. [PMID: 36031175 DOI: 10.1016/j.critrevonc.2022.103798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/28/2022] [Accepted: 08/21/2022] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy is required to deliver an accurate dose to the tumor while protecting surrounding normal tissues. Breast cancer radiotherapy involves a number of factors that can influence patient setup and error management, including the immobilization device used, the verification system and the patient's treatment position. The aim of this review is to compile and discuss the setup errors that occur due to the above-mentioned factors. In view of this, a systematic search of the scientific literature in the Medline/PubMed databases was performed over the 1990-2021 time period, with 93 articles found to be relevant for the study. To be accessible to all, this study not only aims to identify factors impacting on patient setup analysis, but also seeks to evaluate the role of each verification device, board immobilization and position in influencing these errors.
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Affiliation(s)
- Ioana-Claudia Costin
- West University of Timisoara, Faculty of Physics, Timisoara, Romania; "Dr. Gavril Curteanu" County Hospital, Oradea 410469, Romania
| | - Loredana G Marcu
- West University of Timisoara, Faculty of Physics, Timisoara, Romania; Faculty of Informatics & Science, University of Oradea, Oradea 410087, Romania; Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia.
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12
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Zhao X, Covington EL, Popple RA. Analysis of a surface imaging system using a six degree-of-freedom couch. J Appl Clin Med Phys 2022; 23:e13697. [PMID: 35819973 PMCID: PMC9359042 DOI: 10.1002/acm2.13697] [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: 10/27/2021] [Revised: 03/31/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To validate surface imaging (SI)‐reported offsets using a six degree‐of‐freedom couch and an anthropomorphic phantom for commissioning and routine quality assurance of an SI system used for stereotactic radiosurgery (SRS). Methods An anthropomorphic phantom with a radiopaque ball bearing (BB) placed either anterior, midline, or posterior, was tracked with SI with a typical SRS region of interest. Couch motion in all six degrees of freedom was programmed and delivered on a linac. SI system logs were synchronized with linac trajectory logs. Ten random couch positions were selected at couch 0°, 45°, 90°, 270°, 315° with megavolt (MV) images taken to account for couch walkout. The SI residual error (ε), the difference between SI reported offset and MV or trajectory log position, was calculated. Residual errors were measured with and without one SI pod blocked. Results The median [range] of magnitude of translational ε was 0.13 [0.07, 0.21], 0.16 [0.11, 0.26], 0.61 [0.50, 0.68], 0.49 [0.42, 0.55], 0.55 [0.38, 0.72] mm for couch rotations of 0°, 45°, 90°, 270°, 315°, respectively, for the midline BB and no pod blocked. The range of all translational ε from all couch angles (with and without pod block) at different BB positions is [0.05, 0.96] mm. The absolute range of difference when changing BB position when no pod is blocked in median translational ε is [0.01, 0.40] mm with the maximum at BB posterior. The absolute range of difference when not changing BB positions with and without pod block in median translational ε is [0.01, 0.37] mm with the maximum at BB posterior and couch 315°. Conclusion SI system and linac trajectory log analysis can be used to assess SI system performance with automated couch motion to validate SI accuracy.
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Affiliation(s)
- Xiaodong Zhao
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth L Covington
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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13
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Batista V, Gober M, Moura F, Webster A, Oellers M, Ramtohul M, Kügele M, Freislederer P, Buschmann M, Anastasi G, Steiner E, Al-Hallaq H, Lehmann J. Surface guided radiation therapy: An international survey on current clinical practice. Tech Innov Patient Support Radiat Oncol 2022; 22:1-8. [PMID: 35402740 PMCID: PMC8984757 DOI: 10.1016/j.tipsro.2022.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/25/2022] [Accepted: 03/21/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Surface Guided Radiation Therapy (SGRT) is being increasingly implemented into clinical practice across a number of techniques and irradiation-sites. This technology, which is provided by different vendors, can be used with most simulation- and delivery-systems. However, limited guidelines and the complexity of clinical settings have led to diverse patterns of operation. With the aim to understand current clinical practice a survey was designed focusing on specifics of the clinical implementation and usage. Materials and methods A 32-question survey covered: type and number of systems, quality assurance (QA), clinical workflows, and identification of strengths/limitations. Respondents from different professional groups and countries were invited to participate. The survey was distributed internationally via ESTRO-membership, social media and vendors. Results Of the 278 institutions responding, 172 had at least one SGRT-system and 136 use SGRT clinically. Implementation and QA were primarily based on the vendors' recommendations and phantoms. SGRT was mainly implemented in breast RT (116/136), with strong but diverse representation of other sites. Many (58/135) reported at least partial elimination of skin-marks and a third (43/126) used open-masks. The most common imaging protocol reported included the combination of radiographic imaging with SGRT. Patient positioning (115/136), motion management (104/136) and DIBH (99/136) were the main applications.Main barriers to broader application were cost, system integration issues and lack of demonstrated clinical value. A lack of guidelines in terms of QA of the system was highlighted. Conclusions This overview of the SGRT status has the potential to support users, vendors and organisations in the development of practices, products and guidelines.
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Affiliation(s)
- V Batista
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany
| | - M Gober
- Department of Radiation Oncology, Medical University of Vienna, Austria.,Institute for Radiation Oncology and Radiotherapy, Landesklinikum Wiener Neustadt, Austria
| | - F Moura
- Hospital CUF Descobertas, Department of Radiation Oncology, Lisbon, Portugal
| | - A Webster
- Radiotherapy and Proton Beam Therapy, University College Hospital, London, United Kingdom
| | - M Oellers
- MAASTRO Clinic, Department of Medical Physics, Maastricht, the Netherlands
| | - M Ramtohul
- Department of Medical Physics, Queen Elizabeth Hospital, University Hospitals Birmingham
| | - M Kügele
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Medical Radiation Physics, Lund University, Lund, Sweden
| | - P Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M Buschmann
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | - G Anastasi
- St. Luke's Cancer Centre, Royal Surrey Foundation Trust, Radiotherapy Physics, United Kingdom
| | - E Steiner
- Institute for Radiation Oncology and Radiotherapy, Landesklinikum Wiener Neustadt, Austria
| | - H Al-Hallaq
- Department of Radiation and Cellular Oncology, University of Chicago, USA
| | - J Lehmann
- Radiation Oncology Department, Calvary Mater Newcastle, Australia.,School of Information and Physical Sciences, University of Newcastle, Callaghan, Australia.,Institute of Medical Physics, University of Sydney, Australia
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14
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Naidoo W, Leech M. Feasibility of surface guided radiotherapy for patient positioning in breast radiotherapy versus conventional tattoo-based setups- a systematic review. Tech Innov Patient Support Radiat Oncol 2022; 22:39-49. [PMID: 35481261 PMCID: PMC9035716 DOI: 10.1016/j.tipsro.2022.03.001] [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: 11/11/2021] [Revised: 02/07/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background Traditionally tattoos are used for patient setup in radiotherapy. However they may pose challenges for the radiotherapists to achieve precise patient alignment, and serve as a permanent visual reminder of the patient’s diagnosis and often challenging cancer journey. The psychological impact of tattoos has been recognized in recent years. The increasing complexity of treatment techniques and the utilization of hypofractionated regimes, requires an enhanced level of accuracy and safety. Surface guided radiotherapy (SGRT) enables improvements in the accuracy and reproducibility of patient isocentric and postural alignment, enhanced efficiency, and safety in breast radiotherapy. Purpose The aim of this review was to compare the accuracy and reproducibility of SGRT to conventional tattoo-based setups in free-breathing breast radiotherapy and to determine if SGRT can reduce the frequency of routine image guided radiotherapy (IGRT). Materials and Methods A systematic literature review was performed as per PRISMA guidelines. Papers identified through PubMed, Embase, Web of Science and Google Scholar database searches between 2010 and 2021, were critically appraised. Systematic, random, mean residual errors and 3D vector shifts as determined by IGRT verification were analysed. Results A review of 13 full papers suggests SGRT improves the accuracy and reproducibility of patient setup in breast radiotherapy with consistent reductions in the residual errors. There appears to be a good correlation between SGRT setups and radiographic imaging. The frequency of IGRT and the corresponding dose could potentially be reduced. Additionally, SGRT improves treatment efficiency. Conclusion SGRT appears to have improved the accuracy and reproducibility of patient setup and treatment efficiency of breast radiotherapy compared to conventional tattoo/laser-based method, with the potential to reduce the frequency of routine IGRT. The reliance on tattoos in breast radiotherapy are likely to become obsolete with positive implications for both patients and clinical practice.
