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D'Souza A, Stowe HB, Green OL, Schiff J, Hugo GD, Ginn J, Maraghechi B, Kang KH, Kim H, Badiyan SN, Samson P, Robinson CG, Price A, Henke LE. Dosimetric predictors of acute and late gastrointestinal toxicities in stereotactic online adaptive magnetic resonance-guided radiotherapy (SMART) for locally advanced pancreatic adenocarcinoma. Radiother Oncol 2024; 200:110473. [PMID: 39137832 DOI: 10.1016/j.radonc.2024.110473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 06/17/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND AND PURPOSE A retrospective evaluation of dosimetric predictors and leveraged dose-volume data for gastrointestinal (GI) toxicities for locally-advanced pancreatic cancer (LAPC) treated with daily stereotactic MRI-guided online-adaptive radiotherapy (SMART). MATERIALS AND METHODS 147 patients with LAPC were treated with SMART at our institution between 2018 and 2021. Patients were evaluated using CTCAE V5.0 for RT-related acute (≤3 months) and late (>3 months) toxicities. Each organ at risk (OAR) was matched to a ≥ grade 2 (Gr2+) toxicity endpoint composite group. A least absolute shrinkage selector operator regression model was constructed by dose-volumes per OAR to account for OAR multicollinearity. A receiver operator curve (ROC) analysis was performed for the combined averages of significant toxicity groups to identify critical volumes per dose levels. RESULTS 18 of 147 patients experienced Gr2+ GI toxicity. 17 Gr2+ duodenal toxicities were seen; the most significant predictor was a V33Gy odds ratio (OR) of 1.69 per cc (95 % CI 1.14-2.88). 17 Gr2+ small bowel (SB) toxicities were seen; the most significant predictor was a V33Gy OR of 1.60 per cc (95 % CI 1.01-2.53). The AUC was 0.72 for duodenum and SB. The optimal duodenal cut-point was 1.00 cc (true positive (TP): 17.8 %; true negative (TN); 94.9 %). The SB cut-point was 1.75 cc (TP: 16.7 %; TN: 94.3 %). No stomach or large bowel dose toxicity predictors were identified. CONCLUSIONS For LAPC treated with SMART, the dose-volume threshold of V33Gy for duodenum and SB was associated with Gr2+ toxicities. These metrics can be utilized to guide future dose-volume constraints for patients undergoing upper abdominal SBRT.
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Affiliation(s)
- Alden D'Souza
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Hayley B Stowe
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Olga L Green
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Joshua Schiff
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Geoffrey D Hugo
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - John Ginn
- Duke University School of Medicine, Department of Radiation Oncology, Box 3085, Duke Cancer Center, Medicine Circle, Durham, NC 27710, USA.
| | - Borna Maraghechi
- City of Hope Orange County, Department of Radiation Oncology, Irvine, CA, USA.
| | - Kylie H Kang
- Fred Hutchinson Cancer Center, Proton Therapy, 1570 N. 115th St., Seattle, WA 98133, USA.
| | - Hyun Kim
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Shahed N Badiyan
- UT Southwestern Medical Center, Department of Radiation Oncology, 5323 Harry Hines Blvd., Dallas, TX 75390, USA.
| | - Pamela Samson
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Clifford G Robinson
- Washington University School of Medicine, Department of Radiation Oncology, 660 S. Euclid Ave, MSC 8224-35-LL, St. Louis, MO 63110, USA.
| | - Alex Price
- University Hospitals, Department of Radiation Oncology, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA.
| | - Lauren E Henke
- University Hospitals, Department of Radiation Oncology, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA.
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Wang H, Zhang X, Leng B, Zhu K, Jiang S, Feng R, Dou X, Shi F, Xu L, Yue J. Efficacy and safety of MR-guided adaptive simultaneous integrated boost radiotherapy to primary lesions and positive lymph nodes in the neoadjuvant treatment of locally advanced rectal cancer: a randomized controlled phase III trial. Radiat Oncol 2024; 19:118. [PMID: 39267085 PMCID: PMC11395642 DOI: 10.1186/s13014-024-02506-6] [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: 03/14/2024] [Accepted: 08/12/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND In locally advanced rectal cancer (LARC), optimizing neoadjuvant strategies, including the addition of concurrent chemotherapy and dose escalation of radiotherapy, is essential to improve tumor regression and subsequent implementation of anal preservation strategies. Currently, dose escalation studies in rectal cancer have focused on the primary lesions. However, a common source of recurrence in LARC is the metastasis of cancer cells to the proximal lymph nodes. In our trial, we implement simultaneous integrated boost (SIB) to both primary lesions and positive lymph nodes in the experimental group based on magnetic resonance-guided adaptive radiotherapy (MRgART), which allows for more precise (and consequently intense) targeting while sparing neighboring healthy tissue. The objective of this study is to evaluate the efficacy and safety of MRgART dose escalation to both primary lesions and positive lymph nodes, in comparison with the conventional radiotherapy of long-course concurrent chemoradiotherapy (LCCRT) group, in the neoadjuvant treatment of LARC. METHODS This is a multi-center, randomized, controlled phase III trial (NCT06246344). 128 patients with LARC (cT3-4/N+) will be enrolled. During LCCRT, patients will be randomized to receive either MRgART with SIB (60-65 Gy in 25-28 fractions to primary lesions and positive lymph nodes; 50-50.4 Gy in 25-28 fractions to the pelvis) or intensity-modulated radiotherapy (50-50.4 Gy in 25-28 fractions). Both groups will receive concurrent chemotherapy with capecitabine and consolidation chemotherapy of either two cycles of CAPEOX or three cycles of FOLFOX between radiotherapy and surgery. The primary endpoints are pathological complete response (pCR) rate and surgical difficulty, while the secondary endpoints are clinical complete response (cCR) rate, 3-year and 5-year disease-free survival (DFS) and overall survival (OS) rates, acute and late toxicity and quality of life. DISCUSSION Since dose escalation of both primary lesions and positive nodes in LARC is rare, we propose conducting a phase III trial to evaluate the efficacy and safety of SIB for both primary lesions and positive nodes in LARC based on MRgART. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov with the Identifier: NCT06246344 (Registered 7th Feb 2024).
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Affiliation(s)
- Haohua Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
- Cheeloo College of Medicine, Shandong University Cancer Center, Shandong University, Jinan, Shandong, China
| | - Xiang Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Boyu Leng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Kunli Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Shumei Jiang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Rui Feng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Xue Dou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Fang Shi
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Lei Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China.
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China.
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Borderías-Villarroel E, Barragán-Montero A, Sterpin E. Time is NTCP: Should we maximize patient throughput or perform online adaptation on proton therapy systems? Radiother Oncol 2024; 198:110389. [PMID: 38885906 DOI: 10.1016/j.radonc.2024.110389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Compared to conventional radiotherapy (XT), proton therapy (PT) may improve normal tissue complication probabilities (NTCP). However, PT typically requires higher adaptation rates due to an increased sensitivity to anatomical changes. Systematic online adaptation may address this issue, but it requires additional replanning time, decreasing patient throughput. Therefore, less patients would benefit in such case from PT for a given machine capacity, with results in worse NTCP. AIM To investigate the trade-off between PT patient throughput and NTCP gain as a function of the time needed for adaptation. METHODS A retrospective database of 14 lung patients with two repeated 4DCTs was used to compare NTCP values between XT and PT for NTCP2ym (2-year mortality), NTCPdysphagia and NTCPpneumonitis. Four scenarios were considered for PT: no adaptation using clinical robustness parameters (4D robust optimization, 3 % range error and PTV-equivalent setup errors); systematic online adaptation with clinical robustness parameters; setup errors reduced to 4 mm and to 2 mm. Dose was accumulated on the planning CT. The number of patients treated with PT depended on the extra time needed for adaptation, assuming an 8-hours capacity (assuming 14 patients a day; thus minimum 34.2 min per treatment session if there is no or instantaneous adaptation). RESULTS Baseline NTCP gains (PT against XT without adaptation) equaled 6.9 %, 6.1 %, and 7.7 % for NTCP2ym, NTCPdysphagia and NTCPpneumonitis, respectively. Using instantaneous online adaptation and setup errors of 2 mm, the overall gains were then 10.7 %, 13.6 % and 12.4 %. Taking into account loss of capacity, 13.7 min was the maximum extra-time allowed to complete adaptation and maintain an advantage on all three metrics for the 2-mm setup error scenario. CONCLUSION This study highlights the critical importance of keeping short online adaptation times when using systems with limited capacity like PT.
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Affiliation(s)
- E Borderías-Villarroel
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - A Barragán-Montero
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - E Sterpin
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium; KU Leuven, Department of Oncology, Laboratory of external radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium.
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Mittauer KE, Tolakanahalli R, Kotecha R, Chuong MD, Mehta MP, Gutierrez AN, Bassiri N. Commissioning Intracranial Stereotactic Radiosurgery for a Magnetic Resonance-Guided Radiation Therapy (MRgRT) System: MR-RT Localization and Dosimetric End-to-End Validation. Int J Radiat Oncol Biol Phys 2024; 118:512-524. [PMID: 37793574 DOI: 10.1016/j.ijrobp.2023.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 08/04/2023] [Accepted: 08/13/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE This is the first reporting of the MRIdian A3iTM intracranial package (BrainTxTM) and benchmarks the end-to-end localization and dosimetric accuracy for commissioning an magnetic resonace (MR)-guided stereotactic radiosurgery program. We characterized the localization accuracy between MR and radiation (RT) isocenter through an end-to-end hidden target test, relative dose profile intercomparison, and absolute dose validation. METHODS AND MATERIALS BrainTx consists of a dedicated head coil, integrated mask immobilization system, and high-resolution MR sequences. Coil and baseplate attenuation was quantified. An in-house phantom (Cranial phantOm foR magNetic rEsonance Localization of a stereotactIc radiosUrgery doSimeter, CORNELIUS) was developed from a mannequin head filled with silicone gel, film, and MR BB with pinprick. A hidden target test evaluated MR-RT localization of the 1×1×1 mm3 TrueFISP MR and relative dose accuracy in film for a 1 cm diameter (International Electrotechnical Commission (IEC)-X/IEC-Y) and 1.5 cm diameter (IEC-Y/IEC-Z) spherical target. Two clinical cases (irregular-shaped target and target abutting brainstem) were mapped to the CORNELIUS phantom for feasibility assessment. A 2-dimensional (2D)-gamma compared calculated and measured dose for spherical and clinical targets with 1 mm/1% and 2 mm/2% criteria, respectively. A small-field chamber (A26MR) measured end-to-end absolute dose for a 1 cm diameter target. RESULTS Coil and baseplate attenuation were 0.7% and 2.7%, respectively. The displacement of MR to RT localization as defined through the pinprick was 0.49 mm (IEC-X), 0.27 mm (IEC-Y), and 0.51 mm (IEC-Z) (root mean square 0.76 mm). The reproducibility across IEC-Y demonstrated high fidelity (<0.02 mm). Gamma pass rates were 97.1% and 95.4% for 1 cm and 1.5 cm targets, respectively. Dose profiles for an irregular-shaped target and abutting organ-at-risk-target demonstrated pass rates of 99.0% and 92.9%, respectively. The absolute end-to-end dose difference was <1%. CONCLUSIONS All localization and dosimetric evaluation demonstrated submillimeter accuracy, per the TG-142, TG-101, MPPG 9.a. criteria for SRS/SRT systems, indicating acceptable delivery capabilities with a 1 mm setup margin.
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Affiliation(s)
- Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida.
