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Han F, Xue Y, Huang S, Lu T, Yang Y, Cao Y, Chen J, Hou H, Sun Y, Wang W, Yuan Z, Tao Z, Jiang S. Development and validation of an automated Tomotherapy planning method for cervical cancer. Radiat Oncol 2024; 19:88. [PMID: 38978062 PMCID: PMC11232346 DOI: 10.1186/s13014-024-02482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024] Open
Abstract
PURPOSE This study aimed to develop an automated Tomotherapy (TOMO) planning method for cervical cancer treatment, and to validate its feasibility and effectiveness. MATERIALS AND METHODS The study enrolled 30 cervical cancer patients treated with TOMO at our center. Utilizing scripting and Python environment within the RayStation (RaySearch Labs, Sweden) treatment planning system (TPS), we developed automated planning methods for TOMO and volumetric modulated arc therapy (VMAT) techniques. The clinical manual TOMO (M-TOMO) plans for the 30 patients were re-optimized using automated planning scripts for both TOMO and VMAT, creating automated TOMO (A-TOMO) and automated VMAT (A-VMAT) plans. We compared A-TOMO with M-TOMO and A-VMAT plans. The primary evaluated relevant dosimetric parameters and treatment plan efficiency were assessed using the two-sided Wilcoxon signed-rank test for statistical analysis, with a P-value < 0.05 indicating statistical significance. RESULTS A-TOMO plans maintained similar target dose uniformity compared to M-TOMO plans, with improvements in target conformity and faster dose drop-off outside the target, and demonstrated significant statistical differences (P+ < 0.01). A-TOMO plans also significantly outperformed M-TOMO plans in reducing V50Gy, V40Gy and Dmean for the bladder and rectum, as well as Dmean for the bowel bag, femoral heads, and kidneys (all P+ < 0.05). Additionally, A-TOMO plans demonstrated better consistency in plan quality. Furthermore, the quality of A-TOMO plans was comparable to or superior than A-VMAT plans. In terms of efficiency, A-TOMO significantly reduced the time required for treatment planning to approximately 20 min. CONCLUSION We have successfully developed an A-TOMO planning method for cervical cancer. Compared to M-TOMO plans, A-TOMO plans improved target conformity and reduced radiation dose to OARs. Additionally, the quality of A-TOMO plans was on par with or surpasses that of A-VMAT plans. The A-TOMO planning method significantly improved the efficiency of treatment planning.
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Affiliation(s)
- Feiru Han
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Yi Xue
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Sheng Huang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Tong Lu
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Yining Yang
- Department of Radiation Oncology, Tianjin First Central Hospital, Tianjin, China
| | - Yuanjie Cao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Jie Chen
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Hailing Hou
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Yao Sun
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Wei Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Zhiyong Yuan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Zhen Tao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Shengpeng Jiang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Tianjin's Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
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Van Damme A, Tummers P, De Visschere P, Van Dorpe J, Van de Vijver K, Vercauteren T, De Gersem W, Denys H, Naert E, Makar A, De Neve W, Vandecasteele K. Exclusion of non-Involved uterus from the target volume (EXIT-trial): An individualized treatment for locally advanced cervical cancer using modern radiotherapy and imaging techniques followed by completion surgery. Clin Transl Radiat Oncol 2024; 47:100793. [PMID: 38798749 PMCID: PMC11126536 DOI: 10.1016/j.ctro.2024.100793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
Background and purpose Chemoradiotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer (LACC). In this study, we postulate that omitting an iconographical unaffected uterus (+12 mm distance from the tumour) from the treatment volume is safe and that no tumour will be found in the non-targeted uterus (NTU) leading to reduction of high-dose volumes of surrounding organs at risk (OARs). Material and Methods In this single-arm phase 2 study, two sets of target volumes were delineated: one standard-volume (whole uterus) and an EXIT-volume (exclusion of non-tumour-bearing parts of the uterus with a minimum 12 mm margin from the tumour). All patients underwent chemoradiotherapy targeting the EXIT-volume, followed by completion hysterectomy. In 15 patients, a plan comparison between two treatment plans (PTV vs PTV_EXIT) was performed. The primary endpoint was the pathological absence of tumour involvement in the non-targeted uterus (NTU). Secondary endpoints included dosimetric impact of target volume reduction on OARs, acute and chronic toxicity, overall survival (OS), locoregional recurrence-free survival (LRFS), and progression-free survival (PFS). Results In all 21 (FIGO stage I: 2; II: 14;III: 3; IV: 2) patients the NTU was pathologically negative. Ssignificant reductions in Dmean in bladder, sigmoid and rectum; V15Gy in sigmoid and rectum, V30Gy in bladder, sigmoid and rectum; V40Gy and V45Gy in bladder, bowel bag, sigmoid and rectum; V50Gy in rectum were achieved. Median follow-up was 54 months (range 7-79 months). Acute toxicity was mainly grade 2 and 5 % grade 3 urinary. The 3y- OS, PFS and LRFS were respectively 76,2%, 64,9% and 81 %. Conclusion MRI-based exclusion of the non-tumour-bearing parts of the uterus at a minimum distance of 12 mm from the tumour out of the target volume in LACC can be done without risk of residual disease in the NTU, leading to a significant reduction of the volume of surrounding OARS treated to high doses.