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15
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Evaluation of the clinical implementation of a tattoo-free positioning technique in breast cancer radiotherapy using ExacTrac. Phys Med 2022; 98:81-87. [DOI: 10.1016/j.ejmp.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 02/28/2022] [Accepted: 04/27/2022] [Indexed: 11/18/2022] Open
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16
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Jiang P, Liu Z, Jiang W, Qu A, Sun H, Wang J. Detection of setup errors with a body-surface laser-scanning system for whole-breast irradiation after breast-conserving surgery. J Appl Clin Med Phys 2022; 23:e13578. [PMID: 35293667 PMCID: PMC9121044 DOI: 10.1002/acm2.13578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/23/2022] [Accepted: 02/15/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE We compared the setup errors determined by an optical imaging system (OSIS) in women who received breast-conserving surgery (BCS) followed by whole-breast radiotherapy (WBRT) with those from cone-beam computed tomography (CBCT) carried out routinely. METHODS We compared 130 setup errors in 10 patients undergoing WBRT following BCS by analyzing the translational and rotational couch shifts via CBCT and OSIS. Patients were treated with intensity-modulated radiotherapy (IMRT). The patient outline extracted from the planning reference Computed tomography (CT) was used as the reference for OSIS and CBCT alignment during treatment. We detected the setup uncertainty using CBCT and OSIS at the first five fractionations of RT and then twice a week. RESULTS The absolute translational setup error (mean ± Standard deviation (SD)) in x (lateral), y (longitudinal), and z (vertical) axes detected by the OSIS was 0.14 ± 0.18, 0.15 ± 0.14, and 0.13 ± 0.13 cm, respectively. The rotational setup error (mean ± SD) in Rx (pitch), Ry (roll), and Rz (yaw) axes was 0.77 ± 0.54, 0.76 ± 0.61, and 1.23 ± 0.95, respectively. Significant difference is observed only in one direction (Rx, p = 0.03) in the paired setup errors obtaining from OSIS and CBCT, without significant differences in five directions. CONCLUSION OSIS is a repeatable and reliable system that can be used to detect misalignments with accuracy, which is capable of supplementing CBCT for WBRT after BCS. We believe that an OSIS may be easier to use, quicker, and reduce overall dose as this method of patient alignment does not require ionizing radiation.
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Affiliation(s)
- Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ziyi Liu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Weijuan Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ang Qu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Haitao Sun
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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17
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Benchmarking the AlignRT surface deformation module for the early detection and quantification of oedema in breast cancer radiotherapy. Tech Innov Patient Support Radiat Oncol 2022; 21:16-22. [PMID: 35079643 PMCID: PMC8777118 DOI: 10.1016/j.tipsro.2021.12.002] [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: 08/25/2021] [Revised: 11/12/2021] [Accepted: 12/16/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine the accuracy of AlignRT surface deformation module in detecting and quantifying oedema in breast cancer radiotherapy. Materials and Methods A female torso phantom and water-equivalent boluses of different thicknesses (0.5–1.5 cm) were used. The variation of surface displacement and the percentage of surface within tolerance, as a function of bolus thickness and Region of Interest (ROI) size, were investigated. Additionally, a dynamic phantom was used to study the impact of patient breathing on the swelling estimation. Lastly, a flowchart was derived to alert physicians in the case of breast swelling. Results Average displacement value proved to be inversely correlated with ROI size (R2 > 0.9). As such, for a ROI smaller than the bolus size (2.5x2.5 cm2), the average displacement (1.05 cm) provides an accurate estimate of the oedema thickness (within 5%). In opposition, with a clinical ROI, the 1 cm-thick bolus was largely underestimated with an average displacement value of 0.28 cm only. To limit the impact of patient breathing on surface deformation, dynamic surface captures and the use of the corrected patient position should be privileged. Using AlignRT, a clinical workflow for breast swelling follow-up was developed to help in the decision for repeat simulation and dosimetry. Conclusion The surface deformation module provides an accurate, simple, and radiation-free approach to detect and quantify breast oedema during the course of radiotherapy.
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18
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Al-Hallaq HA, Cerviño L, Gutierrez AN, Havnen-Smith A, Higgins SA, Kügele M, Padilla L, Pawlicki T, Remmes N, Smith K, Tang X, Tomé WA. AAPM task group report 302: Surface guided radiotherapy. Med Phys 2022; 49:e82-e112. [PMID: 35179229 PMCID: PMC9314008 DOI: 10.1002/mp.15532] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/26/2021] [Accepted: 02/05/2022] [Indexed: 11/06/2022] Open
Abstract
The clinical use of surface imaging has increased dramatically with demonstrated utility for initial patient positioning, real-time motion monitoring, and beam gating in a variety of anatomical sites. The Therapy Physics Subcommittee and the Imaging for Treatment Verification Working Group of the American Association of Physicists in Medicine commissioned Task Group 302 to review the current clinical uses of surface imaging and emerging clinical applications. The specific charge of this task group was to provide technical guidelines for clinical indications of use for general positioning, breast deep-inspiration breath-hold (DIBH) treatment, and frameless stereotactic radiosurgery (SRS). Additionally, the task group was charged with providing commissioning and on-going quality assurance (QA) requirements for surface guided radiation therapy (SGRT) as part of a comprehensive QA program including risk assessment. Workflow considerations for other anatomic sites and for computed tomography (CT) simulation, including motion management are also discussed. Finally, developing clinical applications such as stereotactic body radiotherapy (SBRT) or proton radiotherapy are presented. The recommendations made in this report, which are summarized at the end of the report, are applicable to all video-based SGRT systems available at the time of writing. Review current use of non-ionizing surface imaging functionality and commercially available systems. Summarize commissioning and on-going quality assurance (QA) requirements of surface image-guided systems, including implementation of risk or hazard assessment of surface guided radiotherapy as a part of a total quality management program (e.g., TG-100). Provide clinically relevant technical guidelines that include recommendations for the use of SGRT for general patient positioning, breast DIBH, and frameless brain SRS, including potential pitfalls to avoid when implementing this technology. Discuss emerging clinical applications of SGRT and associated QA implications based on evaluation of technology and risk assessment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hania A Al-Hallaq
- Department of Radiation & Cellular Oncology, University of Chicago, Chicago, IL, 60637, USA
| | - Laura Cerviño
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, 33173, USA
| | | | - Susan A Higgins
- Department of Therapeutic Radiology, Yale University, New Haven, CT, 06520, USA
| | - Malin Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University, Lund, 221 00, Sweden.,Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, 221 00, Sweden
| | - Laura Padilla
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Nicholas Remmes
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Koren Smith
- IROC Rhode Island, University of Massachusetts Chan Medical School, Lincoln, RI, 02865, USA
| | | | - Wolfgang A Tomé
- Department of Radiation Oncology and Department of Neurology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, 10461, USA
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19
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Evaluation of image-guided and surface-guided radiotherapy for breast cancer patients treated in deep inspiration breath-hold: A single institution experience. Tech Innov Patient Support Radiat Oncol 2022; 21:51-57. [PMID: 35243045 PMCID: PMC8861395 DOI: 10.1016/j.tipsro.2022.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Nowadays, deep inspiratory breath-hold is a common technique to reduce heart dose in left-sided breast radiotherapy. This study evaluates the evolution of the breath-hold technique in our institute, from portal imaging during dose delivery to continuous monitoring with surface-guided radiotherapy (SGRT). MATERIALS AND METHODS Setup data and portal imaging results were analyzed for 98 patients treated before 2014, and SGRT data for 228 patients treated between 2018 and 2020. For the pre-SGRT group, systematic and random setup errors were calculated for different correction protocols. Residual errors and reproducibility of breath-holds were evaluated for both groups. The benefit of using SGRT for initial positioning was evaluated for another cohort of 47 patients. RESULTS Online correction reduced the population mean error from 3.9 mm (no corrections) to 1.4 mm. Despite online setup correction, deviations greater than 3 mm were observed in about 10% and 20% of the treatment beams in ventral-dorsal and cranial-caudal directions, respectively. However, these percentages were much smaller than with offline protocols or no corrections. Mean absolute differences between breath-holds within a fraction were smaller in the SGRT-group (1.69 mm) than in the pre-SGRT-group (2.10 mm), and further improved with addition of visual feedback (1.30 mm). SGRT for positioning did not improve setup accuracy, but slightly reduced the time for imaging and setup correction, allowing completion within 3.5 min for 95% of fractions. CONCLUSION For accurate radiotherapy breast treatments using deep inspiration breath-hold, daily imaging and correction is required. SGRT provides accurate information on patient positioning during treatment and improves patient compliance with visual feedback.
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Key Words
- (U, V), ventral-dorsal and cranial-caudal direction in the tangential beam, respectively
- Breast
- Breath-hold
- CBCT, cone-beam CT
- CT, computer tomography
- DIBH
- DIBH, Deep inspiratory breath-hold
- DRRs, digitally reconstructed radiographs
- LAT, medio-lateral direction
- LNG, cranial-caudal direction
- NAL, no-action-level setup correction protocol
- OTM, online treatment monitor
- SGRT, surface-guided radiotherapy
- Surface-guided radiotherapy
- VRT, anterior-posterior direction
- eNAL, extended NAL setup correction protocol
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Patient setup accuracy in DIBH radiotherapy of breast cancer with lymph node inclusion using surface tracking and image guidance. Med Dosim 2022; 47:146-150. [PMID: 35039223 DOI: 10.1016/j.meddos.2021.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/20/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022]
Abstract
Studying setup accuracy in breast cancer patients with axillary lymph node inclusion in deep inspiration breath-hold (DIBH) after patient setup with surface-guided radiotherapy (SGRT) and image-guided radiotherapy (IGRT). Breast cancer patients (N = 51) were treated (50 Gy in 25 fractions) with axillary lymph nodes within the planning target volume (PTV). Patient setup was initiated with tattoos and lasers, and further adjusted with SGRT. The DIBH guidance was based on SGRT. Orthogonal and/or tangential imaging was analyzed for residual position errors of bony landmarks, the breath-hold level (BHL), the skin outline, and the heart; and setup margins were calculated for the PTV. The calculated PTV margins were 4.3 to 6.3 and 2.8 to 4.6 mm before and after orthogonal imaging, respectively. The residual errors of the heart were 3.6 ± 2.2 mm and 2.5 ± 2.4 mm before and 3.0 ± 2.5 and 2.9 ± 2.3 mm after orthogonal imaging in the combined anterior-posterior/lateral and the cranio-caudal directions, respectively, in tangential images. The humeral head did not benefit from daily IGRT, but SGRT guided it to the correct location. We presented a slightly complicated but highly accurate workflow for DIBH treatments. The residual position errors after both SGRT and IGRT were excellent compared to previous literature. With well-planned SGRT, IGRT brings only slight improvements to systematic accuracy. However, with the calculated PTV margins and the number of outliers, imaging cannot be omitted despite SGRT, unless the PTV margins are re-evaluated.