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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Nasser N, Yang GQ, Koo J, Bowers M, Greco K, Feygelman V, Moros EG, Caudell JJ, Redler G. A head and neck treatment planning strategy for a CBCT-guided ring-gantry online adaptive radiotherapy system. J Appl Clin Med Phys 2023; 24:e14134. [PMID: 37621133 PMCID: PMC10691641 DOI: 10.1002/acm2.14134] [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: 06/16/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE A planning strategy was developed and the utility of online-adaptation with the Ethos CBCT-guided ring-gantry adaptive radiotherapy (ART) system was evaluated using retrospective data from Head-and-neck (H&N) patients that required clinical offline adaptation during treatment. METHODS Clinical data were used to re-plan 20 H&N patients (10 sequential boost (SEQ) with separate base and boost plans plus 10 simultaneous integrated boost (SIB)). An optimal approach, robust to online adaptation, for Ethos-initial plans using clinical goal prioritization was developed. Anatomically-derived isodose-shaping helper structures, air-density override, goals for controlling hotspot location(s), and plan normalization were investigated. Online adaptation was simulated using clinical offline adaptive simulation-CTs to represent an on-treatment CBCT. Dosimetric comparisons were based on institutional guidelines for Clinical-initial versus Ethos-initial plans and Ethos-scheduled versus Ethos-adapted plans. Timing for five components of the online adaptive workflow was analyzed. RESULTS The Ethos H&N planning approach generated Ethos-initial SEQ plans with clinically comparable PTV coverage (average PTVHigh V100% = 98.3%, Dmin,0.03cc = 97.9% and D0.03cc = 105.5%) and OAR sparing. However, Ethos-initial SIB plans were clinically inferior (average PTVHigh V100% = 96.4%, Dmin,0.03cc = 93.7%, D0.03cc = 110.6%). Fixed-field IMRT was superior to VMAT for 93.3% of plans. Online adaptation succeeded in achieving conformal coverage to the new anatomy in both SEQ and SIB plans that was even superior to that achieved in the initial plans (which was due to the changes in anatomy that simplified the optimization). The average adaptive workflow duration for SIB, SEQ base and SEQ boost was 30:14, 22.56, and 14:03 (min: sec), respectively. CONCLUSIONS With an optimal planning approach, Ethos efficiently auto-generated dosimetrically comparable and clinically acceptable initial SEQ plans for H&N patients. Initial SIB plans were inferior and clinically unacceptable, but adapted SIB plans became clinically acceptable. Online adapted plans optimized dose to new anatomy and maintained target coverage/homogeneity with improved OAR sparing in a time-efficient manner.
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Affiliation(s)
- Nour Nasser
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - George Q. Yang
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jihye Koo
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Mark Bowers
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Kevin Greco
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | | | - Eduardo G. Moros
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jimmy J. Caudell
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Gage Redler
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
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Young T, Lee M, Johnston M, Nguyen T, Ko R, Arumugam S. Assessment of interfraction dose variation in pancreas SBRT using daily simulation MR images. Phys Eng Sci Med 2023; 46:1619-1627. [PMID: 37747645 DOI: 10.1007/s13246-023-01324-6] [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: 06/05/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
Pancreatic Cancer is associated with poor treatment outcomes compared to other cancers. High local control rates have been achieved by using hypofractionated stereotactic body radiotherapy (SBRT) to treat pancreatic cancer. Challenges in delivering SBRT include close proximity of several organs at risk (OARs) and target volume inter and intra fraction positional variations. Magnetic resonance image (MRI) guided radiotherapy has shown potential for online adaptive radiotherapy for pancreatic cancer, with superior soft tissue contrast compared to CT. The aim of this study was to investigate the variability of target and OAR volumes for different treatment approaches for pancreatic cancer, and to assess the suitability of utilizing a treatment-day MRI for treatment planning purposes. Ten healthy volunteers were scanned on a Siemens Skyra 3 T MRI scanner over two sessions (approximately 3 h apart), per day over 5 days to simulate an SBRT daily simulation scan for treatment planning. A pretreatment scan was also done to simulate patient setup and treatment. A 4D MRI scan was taken at each session for internal target volume (ITV) generation and assessment. For each volunteer a treatment plan was generated in the Raystation treatment planning system (TPS) following departmental protocols on the day one, first session dataset (D1S1), with bulk density overrides applied to enable dose calculation. This treatment plan was propagated through other imaging sessions, and the dose calculated. An additional treatment plan was generated on each first session of each day (S1) to simulate a daily replan process, with this plan propagated to the second session of the day. These accumulated mock treatment doses were assessed against the original treatment plan through DVH comparison of the PTV and OAR volumes. The generated ITV showed large variations when compared to both the first session ITV and daily ITV, with an average magnitude of 22.44% ± 13.28% and 25.83% ± 37.48% respectively. The PTV D95 was reduced by approximately 23.3% for both plan comparisons considered. Surrounding OARs had large variations in dose, with the small bowel V30 increasing by 128.87% when compared to the D1S1 plan, and 43.11% when compared to each daily S1 plan. Daily online adaptive radiotherapy is required for accurate dose delivery for pancreas cancer in the absence of additional motion management and tumour tracking techniques.
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Affiliation(s)
- Tony Young
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.
- Ingham Institute, Sydney, Australia.
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia.
| | - Mark Lee
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | | | - Theresa Nguyen
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Rebecca Ko
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
- Ingham Institute, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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Mittauer KE, Yarlagadda S, Bryant JM, Bassiri N, Romaguera T, Gomez AG, Herrera R, Kotecha R, Mehta MP, Gutierrez AN, Chuong MD. Online adaptive radiotherapy: Assessment of planning technique and its impact on longitudinal plan quality robustness in pancreatic cancer. Radiother Oncol 2023; 188:109869. [PMID: 37657726 DOI: 10.1016/j.radonc.2023.109869] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/14/2023] [Accepted: 08/22/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND AND PURPOSE Planning on a static dataset that reflects the simulation day anatomy is routine for SBRT. We hypothesize the quality of on-table adaptive plans is similar to the baseline plan when delivering stereotactic MR-guided adaptive radiotherapy (SMART) for pancreatic cancer (PCa). MATERIALS AND METHODS Sixty-seven inoperable PCa patients were prescribed 50 Gy/5-fraction SMART. Baseline planning included: 3-5 mm gastrointestinal (GI) PRV, 50 Gy optimization target (PTVopt) based on GI PRV, conformality rings, and contracted GTV to guide the hotspot. For each adaptation, GI anatomy was re-contoured, followed by re-optimization. Plan quality was evaluated for target coverage (TC = PTVopt V100%/volume), PTV D90% and D80%, homogeneity index (HI = PTVopt D2%/D98%), prescription isodose/target volume (PITV), low-dose conformity (D2cm = maximum dose at 2 cm from PTVopt/Rx dose), and gradient index (R50%=50% Rx isodose volume/PTVopt volume).A novel global planning metric, termed the Pancreas Adaptive Radiotherapy Score (PARTS), was developed and implemented based on GI OAR sparing, PTV/GTV coverage, and conformality. Adaptive robustness (baseline to fraction 1) and stability (difference between two fractions with highest GI PRV variation) were quantified. RESULTS OAR constraints were met on all baseline (n = 67) and adaptive (n = 318) plans. Coverage for baseline/adaptive plans was mean ± SD at 44.9 ± 5.8 Gy/44.3 ± 5.5 Gy (PTV D80%), 50.1 ± 4.2 Gy/49.1 ± 4.7 Gy (PTVopt D80%), and 80%±18%/74%±18% (TC), respectively. Mean homogeneity and conformality for baseline/adaptive plans were 0.87 ± 0.25/0.81 ± 0.30 (PITV), 3.81 ± 1.87/3.87 ± 2.0 (R50%), 1.53 ± 0.23/1.55 ± 0.23 (HI), and 58%±7%/59%±7% (D2cm), respectively. PARTS was found to be a sensitive metric due to its additive influence of geometry changes on PARTS' sub-metrics. There were no statistical differences (p > 0.05) for stability, except for PARTS (p = 0.04, median difference -0.6%). Statistical differences for robustness when significant were small for most metrics (<2.0% median). Median adaptive re-optimizations were 2. CONCLUSION We describe a 5-fraction ablative SMART planning approach for PCa that is robust and stable during on-table adaption, due to gradients controlled by a GI PRV technique and the use of rings. These findings are noteworthy given that daily interfraction anatomic GI OAR differences are routine, thus necessitating on-table adaptation. This work supports feasibility towards utilizing a patient-independent, template on-table adaptive approach.
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Affiliation(s)
- Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Sreenija Yarlagadda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA.
| | - John M Bryant
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Tino Romaguera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Andres G Gomez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA.
| | - Robert Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA.
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Liu H, Schaal D, Curry H, Clark R, Magliari A, Kupelian P, Khuntia D, Beriwal S. Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction. Radiat Oncol 2023; 18:144. [PMID: 37660057 PMCID: PMC10475190 DOI: 10.1186/s13014-023-02340-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Abstract
Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.
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Affiliation(s)
- Hefei Liu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | - Ryan Clark
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc, Palo Alto, CA, USA.
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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9
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Pan S, Chang CW, Wang T, Wynne J, Hu M, Lei Y, Liu T, Patel P, Roper J, Yang X. Abdomen CT multi-organ segmentation using token-based MLP-Mixer. Med Phys 2023; 50:3027-3038. [PMID: 36463516 PMCID: PMC10175083 DOI: 10.1002/mp.16135] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Manual contouring is very labor-intensive, time-consuming, and subject to intra- and inter-observer variability. An automated deep learning approach to fast and accurate contouring and segmentation is desirable during radiotherapy treatment planning. PURPOSE This work investigates an efficient deep-learning-based segmentation algorithm in abdomen computed tomography (CT) to facilitate radiation treatment planning. METHODS In this work, we propose a novel deep-learning model utilizing U-shaped multi-layer perceptron mixer (MLP-Mixer) and convolutional neural network (CNN) for multi-organ segmentation in abdomen CT images. The proposed model has a similar structure to V-net, while a proposed MLP-Convolutional block replaces each convolutional block. The MLP-Convolutional block consists of three components: an early convolutional block for local features extraction and feature resampling, a token-based MLP-Mixer layer for capturing global features with high efficiency, and a token projector for pixel-level detail recovery. We evaluate our proposed network using: (1) an institutional dataset with 60 patient cases and (2) a public dataset (BCTV) with 30 patient cases. The network performance was quantitatively evaluated in three domains: (1) volume similarity between the ground truth contours and the network predictions using the Dice score coefficient (DSC), sensitivity, and precision; (2) surface similarity using Hausdorff distance (HD), mean surface distance (MSD) and residual mean square distance (RMS); and (3) the computational complexity reported by the number of network parameters, training time, and inference time. The performance of the proposed network is compared with other state-of-the-art networks. RESULTS In the institutional dataset, the proposed network achieved the following volume similarity measures when averaged over all organs: DSC = 0.912, sensitivity = 0.917, precision = 0.917, average surface similarities were HD = 11.95 mm, MSD = 1.90 mm, RMS = 3.86 mm. The proposed network achieved DSC = 0.786 and HD = 9.04 mm on the public dataset. The network also shows statistically significant improvement, which is evaluated by a two-tailed Wilcoxon Mann-Whitney U test, on right lung (MSD where the maximum p-value is 0.001), spinal cord (sensitivity, precision, HD, RMSD where p-value ranges from 0.001 to 0.039), and stomach (DSC where the maximum p-value is 0.01) over all other competing networks. On the public dataset, the network report statistically significant improvement, which is shown by the Wilcoxon Mann-Whitney test, on pancreas (HD where the maximum p-value is 0.006), left (HD where the maximum p-value is 0.022) and right adrenal glands (DSC where the maximum p-value is 0.026). In both datasets, the proposed method can generate contours in less than 5 s. Overall, the proposed MLP-Vnet demonstrates comparable or better performance than competing methods with much lower memory complexity and higher speed. CONCLUSIONS The proposed MLP-Vnet demonstrates superior segmentation performance, in terms of accuracy and efficiency, relative to state-of-the-art methods. This reliable and efficient method demonstrates potential to streamline clinical workflows in abdominal radiotherapy, which may be especially important for online adaptive treatments.