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Affiliation(s)
- Axel Van Damme
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter De Visschere
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Departement of Radiology and Nuclear Medicine, Ghent University Hospital, Belgium
| | - Jo Van Dorpe
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Koen Van de Vijver
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Werner De Gersem
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Hannelore Denys
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Eline Naert
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Amin Makar
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Katrien Vandecasteele
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Yoshimura T, Yamada R, Kinoshita R, Matsuura T, Kanehira T, Tamura H, Nishioka K, Yasuda K, Taguchi H, Katoh N, Kobashi K, Hashimoto T, Aoyama H. Probability of normal tissue complications for hematologic and gastrointestinal toxicity in postoperative whole pelvic radiotherapy for gynecologic malignancies using intensity-modulated proton therapy with robust optimization. JOURNAL OF RADIATION RESEARCH 2024; 65:369-378. [PMID: 38499489 PMCID: PMC11115445 DOI: 10.1093/jrr/rrae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/26/2023] [Indexed: 03/20/2024]
Abstract
This retrospective treatment-planning study was conducted to determine whether intensity-modulated proton therapy with robust optimization (ro-IMPT) reduces the risk of acute hematologic toxicity (H-T) and acute and late gastrointestinal toxicity (GI-T) in postoperative whole pelvic radiotherapy for gynecologic malignancies when compared with three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated X-ray (IMXT) and single-field optimization proton beam (SFO-PBT) therapies. All plans were created for 13 gynecologic-malignancy patients. The prescribed dose was 45 GyE in 25 fractions for 95% planning target volume in 3D-CRT, IMXT and SFO-PBT plans and for 99% clinical target volume (CTV) in ro-IMPT plans. The normal tissue complication probability (NTCP) of each toxicity was used as an in silico surrogate marker. Median estimated NTCP values for acute H-T and acute and late GI-T were 0.20, 0.94 and 0.58 × 10-1 in 3D-CRT; 0.19, 0.65 and 0.24 × 10-1 in IMXT; 0.04, 0.74 and 0.19 × 10-1 in SFO-PBT; and 0.06, 0.66 and 0.15 × 10-1 in ro-IMPT, respectively. Compared with 3D-CRT and IMXT plans, the ro-IMPT plan demonstrated significant reduction in acute H-T and late GI-T. The risk of acute GI-T in ro-IMPT plan is equivalent with IMXT plan. The ro-IMPT plan demonstrated potential clinical benefits for reducing the risk of acute H-T and late GI-T in the treatment of gynecologic malignances by reducing the dose to the bone marrow and bowel bag while maintaining adequate dose coverage to the CTV. Our results indicated that ro-IMPT may reduce acute H-T and late GI-T risk with potentially improving outcomes for postoperative gynecologic-malignancy patients with concurrent chemotherapy.