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21
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Johnson PB, Jackson A, Saki M, Feldman E, Bradley J. Patient posture correction and alignment using mixed reality visualization and the HoloLens 2. Med Phys 2021; 49:15-22. [PMID: 34780068 DOI: 10.1002/mp.15349] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/08/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The purpose of this study was to develop and preliminarily test a radiotherapy system for patient posture correction and alignment using mixed reality (MixR) visualization. The write-up of this work also provides an opportunity to introduce the concepts and technology of MixR for a medical physics audience who may be unfamiliar with the topic. METHODS A MixR application was developed for on optical-see-through head-mounted display (HoloLens 2) allowing a user to simultaneously and directly view a patient and a reference hologram derived from their simulation CT scan. The hologram provides a visual reference for the exact posture needed during treatment and is initialized in relation to the origin of a radiotherapy device using marker-based tracking. The system further provides marker-less tracking that allows the user tofreely navigate the room as they view and align the patient from various angles. The system was preliminarily tested using both a rigid (pelvis) and nonrigid (female mannequin) anthropomorphic phantom. Each phantom was aligned via hologram and accuracy quantified using CBCT and CT. RESULTS A fully realized system was developed. Rigid registration accuracy was on the order of 3.0 ± 1.5 mm based on the performance of three users repeating alignment five times each. The lateral direction showed the most variability among users and was associated with the largest off-sets (approximately 2.0 mm). For nonrigid alignment, the MixR setup outperformed a setup based on three-point alignment and setup photos, the latter of which showed a difference in arm position of 2 cm and a torso roll of 6-7°. CONCLUSIONS MixR visualization is a rapidly emerging domain that has the potential to significantly impact the field of medicine. The current application is an illustration of this and highlights the advantages of MixR for patient setup in radiation oncology. The key feature of the system is the way in which it transforms nonrigid registration into rigid registration by providing an efficient, portable, and cost-effective mechanism for reproducing patient posture without the use of ionizing radiation. Preliminary estimates of registration accuracy indicate clinical viability and form the foundation for further development and clinical testing.
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Affiliation(s)
- Perry B Johnson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | - Amanda Jackson
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mohammad Saki
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | - Emily Feldman
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | - Julie Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
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22
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Sauer TO, Ott OJ, Lahmer G, Fietkau R, Bert C. Region of interest optimization for radiation therapy of breast cancer. J Appl Clin Med Phys 2021; 22:152-160. [PMID: 34543500 PMCID: PMC8504613 DOI: 10.1002/acm2.13410] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/11/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The goal of this study was to investigate how the choice of the region of interest (ROI) affects the registration results of surface imaging for daily positioning of breast cancer patients. Methods The AlignRT system (VisionRT, London) and the XVI Cone beam CT (CBCT; Elekta, Stockholm) installed on two Versa HD linacs (Elekta) were used in this study, which included 28 patients (160 fractions). In the clinical workflow, patients were prepositioned with AlignRT and then shifted in 6 degrees of freedom (DOF) according to the CBCT. A new reference capture was taken immediately afterward. Retrospectively, the surface capture resulting from prepositioning was registered to the latest reference capture. By varying the ROI used for registration, the surface‐based results were optimized in terms of minimizing the deviation to the clinically applied CBCT shifts. Two sets of ROIs were used: one obtained by applying a variable margin to the breast surface, another by combining ROIs of anatomical structures, including the sternum and contralateral breast. Results Registration results showed significant differences from one ROI to another. Generally, the results improved with increasing ROI size, especially for rotational DOFs. ROIs, including the axilla or supraclavicular lymph drainage region, did not yield an improved registration result. On the other hand, an ROI comprising the breast surface, sternum, and a belt caudal to the breasts decreased the average magnitude of the translational and rotational deviations by 6.6% and 30.8% (p < 0.01), respectively, compared to the breast surface only results. Conclusion The influence of the ROI choice on surface imaging registration results was analyzed and the surface‐based shifts were compared to clinically applied CBCT shifts. An optimal ROI for the treatment of breast cancer patients, consisting of the breast surface, sternum, and a belt, was identified.
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Affiliation(s)
- Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Godehard Lahmer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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23
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Laaksomaa M, Moser T, Kritz J, Pynnönen K, Rossi M. Comparison of three differently shaped ROIs in free breathing breast radiotherapy setup using surface guidance with AlignRT ®. Rep Pract Oncol Radiother 2021; 26:545-552. [PMID: 34434570 DOI: 10.5603/rpor.a2021.0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Setup accuracy within adjuvant radiotherapy of breast cancer treated in free breathing is well studied, but a comparison of the typical regions of interest (ROI) used in surface guided radiation therapy (SGRT) does not exist. The aim of this study was to estimate the setup accuracy obtained with differently shaped ROIs in SGRT. Materials and methods A total of 573 orthogonal image pairs were analyzed from free breathing breast patients in two groups: positioning using AlignRT® surface guidance system (Group A, n = 20), and setup using conventional laser and tattoo setup (Group L, n = 20). For SGRT, three different setup ROIs were used: a Breast-shaped, O-shaped and T-shaped (B-O and T-ROI). We evaluated the isocenter-, rotation-, pitch and arm position accuracy and residual errors for the chest wall and shoulder joint in kV orthogonal and tangential setup images with laser- or SGRT-based setup. Results Less isocenter variance was found in Group A than in Group L. Rotations and posture errors were larger in group L than in Group A (p ≤ 0.05). Rotation error was smaller with T-shaped ROI than with O- or B-shape (p = 0.01-0.04). Conclusion Setup with AlignRT® improves reproducibility compared to laser setup. Between the different ROI shapes only small differences were found in the patient posture or the isocenter position in the images. The T-ROI is recommended to set up the chest wall bony structure and an additional B-ROI may be used to fine-tune the soft tissue accuracy.
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Affiliation(s)
- Marko Laaksomaa
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | | | - Julia Kritz
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Kiira Pynnönen
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Maija Rossi
- Department of Oncology, Tampere University Hospital, Tampere, Finland.,Department of Medical Physics, Tampere University Hospital, Tampere, Finland
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24
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MacFarlane MJ, Jiang K, Mundis M, Nichols E, Gopal A, Chen S, Biswal NC. Comparison of the dosimetric accuracy of proton breast treatment plans delivered with SGRT and CBCT setups. J Appl Clin Med Phys 2021; 22:153-158. [PMID: 34288378 PMCID: PMC8425866 DOI: 10.1002/acm2.13357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/18/2021] [Accepted: 06/29/2021] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To compare the dosimetric accuracy of surface-guided radiation therapy (SGRT) and cone-beam computed tomography (CBCT) setups in proton breast treatment plans. METHODS Data from 30 patients were retrospectively analyzed in this IRB-approved study. Patients were prescribed 4256-5040 cGy in 16-28 fractions. CBCT and AlignRT (SGRT; Vision RT Ltd.) were used for treatment setup during the first three fractions, then daily AlignRT and weekly CBCT thereafter. Each patient underwent a quality assurance CT (QA-CT) scan midway through the treatment course to assess anatomical and dosimetric changes. To emulate the SGRT and CBCT setups during treatment, the planning CT and QA-CT images were registered in two ways: (1) by registering the volume within the CTs covered by the CBCT field of view; and (2) by contouring and registering the surface surveyed by the AlignRT system. The original plan was copied onto these two datasets and the dose was recalculated. The clinical treatment volume (CTV): V95% ; heart: V25Gy , V15Gy , and mean dose; and ipsilateral lung: V20Gy , V10Gy , and V5Gy , were recorded. Multi and univariate analyses of variance were performed to assess the differences in dose metric values between the planning CT and the SGRT and CBCT setups. RESULTS The CTV V95% and lung V20Gy , V10Gy , and V5Gy dose metrics were all significantly (p < 0.01) lower on the QA-CT in both the CBCT and SGRT setup. The differences were not clinically significant and were, on average, 1.4-1.6% lower for CTV V95% and 1.8%-6.0% lower for the lung dose metrics. When comparing the lung and CTV V95% dose metrics between the CBCT and SGRT setups, no significant difference was observed. This indicates that the SGRT setup provides similar dosimetric accuracy as CBCT. CONCLUSION This study supports the daily use of SGRT systems for the accurate dose delivery of proton breast treatment plans.