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Affiliation(s)
- Shaoyan Pan
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30322, USA
| | - Chih-Wei Chang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Jacob Wynne
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Mingzhe Hu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30322, USA
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Tian Liu
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, NY, 10029, USA
| | - Pretesh Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Justin Roper
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Biomedical Informatics, Emory University, Atlanta, GA 30322, USA
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10
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Han Z, Sudhyadhom A, Hsu SH, Hu YH, Mak RH, Huynh MA, van Dams RR, Tanguturi S, Venkatachalam V, Mancias JD, Mamon HJ, Martin NE, Lam MB, Leeman JE. Comparison of MR-soft tissue based versus biliary stent based alignment for image guidance in pancreatic SBRT. J Appl Clin Med Phys 2023:e13965. [PMID: 36924220 DOI: 10.1002/acm2.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/27/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE The role of biliary stents in image-guided localization for pancreatic cancer has been inconclusive. To date, stent accuracy has been largely evaluated against implanted fiducials on cone beam computed tomography. We aim to use magnetic resonance (MR) soft tissue as a direct reference to examine the geometric and dosimetric impacts of stent-based localization on the newly available MR linear accelerator. METHODS Thirty pancreatic cancer patients (132 fractions) treated on our MR linear accelerator were identified to have a biliary stent. In our standard adaptive workflow, patients were set up to the target using soft tissue for image registration and structures were re-contoured on daily MR images. The original plan was then projected on treatment anatomy and dose predicted, followed by plan re-optimization and treatment delivery. These online predicted plans were soft tissue-based and served as reference plans. Retrospective image registration to the stent was performed offline to simulate stent-based localization and the magnitude of shifts was taken as the geometric accuracy of stent localization. New predicted plans were generated based on stent-alignment for dosimetric comparison. RESULTS Shifts were within 3 mm for 90% of the cases (mean = 1.5 mm); however, larger shifts up to 7.2 mm were observed. Average PTV coverage dropped by 1.1% with a maximum drop of 26.8%. The mean increase in V35Gy was 0.15, 0.05, 0.02, and 0.02 cc for duodenum, stomach, small bowel and large bowel, respectively. Stent alignment was significantly worse for all metrics except for small bowel (p = 0.07). CONCLUSIONS Overall discrepancy between stent- and soft tissue-alignment was modest; however, large discrepancies were observed for select cases. While PTV coverage loss may be compensated for by using a larger margin, the increase in dose to gastrointestinal organs at risk may limit the role of biliary stents in image-guided localization.
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Affiliation(s)
- Zhaohui Han
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Atchar Sudhyadhom
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Shu-Hui Hsu
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Yue-Houng Hu
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Mai Anh Huynh
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Ritchell R van Dams
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Shyam Tanguturi
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Veena Venkatachalam
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Mancias
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil E Martin
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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11
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Guevara B, Cullison K, Maziero D, Azzam GA, De La Fuente MI, Brown K, Valderrama A, Meshman J, Breto A, Ford JC, Mellon EA. Simulated Adaptive Radiotherapy for Shrinking Glioblastoma Resection Cavities on a Hybrid MRI-Linear Accelerator. Cancers (Basel) 2023; 15:1555. [PMID: 36900346 PMCID: PMC10000839 DOI: 10.3390/cancers15051555] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
During radiation therapy (RT) of glioblastoma, daily MRI with combination MRI-linear accelerator (MRI-Linac) systems has demonstrated significant anatomic changes, including evolving post-surgical cavity shrinkage. Cognitive function RT for brain tumors is correlated with radiation doses to healthy brain structures, especially the hippocampi. Therefore, this study investigates whether adaptive planning to the shrinking target could reduce normal brain RT dose with the goal of improving post-RT function. We evaluated 10 glioblastoma patients previously treated on a 0.35T MRI-Linac with a prescription of 60 Gy delivered in 30 fractions over six weeks without adaptation ("static plan") with concurrent temozolomide chemotherapy. Six weekly plans were created per patient. Reductions in the radiation dose to uninvolved hippocampi (maximum and mean) and brain (mean) were observed for weekly adaptive plans. The dose (Gy) to the hippocampi for static vs. weekly adaptive plans were, respectively: max 21 ± 13.7 vs. 15.2 ± 8.2 (p = 0.003) and mean 12.5 ± 6.7 vs. 8.4 ± 4.0 (p = 0.036). The mean brain dose was 20.6 ± 6.0 for static planning vs. 18.7 ± 6.8 for weekly adaptive planning (p = 0.005). Weekly adaptive re-planning has the potential to spare the brain and hippocampi from high-dose radiation, possibly reducing the neurocognitive side effects of RT for eligible patients.
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Affiliation(s)
- Beatriz Guevara
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Kaylie Cullison
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Danilo Maziero
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Radiation Medicine & Applied Sciences, UC San Diego Health, La Jolla, CA 92093, USA
| | - Gregory A. Azzam
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Macarena I. De La Fuente
- Department of Neurology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Karen Brown
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alessandro Valderrama
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Jessica Meshman
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Adrian Breto
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - John Chetley Ford
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Eric A. Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
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12
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Chen J, Bissonnette JP, Craig T, Munoz-Schuffenegger P, Tadic T, Dawson LA, Velec M. Liver SBRT dose accumulation to assess the impact of anatomic variations on normal tissue doses and toxicity in patients treated with concurrent sorafenib. Radiother Oncol 2023; 182:109588. [PMID: 36858203 DOI: 10.1016/j.radonc.2023.109588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND AND PURPOSE Unexpected liver volume reductions occurred during trials of liver SBRT and concurrent sorafenib. The aims were to accumulate liver SBRT doses to assess the impact of these anatomic variations on normal tissue dose parameters and toxicity. MATERIALS AND METHODS Thirty-two patients with hepatocellular carcinoma (HCC) or metastases treated on trials of liver SBRT (30-57 Gy, 6 fractions) and concurrent sorafenib were analyzed. SBRT doses were accumulated using biomechanical deformable registration of daily cone-beam CT. Dose deviations (accumulated-planned) for normal tissues were compared for patients with liver volume reductions > 100 cc versus stable volumes, and accumulated doses were reported for three patients with grade 3-5 luminal gastrointestinal toxicities. RESULTS Patients with reduced (N = 12) liver volumes had larger mean deviations of 0.4-1.3 Gy in normal tissues, versus -0.2-0.4 Gy for stable cases (N = 20), P > 0.05. Deviations > 5% of the prescribed dose occurred in both groups. Two HCC patients with toxicities to small and large bowel had liver volume reductions and deviations to the maximum dose of 4% (accumulated 36.9 Gy) and 3% (accumulated 33.4 Gy) to these organs respectively. Another HCC patient with a toxicity of unknown location plus tumor rupture, had stable liver volumes and deviations to luminal organs of -6% to 4.5% (accumulated < 30.5 Gy). CONCLUSION Liver volume reductions during SBRT and concurrent sorafenib were associated with larger increases in accumulated dose to normal tissues versus stable liver volumes. These dosimetric changes may have further contributed to toxicities in HCC patients who have higher baseline risks.
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Affiliation(s)
- Jasmine Chen
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Jean-Pierre Bissonnette
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada; Techna Insitute, University Health Network, Toronto, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Pablo Munoz-Schuffenegger
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Michael Velec
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, University of Toronto, Canada; Techna Insitute, University Health Network, Toronto, Canada.
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13
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Kim H, Olsen JR, Green OL, Chin RI, Hawkins WG, Fields RC, Hammill C, Doyle MB, Chapman W, Suresh R, Tan B, Pedersen K, Jansen B, DeWees TA, Lu E, Henke LE, Badiyan S, Parikh PJ, Roach MC, Wang-Gillam A, Lim KH. MR-Guided Radiation Therapy With Concurrent Gemcitabine/Nab-Paclitaxel Chemotherapy in Inoperable Pancreatic Cancer: A TITE-CRM Phase I Trial. Int J Radiat Oncol Biol Phys 2023; 115:214-223. [PMID: 35878713 DOI: 10.1016/j.ijrobp.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Ablative radiation therapy for borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) may limit concurrent chemotherapy dosing and usually is only safely deliverable to tumors distant from gastrointestinal organs. Magnetic resonance guided radiation therapy may safely permit radiation and chemotherapy dose escalation. METHODS AND MATERIALS We conducted a single-arm phase I study to determine the maximum tolerated dose of ablative hypofractionated radiation with full-dose gemcitabine/nab-paclitaxel in patients with BR/LA-PDAC. Patients were treated with gemcitabine/nab-paclitaxel (1000/125 mg/m2) x 1c then concurrent gemcitabine/nab-paclitaxel and radiation. Gemcitabine/nab-paclitaxel and radiation doses were escalated per time-to-event continual reassessment method from 40 to 45 Gy 25 fxs with chemotherapy (600-800/75 mg/m2) to 60 to 67.5 Gy/15 fractions and concurrent gemcitabine/nab-paclitaxel (1000/100 mg/m2). The primary endpoint was maximum tolerated dose of radiation as defined by 60-day dose limiting toxicity (DLT). DLT was treatment-related G5, G4 hematologic, or G3 gastrointestinal requiring hospitalization >3 days. Secondary endpoints included resection rates, local progression free survival (LPFS), distant metastasis free survival (DMFS), and overall survival (OS). RESULTS Thirty patients enrolled (March 2015-February 2019), with 26 evaluable patients (2 progressed before radiation, 1 was determined ineligible for radiation during planning, 1 withdrew consent). One DLT was observed. The DLT rate was 14.1% (3.3%-24.9%) with a maximum tolerated dose of gemcitabine/nab-paclitaxel (1000/100 mg/m2) and 67.5 Gy/15 fractions. At a median follow-up of 40.6 months for living patients the median OS was 14.5 months (95% confidence interval [CI], 10.9-28.2 months). The median OS for patients with Eastern Collaborative Oncology Group 0 and carbohydrate antigen 19-9 <90 were 34.1 (95% CI, 13.6-54.1) and 43.0 (95% CI, 8.0-not reached) months, respectively. Two-year LPFS and DMFS were 85% (95% CI, 63%-94%) and 57% (95% CI, 34%-73%), respectively. CONCLUSIONS Full-dose gemcitabine/nab-paclitaxel with ablative magnetic resonance guided radiation therapy dosing is safe in patients with BR/LA-PDAC, with promising LPFS and DMFS.
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Affiliation(s)
- Hyun Kim
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri.
| | - Jeffrey R Olsen
- University of Colorado School of Medicine, Department of Radiation Oncology, Denver, Colorado
| | - Olga L Green
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Re-I Chin
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - William G Hawkins
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Ryan C Fields
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Chet Hammill
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Majella B Doyle
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - William Chapman
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Rama Suresh
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Benjamin Tan
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Katrina Pedersen
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Brandi Jansen
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Todd A DeWees
- Mayo Clinic, Scottsdale, Division of Biomedical Statistics and Informatics, Scottsdale, Arizona
| | - Esther Lu
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, Missouri
| | - Lauren E Henke
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Shahed Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Parag J Parikh
- Henry Ford Health System, Department of Radiation Oncology, Detroit, Michigan
| | - Michael C Roach
- Hawai'i Pacific Health, Department of Radiation Oncology, Honolulu, Hawaii
| | - Andrea Wang-Gillam
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Kian-Huat Lim
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
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14
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Zhao X, Stanley DN, Cardenas CE, Harms J, Popple RA. Do we need patient-specific QA for adaptively generated plans? Retrospective evaluation of delivered online adaptive treatment plans on Varian Ethos. J Appl Clin Med Phys 2022; 24:e13876. [PMID: 36560887 PMCID: PMC9924122 DOI: 10.1002/acm2.13876] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The clinical introduction of dedicated treatment units for online adaptive radiation therapy (OART) has led to widespread adoption of daily adaptive radiotherapy. OART allows for rapid generation of treatment plans using daily patient anatomy, potentially leading to reduction of treatment margins and increased normal tissue sparing. However, the OART workflow does not allow for measurement of patient-specific quality assurance (PSQA) during treatment delivery sessions and instead relies on secondary dose calculations for verification of adapted plans. It remains unknown if independent dose verification is a sufficient surrogate for PSQA measurements. PURPOSE To evaluate the plan quality of previously treated adaptive plans through multiple standard PSQA measurements. METHODS This IRB-approved retrospective study included sixteen patients previously treated with OART at our institution. PSQA measurements were performed for each patient's scheduled and adaptive plans: five adaptive plans were randomly selected to perform ion chamber measurements and two adaptive plans were randomly selected for ArcCHECK measurements. The same ArcCHECK 3D dose distribution was also sent to Mobius3D to evaluate the second-check dosimetry system. RESULTS All (n = 96) ion chamber measurements agreed with the planned dose within 3% with a mean of 1.4% (± 0.7%). All (n = 48) plans passed ArcCHECK measurements using a 95% gamma passing threshold and 3%/2 mm criteria with a mean of 99.1% (± 0.7%). All (n = 48) plans passed Mobius3D second-check performed with 95% gamma passing threshold and 5%/3 mm criteria with a mean of 99.0% (± 0.2%). CONCLUSION Plan measurement for PSQA may not be necessary for every online-adaptive treatment verification. We recommend the establishment of a periodic PSQA check to better understand trends in passing rates for delivered adaptive treatments.