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Affiliation(s)
- Takaaki Yoshimura
- Department of Health Sciences and Technology, Faculty of Health Sciences, Hokkaido University, Sapporo 060-0812, Japan
- Department of Medical Physics, Hokkaido University Hospital, Sapporo 060-8648, Japan
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Ryota Yamada
- Department of Radiation Technology, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Taeko Matsuura
- Department of Medical Physics, Hokkaido University Hospital, Sapporo 060-8648, Japan
- Faculty of Engineering, Hokkaido University, Sapporo 060–8638, Japan
| | - Takahiro Kanehira
- Department of Medical Physics, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Hiroshi Tamura
- Department of Radiation Technology, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Kentaro Nishioka
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Koichi Yasuda
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Keiji Kobashi
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Takayuki Hashimoto
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo 060-8648, Japan
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Yen A, Zhong X, Lin MH, Nwachukwu C, Albuquerque K, Hrycushko B. Improved Dosimetry with Daily Online Adaptive Radiotherapy for Cervical Cancer: Waltzing the Pear. Clin Oncol (R Coll Radiol) 2024; 36:165-172. [PMID: 38246849 DOI: 10.1016/j.clon.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
AIMS Standard of care radiotherapy for locally advanced cervical cancer includes large margins to ensure the uterocervix remains within the treatment fields over the course of treatment. Daily online cone-beam adaptive radiotherapy corrects for interfractional changes by adjusting the plan to match the target position during each treatment session, thus allowing for significantly reduced clinical target volume (CTV) to planning target volume (PTV) margins. We hypothesise that reduced margins from daily online adaptive radiotherapy will reduce organ at risk dose without compromising target coverage. MATERIALS AND METHODS Ten patients with cervical cancer (stage IIB-IIIC2) were treated with definitive chemoradiation using daily online cone-beam adaptive radiotherapy in 25-27 fractions. Initial and all adapted treatment plans were generated with CTV to PTV margins versus standard of care image-guided radiotherapy (IGRT) plans as follows: cervix/uterus/gross tumour volume (0.5 versus 1.5 cm), parametria/vagina (0.5 versus 1.0 cm) and nodal chains and gross nodes (0.5 versus 0.5 cm). IGRT plans were created and copied to synthetic computed tomography scans and contours generated from each daily adapted fraction. The dosimetry of each clinically treated online adapted fraction was compared with emulated IGRT plans. Statistical significance was defined as P < 0.05. RESULTS Daily online cone-beam adaptive radiotherapy significantly improves bowel bag dosimetry compared with IGRT, with a reduction in V40 by an average of 91.3 cm3 [V40 (-6.2%) and V45 (-6.1%)]. The daily adapted plans showed significant improvements in bladder and rectum [V40 (-25.2% and -36.0%) and V30 (-9.7% and -17.1%), respectively]. Additionally, bone marrow had a significantly reduced dose [V10 (-2.7%) and V20 (-3.3%)]. Daily online cone-beam adaptive radiotherapy improved uterocervix CTV coverage and reduced hotspots compared with IGRT [D95% (+1.6%) and Dmax (-0.9%)]. CONCLUSIONS Reduced CTV to PTV margins achievable with daily online adaptive radiotherapy improves organ at risk dosimetry and target coverage when compared with standard of care IGRT for locally advanced cervical cancer. The clinical impact of improved dosimetry is currently undergoing investigation.
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Affiliation(s)
- A Yen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - X Zhong
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M-H Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - C Nwachukwu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - K Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - B Hrycushko
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023; 70:417-423. [PMID: 37394743 PMCID: PMC10715335 DOI: 10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Correlations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter-provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy. METHODS Ten radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter-provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3 ). RESULTS The bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter-provider agreement for bowel bag compared with bladder and rectum. CONCLUSION Inter-provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of OncologyUniversity Hospital Centre Mother TeresaTiranaAlbania
| | - Kevin Kauweloa
- Department of Radiation OncologyQueen's Medical CentreHonoluluHawaiiUSA
| | | | - Andrew C. Hoover
- Department of Radiation OncologyUniversity of Kansas Cancer Centre, Kansas University Medical CentreKansas CityKansasUSA
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Zhang F, Zhou M, Wang G, Li X, Yue L, Deng L, Chi K, Chen K, Qi Z, Deng X, Peng Y, Liu Y. Evaluation of bladder filling effects on the dose distribution during radiotherapy for cervical cancer based on daily CT images. J Appl Clin Med Phys 2023; 24:e14097. [PMID: 37438966 PMCID: PMC10647976 DOI: 10.1002/acm2.14097] [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: 02/13/2023] [Revised: 06/15/2023] [Accepted: 06/28/2023] [Indexed: 07/14/2023] Open
Abstract
PURPOSE This study aimed to assess the effects of bladder filling during cervical cancer radiotherapy on target volume and organs at risk (OARs) dose based on daily computed tomography (daily-CT) images and provide bladder-volume-based dose prediction models. METHODS Nineteen patients (475 daily-CTs) comprised the study group, and five patients comprised the validation set (25 daily-CTs). Target volumes and OARs were delineated on daily-CT images and the treatment plan was recalculated accordingly. The deviation from the planning bladder volume (DVB), the correlation between DVB and clinical (CTV)/planning (PTV) target volume in terms of prescribed dose coverage, and the relationship of small bowel volume and bladder dose with the ratio of bladder volume (RVB) were analyzed. RESULTS In all cases, the prescribed dose coverage in the CTV was >95% when DVB was <200 cm3 , whereas that in the PTV was >95% when RVB was <160%. The ratio of bladder V45 Gy to the planning bladder V45 Gy (RBV45 ) exhibited a negative linear relationship with RVB (RBV45 = -0.18*RVB + 120.8; R2 = 0.80). Moreover, the ratio of small bowel volume to planning small bowel volume (RVS) exhibited a negative linear relationship with RVB (RVS = -1.06*RVB +217.59; R2 = 0.41). The validation set results showed that the linear model predicted well the effects of bladder volume changes on target volume coverage and bladder dose. CONCLUSIONS This study assessed dosimetry and volume effects of bladder filling on target and OARs based on daily-CT images. We established a quantitative relationship between these parameters, providing dose prediction models for cervical cancer radiotherapy.