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Affiliation(s)
- Michael J MacFarlane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Kai Jiang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Michelle Mundis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Arun Gopal
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Nrusingh C Biswal
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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25
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Excluding Lung Tissue from the PTV during Internal Mammary Irradiation. A Safe Technique for OAR-Sparing? Cancers (Basel) 2021; 13:cancers13081951. [PMID: 33919587 PMCID: PMC8073233 DOI: 10.3390/cancers13081951] [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: 02/22/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
Simple Summary The planning treatment volume (PTV) during internal mammary irradiation (IMNI) regularly overlaps with lung tissue and is often in close proximity to the heart. Thus, exclusion of lung tissue from the PTV is a potential technique to spare the organs at risk (OARs) during adjuvant breast cancer irradiation. Using an innovative dose recalculation and accumulation algorithm, we evaluated the safety of exclusion of lung tissue from the PTV. According to our data, exclusion of lung tissue from the PTV to spare the OARs leads to significant dose reduction in the target volume and can, therefore, not be recommended. Abstract The current study aims to determine whether exclusion of lung tissue from planning treatment volume (PTV) is a valid organ at risk (OAR)-sparing technique during internal mammary irradiation (IMNI). Twenty patients with left-sided breast cancer undergoing adjuvant radiotherapy including IMNI after mastectomy or lumpectomy with daily ConeBeam CT (CBCT; median n = 28) were enrolled in the current study. The daily dose distribution of the patients was estimated by recalculating treatment plans on CBCT-scans based on a standard PTV (PTV margin: 5mm-STD) and a modified PTV, which excluded overlapping lung tissue (ExLung). Using 3D-deformable dose accumulation, the dose coverage in the target volume was estimated in dependence of the PTV-margins. The estimated delivered dose in the IMN-CTV was significantly lower for the ExLung PTV compared to the STD PTV: ExLung: V95%: 76.6 ± 22.9%; V90%: 89.6 ± 13.2%, STD: V95%: 95.6 ± 7.4%; V90%: 99.1 ± 2.7%. Daily CBCT imaging cannot sufficiently compensate the anatomic changes and intrafraction movement throughout the treatment. Therefore, to ensure adequate delivery of the prescribed dose to the IMN-CTV, exclusion of lung tissue from the PTV to spare the OARs is not recommended.
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26
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Covington EL, Stanley DN, Fiveash JB, Thomas EM, Marcrom SR, Bredel M, Willey CD, Riley KO, Popple RA. Surface guided imaging during stereotactic radiosurgery with automated delivery. J Appl Clin Med Phys 2020; 21:90-95. [PMID: 33095971 PMCID: PMC7769383 DOI: 10.1002/acm2.13066] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/29/2020] [Accepted: 09/22/2020] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To report on the use of surface guided imaging during frameless intracranial stereotactic radiotherapy with automated delivery via HyperArcTM (Varian Medical Systems, Palo Alto, CA). METHODS All patients received intracranial radiotherapy with HyperArcTM and were monitored for intrafraction motion by the AlignRT® (VisionRT, London, UK) surface imaging (SI) system. Immobilization was with the EncompassTM (Qfix, Avondale, PA) aquaplast mask device. AlignRT® log files were correlated with trajectory log files to correlate treatment parameters with SI reported offsets. SI reported offsets were correlated with gantry angle and analyzed for performance issues at non-zero couch angles and during camera-pod blockage during gantry motion. Demographics in the treatment management system were used to identify race and determine if differences in SI reported offsets are due to skin tone settings. RESULTS A total of 981 fractions were monitored over 14 months and 819 were analyzed. The median AlignRT® reported motion from beginning to the end of treatment was 0.24 mm. The median offset before beam on at non-zero couch angles was 0.55 mm. During gantry motion when camera pods are blocked, the median magnitude was below 1 mm. Median magnitude of offsets at non-zero couch angles was not found to be significantly different for patients stratified by race. CONCLUSIONS Surface image guidance is a viable alternative to scheduled mid-treatment imaging for monitoring intrafraction motion during stereotactic radiosurgery with automated delivery.
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Affiliation(s)
- Elizabeth L Covington
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Dennis N Stanley
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Evan M Thomas
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Samuel R Marcrom
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Marcus Bredel
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama - Birmingham, Birmingham, AL, USA
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Crawl positioning improves set-up precision and patient comfort in prone whole breast irradiation. Sci Rep 2020; 10:16376. [PMID: 33009448 PMCID: PMC7532156 DOI: 10.1038/s41598-020-72702-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 09/06/2020] [Indexed: 12/25/2022] Open
Abstract
Prone positioning for whole-breast irradiation (WBI) reduces dose to organs at risk, but reduces set-up speed, precision, and comfort. We aimed to improve these problems by placing patients in prone crawl position on a newly developed crawl couch (CrC). A group of 10 right-sided breast cancer patients requiring WBI were randomized in this cross-over trial, comparing the CrC to a standard prone breastboard (BB). Laterolateral (LL), craniocaudal (CC) and anterioposterior (AP) set-up errors were evaluated with cone beam CT. Comfort, preference and set-up time (SUT) were assessed. Forty left and right-sided breast cancer patients served as a validation group. For BB versus CrC, AP, LL and CC mean patient shifts were - 0.8 ± 2.8, 0.2 ± 11.7 and - 0.6 ± 4.4 versus - 0.2 ± 3.3, - 0.8 ± 2.5 and - 1.9 ± 5.7 mm. LL shift spread was reduced significantly. Nine out of 10 patients preferred the CrC. SUT did not differ significantly. The validation group had mean patient shifts of 1.7 ± 2.9 (AP), 0.2 ± 3.6 (LL) and - 0.2 ± 3.3 (CC) mm. Mean SUT in the validation group was 1 min longer (P < 0.05) than the comparative group. Median SUT was 3 min in all groups. The CrC improved precision and comfort compared to BB. Set-up errors compare favourably to other prone-WBI trials and rival supine positioning.
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28
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Batista V, Meyer J, Kügele M, Al-Hallaq H. Clinical paradigms and challenges in surface guided radiation therapy: Where do we go from here? Radiother Oncol 2020; 153:34-42. [PMID: 32987044 DOI: 10.1016/j.radonc.2020.09.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/26/2022]
Abstract
Surface guided radiotherapy (SGRT) is becoming a routine tool for patient positioning for specific clinical sites in many clinics. However, it has not yet gained its full potential in terms of widespread adoption. This vision paper first examines some of the difficulties in transitioning to SGRT before exploring the current and future role of SGRT alongside and in concert with other imaging techniques. Finally, future horizons and innovative ideas that may shape and impact the direction of SGRT going forward are reviewed.
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Affiliation(s)
- Vania Batista
- Department of Radiation Oncology, Heidelberg University Hospital, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany.
| | - Juergen Meyer
- Seattle Cancer Care Alliance, University of Washington, Department of Radiation Oncology, United States.
| | - Malin Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Medical Radiation Physics, Department of Clinical Sciences, Lund University, Sweden.
| | - Hania Al-Hallaq
- The University of Chicago, Department of Radiation and Cellular Oncology, United States.
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Noël G, Thariat J, Antoni D. [Uncertainties in the current concept of radiotherapy planning target volume]. Cancer Radiother 2020; 24:667-675. [PMID: 32828670 DOI: 10.1016/j.canrad.2020.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/01/2020] [Accepted: 06/07/2020] [Indexed: 12/12/2022]
Abstract
The planning target volume is an essential notion in radiotherapy, that requires a new conceptualization. Indeed, the variability and diversity of the uncertainties involved or improved with the development of the new modern technologies and devices in radiotherapy suggest that random and systematic errors cannot be currently generalized. This article attempts to discuss these various uncertainties and tries to demonstrate that a redefinition of the concept of planning target volume toward its personalization for each patient and the robustness notion are likely an improvement basis to take into account the radiotherapy uncertainties.
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Affiliation(s)
- G Noël
- Service d'oncologie radiothérapie, Institut de cancérologie Strasbourg Europe (Icans), 17, rue Albert-Calmette, 67033 Strasbourg, France.
| | - J Thariat
- Département de radiothérapie, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Association Advance Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue General-Harris, 14000 Caen, France; Laboratoire de physique corpusculaire, Institut national de physique nucléaire et de physique des particules (IN2P3), 6, boulevard Maréchal-Juin, 14000 Caen, France; École nationale supérieure d'ingénieurs de Caen (ENSICaen), 6, boulevard Maréchal-Juin, CS 45053 14050 Caen cedex 4, France; Centre national de la recherche scientifique (CNRS), UMR 6534, 6, boulevard Maréchal-Juin, 14000 Caen, France; Université de Caen Normandie (Unicaen), esplanade de la Paix, CS 14032, 14032 Caen, France
| | - D Antoni
- Service d'oncologie radiothérapie, Institut de cancérologie Strasbourg Europe (Icans), 17, rue Albert-Calmette, 67033 Strasbourg, France
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Freislederer P, Kügele M, Öllers M, Swinnen A, Sauer TO, Bert C, Giantsoudi D, Corradini S, Batista V. Recent advanced in Surface Guided Radiation Therapy. Radiat Oncol 2020; 15:187. [PMID: 32736570 PMCID: PMC7393906 DOI: 10.1186/s13014-020-01629-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/21/2020] [Indexed: 01/27/2023] Open
Abstract
The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques.SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments.The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations.Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests.Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition).This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.