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Affiliation(s)
- Xiaodong Zhao
- Department of Radiation OncologyWashington University in St. LouisSt. LouisMissouriUSA
| | - Dennis N. Stanley
- Department of Radiation OncologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Carlos E. Cardenas
- Department of Radiation OncologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Richard A. Popple
- Department of Radiation OncologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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15
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McComas KN, Yock A, Darrow K, Shinohara ET. Online Adaptive Radiation Therapy and Opportunity Cost. Adv Radiat Oncol 2022. [DOI: 10.1016/j.adro.2022.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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16
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Milder MT, Magallon-Baro A, den Toom W, de Klerck E, Luthart L, Nuyttens JJ, Hoogeman MS. Technical feasibility of online adaptive stereotactic treatments in the abdomen on a robotic radiosurgery system. Phys Imaging Radiat Oncol 2022; 23:103-108. [PMID: 35928600 PMCID: PMC9344339 DOI: 10.1016/j.phro.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Maaike T.W. Milder
- Corresponding author at: Department of Radiation Oncology, Erasmus MC – Cancer Institute, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
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Kim H, Lee P, Tree AC, Chuong MD, Raldow AC, Kishan AU, Fuller CD, Rosenberg SA, Hall WA, Chie EK, Portelance L. Adaptive radiation therapy physician guidelines: Recommendations from an expert users’ panel. Pract Radiat Oncol 2022; 12:e355-e362. [DOI: 10.1016/j.prro.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
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Nierer L, Eze C, da Silva Mendes V, Braun J, Thum P, von Bestenbostel R, Kurz C, Landry G, Reiner M, Niyazi M, Belka C, Corradini S. Dosimetric benefit of MR-guided online adaptive radiotherapy in different tumor entities: liver, lung, abdominal lymph nodes, pancreas and prostate. Radiat Oncol 2022; 17:53. [PMID: 35279185 PMCID: PMC8917666 DOI: 10.1186/s13014-022-02021-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/27/2022] [Indexed: 01/18/2023] Open
Abstract
Background Hybrid magnetic resonance (MR)-Linac systems have recently been introduced into clinical practice. The systems allow online adaption of the treatment plan with the aim of compensating for interfractional anatomical changes. The aim of this study was to evaluate the dose volume histogram (DVH)-based dosimetric benefits of online adaptive MR-guided radiotherapy (oMRgRT) across different tumor entities and to investigate which subgroup of plans improved the most from adaption. Methods Fifty patients treated with oMRgRT for five different tumor entities (liver, lung, multiple abdominal lymph nodes, pancreas, and prostate) were included in this retrospective analysis. Various target volume (gross tumor volume GTV, clinical target volume CTV, and planning target volume PTV) and organs at risk (OAR) related DVH parameters were compared between the dose distributions before and after plan adaption. Results All subgroups clearly benefited from online plan adaption in terms of improved PTV coverage. For the liver, lung and abdominal lymph nodes cases, a consistent improvement in GTV coverage was found, while many fractions of the prostate subgroup showed acceptable CTV coverage even before plan adaption. The largest median improvements in GTV near-minimum dose (D98%) were found for the liver (6.3%, p < 0.001), lung (3.9%, p < 0.001), and abdominal lymph nodes (6.8%, p < 0.001) subgroups. Regarding OAR sparing, the largest median OAR dose reduction during plan adaption was found for the pancreas subgroup (-87.0%). However, in the pancreas subgroup an optimal GTV coverage was not always achieved because sparing of OARs was prioritized. Conclusion With online plan adaptation, it was possible to achieve significant improvements in target volume coverage and OAR sparing for various tumor entities and account for interfractional anatomical changes.
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Proposal and Evaluation of a Physician-Free, Real-Time On-Table Adaptive Radiotherapy (PF-ROAR) Workflow for the MRIdian MR-Guided LINAC. J Clin Med 2022; 11:jcm11051189. [PMID: 35268279 PMCID: PMC8911471 DOI: 10.3390/jcm11051189] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
With the implementation of MR-LINACs, real-time adaptive radiotherapy has become a possibility within the clinic. However, the process of adapting a patient’s plan is time consuming and often requires input from the entire clinical team, which translates to decreased throughput and limited patient access. In this study, the authors propose and simulate a workflow to address these inefficiencies in staffing and patient throughput. Two physicians, three radiation therapists (RTT), and a research fellow each adapted bladder and bowel contours for 20 fractions from 10 representative patient plans. Contouring ability was compared via calculation of a Dice Similarity Index (DSI). The DSI for bladder and bowel based on each potential physician–therapist pair, as well as an inter-physician comparison, exhibited good overlap amongst all comparisons (p = 0.868). Plan quality was compared through calculation of the conformity index (CI), as well as an evaluation of the plan’s dose to a ‘gold standard’ set of structures. Overall, non-physician plans passed 91.2% of the time. Of the eight non-physician plans that failed their clinical evaluation, six also failed their evaluation against the ‘gold standard’. Another two plans that passed their clinical evaluation subsequently failed in their evaluation against the ‘gold standard’. Thus, the PF-ROAR process has a success rate of 97.5%, with 78/80 plans correctly adapted to the gold standard or halted at treatment. These findings suggest that a physician-free workflow can be well tolerated provided RTTs continue to develop knowledge of MR anatomy and careful attention is given to understanding the complexity of the plan prior to treatment.
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Ermongkonchai T, Khor R, Muralidharan V, Tebbutt N, Lim K, Kutaiba N, Ng SP. Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer. World J Gastroenterol 2022; 28:745-754. [PMID: 35317275 PMCID: PMC8891728 DOI: 10.3748/wjg.v28.i7.745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers. Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens. Conventional techniques are often associated with acute gastrointestinal toxicities, as adjacent critical structures such as the duodenum ultimately limits delivered doses. Stereotactic body radiotherapy (SBRT) is an advanced radiation technique that delivers highly ablative radiation split into several fractions, with a steep dose fall-off outside target volumes.
AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced, unresectable pancreatic cancer.
METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer. Out of 1229 total records retrieved from our search, 36 studies were included in this review.
RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques. Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery. Magnetic resonance-guided techniques have been introduced to improve imaging quality, enabling treatment plan adaptation and re-optimisation before delivering each fraction.
CONCLUSION Therefore, SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques, and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.
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Affiliation(s)
- Tai Ermongkonchai
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kelvin Lim
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
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Pavic M, Niyazi M, Wilke L, Corradini S, Vornhülz M, Mansmann U, Al Tawil A, Fritsch R, Hörner-Rieber J, Debus J, Guckenberger M, Belka C, Mayerle J, Beyer G. MR-guided adaptive stereotactic body radiotherapy (SBRT) of primary tumor for pain control in metastatic pancreatic ductal adenocarcinoma (mPDAC): an open randomized, multicentric, parallel group clinical trial (MASPAC). Radiat Oncol 2022; 17:18. [PMID: 35078490 PMCID: PMC8788088 DOI: 10.1186/s13014-022-01988-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/12/2022] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background
Pain symptoms in the upper abdomen and back are prevalent in 80% of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC), where the current standard treatment is a systemic therapy consisting of at least doublet-chemotherapy for fit patients. Palliative low-dose radiotherapy is a well-established local treatment option but there is some evidence for a better and longer pain response after a dose-intensified radiotherapy of the primary pancreatic cancer (pPCa). Stereotactic body radiation therapy (SBRT) can deliver high radiation doses in few fractions, therefore reducing chemotherapy-free intervals. However, prospective data on pain control after SBRT of pPCa is very limited. Therefore, we aim to investigate the impact of SBRT on pain control in patients with mPDAC in a prospective trial.
Methods
This is a prospective, double-arm, randomized controlled, international multicenter study testing the added benefit of MR-guided adaptive SBRT of the pPca embedded between standard of care-chemotherapy (SoC-CT) cycles for pain control and prevention of pain in patients with mPDAC. 92 patients with histologically proven mPDAC and at least stable disease after initial 8 weeks of SoC-CT will be eligible for the trial and 1:1 randomized in 3 centers in Germany and Switzerland to either experimental arm A, receiving MR-guided SBRT of the pPCa with 5 × 6.6 Gy at 80% isodose with continuation of SoC-CT thereafter, or control arm B, continuing SoC-CT without SBRT. Daily MR-guided plan adaptation intents to achieve good target coverage, while simultaneously minimizing dose to organs at risk. Patients will be followed up for minimum 6 and maximum of 18 months. The primary endpoint of the study is the “mean cumulative pain index” rated every 4 weeks until death or end of study using numeric rating scale.
Discussion
An adequate long-term control of pain symptoms in patients with mPDAC is an unmet clinical need. Despite improvements in systemic treatment, local complications due to pPCa remain a clinical challenge. We hypothesize that patients with mPDAC will benefit from a local treatment of the pPCa by MR-guided SBRT in terms of a durable pain control with a simultaneously favorable safe toxicity profile translating into an improvement of quality-of-life.
Trial registration
German Registry for Clinical Trials (DRKS): DRKS00025801. Meanwhile the study is also registered at ClinicalTrials.gov with the Identifier: NCT05114213.
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Yazal T, Bailleul J, Ruan Y, Sung D, Chu FI, Palomera D, Dao A, Sehgal A, Gurunathan V, Aryan L, Eghbali M, Vlashi E. Radiosensitizing Pancreatic Cancer via Effective Autophagy Inhibition. Mol Cancer Ther 2022; 21:79-88. [PMID: 34725193 DOI: 10.1158/1535-7163.mct-20-1103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/02/2021] [Accepted: 10/29/2021] [Indexed: 12/09/2022]
Abstract
Despite aggressive treatments, pancreatic ductal adenocarcinoma (PDAC) remains an intractable disease, largely because it is refractory to therapeutic interventions. To overcome its nutrient-poor microenvironment, PDAC heavily relies on autophagy for metabolic needs to promote tumor growth and survival. Here, we explore autophagy inhibition as a method to enhance the effects of radiotherapy on PDAC tumors. Hydroxychloroquine is an autophagy inhibitor at the focus of many PDAC clinical trials, including in combination with radiotherapy. However, its acid-labile properties likely reduce its intratumoral efficacy. Here, we demonstrate that EAD1, a synthesized analogue of HCQ, is a more effective therapeutic for sensitizing PDAC tumors of various KRAS mutations to radiotherapy. Specifically, in vitro models show that EAD1 is an effective inhibitor of autophagic flux in PDAC cells, accompanied by a potent inhibition of proliferation. When combined with radiotherapy, EAD1 is consistently superior to HCQ not only as a single agent, but also in radiosensitizing PDAC cells, and perhaps most importantly, in decreasing the self-renewal capacity of PDAC cancer stem cells (PCSC). The more pronounced sensitizing effects of autophagy inhibitors on pancreatic stem over differentiated cells points to a new understanding that PCSCs may be more dependent on autophagy to counter the effects of radiation toxicity, a potential mechanism explaining the resistance of PCSCs to radiotherapy. Finally, in vivo subcutaneous tumor models demonstrate that combination of radiotherapy and EAD1 is the most successful at controlling tumor growth. The models also confirmed a similar toxicity profile between EAD1 and Hydroxychloroquine.
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Affiliation(s)
- Taha Yazal
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Justine Bailleul
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Yangjingyi Ruan
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - David Sung
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Fang-I Chu
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Daisy Palomera
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Amy Dao
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Anahita Sehgal
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Vibha Gurunathan
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Laila Aryan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Erina Vlashi
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
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Assessment of MRI-Linac Economics under the RO-APM. J Clin Med 2021; 10:jcm10204706. [PMID: 34682829 PMCID: PMC8539760 DOI: 10.3390/jcm10204706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/08/2021] [Indexed: 01/16/2023] Open
Abstract
The implementation of the radiation oncology alternative payment model (RO-APM) has raised concerns regarding the development of MRI-guided adaptive radiotherapy (MRgART). We sought to compare technical fee reimbursement under Fee-For-Service (FFS) to the proposed RO-APM for a typical MRI-Linac (MRL) patient load and distribution of 200 patients. In an exploratory aim, a modifier was added to the RO-APM (mRO-APM) to account for the resources necessary to provide this care. Traditional Medicare FFS reimbursement rates were compared to the diagnosis-based reimbursement in the RO-APM. Reimbursement for all selected diagnoses were lower in the RO-APM compared to FFS, with the largest differences in the adaptive treatments for lung cancer (−89%) and pancreatic cancer (−83%). The total annual reimbursement discrepancy amounted to −78%. Without implementation of adaptive replanning there was no difference in reimbursement in breast, colorectal and prostate cancer between RO-APM and mRO-APM. Accommodating online adaptive treatments in the mRO-APM would result in a reimbursement difference from the FFS model of −47% for lung cancer and −46% for pancreatic cancer, mitigating the overall annual reimbursement difference to −54%. Even with adjustment, the implementation of MRgART as a new treatment strategy is susceptible under the RO-APM.