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Affiliation(s)
- Fan Zhang
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Mi Zhou
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Gang Wang
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Xutong Li
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Lu Yue
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Lihua Deng
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Kun Chi
- Department of Radiation OncologyQingdao Municipal HospitalQingdaoChina
| | - Kai Chen
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
| | - Zhenyu Qi
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
| | - Xiaowu Deng
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
| | - Yinglin Peng
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
| | - Yimei Liu
- Department of Radiation OncologyState Key Laboratory of Oncology in South ChinaGuangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and TherapySun Yat‐sen University Cancer CenterGuangzhouChina
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Acosta Roa AM, Skingen VE, Rekstad BL, Undseth C, Rusten E, Hernes E, Guren MG, Malinen E. Stability of metabolic tumor volume may enable radiotherapy dose painting in anal cancer. Phys Med 2023; 114:103151. [PMID: 37813051 DOI: 10.1016/j.ejmp.2023.103151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/19/2023] [Accepted: 09/22/2023] [Indexed: 10/11/2023] Open
Abstract
PURPOSE To evaluate the variability of the 18F-FDG-PET/CT-based metabolic tumor volume (MTV) in anal cancers during fractionated chemoradiotherapy (CRT), and assess the impact of this variability on dosimetric accuracy in MTV-targeted dose painting. METHODS Eleven patients with anal squamous cell carcinoma who received fractionated chemoradiotherapy with curative intent were included. 18F-FDG PET/CT images were acquired at pre- and mid-treatment. Target volumes and organs at risk (OARs) were contoured manually on both image series. The MTV was generated from the PET images by thresholding. Treatment plans were retrospectively optimized for both image series using volumetric modulated arc therapy (VMAT). Standard plans prescribed 48.6 Gy, 54 Gy and 57.5 Gy in 27 fractions to elective regions, lymph node metastases and primary tumor, respectively. Dose painting plans included an extra dose level of 65 Gy to the MTV. Pre-treatment plans were transferred and re-calculated at mid-treatment basis. RESULTS MTV decreased from pre- to mid-treatment in 10 of the 11 patients. On average, 71 % of MTVmid overlapped with MTVpre. The median and mean doses to the MTV were robust against anatomical changes, but the transferred dose painting plans had lower D98% values than the original and re-optimized plans. No major differences were found between standard and dose painting plans for OARs. CONCLUSIONS Despite volumetric changes in the MTV, adequate dose coverage was observed in most dose painting plans. The findings indicate little or no need for adaptive dose painting at mid-treatment. Dose painting appears to be a safe treatment alternative with similar dose sparing of OARs.