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Affiliation(s)
- P. Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M. Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M. Öllers
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - A. Swinnen
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - T.-O. Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - C. Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - D. Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - V. Batista
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
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Leong B, Padilla L. Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments. J Appl Clin Med Phys 2020; 20:149-158. [PMID: 31833639 PMCID: PMC6909112 DOI: 10.1002/acm2.12779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose To evaluate the effectiveness of surface image guidance (SG) for pre‐imaging setup of stereotactic body radiotherapy (SBRT) patients, and to investigate the impact of SG reference surface selection on this process. Methods and materials 284 SBRT fractions (SG‐SBRT = 113, non‐SG‐SBRT = 171) were retrospectively evaluated. Differences between initial (pre‐imaging) and treatment couch positions were extracted from the record‐and‐verify system and compared for the two groups. Rotational setup discrepancies were also computed. The utility of orthogonal kVs in reducing CBCT shifts in the SG‐SBRT/non‐SG‐SBRT groups was also calculated. Additionally, the number of CBCTs acquired for setup was recorded and the average for each cohort was compared. These data served to evaluate the effectiveness of surface imaging in pre‐imaging patient positioning and its potential impact on the necessity of including orthogonal kVs for setup. Since reference surface selection can affect SG setup, daily surface reproducibility was estimated by comparing camera‐acquired surface references (VRT surface) at each fraction to the external surface of the planning CT (DICOM surface) and to the VRT surface from the previous fraction. Results The reduction in all initial‐to‐treatment translation/rotation differences when using SG‐SBRT was statistically significant (Rank‐Sum test, α = 0.05). Orthogonal kV imaging kept CBCT shifts below reimaging thresholds in 19%/51% of fractions for SG‐SBRT/non‐SG‐SBRT cohorts. Differences in average number of CBCTs acquired were not statistically significant. The reference surface study found no statistically significant differences between the use of DICOM or VRT surfaces. Conclusions SG‐SBRT improved pre‐imaging treatment setup compared to in‐room laser localization alone. It decreased the necessity of orthogonal kV imaging prior to CBCT but did not affect the average number of CBCTs acquired for setup. The selection of reference surface did not have a significant impact on initial patient positioning.
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Affiliation(s)
- Brian Leong
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Laura Padilla
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
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Wei W, Ioannides PJ, Sehgal V, Daroui P. Quantifying the impact of optical surface guidance in the treatment of cancers of the head and neck. J Appl Clin Med Phys 2020; 21:73-82. [PMID: 32250046 PMCID: PMC7324691 DOI: 10.1002/acm2.12867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 02/08/2020] [Accepted: 02/27/2020] [Indexed: 12/25/2022] Open
Abstract
Surface guided radiation therapy (SGRT) is increasingly being adopted for use in radiation treatment delivery for Head and Neck (H&N) cancer patients. This study investigated the improvement of patient setup accuracy and reduction of setup time for SGRT compared to a conventional setup. A total of 60 H&N cancer patients were retrospectively included. Patients were categorized into three groups: oral cavity, oropharynx and nasopharynx/sinonasal sites with 20 patients in each group. They were further separated into two (2) subgroups, depending on whether they were set up with the aid of SGRT. The Align‐RT™ system was used for SGRT in this work. Positioning was confirmed by daily kV‐kV imaging in conjunction with weekly CBCT scans. Translational and rotational couch shifts along with patient setup times were recorded. Imaging setup time, which was defined as the elapsed time from the acquisition of the first image set to the end of the last image set, was recorded. Average translational shifts were larger in the non‐SGRT group. Vertical shifts showed the most significant reduction in the SGRT group for both oropharynx and oral cavity groups. Pitch corrections were significantly higher in the SGRT group for oropharynx patients and higher pitch corrections were also observed in the SGRT groups of oral cavity and nasopharynx/sinonasal patients. The average setup time when SGRT guidance was employed was shorter for all three treatment sites although this did not reach statistical significance. The largest time reduction between the SGRT and non‐SGRT groups was seen in the nasopharynx/sinonasal group. This study suggests that the use of SGRT decreases the magnitude of translational couch shifts during patient setup. However, the rotational corrections needed were generally higher with SGRT group. When SGRT was employed, a definite reduction in patient setup time was observed for nasopharynx/sinonasal and hypopharynx cancer patients.
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Affiliation(s)
- Wenbo Wei
- Department of Radiation Oncology University of California Irvine Orange CA USA
| | | | - Varun Sehgal
- Department of Radiation Oncology University of California Irvine Orange CA USA
| | - Parima Daroui
- Department of Radiation Oncology The Permanente Medical Group Santa Clara CA USA
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Rigley J, Robertson P, Scattergood L. Radiotherapy without tattoos: Could this work? Radiography (Lond) 2020; 26:288-293. [PMID: 32245712 DOI: 10.1016/j.radi.2020.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION An evaluation to compare the traditional tattoo based set up procedure with a surface guided method to assess the possibility of eliminating permanent tattoos in breast cancer patents who are undergoing radiotherapy to the breast/chest wall. METHODS Forty-three patients that were having radiotherapy to the breast or chest wall were included in this evaluation. The patients were divided into two groups and further divided into 2 sub-groups. The first group received standard dark ink tattoos and were positioned by aligning these tattoos with lasers. The second group had no tattoo's and were positioned using the Surface-Guided technology (SGRT). Within each group the patients were split into 2 sub-group; right and left sided treatment areas. The right side were treated using a Free-Breathing (FB) technique and the left sided were treated using a Deep-Inspiration Breath-Hold (DIBH) technique. RESULTS For the patients having right sided breast radiotherapy, the mean shift using the standard tattoos and laser set up was 0.52 cm, compared with using the SGRT method where the mean shift was 0.47 cm. (p-value 0.04) For patients having left sided breast radiotherapy with DIBH the mean shift using the standard tattoo's and laser set up was 0.76 cm, compared with a mean shift of 0.45 cm using SGRT alone (p-value < 0.001). CONCLUSION The elimination of tattoos together with SGRT offers a comparable set-up for right sided breast treatments against the traditional tattoo method. A significant set-up improvement was observed for the left sided breast DIBH treatments. IMPLICATIONS FOR PRACTICE To set up patients having breast Radiotherapy, with no tattoo's.
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Affiliation(s)
- J Rigley
- GenesisCare Nottingham, The Park Centre of Oncology, Sherwood Lodge Drive, Nottingham, NG5 8RX, UK.
| | - P Robertson
- GenesisCare Guildford, 46 Harvey Road, Guildford, GU1 3XL, UK
| | - L Scattergood
- GenesisCare Nottingham, The Park centre of oncology, Sherwood Lodge Drive, Nottingham, NG5 8RX, UK
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34
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Heinzerling JH, Hampton CJ, Robinson M, Bright M, Moeller BJ, Ruiz J, Prabhu R, Burri SH, Foster RD. Use of surface-guided radiation therapy in combination with IGRT for setup and intrafraction motion monitoring during stereotactic body radiation therapy treatments of the lung and abdomen. J Appl Clin Med Phys 2020; 21:48-55. [PMID: 32196944 PMCID: PMC7286017 DOI: 10.1002/acm2.12852] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/08/2020] [Accepted: 02/16/2020] [Indexed: 12/24/2022] Open
Abstract
Background and purpose Multiple techniques can be used to assist with more accurate patient setup and monitoring during Stereotactic body radiation therapy (SBRT) treatment. This study analyzes the accuracy of 3D surface mapping with Surface‐guided radiation therapy (SGRT) in detecting interfraction setup error and intrafraction motion during SBRT treatments of the lung and abdomen. Materials and Methods Seventy‐one patients with 85 malignant thoracic or abdominal tumors treated with SBRT were analyzed. For initial patient setup, an alternating scheme of kV/kV imaging or SGRT was followed by cone beam computed tomography (CBCT) for more accurate tumor volumetric localization. The CBCT six degree shifts after initial setup with each method were recorded to assess interfraction setup error. Patients were then monitored continuously with SGRT during treatment. If an intrafractional shift in any direction >2 mm for longer than 2 sec was detected by SGRT, then CBCT was repeated and the recorded deltas were compared to those detected by SGRT. Results Interfractional shifts after SGRT setup and CBCT were small in all directions with mean values of <5 mm and < 0.5 degrees in all directions. Additionally, 25 patients had detected intrafraction motion by SGRT during a total of 34 fractions. This resulted in 25 (73.5%) additional shifts of at least 2 mm on subsequent CBCT. When comparing the average vector detected shift by SGRT to the resulting vector shift on subsequent CBCT, no significant difference was found between the two. Conclusions Surface‐guided radiation therapy provides initial setup within 5 mm for patients treated with SBRT and can be used in place of skin marks or planar kV imaging prior to CBCT. In addition, continuous monitoring with SGRT during treatment was valuable in detecting potentially clinically meaningful intrafraction motion and was comparable in magnitude to shifts from additional CBCT scans. PTV margin reduction may be feasible for SBRT in the lung and abdomen when using SGRT for continuous patient monitoring during treatment.