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Cuccia F, Alongi F, Belka C, Boldrini L, Hörner-Rieber J, McNair H, Rigo M, Schoenmakers M, Niyazi M, Slagter J, Votta C, Corradini S. Patient positioning and immobilization procedures for hybrid MR-Linac systems. Radiat Oncol 2021; 16:183. [PMID: 34544481 PMCID: PMC8454038 DOI: 10.1186/s13014-021-01910-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/09/2021] [Indexed: 02/08/2023] Open
Abstract
Hybrid magnetic resonance (MR)-guided linear accelerators represent a new horizon in the field of radiation oncology. By harnessing the favorable combination of on-board MR-imaging with the possibility to daily recalculate the treatment plan based on real-time anatomy, the accuracy in target and organs-at-risk identification is expected to be improved, with the aim to provide the best tailored treatment. To date, two main MR-linac hybrid machines are available, Elekta Unity and Viewray MRIdian. Of note, compared to conventional linacs, these devices raise practical issues due to the positioning phase for the need to include the coil in the immobilization procedure and in order to perform the best reproducible positioning, also in light of the potentially longer treatment time. Given the relative novelty of this technology, there are few literature data regarding the procedures and the workflows for patient positioning and immobilization for MR-guided daily adaptive radiotherapy. In the present narrative review, we resume the currently available literature and provide an overview of the positioning and setup procedures for all the anatomical districts for hybrid MR-linac systems.
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Affiliation(s)
- Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy.
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy
- University of Brescia, Brescia, Italy
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Luca Boldrini
- Radiology, Radiation Oncology and Hematology Department, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Helen McNair
- The Royal Marsden NHS Foundation Trust, and Institute of Cancer Research Sutton, Surrey, UK
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy
| | - Maartje Schoenmakers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Judith Slagter
- Department of Radiation Oncology - Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio Votta
- Radiology, Radiation Oncology and Hematology Department, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Stereotactic body radiotherapy of lymph node metastases under MR-guidance: First clinical results and patient-reported outcomes. Strahlenther Onkol 2021; 198:56-65. [PMID: 34468783 PMCID: PMC8760210 DOI: 10.1007/s00066-021-01834-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/01/2021] [Indexed: 12/04/2022]
Abstract
Objective Stereotactic body radiotherapy (SBRT) is a noninvasive treatment option for lymph node metastases (LNM). Magnetic resonance (MR)-guidance offers superior tissue contrast and enables treatment of targets in close vicinity to radiosensitive organs at risk (OAR). However, literature on MR-guided SBRT of LNM is scarce with no report on outcome parameters. Materials and methods We report a subgroup analysis of a prospective observational study comprising patients with LNM. Patients received MR-guided SBRT at our MRIdian Linac (ViewRay Inc., Mountain View, CA, USA) between January 2019 and February 2020. Local control (LC), progression-free survival (PFS) and overall survival (OS) analysis were performed using the Kaplan–Meier method with log rank test to test for significance (p < 0.05). Our patient-reported outcome questionnaire was utilized to evaluate patients’ perspective. The CTCAE (Common Terminology Criteria for Adverse Events) v. 5.0 was used to describe toxicity. Results Twenty-nine patients (72.4% with prostate cancer; 51.7% with no distant metastases) received MR-guided SBRT for in total 39 LNM. Median dose was 27 Gy in three fractions, prescribed to the 80% isodose. At 1‑year, estimated LC, PFS and OS were 92.6, 67.4 and 100.0%. Compared to baseline, six patients (20.7%) developed new grade I toxicities (mainly fatigue). One grade II toxicity occurred (fatigue), with no adverse event grade ≥III. Overall treatment experience was rated particularly positive, while the technically required low room temperature still represents the greatest obstacle in the pursuit of the ideal patient acceptance. Conclusion MR-guided SBRT of LNM was demonstrated to be a well-accepted treatment modality with excellent preliminary results. Future studies should evaluate the clinical superiority to conventional SBRT. Video online The online version of this article contains one video. The article and the video are available online (10.1007/s00066-021-01834-w). The video can be found in the article back matter as “Supplementary Information”.
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Magallon-Baro A, Milder MTW, Granton PV, Nuyttens JJ, Hoogeman MS. Comparison of Daily Online Plan Adaptation Strategies for a Cohort of Pancreatic Cancer Patients Treated with SBRT. Int J Radiat Oncol Biol Phys 2021; 111:208-219. [PMID: 33811976 DOI: 10.1016/j.ijrobp.2021.03.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/01/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To study the trade-offs of three online strategies to adapt treatment plans of patients with locally advanced pancreatic carcinoma (LAPC) treated using the CyberKnife with tumor tracking. METHODS AND MATERIALS A total of 35 planning computed tomography scans and 98 daily in-room computed tomography scans were collected from 35 patients with LAPC. Planned dose distributions, optimized with VOLO, were evaluated on manually contoured daily anatomies to collect daily doses. Three strategies were tested to adapt treatment plans: (1) unrestricted full replanning using a patient-specific plan template, (2) time-restricted replanning on organs at risk (OARs) within 3 cm from the planning target volume (PTV) structure, and (3) dose realignment optimization to stay within OAR constraints. Dose distributions resulting from each plan adaptation strategy were dosimetrically compared by means of gross tumor volume (GTV), PTV coverage, and OAR tolerances. RESULTS Planned doses did not result in dose-constraint violations for 28 of 98 daily anatomies. None of the suggested plan adaptation strategies improved planned doses significantly for this subset. For 70 of the 98 reported violations, the median (interquartile range) PTV coverage of the planned dose was 84% (76% to 86%). After plan adaptation, unrestricted replanning achieved clinically acceptable plans in 93% of these fractions, time-restricted replanning in 90%, and dose realignment in 74%, at median computational times of 8.5, 3, and 0.5 minutes. Over all 98 fractions, PTV coverage was reduced: -1% (-3% to 1%), -2% (-5% to 0%), and -2% (-8% to 0%) after each strategy, respectively. In 3 of 70 fractions, none of the suggested strategies achieved clinically acceptable OAR dose volumes. CONCLUSIONS Unrestricted replanning was the most time-consuming method but reached the highest number of successfully adapted plans. Time-restricted replanning and dose realignment resulted in a high number of plans within dose constraints. Depending on the resources available, an adaptive strategy can be selected for each patient to address the specific anatomic challenges on the treatment day. The increase in the complexity of the strategy corresponds with an increasing number of successfully adapted plans.
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Affiliation(s)
- Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.
| | - Maaike T W Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Patrick V Granton
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Joost J Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Yoon SM, Luterstein E, Chu FI, Cao M, Lamb J, Agazaryan N, Low D, Raldow A, Steinberg ML, Lee P. Clinical outcomes of stereotactic magnetic resonance image-guided adaptive radiotherapy for primary and metastatic tumors in the abdomen and pelvis. Cancer Med 2021; 10:5897-5906. [PMID: 34288538 PMCID: PMC8419771 DOI: 10.1002/cam4.4139] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Stereotactic body radiotherapy (SBRT) delivers ablative doses with excellent local control. However, implementing SBRT for abdominal and pelvic tumors has been limited by the risk for treatment‐related gastrointestinal toxicity. MRI‐guided radiotherapy may ameliorate these risks and increase the therapeutic ratio. We report the clinical outcomes of stereotactic MRI‐guided adaptive radiotherapy (SMART) for primary and metastatic tumors in the abdomen and pelvis. Methods From November 2014 to August 2017, the first 106 consecutive patients with 121 tumors in the abdomen and pelvis were treated with SMART at a single institution. Of the cohort, 41.5%, 15.1%, and 43.4% had primary, locally recurrent, and oligometastatic tumors, respectively. SMART was delivered using a tri‐cobalt‐60 gantry with on‐board 0.35 Tesla MRI with respiratory breath‐hold and daily adaptive re‐planning when anatomically necessary. A median of 40Gy in five fractions was prescribed. The Common Terminology Criteria for Adverse Events v.4.03 was used to score treatment‐related toxicities. Local control (LC), progression‐free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier method. Results Of the 510 treatments, seventy‐one (13.9%) were adapted. Fatigue, nausea, and pain were the most common acute toxicities. 0.9 and 0% of patients experienced acute grade three and four toxicities, respectively. 5.2 and 2.1% of patients experienced late grade three and four toxicities, respectively. After a median follow‐up of 20.4 months, the 2‐year LC rate was 74% on a per‐lesion basis. Two‐year LC was 96% for lesions that were treated with BED10≥100 versus 69% for BED10<100 (p = 0.02). PFS was significantly different between patients with and without locally controlled tumors (2‐year PFS 21 vs. 8%, p = 0.03). Two‐year OS was 57% for the entire cohort. Conclusions Favorable LC and PFS outcomes were observed with minimal morbidity for tumors in the abdomen and pelvis treated with SMART. Future prospective clinical trials to validate these findings are warranted.
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Affiliation(s)
- Stephanie M Yoon
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Elaine Luterstein
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Fang-I Chu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - James Lamb
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel Low
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ann Raldow
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Percy Lee
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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Tchelebi LT, Zaorsky NG, Rosenberg JC, Sharma NK, Tuanquin LC, Mackley HB, Ellis RJ. Reducing the Toxicity of Radiotherapy for Pancreatic Cancer With Magnetic Resonance-guided Radiotherapy. Toxicol Sci 2021; 175:19-23. [PMID: 32053201 DOI: 10.1093/toxsci/kfaa021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer is a highly fatal malignancy for which surgery is currently considered to be the only curative treatment. However, less than a quarter of patients have disease amenable to definitive surgical resection. Local treatment with radiation therapy is a promising alternative to surgery for those patients with unresectable disease. However, conventional radiation techniques with computed tomography (CT)-guided therapy have yielded disappointing results due to the inability to deliver ablative doses of ionizing radiation, while sparing the radiosensitive adjacent organs at risk. Magnetic resonance-guided radiotherapy (MRgRT) has emerged as an alternative to CT-guided radiation treatment which allows for the delivery of higher doses of radiation with low toxicity to surrounding structures. Further study into the use of MRgRT and dose escalation for locally advanced unresectable pancreatic cancer is needed.
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Affiliation(s)
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania 17033
| | | | - Navesh K Sharma
- Department of Radiation Oncology, Penn State Cancer Institute
| | | | - Heath B Mackley
- Department of Radiation Oncology, Penn State Cancer Institute
| | - Rodney J Ellis
- Department of Radiation Oncology, Penn State Cancer Institute
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30
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Ugurluer G, Mustafayev TZ, Gungor G, Atalar B, Abacioglu U, Sengoz M, Agaoglu F, Demir G, Ozyar E. Stereotactic MR-guided online adaptive radiation therapy (SMART) for the treatment of liver metastases in oligometastatic patients: initial clinical experience. Radiat Oncol J 2021; 39:33-40. [PMID: 33794572 PMCID: PMC8024184 DOI: 10.3857/roj.2020.00976] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose We aimed to present our initial clinical experience on the implementation of a stereotactic MR-guided online adaptive radiation therapy (SMART) for the treatment of liver metastases in oligometastatic disease. Materials and Methods Twenty-one patients (24 lesions) with liver metastasis treated with SMART were included in this retrospective study. Step-and-shoot intensity-modulated radiotherapy technique was used with daily plan adaptation. During delivery, real-time imaging was used by acquiring planar magnetic resonance images in sagittal plane for monitoring and gating. Acute and late toxicities were recorded both during treatment and follow-up visits. Results The median follow-up time was 11.6 months (range, 2.2 to 24.6 months). The median delivered total dose was 50 Gy (range, 40 to 60 Gy); with a median fraction number of 5 (range, 3 to 8 fractions) and the median fraction dose was 10 Gy (range, 7.5 to 18 Gy). Ninety-three fractions (83.7%) among 111 fractions were re-optimized. No patients were lost to follow-up and all patients were alive except one at the time of analysis. All of the patients had either complete (80.9%) or partial (19.1%) response at irradiated sites. Estimated 1-year overall survival was 93.3%. Intrahepatic and extrahepatic progression-free survival was 89.7% and 73.5% at 1 year, respectively. There was no grade 3 or higher acute or late toxicities experienced during the treatment and follow-up course. Conclusion SMART represents a new, noninvasive and effective alternative to current ablative radiotherapy methods for treatment of liver metastases in oligometastatic disease with the advantages of better visualization of soft tissue, real-time tumor tracking and potentially reduced toxicity to organs at risk.
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Affiliation(s)
- Gamze Ugurluer
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Teuta Zoto Mustafayev
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Gorkem Gungor
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Banu Atalar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Ufuk Abacioglu
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Meric Sengoz
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Fulya Agaoglu
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Gokhan Demir
- Department of Medical Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Enis Ozyar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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31
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Hill CS, Han-Oh S, Cheng Z, Wang KKH, Meyer JJ, Herman JM, Narang AK. Fiducial-based image-guided SBRT for pancreatic adenocarcinoma: Does inter-and intra-fraction treatment variation warrant adaptive therapy? Radiat Oncol 2021; 16:53. [PMID: 33741015 PMCID: PMC7980583 DOI: 10.1186/s13014-021-01782-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/10/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Variation in target positioning represents a challenge to set-up reproducibility and reliability of dose delivery with stereotactic body radiation therapy (SBRT) for pancreatic adenocarcinoma (PDAC). While on-board imaging for fiducial matching allows for daily shifts to optimize target positioning, the magnitude of the shift as a result of inter- and intra-fraction variation may directly impact target coverage and dose to organs-at-risk. Herein, we characterize the variation patterns for PDAC patients treated at a high-volume institution with SBRT. Methods We reviewed 30 consecutive patients who received SBRT using active breathing coordination (ABC). Patients were aligned to bone and then subsequently shifted to fiducials. Inter-fraction and intra-fraction scans were reviewed to quantify the mean and maximum shift along each axis, and the shift magnitude. A linear regression model was conducted to investigate the relationship between the inter- and intra-fraction shifts. Results The mean inter-fraction shift in the LR, AP, and SI axes was 3.1 ± 1.8 mm, 2.9 ± 1.7 mm, and 3.5 ± 2.2 mm, respectively, and the mean vector shift was 6.4 ± 2.3 mm. The mean intra-fraction shift in the LR, AP, and SI directions were 2.0 ± 0.9 mm, 2.0 ± 1.3 mm, and 2.3 ± 1.4 mm, respectively, and the mean vector shift was 4.3 ± 1.8 mm. A linear regression model showed a significant relationship between the inter- and intra-fraction shift in the AP and SI axis and the shift magnitude. Conclusions Clinically significant inter- and intra-fraction variation occurs during treatment of PDAC with SBRT even with a comprehensive motion management strategy that utilizes ABC. Future studies to investigate how these variations could lead to variation in the dose to the target and OAR should be investigated. Strategies to mitigate the dosimetric impact, including real time imaging and adaptive therapy, in select cases should be considered. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01782-w.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA.
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA
| | - Zhi Cheng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA
| | - Ken Kang-Hsin Wang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA
| | - Jeffrey J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine At Hofstra/Northwell, Lake Success, USA
| | - Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N. Broadway, Suite 1440, Baltimore, MD, 21231, USA
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32
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Maziero D, Straza MW, Ford JC, Bovi JA, Diwanji T, Stoyanova R, Paulson ES, Mellon EA. MR-Guided Radiotherapy for Brain and Spine Tumors. Front Oncol 2021; 11:626100. [PMID: 33763361 PMCID: PMC7982530 DOI: 10.3389/fonc.2021.626100] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/12/2021] [Indexed: 12/19/2022] Open
Abstract
MRI is the standard modality to assess anatomy and response to treatment in brain and spine tumors given its superb anatomic soft tissue contrast (e.g., T1 and T2) and numerous additional intrinsic contrast mechanisms that can be used to investigate physiology (e.g., diffusion, perfusion, spectroscopy). As such, hybrid MRI and radiotherapy (RT) devices hold unique promise for Magnetic Resonance guided Radiation Therapy (MRgRT). In the brain, MRgRT provides daily visualizations of evolving tumors that are not seen with cone beam CT guidance and cannot be fully characterized with occasional standalone MRI scans. Significant evolving anatomic changes during radiotherapy can be observed in patients with glioblastoma during the 6-week fractionated MRIgRT course. In this review, a case of rapidly changing symptomatic tumor is demonstrated for possible therapy adaptation. For stereotactic body RT of the spine, MRgRT acquires clear isotropic images of tumor in relation to spinal cord, cerebral spinal fluid, and nearby moving organs at risk such as bowel. This visualization allows for setup reassurance and the possibility of adaptive radiotherapy based on anatomy in difficult cases. A review of the literature for MR relaxometry, diffusion, perfusion, and spectroscopy during RT is also presented. These techniques are known to correlate with physiologic changes in the tumor such as cellularity, necrosis, and metabolism, and serve as early biomarkers of chemotherapy and RT response correlating with patient survival. While physiologic tumor investigations during RT have been limited by the feasibility and cost of obtaining frequent standalone MRIs, MRIgRT systems have enabled daily and widespread physiologic measurements. We demonstrate an example case of a poorly responding tumor on the 0.35 T MRIgRT system with relaxometry and diffusion measured several times per week. Future studies must elucidate which changes in MR-based physiologic metrics and at which timepoints best predict patient outcomes. This will lead to early treatment intensification for tumors identified to have the worst physiologic responses during RT in efforts to improve glioblastoma survival.
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Affiliation(s)
- Danilo Maziero
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Michael W Straza
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - John C Ford
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Tejan Diwanji
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Radka Stoyanova
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Eric S Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
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Su C, Okamoto H, Nishioka S, Sakasai T, Fujiyama D, Miura Y, Tsunoda Y, Kuwahara J, Nakamura S, Iijima K, Chiba T, Kaga K, Takemori M, Nakayama H, Katsuta S, Inaba K, Igaki H, Nakayama Y, Itami J. Dosimetric effect of the intestinal gas of online adaptive stereotactic body radiotherapy on target and critical organs without online electron density correction for pancreatic cancer. Br J Radiol 2021; 94:20200239. [PMID: 33353402 DOI: 10.1259/bjr.20200239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE This study aimed to assess the dosimetric effect of intestinal gas of stereotactic magnetic resonance (MR)-guided adaptive radiation therapy (SMART) on target and critical organs for pancreatic cancer without online electron density correction (EDC). METHODS Thirty pancreatic cancer patients who underwent online SMART were selected for this study. The treatment time of each stage and the total treatment time were recorded and analyzed. The concerned dose-volume parameters of target and organs-at-risk (OAR) were compared with and without an intestinal gas EDC using the Wilcoxon-signed rank test. Analysis items with p value < 0.05 were considered statistically significant. The relationships between dosimetric differences and intestinal gas volume variations were investigated using the Spearman test. RESULTS The average treatment time was 82 min, and the average EDC time was 8 min, which accounted for 10% of the overall treatment time. There were no significant differences in CTV (GTV), PTV, bowel, stomach, duodenum, and skin (p > 0.05) with respect to dose volume parameters. For the Dmax of gastrointestinal organs (p = 0.03), the mean dose of the liver (p = 0.002) and kidneys (p = 0.03 and p = 0.04 for the left and right kidneys, respectively), there may be a risk of slight overestimation compared with EDC, and for the Dmax of the spinal cord (p = 0.02), there may be a risk of slight underestimation compared with EDC. A weak correlation for D95 in the PTV and D0.5 cc in the duodenum was observed. CONCLUSION For patients with similar inter-fractional intestinal gas distribution, EDC had little dosimetric effects on the D0.5 cc of all GI organs and dose volume parameters of target in most plans. ADVANCES IN KNOWLEDGE By omitting the EDC of intestinal gas, the online SMART treatment time can be shortened.
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Affiliation(s)
- Chen Su
- Department of Oncology, Jinan Central Hospital, Cheeloo College of Medcine, Shandong University, Central Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Hiroyuki Okamoto
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Shie Nishioka
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Tatsuya Sakasai
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Fujiyama
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuki Miura
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuki Tsunoda
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Junichi Kuwahara
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nakamura
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Kotaro Iijima
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Takahito Chiba
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Keita Kaga
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Mihiro Takemori
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroki Nakayama
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Shouichi Katsuta
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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Lee M, Simeonov A, Stanescu T, Dawson LA, Brock KK, Velec M. MRI evaluation of normal tissue deformation and breathing motion under an abdominal compression device. J Appl Clin Med Phys 2021; 22:90-97. [PMID: 33449447 PMCID: PMC7882116 DOI: 10.1002/acm2.13165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose Abdominal compression can minimize breathing motion in stereotactic radiotherapy, though it may impact the positioning of dose‐limiting normal tissues. This study quantified the reproducibility of abdominal normal tissues and respiratory motion with the use of an abdominal compression device using MR imaging. Methods Twenty healthy volunteers had repeat MR over 3 days under an abdominal compression plate device. Normal tissues were delineated on daily axial T2‐weighted MR and compared on days 2 and 3 relative to day 1, after adjusting for baseline shifts relative to bony anatomy. Inter‐fraction organ deformation was computed using deformable registration of axial T2 images. Deformation > 5 mm was assumed to be clinically relevant. Inter‐fraction respiratory amplitude changes and intra‐fraction baseline drifts during imaging were quantified on daily orthogonal cine‐MR (70 s each), and changes > 3 mm were assumed to be relevant. Results On axial MR, the mean inter‐fraction normal tissue deformation was > 5 mm for all organs (range 5.1–13.4 mm). Inter‐fraction compression device misplacements > 5 mm and changes in stomach volume > 50% occurred at a rate of 93% and 38%, respectively, in one or more directions and were associated with larger adjacent organ deformation, in particular for the duodenum. On cine‐MR, inter‐fraction amplitude changes > 3 mm on day 2 and 3 relative to day 1 occurred at a rate of < 12.5% (mean superior–inferior change was 1.6 mm). Intra‐fraction baseline drifts > 3 mm during any cine‐MR acquisition occurred at a rate of 23% (mean superior–inferior changes was 2.4 mm). Conclusions Respiratory motion under abdominal compression is reproducible in most subjects within 3 mm. However, inter‐fraction deformations greater than 5 mm in normal tissues were common and larger than inter‐ and intra‐fraction respiratory changes. Deformations were driven mostly by variable stomach contents and device positioning. The magnitude of this motion may impact normal tissue dosimetry during stereotactic radiotherapy.
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Affiliation(s)
- Maureen Lee
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Anna Simeonov
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Teo Stanescu
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.,TECHNA Institute, University Health Network, 100 College Street, Toronto, ON, M5G 1L5, Canada
| | - Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Kristy K Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Michael Velec
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.,TECHNA Institute, University Health Network, 100 College Street, Toronto, ON, M5G 1L5, Canada
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35
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Cusumano D, Boldrini L, Yadav P, Casà C, Lee SL, Romano A, Piras A, Chiloiro G, Placidi L, Catucci F, Votta C, Mattiucci GC, Indovina L, Gambacorta MA, Bassetti M, Valentini V. Delta Radiomics Analysis for Local Control Prediction in Pancreatic Cancer Patients Treated Using Magnetic Resonance Guided Radiotherapy. Diagnostics (Basel) 2021; 11:diagnostics11010072. [PMID: 33466307 PMCID: PMC7824764 DOI: 10.3390/diagnostics11010072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 02/07/2023] Open
Abstract
The aim of this study is to investigate the role of Delta Radiomics analysis in the prediction of one-year local control (1yLC) in patients affected by locally advanced pancreatic cancer (LAPC) and treated using Magnetic Resonance guided Radiotherapy (MRgRT). A total of 35 patients from two institutions were enrolled: A 0.35 Tesla T2*/T1 MR image was acquired for each case during simulation and on each treatment fraction. Physical dose was converted in biologically effective dose (BED) to compensate for different radiotherapy schemes. Delta Radiomics analysis was performed considering the gross tumour volume (GTV) delineated on MR images acquired at BED of 20, 40, and 60 Gy. The performance of the delta features in predicting 1yLC was investigated in terms of Wilcoxon Mann-Whitney test and area under receiver operating characteristic (ROC) curve (AUC). The most significant feature in predicting 1yLC was the variation of cluster shade calculated at BED = 40 Gy, with a p-value of 0.005 and an AUC of 0.78 (0.61-0.94). Delta Radiomics analysis on low-field MR images might play a promising role in 1yLC prediction for LAPC patients: further studies including an external validation dataset and a larger cohort of patients are recommended to confirm the validity of this preliminary experience.