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Affiliation(s)
- John H Heinzerling
- Levine Cancer Institute, Southeast Radiation Oncology Group, Atrium Health, Charlotte, NC, USA
| | - Carnell J Hampton
- Levine Cancer Institute, Department of Radiation Oncology, Atrium Health, Charlotte, NC, USA
| | - Myra Robinson
- Levine Cancer Institute, Department of Biostatistics, Atrium Health, Charlotte, NC, USA
| | - Megan Bright
- Levine Cancer Institute, Department of Radiation Oncology, Atrium Health, Charlotte, NC, USA
| | - Benjamin J Moeller
- Levine Cancer Institute, Southeast Radiation Oncology Group, Atrium Health, Charlotte, NC, USA
| | - Justin Ruiz
- Levine Cancer Institute, Department of Radiation Oncology, Atrium Health, Charlotte, NC, USA
| | - Roshan Prabhu
- Levine Cancer Institute, Southeast Radiation Oncology Group, Atrium Health, Charlotte, NC, USA
| | - Stuart H Burri
- Levine Cancer Institute, Southeast Radiation Oncology Group, Atrium Health, Charlotte, NC, USA
| | - Ryan D Foster
- Levine Cancer Institute, Department of Radiation Oncology, Atrium Health, Charlotte, NC, USA
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Zhao H, Williams N, Poppe M, Sarkar V, Wang B, Rassiah-Szegedi P, Huang YJ, Kokeny K, Gaffney D, Salter B. Comparison of surface guidance and target matching for image-guided accelerated partial breast irradiation (APBI). Med Phys 2019; 46:4717-4724. [PMID: 31509632 DOI: 10.1002/mp.13816] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 11/06/2022] Open
Abstract
PURPOSE We investigate the feasibility of surface guided radiation therapy (SGRT) for accelerated partial breast irradiation (APBI) by comparing it with in-room, fan beam kV computed tomography on rails (CTOR) imaging of the targeted region. The uniqueness of our study is that all patients have multiple daily CTOR scans to compare corresponding SGRT AlignRT (VisionRT, United Kingdom) images to. METHODS/MATERIALS Twelve patients receiving APBI were enrolled in this study. Before each treatment fraction, after patients were setup on tattoos, SGRT was performed using AlignRT, and then target matching was performance using CTOR. The average and maximum difference in shifts between SGRT and CTOR were calculated and analyzed for each patient, so as the correlation between surgical cavity size and shift difference. RESULTS Our study showed that SGRT agreed well with CTOR for patients with small surgical cavity volume changes (<10%). There were nine patients who had a ≥5 mm maximum shift difference between SGRT and CTOR along any direction, and in two patients the difference was more than 10 mm (one patient with surgical cavity change 44.3% and one patient with 27 cc cavity volume decrease). All patients, except one, had a mean shift difference < 5 mm along any direction. CONCLUSION For the patients studied here, SGRT appears to be a reasonable and potentially valuable image guidance approach for APBI for patients who experience small changes in surgical cavity volume (<10%) between CT simulation and treatment. However, there is potential for larger alignment errors (up to 11 mm) when using SGRT for patients who experience larger surgical cavity changes.
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Affiliation(s)
- Hui Zhao
- University of Utah, Salt Lake City, UT, 84112, USA
| | - Ned Williams
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | | | | | - Brian Wang
- University of Louisville, 2301 S 3rd St, Louisville, KY, 40292, USA
| | | | | | | | | | - Bill Salter
- University of Utah, Salt Lake City, UT, 84112, USA
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36
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Kang S, Li J, Ma J, Zhang W, Liao X, Qing H, Tan T, Xin X, Tang B, Piermattei A, Orlandini LC. Evaluation of interfraction setup variations for postmastectomy radiation therapy using EPID-based in vivo dosimetry. J Appl Clin Med Phys 2019; 20:43-52. [PMID: 31541537 PMCID: PMC6806484 DOI: 10.1002/acm2.12712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 07/18/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022] Open
Abstract
Postmastectomy radiation therapy is technically difficult and can be considered one of the most complex techniques concerning patient setup reproducibility. Slight patient setup variations — particularly when high‐conformal treatment techniques are used — can adversely affect the accuracy of the delivered dose and the patient outcome. This research aims to investigate the inter‐fraction setup variations occurring in two different scenarios of clinical practice: at the reference and at the current patient setups, when an image‐guided system is used or not used, respectively. The results were used with the secondary aim of assessing the robustness of the patient setup procedure in use. Forty eight patients treated with volumetric modulated arc and intensity modulated therapies were included in this study. EPID‐based in vivo dosimetry (IVD) was performed at the reference setup concomitantly with the weekly cone beam computed tomography acquisition and during the daily current setup. Three indices were analyzed: the ratio R between the reconstructed and planned isocenter doses, γ% and the mean value of γ from a transit dosimetry based on a two‐dimensional γ‐analysis of the electronic portal images using 5% and 5 mm as dose difference and distance to agreement gamma criteria; they were considered in tolerance if R was within 5%, γ% > 90% and γmean < 0.4. One thousand and sixteen EPID‐based IVD were analyzed and 6.3% resulted out of the tolerance level. Setup errors represented the main cause of this off tolerance with an occurrence rate of 72.2%. The percentage of results out of tolerance obtained at the current setup was three times greater (9.5% vs 3.1%) than the one obtained at the reference setup, indicating weaknesses in the setup procedure. This study highlights an EPID‐based IVD system's utility in the radiotherapy routine as part of the patient’s treatment quality controls and to optimize (or confirm) the performed setup procedures’ accuracy.
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Affiliation(s)
- Shengwei Kang
- Key Laboratory of Radiation Physics and Technology, Institute of Nuclear Science and Technology, Sichuan University, Chengdu, China.,Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Jie Li
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Jiabao Ma
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Wei Zhang
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Xiongfei Liao
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Hou Qing
- Institute of Nuclear Science and Technology, Sichuan University, Chengdu, China
| | - Tingqiang Tan
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Xin Xin
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Bin Tang
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - Angelo Piermattei
- UOC Fisica Sanitaria, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Lucia Clara Orlandini
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Chengdu, China
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37
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Moser T, Creed M, Walker R, Meier G. Radiotherapy tattoos: Women's skin as a carrier of personal memory-What do we cause by tattooing our patients? Breast J 2019; 26:316-318. [PMID: 31524308 PMCID: PMC7065023 DOI: 10.1111/tbj.13591] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/28/2022]
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38
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Kügele M, Mannerberg A, Nørring Bekke S, Alkner S, Berg L, Mahmood F, Thornberg C, Edvardsson A, Bäck SÅJ, Behrens CF, Ceberg S. Surface guided radiotherapy (SGRT) improves breast cancer patient setup accuracy. J Appl Clin Med Phys 2019; 20:61-68. [PMID: 31478615 PMCID: PMC6753725 DOI: 10.1002/acm2.12700] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/13/2019] [Accepted: 07/26/2019] [Indexed: 11/11/2022] Open
Abstract
PURPOSE The purpose of the study was to investigate if surface guided radiotherapy (SGRT) can decrease setup deviations for tangential and locoregional breast cancer patients compared to conventional laser-based setup (LBS). MATERIALS AND METHODS Both tangential (63 patients) and locoregional (76 patients) breast cancer patients were enrolled in this study. For LBS, the patients were positioned by aligning skin markers to the room lasers. For the surface based setup (SBS), an optical surface scanning system was used for daily setup using both single and three camera systems. To compare the two setup methods, the patient position was evaluated using verification imaging (field images or orthogonal images). RESULTS For both tangential and locoregional treatments, SBS decreased the setup deviation significantly compared to LBS (P < 0.01). For patients receiving tangential treatment, 95% of the treatment sessions were within the clinical tolerance of ≤ 4 mm in any direction (lateral, longitudinal or vertical) using SBS, compared to 84% for LBS. Corresponding values for patients receiving locoregional treatment were 70% and 54% for SBS and LBS, respectively. No significant difference was observed comparing the setup result using a single camera system or a three camera system. CONCLUSIONS Conventional laser-based setup can with advantage be replaced by surface based setup. Daily SGRT improves patient setup without additional imaging dose to breast cancer patients regardless if a single or three camera system was used.
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Affiliation(s)
- Malin Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Annika Mannerberg
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Susanne Nørring Bekke
- Radiotherapy Research Unit, Department of Oncology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sara Alkner
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - Lovisa Berg
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Faisal Mahmood
- Department of Oncology, Odense University Hospital, Odense C, Denmark
| | - Charlotte Thornberg
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Anneli Edvardsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Sven Å J Bäck
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Claus F Behrens
- Radiotherapy Research Unit, Department of Oncology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sofie Ceberg
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
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Pazos M, Walter F, Reitz D, Schönecker S, Konnerth D, Schäfer A, Rottler M, Alongi F, Freislederer P, Niyazi M, Belka C, Corradini S. Impact of surface-guided positioning on the use of portal imaging and initial set-up duration in breast cancer patients. Strahlenther Onkol 2019; 195:964-971. [PMID: 31332457 DOI: 10.1007/s00066-019-01494-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/27/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The impact of optical surface guidance on the use of portal imaging and the initial set-up duration in patients receiving postoperative radiotherapy of the breast or chest wall was investigated. MATERIAL AND METHODS A retrospective analysis was performed including breast cancer patients who received postoperative radiotherapy between January 2016 and December 2016. One group of patients received treatment before the optical surface scanner was installed (no-OSS) and the other group was positioned using the additional information derived by the optical surface scanner (OSS). The duration of the initial set-up was recorded for each patient and a comparison of both groups was performed. Accordingly, the differences between planned and actually acquired portal images during the course of radiotherapy were compared between both groups. RESULTS A total of 180 breast cancer patients were included (90 no-OSS, 90 OSS) in this analysis. Of these, 30 patients with left-sided breast cancer received radiotherapy in deep inspiration breath hold (DIBH). The mean set-up time was 10 min and 18 s and no significant difference between the two groups of patients was found (p = 0.931). The mean set-up time in patients treated without DIBH was 9 min and 45 s compared to 13 min with DIBH (p < 0.001), as portal imaging was performed in DIBH. No significant difference was found in the number of acquired to the planned number of portal images during the entire radiotherapy treatment for both groups (p = 0.287). CONCLUSION Optical surface imaging is a valuable addition for primary patient set-up. The findings confirm that the addition of surface-based imaging did not prolong the clinical workflow and had no significant impact on the number of portal verification images carried out during the course of radiotherapy.