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Affiliation(s)
- Davide Cusumano
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Luca Boldrini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Poonam Yadav
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA; (P.Y.); (M.B.)
| | - Calogero Casà
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
- Correspondence: ; Tel.: +39-06-3015-5226
| | - Sangjune Laurence Lee
- Department of Oncology, University of Calgary, 1331 29 Street NW, Calgary, AB T2N 1N4, Canada;
| | - Angela Romano
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Antonio Piras
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Francesco Catucci
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Claudio Votta
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Gian Carlo Mattiucci
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Luca Indovina
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Maria Antonietta Gambacorta
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Michael Bassetti
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA; (P.Y.); (M.B.)
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
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McNair H, Wiseman T, Joyce E, Peet B, Huddart R. International survey; current practice in On-line adaptive radiotherapy (ART) delivered using Magnetic Resonance Image (MRI) guidance. Tech Innov Patient Support Radiat Oncol 2020; 16:1-9. [PMID: 32995576 PMCID: PMC7501460 DOI: 10.1016/j.tipsro.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 08/19/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The uptake of new technologies has varied internationally and there have often been barriers to implementation. On-line adaptive radiotherapy (ART) promises to improve patient outcome. This survey focuses on the implementation phase of delivering ART and professional roles and responsibilities currently involved in the workflow and changes which may be expected in the future. MATERIALS AND METHODS A 38 question survey included aspects on current practice; professional responsibilities; benefits and barriers; and decision making and responsibilities. For the purposes of the questionnaire and paper, ART was considered where tumour and /or organs at risk were contoured and re-planning was performed on-line. The questionnaire was electronically distributed via radiotherapy networks. RESULTS Nineteen international responses were received. Europe (n = 11), United States of America (n = 4); Canada (n = 2), Australia (n = 1) and Hong Kong (n = 1). The majority of centres started using ART in either 2018 (n = 7) or 2019 (n = 6). Four centres started treating with ART between 2015 and 2017, and the first was in 2014. Centres initially treated prostate and oligometastases patients, expanding to treat prostate, oligometastases, pancreas and rectum. The majority of centres were working in conventional roles, however moving towards radiographers taking more responsibility in contouring organs at risk (OAR), target and dosimetry. The three most important criteria chosen by medical doctors to determine if ART should be used were overall gross anatomy changes of target and OAR, target not covered by planning target volume (PTV) and OAR close to the high dose area. There was no clear consensus on the minimum improvement in dose to target or reduction in dose to OAR to warrant adaption. CONCLUSION On-line ART has been implemented successfully internationally. Initial practice maintains conventional professional roles and responsibilities, however there is trend to changing roles for the future. There is little consensus regarding the triggers of adaption.
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Affiliation(s)
- H.A. McNair
- Institute of Cancer Research, United Kingdom
| | - T Wiseman
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - E Joyce
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - B Peet
- Royal Marsden NHS Foundation Trust, United Kingdom
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Thomas MA, Olick-Gibson J, Fu Y, Parikh PJ, Green O, Yang D. Using prediction models to evaluate magnetic resonance image guided radiation therapy plans. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 16:99-102. [PMID: 33458351 PMCID: PMC7807572 DOI: 10.1016/j.phro.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 10/26/2022]
Abstract
Comprehensive analysis of daily, online adaptive plan quality and safety in magnetic resonance imaging (MRI) guided radiation therapy is critical to its widespread use. Artificial neural network models developed with offline plans created after simulation were used to analyze and compare online plans that were adapted and reoptimized in real time prior to treatment. Roughly one third of 60Co adapted plans were of inferior quality relative to fully optimized, offline plans, but MRI-linac adapted plans were essentially equivalent to offline plans. The models also enabled clear justification that MRI-linac plans are superior to 60Co in an overwhelming majority of cases.
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Affiliation(s)
- M Allan Thomas
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States.,Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Joshua Olick-Gibson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
| | - Yabo Fu
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States.,Department of Radiation Oncology, Emory University, Atlanta, GA 30332, United States
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI 48202, United States
| | - Olga Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
| | - Deshan Yang
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
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Glide-Hurst CK, Lee P, Yock AD, Olsen JR, Cao M, Siddiqui F, Parker W, Doemer A, Rong Y, Kishan AU, Benedict SH, Li XA, Erickson BA, Sohn JW, Xiao Y, Wuthrick E. Adaptive Radiation Therapy (ART) Strategies and Technical Considerations: A State of the ART Review From NRG Oncology. Int J Radiat Oncol Biol Phys 2020; 109:1054-1075. [PMID: 33470210 DOI: 10.1016/j.ijrobp.2020.10.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022]
Abstract
The integration of adaptive radiation therapy (ART), or modifying the treatment plan during the treatment course, is becoming more widely available in clinical practice. ART offers strong potential for minimizing treatment-related toxicity while escalating or de-escalating target doses based on the dose to organs at risk. Yet, ART workflows add complexity into the radiation therapy planning and delivery process that may introduce additional uncertainties. This work sought to review presently available ART workflows and technological considerations such as image quality, deformable image registration, and dose accumulation. Quality assurance considerations for ART components and minimum recommendations are described. Personnel and workflow efficiency recommendations are provided, as is a summary of currently available clinical evidence supporting the implementation of ART. Finally, to guide future clinical trial protocols, an example ART physician directive and a physics template following standard NRG Oncology protocol is provided.
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Affiliation(s)
- Carri K Glide-Hurst
- Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam D Yock
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado- Denver, Denver, Colorado
| | - Minsong Cao
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - William Parker
- Department of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | - Anthony Doemer
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Yi Rong
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason W Sohn
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Evan Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
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Padgett KR, Simpson G, Asher D, Portelance L, Bossart E, Dogan N. Assessment of online adaptive MR-guided stereotactic body radiotherapy of liver cancers. Phys Med 2020; 77:54-63. [DOI: 10.1016/j.ejmp.2020.07.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/24/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
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Schumacher LED, Dal Pra A, Hoffe SE, Mellon EA. Toxicity reduction required for MRI-guided radiotherapy to be cost-effective in the treatment of localized prostate cancer. Br J Radiol 2020; 93:20200028. [PMID: 32783629 DOI: 10.1259/bjr.20200028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the toxicity reduction required to justify the added costs of MRI-guided radiotherapy (MR-IGRT) over CT-based image guided radiotherapy (CT-IGRT) for the treatment of localized prostate cancer. METHODS The costs of delivering prostate cancer radiotherapy with MR-IGRT and CT-IGRT in conventional 39 fractions and stereotactic body radiotherapy (SBRT) 5 fractions schedules were determined using literature values and cost accounting from two institutions. Gastrointestinal and genitourinary toxicity rates associated with CT-IGRT were summarized from 20 studies. Toxicity-related costs and utilities were obtained from literature values and cost databases. Markov modeling was used to determine the savings per patient for every 1% relative reduction in acute and chronic toxicities by MR-IGRT over 15 years. The costs and quality adjusted life years (QALYs) saved with toxicity reduction were juxtaposed with the cost increase of MR-IGRT to determine toxicity reduction thresholds for cost-effectiveness. One way sensitivity analyses were performed. Standard $100,000 and $50,000 per QALY ratios were used. RESULTS The added cost of MR-IGRT was $1,459 per course of SBRT and $10,129 per course of conventionally fractionated radiotherapy. Relative toxicity reductions of 7 and 14% are required for SBRT to be cost-effective using $100,000 and $50,000 per QALY, respectively. Conventional radiotherapy requires relative toxicity reductions of 50 and 94% to be cost-effective. CONCLUSION From a healthcare perspective, MR-IGRT can reasonably be expected to be cost-effective. Hypofractionated schedules, such a five fraction SBRT, are most likely to be cost-effective as they require only slight reductions in toxicity (7-14%). ADVANCES IN KNOWLEDGE This is the first detailed economic assessment of MR-IGRT, and it suggests that MR-IGRT can be cost-effective for prostate cancer treatment through toxicity reduction alone.
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Affiliation(s)
- Leif-Erik D Schumacher
- Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Alan Dal Pra
- Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Sarah E Hoffe
- Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | - Eric A Mellon
- Radiation Oncology and Bioengineering, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
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Loi M, Magallon-Baro A, Suker M, Van Eijck C, Hoogeman M, Nuyttens JJ. Daily dose to organs at risk predicts acute toxicity in pancreatic stereotactic radiotherapy. Acta Oncol 2020; 59:944-948. [PMID: 32207351 DOI: 10.1080/0284186x.2020.1742931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Mauro Loi
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Casper Van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Thomas MA, Fu Y, Yang D. Development and evaluation of machine learning models for voxel dose predictions in online adaptive magnetic resonance guided radiation therapy. J Appl Clin Med Phys 2020; 21:60-69. [PMID: 32306535 PMCID: PMC7386189 DOI: 10.1002/acm2.12884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/18/2020] [Accepted: 03/22/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Daily online adaptive plan quality in magnetic resonance imaging guided radiation therapy (MRgRT) is difficult to assess in relation to the fully optimized, high quality plans traditionally established offline. Machine learning prediction models developed in this work are capable of predicting 3D dose distributions, enabling the evaluation of online adaptive plan quality to better inform adaptive decision-making in MRgRT. METHODS Artificial neural networks predicted 3D dose distributions from input variables related to patient anatomy, geometry, and target/organ-at-risk relationships in over 300 treatment plans from 53 patients receiving adaptive, linac-based MRgRT for abdominal cancers. The models do not include any beam related variables such as beam angles or fluence and were optimized to balance errors related to raw dose and specific plan quality metrics used to guide daily online adaptive decisions. RESULTS Averaged over all plans, the dose prediction error and the absolute error were 0.1 ± 3.4 Gy (0.1 ± 6.2%) and 3.5 ± 2.4 Gy (6.4 ± 4.3%) respectively. Plan metric prediction errors were -0.1 ± 1.5%, -0.5 ± 2.1%, -0.9 ± 2.2 Gy, and 0.1 ± 2.7 Gy for V95, V100, D95, and Dmean respectively. Plan metric prediction absolute errors were 1.1 ± 1.1%, 1.5 ± 1.5%, 1.9 ± 1.4 Gy, and 2.2 ± 1.6 Gy. Approximately 10% (25) of the plans studied were clearly identified by the prediction models as inferior quality plans needing further optimization and refinement. CONCLUSION Machine learning prediction models for treatment plan 3D dose distributions in online adaptive MRgRT were developed and tested. Clinical integration of the models requires minimal effort, producing 3D dose predictions for a new patient's plan using only target and OAR structures as inputs. These models can enable improved workflows for MRgRT through more informed plan optimization and plan quality assessment in real time.
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Affiliation(s)
- M. Allan Thomas
- Department of Radiation OncologyWashington University in St. LouisSt. LouisMOUSA
- Present address:
Department of Imaging PhysicsUT MD Anderson Cancer CenterHoustonTXUSA
| | - Yabo Fu
- Department of Radiation OncologyWashington University in St. LouisSt. LouisMOUSA
- Present address:
Department of Radiation OncologyEmory University School of MedicineAtlantaGAUSA
| | - Deshan Yang
- Department of Radiation OncologyWashington University in St. LouisSt. LouisMOUSA
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Grégoire V, Guckenberger M, Haustermans K, Lagendijk JJW, Ménard C, Pötter R, Slotman BJ, Tanderup K, Thorwarth D, van Herk M, Zips D. Image guidance in radiation therapy for better cure of cancer. Mol Oncol 2020; 14:1470-1491. [PMID: 32536001 PMCID: PMC7332209 DOI: 10.1002/1878-0261.12751] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
The key goal and main challenge of radiation therapy is the elimination of tumors without any concurring damages of the surrounding healthy tissues and organs. Radiation doses required to achieve sufficient cancer-cell kill exceed in most clinical situations the dose that can be tolerated by the healthy tissues, especially when large parts of the affected organ are irradiated. High-precision radiation oncology aims at optimizing tumor coverage, while sparing normal tissues. Medical imaging during the preparation phase, as well as in the treatment room for localization of the tumor and directing the beam, referred to as image-guided radiotherapy (IGRT), is the cornerstone of precision radiation oncology. Sophisticated high-resolution real-time IGRT using X-rays, computer tomography, magnetic resonance imaging, or ultrasound, enables delivery of high radiation doses to tumors without significant damage of healthy organs. IGRT is the most convincing success story of radiation oncology over the last decades, and it remains a major driving force of innovation, contributing to the development of personalized oncology, for example, through the use of real-time imaging biomarkers for individualized dose delivery.
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Affiliation(s)
- Vincent Grégoire
- Department of Radiation OncologyLéon Bérard Cancer CenterLyonFrance
| | - Matthias Guckenberger
- Department for Radiation OncologyUniversity Hospital ZurichUniversity of ZurichSwitzerland
| | - Karin Haustermans
- Department of Radiation OncologyLeuven Cancer InstituteUniversity Hospital GasthuisbergLeuvenBelgium
| | | | | | - Richard Pötter
- Department of Radiation OncologyMedical UniversityGeneral Hospital of ViennaAustria
| | - Ben J. Slotman
- Department of Radiation OncologyAmsterdam University Medical CentersThe Netherlands
| | - Kari Tanderup
- Department of OncologyAarhus University HospitalDenmark
| | - Daniela Thorwarth
- Section for Biomedical PhysicsDepartment of Radiation OncologyUniversity of TübingenGermany
| | - Marcel van Herk
- Department of Biomedical Engineering and PhysicsCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamThe Netherlands
- Institute of Cancer SciencesUniversity of ManchesterUK
- Department of Radiotherapy Related ResearchThe Christie NHS Foundation TrustManchesterUK
| | - Daniel Zips
- Department of Radiation OncologyUniversity of TübingenGermany
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Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines. Cancers (Basel) 2020; 12:cancers12071729. [PMID: 32610592 PMCID: PMC7407382 DOI: 10.3390/cancers12071729] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on (i) the current indications by the available national and international guidelines; (ii) the current standard indications for target volume delineation in radiotherapy (RT); (iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); (iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; (v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and (vi) a multimodal integration opportunity: the combination of RT with immunotherapy.
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45
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Hassanzadeh C, Rudra S, Bommireddy A, Hawkins WG, Wang-Gillam A, Fields RC, Cai B, Park J, Green O, Roach M, Henke L, Kim H. Ablative Five-Fraction Stereotactic Body Radiation Therapy for Inoperable Pancreatic Cancer Using Online MR-Guided Adaptation. Adv Radiat Oncol 2020; 6:100506. [PMID: 33665480 PMCID: PMC7897757 DOI: 10.1016/j.adro.2020.06.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/04/2020] [Accepted: 06/13/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose Patients with inoperable pancreatic adenocarcinoma have limited options, with traditional chemoradiation providing modest clinical benefit and an otherwise poor prognosis. Stereotactic body radiation therapy for pancreatic cancer is limited by proximity to organs-at-risk (OAR). However, stereotactic magnetic resonance-guided adaptive radiation therapy (SMART) has shown promise in delivering ablative doses safely. We sought to demonstrate the benefits of SMART using a 5-fraction approach with daily on-table adaptation. Methods and Materials Patients with locally advanced, nonmetastatic pancreatic adenocarcinoma were treated with 50 Gy in 5 fractions (biologically effective dose10 100 Gy) with a prescribed goal of 95% planning target volume coverage by 95% of prescription, prioritizing hard OAR constraints. Daily online adaptation was performed using magnetic resonance-guidance and on-table reoptimization. Patient outcomes, treatment factors, and daily adaptation were evaluated. Results Forty-four patients were treated with SMART at our institution from 2014 to 2019. Median follow-up from date of diagnosis was 16 months (range, 6.7-51.6). Late toxicity was limited to 2 (4.6%) grade 3 (gastrointestinal ulcers) and 3 (6.8%) grade 2 toxicities (duodenal perforation, antral ulcer, and gastric bleed). Tumor abutted OARs in 35 patients (79.5%) and tumor invaded OARs in 5 patients (11.1%). Reoptimization was performed for 93% of all fractions. Median overall survival was 15.7 months (95% confidence interval, 10.2-21.2), while 1-year and 2-year overall survival rates were 68.2% and 37.9%, respectively. One-year local control was 84.3%. Conclusions This is the first reported experience using 50 Gy in 5 fractions for inoperable pancreatic cancer. SMART allows this ablative dose with promising outcomes while minimizing toxicity. Additional prospective trials evaluating efficacy and safety are warranted.
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Affiliation(s)
- Comron Hassanzadeh
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Soumon Rudra
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Ani Bommireddy
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Andrea Wang-Gillam
- Department of Medical Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Bin Cai
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Justin Park
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Olga Green
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | | | - Lauren Henke
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine and Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri
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Simpson G, Spieler B, Dogan N, Portelance L, Mellon EA, Kwon D, Ford JC, Yang F. Predictive value of 0.35 T magnetic resonance imaging radiomic features in stereotactic ablative body radiotherapy of pancreatic cancer: A pilot study. Med Phys 2020; 47:3682-3690. [DOI: 10.1002/mp.14200] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Garrett Simpson
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | - Benjamin Spieler
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | - Nesrin Dogan
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | | | - Eric A. Mellon
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | - Deukwoo Kwon
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | - John C. Ford
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
| | - Fei Yang
- Department of Radiation Oncology University of Miami Miami FL 33136 USA
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Pettersson N, Oderinde OM, Murphy J, Simpson D, Cerviño LI. Intrafractional relationship changes between an external breathing signal and fiducial marker positions in pancreatic cancer patients. J Appl Clin Med Phys 2020; 21:153-161. [PMID: 32170900 PMCID: PMC7075406 DOI: 10.1002/acm2.12841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/16/2020] [Accepted: 01/26/2020] [Indexed: 12/25/2022] Open
Abstract
Background and purpose The purpose of this study of pancreatic cancer patients treated with respiratory‐guided stereotactic body radiotherapy (SBRT) on a standard linac was to investigate (a) the intrafractional relationship change (IRC) between a breathing signal and the tumor position, (b) the impact of IRC on the delivered dose, and (c) potential IRC predictors. Materials and methods We retrospectively investigated 10 pancreatic cancer patients with 2–4 implanted fiducial markers in the tumor treated with SBRT. Fluoroscopic images were acquired before and after treatment delivery simultaneously with the abdominal breathing motion. We quantified the IRC as the change in fiducial location for a given breathing amplitude in the left–right (LR), anterior–posterior (AP), and superior–inferior (SI) directions from before to after treatment delivery. The treatment plans were re‐calculated after changing the isocenter coordinates according to the IRCs. Four treatment‐ or patient‐related factors were investigated as potential predictors for IRC using linear models. Results The average (±1 SD) absolute IRCs in the LR, AP, and SI directions were 1.2 ± 1.2 mm, 0.7 ± 0.7 mm, and 1.1 ± 0.8 mm, respectively. The average 3D IRC was 2.0 ± 1.3 mm (range: 0.4–5.3 mm) for a median treatment delivery time of 8.5 min (range: 5.7–19.9 min; n = 31 fractions). The dose coverage of the internal target volume (ITV) decreased by more than 3% points in three of 31 fractions. In those cases, the 3D IRC had been larger than 4.3 mm. The 3D IRC was found to correlate with changes in the minimum breathing amplitude during treatment delivery. Conclusion On average, 2 mm of treatment delivery accuracy was lost due to IRC. Periodical intrafractional imaging is needed to safely deliver respiratory‐guided SBRT.
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Affiliation(s)
- Niclas Pettersson
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Göteborg, Sweden.,Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Oluwaseyi M Oderinde
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA
| | - James Murphy
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA
| | - Daniel Simpson
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA
| | - Laura I Cerviño
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA.,Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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48
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Liang Y, Schott D, Zhang Y, Wang Z, Nasief H, Paulson E, Hall W, Knechtges P, Erickson B, Li XA. Auto-segmentation of pancreatic tumor in multi-parametric MRI using deep convolutional neural networks. Radiother Oncol 2020; 145:193-200. [PMID: 32045787 DOI: 10.1016/j.radonc.2020.01.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The recently introduced MR-Linac enables MRI-guided Online Adaptive Radiation Therapy (MRgOART) of pancreatic cancer, for which fast and accurate segmentation of the gross tumor volume (GTV) is essential. This work aims to develop an algorithm allowing automatic segmentation of the pancreatic GTV based on multi-parametric MRI using deep neural networks. METHODS We employed a square-window based convolutional neural network (CNN) architecture with three convolutional layer blocks. The model was trained using about 245,000 normal and 230,000 tumor patches extracted from 37 DCE MRI sets acquired in 27 patients with data augmentation. These images were bias corrected, intensity standardized, and resampled to a fixed voxel size of 1 × 1 × 3 mm3. The trained model was tested on 19 DCE MRI sets from another 13 patients, and the model-generated GTVs were compared with the manually segmented GTVs by experienced radiologist and radiation oncologists based on Dice Similarity Coefficient (DSC), Hausdorff Distance (HD), and Mean Surface Distance (MSD). RESULTS The mean values and standard deviations of the performance metrics on the test set were DSC = 0.73 ± 0.09, HD = 8.11 ± 4.09 mm, and MSD = 1.82 ± 0.84 mm. The interobserver variations were estimated to be DSC = 0.71 ± 0.08, HD = 7.36 ± 2.72 mm, and MSD = 1.78 ± 0.66 mm, which had no significant difference with model performance at p values of 0.6, 0.52, and 0.88, respectively. CONCLUSION We developed a CNN-based model for auto-segmentation of pancreatic GTV in multi-parametric MRI. Model performance was comparable to expert radiation oncologists. This model provides a framework to incorporate multimodality images and daily MRI for GTV auto-segmentation in MRgOART.
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Affiliation(s)
- Ying Liang
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Diane Schott
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Ying Zhang
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Zhiwu Wang
- Department of Chemoradiotherapy, Tangshan People's Hospital, PR China
| | - Haidy Nasief
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Paul Knechtges
- Department of Radiology, Medical College of Wisconsin, Milwaukee, USA
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA.
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49
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Chin S, Eccles CL, McWilliam A, Chuter R, Walker E, Whitehurst P, Berresford J, Van Herk M, Hoskin PJ, Choudhury A. Magnetic resonance-guided radiation therapy: A review. J Med Imaging Radiat Oncol 2020; 64:163-177. [PMID: 31646742 DOI: 10.1111/1754-9485.12968] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
Magnetic resonance-guided radiation therapy (MRgRT) is a promising approach to improving clinical outcomes for patients treated with radiation therapy. The roles of image guidance, adaptive planning and magnetic resonance imaging in radiation therapy have been increasing over the last two decades. Technical advances have led to the feasible combination of magnetic resonance imaging and radiation therapy technologies, leading to improved soft-tissue visualisation, assessment of inter- and intrafraction motion, motion management, online adaptive radiation therapy and the incorporation of functional information into treatment. MRgRT can potentially transform radiation oncology by improving tumour control and quality of life after radiation therapy and increasing convenience of treatment by shortening treatment courses for patients. Multiple groups have developed clinical implementations of MRgRT predominantly in the abdomen and pelvis, with patients having been treated since 2014. While studies of MRgRT have primarily been dosimetric so far, an increasing number of trials are underway examining the potential clinical benefits of MRgRT, with coordinated efforts to rigorously evaluate the benefits of the promising technology. This review discusses the current implementations, studies, potential benefits and challenges of MRgRT.
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Affiliation(s)
- Stephen Chin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Cynthia L Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Alan McWilliam
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Robert Chuter
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Emma Walker
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Philip Whitehurst
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Joseph Berresford
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel Van Herk
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Peter J Hoskin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
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50
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Tchelebi LT, Romesser PB, Feuerlein S, Hoffe S, Latifi K, Felder S, Chuong MD. Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management. Cancer Control 2020; 27:1073274820969449. [PMID: 33118384 PMCID: PMC7791447 DOI: 10.1177/1073274820969449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.
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Affiliation(s)
- Leila T. Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine,
Hershey, PA, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Sebastian Feuerlein
- Department of Diagnostic Imaging and Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center,
Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL,
USA
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