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Affiliation(s)
- Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.
| | - Daniel Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Dinah Konnerth
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Annemarie Schäfer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maya Rottler
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar-Verona, Italy.,University of Brescia, Brescia, Italy
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Hamming VC, Visser C, Batin E, McDermott LN, Busz DM, Both S, Langendijk JA, Sijtsema NM. Evaluation of a 3D surface imaging system for deep inspiration breath-hold patient positioning and intra-fraction monitoring. Radiat Oncol 2019; 14:125. [PMID: 31296245 PMCID: PMC6624957 DOI: 10.1186/s13014-019-1329-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine the accuracy of a surface guided radiotherapy (SGRT) system for positioning of breast cancer patients in breath-hold (BH) with respect to cone-beam computed tomography (CBCT). Secondly, to evaluate the thorax position stability during BHs with SGRT, when using an air-volume guidance system. METHODS AND MATERIALS Eighteen left-sided breast cancer patients were monitored with SGRT during CBCT and treatment, both in BH. CBCT scans were matched on the target volume and the patient surface. The setup error differences were evaluated, including with linear regression analysis. The intra-fraction variability and stability of the air-volume guided BHs were determined from SGRT measurements. The variability was determined from the maximum difference between the different BH levels within one treatment fraction. The stability was determined from the difference between the start and end position of each BH. RESULTS SGRT data correlated well with CBCT data. The correlation was stronger for surface-to-CBCT (0.61) than target volume-to-CBCT (0.44) matches. Systematic and random setup error differences were ≤ 2 mm in all directions. The 95% limits of agreement (mean ± 2SD) were 0.1 ± 3.0, 0.6 ± 4.1 and 0.4 ± 3.4 mm in the three orthogonal directions, for the surface-to-CBCT matches. For air-volume guided BHs, the variability detected with SGRT was 2.2, 2.8 and 2.3 mm, and the stability - 1.0, 2.1 and 1.5 mm, in three orthogonal directions. Furthermore, the SGRT system could detect unexpected patient movement, undetectable by the air-volume BH system. CONCLUSION With SGRT, left-sided breast cancer patients can be positioned and monitored continuously to maintain position errors within 5 mm. Low intra-fraction variability and good stability can be achieved with the air-volume BH system, however, additional patient position information is available with SGRT, that cannot be detected with air-volume BH systems.
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Affiliation(s)
- Vincent C Hamming
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
| | - Christa Visser
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Estelle Batin
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Leah N McDermott
- Department of Radiation Oncology, Northwest Clinics, Alkmaar, The Netherlands
| | - Dianne M Busz
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Stefan Both
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Nanna M Sijtsema
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
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41
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Kost S, Guo B, Xia P, Shah C. Assessment of Setup Accuracy Using Anatomical Landmarks for Breast and Chest Wall Irradiation With Surface Guided Radiation Therapy. Pract Radiat Oncol 2019; 9:239-247. [DOI: 10.1016/j.prro.2019.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/14/2019] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
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42
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Kalet AM, Cao N, Smith WP, Young L, Wootton L, Stewart RD, Fang LC, Kim J, Horton T, Meyer J. Accuracy and stability of deep inspiration breath hold in gated breast radiotherapy – A comparison of two tracking and guidance systems. Phys Med 2019; 60:174-181. [DOI: 10.1016/j.ejmp.2019.03.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 03/14/2019] [Accepted: 03/24/2019] [Indexed: 01/22/2023] Open
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43
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Edmunds D, Sharp G, Winey B. Automatic diaphragm segmentation for real-time lung tumor tracking on cone-beam CT projections: a convolutional neural network approach. Biomed Phys Eng Express 2019; 5:035005. [PMID: 34234960 PMCID: PMC8260092 DOI: 10.1088/2057-1976/ab0734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To automatically segment the diaphragm on individual lung cone-beam CT projection images, to enable real-time tracking of lung tumors using kilovoltage imaging. METHODS The deep neural network Mask R-CNN was trained on 3500 raw cone-beam CT projection images from 10 lung cancer patients, with the diaphragm manually segmented on each image used as a ground truth label. Ground-truth breathing traces were extracted from each patient for both diaphragm hemispheres, and apex positions were compared against the predicted output of the neural network. Ten-fold cross-validation was used to evaluate the segmentation accuracy. RESULTS The mean diaphragm apex prediction error was 4.4 mm. The mean percentage of projection images for which a successful prediction could me made was 87.3%. Prediction accuracy at some lateral gantry angles was worse due to overlap between diaphragm hemispheres, and the increased amount of fatty tissue. CONCLUSIONS The neural network was able to track the diaphragm apex position successfully. This allows accurate assessment of the breathing phase, which can be used to estimate the position of the lung tumor in real time.
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Affiliation(s)
- David Edmunds
- Massachusetts General Hospital, United States of America
| | - Greg Sharp
- Massachusetts General Hospital, United States of America
| | - Brian Winey
- Massachusetts General Hospital, United States of America
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44
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Carl G, Reitz D, Schönecker S, Pazos M, Freislederer P, Reiner M, Alongi F, Niyazi M, Ganswindt U, Belka C, Corradini S. Optical Surface Scanning for Patient Positioning in Radiation Therapy: A Prospective Analysis of 1902 Fractions. Technol Cancer Res Treat 2019; 17:1533033818806002. [PMID: 30453842 PMCID: PMC6243634 DOI: 10.1177/1533033818806002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose/Objective: Reproducible patient positioning remains one of the major challenges in modern radiation therapy. Recently, optical surface scanners have been introduced into clinical practice in addition to well-established positioning systems, such as room laser and skin marks. The aim of this prospective study was to evaluate setup errors of the optical surface scanner Catalyst HD (C-RAD AB) in different anatomic regions. Material/Methods: Between October 2016 and June 2017 a total of 1902 treatment sessions in 110 patients were evaluated. The workflow of this study included conventional setup procedures using laser-based positioning with skin marks and an additional registration of the 3-dimensional (3D) deviations detected by the Catalyst system. The deviations of the surface-based method were then compared to the corrections of cone beam computed tomography alignment which was considered as gold standard. A practical Catalyst setup error was calculated between the translational deviations of the surface scanner and the laser positioning. Two one-sided t tests for equivalence were used for statistical analysis. Results: Data analysis revealed total deviations of 0.09 mm ± 2.03 mm for the lateral axis, 0.07 mm ± 3.21 mm for the longitudinal axis, and 0.44 mm ± 3.08 mm vertical axis for the Catalyst system, compared to −0.06 ± 3.54 mm lateral, 0.53 ± 3.47 mm longitudinal, and 0.19 ± 3.49 mm vertical for the laser positioning compared to cone beam computed tomography. The lowest positional deviations were found in the cranial region, and larger deviations occurred in the thoracic and abdominal sites. A statistical comparison using 2 one-sided t tests showed a general concordance of the 2 methods (P ≤ 0.036), excluding the vertical direction of the abdominal region (P = 0.198). Conclusion: The optical surface scanner Catalyst HD is a reliable and feasible patient positioning system without any additional radiation exposure. From the head to the thoracic and abdominal region, a decrease in accuracy was observed within a comparable range for Catalyst and laser-assisted positioning.
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Affiliation(s)
- G Carl
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,Authors have contributed equally to this study
| | - D Reitz
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,Authors have contributed equally to this study
| | - S Schönecker
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M Pazos
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - P Freislederer
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M Reiner
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - F Alongi
- 2 Department of Radiation Oncology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy.,3 University of Brescia, Brescia, Italy
| | - M Niyazi
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - U Ganswindt
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,4 Department of Therapeutic Radiology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - C Belka
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - S Corradini
- 1 Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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45
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Pogue BW, Wilson BC. Optical and x-ray technology synergies enabling diagnostic and therapeutic applications in medicine. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-17. [PMID: 30350489 PMCID: PMC6197862 DOI: 10.1117/1.jbo.23.12.121610] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/24/2018] [Indexed: 05/10/2023]
Abstract
X-ray and optical technologies are the two central pillars for human imaging and therapy. The strengths of x-rays are deep tissue penetration, effective cytotoxicity, and the ability to image with robust projection and computed-tomography methods. The major limitations of x-ray use are the lack of molecular specificity and the carcinogenic risk. In comparison, optical interactions with tissue are strongly scatter dominated, leading to limited tissue penetration, making imaging and therapy largely restricted to superficial or endoscopically directed tissues. However, optical photon energies are comparable with molecular energy levels, thereby providing the strength of intrinsic molecular specificity. Additionally, optical technologies are highly advanced and diversified, being ubiquitously used throughout medicine as the single largest technology sector. Both have dominant spatial localization value, achieved with optical surface scanning or x-ray internal visualization, where one often is used with the other. Therapeutic delivery can also be enhanced by their synergy, where radio-optical and optical-radio interactions can inform about dose or amplify the clinical therapeutic value. An emerging trend is the integration of nanoparticles to serve as molecular intermediates or energy transducers for imaging and therapy, requiring careful design for the interaction either by scintillation or Cherenkov light, and the nanoscale design is impacted by the choices of optical interaction mechanism. The enhancement of optical molecular sensing or sensitization of tissue using x-rays as the energy source is an important emerging field combining x-ray tissue penetration in radiation oncology with the molecular specificity and packaging of optical probes or molecular localization. The ways in which x-rays can enable optical procedures, or optics can enable x-ray procedures, provide a range of new opportunities in both diagnostic and therapeutic medicine. Taken together, these two technologies form the basis for the vast majority of diagnostics and therapeutics in use in clinical medicine.
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Affiliation(s)
- Brian W. Pogue
- Dartmouth College, Thayer School of Engineering, Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Brian C. Wilson
- University of Toronto, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada
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46
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Kammerer E, Fenoglietto P, Bourgier C. [Modalities and advantages of image guided radiation therapy of breast cancer in adjuvant setting]. Cancer Radiother 2018; 22:581-585. [PMID: 30145089 DOI: 10.1016/j.canrad.2018.07.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 11/18/2022]
Abstract
In adjuvant setting, breast cancer radiotherapy volumes include whole mammary gland or chest wall, and when indicated, nodal area such as axilla, supraclavicular, and internal mammary chain. An accurate patients positioning is required due to some geometric complexity of target volumes closed to organs at risk as heart and lung. Image guided radiation therapy allows such accuracy. Here we propose a review on image guided radiotherapy for breast cancer.
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Affiliation(s)
- E Kammerer
- Centre François-Baclesse, 3, avenue du Général-Harris, 14000 Caen, France
| | - P Fenoglietto
- Institut régional du cancer de Montpellier (ICM), Val d'Aurelle, 208, avenue des Apothicaires, 34298 Montpellier, France
| | - C Bourgier
- Institut régional du cancer de Montpellier (ICM), Val d'Aurelle, 208, avenue des Apothicaires, 34298 Montpellier, France; Inserm U1194, 641, avenue du Doyen Gaston-Giraud, 34000 Montpellier, France; Faculté de médecine, université de Montpellier, 641, avenue du Doyen Gaston-Giraud, 34000 Montpellier, France.
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47
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Hoisak JD, Pawlicki T. The Role of Optical Surface Imaging Systems in Radiation Therapy. Semin Radiat Oncol 2018; 28:185-193. [DOI: 10.1016/j.semradonc.2018.02.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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48
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Edmunds DM, Gothard L, Khabra K, Kirby A, Madhale P, McNair H, Roberts D, Tang KK, Symonds‐Tayler R, Tahavori F, Wells K, Donovan E. Low-cost Kinect Version 2 imaging system for breath hold monitoring and gating: Proof of concept study for breast cancer VMAT radiotherapy. J Appl Clin Med Phys 2018; 19:71-78. [PMID: 29536664 PMCID: PMC5978957 DOI: 10.1002/acm2.12286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/12/2017] [Accepted: 01/09/2018] [Indexed: 11/30/2022] Open
Abstract
Voluntary inspiration breath hold (VIBH) for left breast cancer patients has been shown to be a safe and effective method of reducing radiation dose to the heart. Currently, VIBH protocol compliance is monitored visually. In this work, we establish whether it is possible to gate the delivery of radiation from an Elekta linac using the Microsoft Kinect version 2 (Kinect v2) depth sensor to measure a patient breathing signal. This would allow contactless monitoring during VMAT treatment, as an alternative to equipment-assisted methods such as active breathing control (ABC). Breathing traces were acquired from six left breast radiotherapy patients during VIBH. We developed a gating interface to an Elekta linac, using the depth signal from a Kinect v2 to control radiation delivery to a programmable motion platform following patient breathing patterns. Radiation dose to a moving phantom with gating was verified using point dose measurements and a Delta4 verification phantom. 60 breathing traces were obtained with an acquisition success rate of 100%. Point dose measurements for gated deliveries to a moving phantom agreed to within 0.5% of ungated delivery to a static phantom using both a conventional and VMAT treatment plan. Dose measurements with the verification phantom showed that there was a median dose difference of better than 0.5% and a mean (3% 3 mm) gamma index of 92.6% for gated deliveries when using static phantom data as a reference. It is possible to use a Kinect v2 device to monitor voluntary breath hold protocol compliance in a cohort of left breast radiotherapy patients. Furthermore, it is possible to use the signal from a Kinect v2 to gate an Elekta linac to deliver radiation only during the peak inhale VIBH phase.
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Affiliation(s)
- David M. Edmunds
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | | | - Komel Khabra
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | - Anna Kirby
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | - Poonam Madhale
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | - Helen McNair
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | - David Roberts
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
| | - KK Tang
- Department of PhysicsUniversity of SurreyGuildfordUK
| | | | - Fatemeh Tahavori
- Centre for Vision, Speech and Signal ProcessingUniversity of SurreyGuildfordUK
| | - Kevin Wells
- Centre for Vision, Speech and Signal ProcessingUniversity of SurreyGuildfordUK
| | - Ellen Donovan
- Department of PhysicsThe Royal Marsden NHS Foundation TrustLondonUK
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49
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Cravo Sá A, Fermento A, Neves D, Ferreira S, Silva T, Marques Coelho C, Vaandering A, Roma A, Quaresma S, Bonnarens E. Radiotherapy setup displacements in breast cancer patients: 3D surface imaging experience. Rep Pract Oncol Radiother 2018; 23:61-67. [PMID: 29379398 PMCID: PMC5773710 DOI: 10.1016/j.rpor.2017.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 12/27/2017] [Indexed: 01/15/2023] Open
Abstract
AIM In this study, we intend to compare two different setup procedures for female breast cancer patients. BACKGROUND Imaging in radiotherapy provides a precise localization of the tumour, increasing the accuracy of the treatment delivery in breast cancer. MATERIALS AND METHODS Twenty breast cancer patients who underwent whole breast radiotherapy (WBRT) were selected for this study. Patients were divided into two groups of ten. Group one (G1) was positioned by tattoos and then the patient positioning was adjusted with the aid of AlignRT (Vision RT, London, UK). In group two (G2), patients were positioned only by tattoos. For both groups, the first 15 fractions were analyzed, a daily kilovoltage (kV) cone beam computed tomography (CBCT) image was made and then the rotational and translational displacements and, posteriorly, the systematic (Σ) and random (σ) errors were analyzed. RESULTS The comparison of CBCT displacements for the two groups showed a statistically significant difference in the translational left-right (LR) direction (ρ = 0.03), considering that the procedure with AlignRT system has smaller lateral displacements. The results of systematic (Σ) and random (σ) errors showed that for translational displacements the group positioned only by tattoos (G2) demonstrated higher values of errors when compared with the group positioned with the aid of AlignRT (G1). CONCLUSIONS AlignRT could help the positioning of breast cancer patients; however, it should be used with another imaging method.
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Affiliation(s)
- Ana Cravo Sá
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Ana Fermento
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Dalila Neves
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Sara Ferreira
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Teresa Silva
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Carina Marques Coelho
- Área Científica de Radioterapia, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa, Avenida D. João II, lote 4.69.01, 1990-096 Lisboa, Portugal
| | - Aude Vaandering
- Service de Radiothérapie Oncologique, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Bruxelles, Belgium
| | - Ana Roma
- Service de Radiothérapie Oncologique, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Bruxelles, Belgium
| | - Sérgio Quaresma
- Service de Radiothérapie Oncologique, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Bruxelles, Belgium
| | - Emmanuel Bonnarens
- Service de Radiothérapie Oncologique, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Bruxelles, Belgium
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50
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Jensen CA, Acosta Roa AM, Lund JÅ, Frengen J. Intrafractional baseline drift during free breathing breast cancer radiation therapy. Acta Oncol 2017; 56:867-873. [PMID: 28464748 DOI: 10.1080/0284186x.2017.1288924] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intrafraction motion in breast cancer radiation therapy (BCRT) has not yet been thoroughly described in the literature. It has been observed that baseline drift occurs as part of the intrafraction motion. This study aims to measure baseline drift and its incidence in free-breathing BCRT patients using an in-house developed laser system for tracking the position of the sternum. MATERIALS AND METHODS Baseline drift was monitored in 20 right-sided breast cancer patients receiving free breathing 3D-conformal RT by using an in-house developed laser system which measures one-dimensional distance in the AP direction. A total of 357 patient respiratory traces from treatment sessions were logged and analysed. Baseline drift was compared to patient positioning error measured from in-field portal imaging. RESULTS The mean overall baseline drift at end of treatment sessions was -1.3 mm for the patient population. Relatively small baseline drift was observed during the first fraction; however it was clearly detected already at the second fraction. Over 90% of the baseline drift occurs during the first 3 min of each treatment session. The baseline drift rate for the population was -0.5 ± 0.2 mm/min in the posterior direction the first minute after localization. Only 4% of the treatment sessions had a 5 mm or larger baseline drift at 5 min, all towards the posterior direction. Mean baseline drift in the posterior direction in free breathing BCRT was observed in 18 of 20 patients over all treatment sessions. CONCLUSIONS This study shows that there is a substantial baseline drift in free breathing BCRT patients. No clear baseline drift was observed during the first treatment session; however, baseline drift was markedly present at the rest of the sessions. Intrafraction motion due to baseline drift should be accounted for in margin calculations.
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Affiliation(s)
| | | | - Jo-Åsmund Lund
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jomar Frengen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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