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Affiliation(s)
| | - Vilde Eide Skingen
- Department of Radiation Biology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | | | | | - Espen Rusten
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | - Eivor Hernes
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Marianne Grønlie Guren
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eirik Malinen
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway
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Caricato P, Trivellato S, Pellegrini R, Montanari G, Daniotti MC, Bordigoni B, Faccenda V, Panizza D, Meregalli S, Bonetto E, Voet P, Arcangeli S, De Ponti E. Updating approach for lexicographic optimization-based planning to improve cervical cancer plan quality. Discov Oncol 2023; 14:180. [PMID: 37775613 PMCID: PMC10541351 DOI: 10.1007/s12672-023-00800-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND To investigate the capability of a not-yet commercially available fully automated lexicographic optimization (LO) planning algorithm, called mCycle (Elekta AB, Stockholm, Sweden), to further improve the plan quality of an already-validated Wish List (WL) pushing on the organs-at-risk (OAR) sparing without compromising target coverage and plan delivery accuracy. MATERIAL AND METHODS Twenty-four mono-institutional consecutive cervical cancer Volumetric-Modulated Arc Therapy (VMAT) plans delivered between November 2019 and April 2022 (50 Gy/25 fractions) have been retrospectively selected. In mCycle the LO planning algorithm was combined with the a-priori multi-criterial optimization (MCO). Two versions of WL have been defined to reproduce manual plans (WL01), and to improve the OAR sparing without affecting minimum target coverage and plan delivery accuracy (WL02). Robust WLs have been tuned using a subset of 4 randomly selected patients. The remaining plans have been automatically re-planned by using the designed WLs. Manual plans (MP) and mCycle plans (mCP01 and mCP02) were compared in terms of dose distributions, complexity, delivery accuracy, and clinical acceptability. Two senior physicians independently performed a blind clinical evaluation, ranking the three competing plans. Furthermore, a previous defined global quality index has been used to gather into a single score the plan quality evaluation. RESULTS The WL tweaking requests 5 and 3 working days for the WL01 and the WL02, respectively. The re-planning took in both cases 3 working days. mCP01 best performed in terms of target coverage (PTV V95% (%): MP 98.0 [95.6-99.3], mCP01 99.2 [89.7-99.9], mCP02 96.9 [89.4-99.5]), while mCP02 showed a large OAR sparing improvement, especially in the rectum parameters (e.g., Rectum D50% (Gy): MP 41.7 [30.2-47.0], mCP01 40.3 [31.4-45.8], mCP02 32.6 [26.9-42.6]). An increase in plan complexity has been registered in mCPs without affecting plan delivery accuracy. In the blind comparisons, all automated plans were considered clinically acceptable, and mCPs were preferred over MP in 90% of cases. Globally, automated plans registered a plan quality score at least comparable to MP. CONCLUSIONS This study showed the flexibility of the Lexicographic approach in creating more demanding Wish Lists able to potentially minimize toxicities in RT plans.
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Affiliation(s)
- Paolo Caricato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
- Department of Physics, University of Milan, Milan, Italy.
| | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | | | - Gianluca Montanari
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milano Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Sofia Meregalli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elisa Bonetto
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Peter Voet
- Research Clinical Liaison, Elekta AB, Stockholm, Sweden
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Sargos P, Stoeckle E, Ducassou A, Giraud A, Mervoyer A, Italiano A, Albert S, Ferron G, Bellera C, Kantor G. High dose (54 Gy) pre-operative helical tomotherapy for retroperitoneal liposarcoma: Results of a phase II multicenter study. Radiother Oncol 2023; 186:109791. [PMID: 37437608 DOI: 10.1016/j.radonc.2023.109791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To evaluate efficacy and feasibility of high-dose intensity-modulated radiotherapy (RT) with pre-operative helical tomotherapy, delivering 54 Gy/30 fractions in patients with retroperitoneal liposarcomas (RPLS). MATERIALS AND METHODS Patients with operable, biopsy-proven, RPLS were included in this phase II multicenter study (ClinicalTrials.gov: NCT01841047). The primary objectives were to analyze loco-regional relapse free survival (LRFS), overall survival (OS) and toxicities, graded according to CTCAE V3.0. RESULTS From April 2009 to September 2013, 48 patients were included. Histological types were: 20 well differentiated and 28 dedifferentiated liposarcomas. Median clinical target volume (CTV) was 2570 cc (range, 230-8734 cc). The radio-surgical schedule was completed as planned in all patients apart from one. A monobloc wide excision was achieved for all patients. Surgical margins were R0 (16; 34%), R1 (28; 60%), R2 (2; 4%) or missing (1, 2%).With a median follow-up of 5.5 years, 3-year LRFS rate was 74.2% (95%CI: [59.1%; 84.5%]). At 5 years, cumulative incidence of loco-regional relapse for well differentiated and dedifferentiated RPLS was 10% and 18%, respectively. The 5-year OS was 73.9% [95%CI: 58.7-84.3%]. During RT, the most common grade 3-4 adverse events were hematological (N = 20; 41.6%). After surgery and during follow-up, 17 patients (35.4%) presented a grade 3-4 toxicity. Two patients (4.1%) died due to a duodenal toxicity. Nine second cancers were observed. CONCLUSION From this phase II trial of preoperative RT in RPLS patients, the dose level proposed cannot be considered safe, leading to non-negligible toxicity and second cancers rates. Our results, combined with STRASS-1 study, suggest that the ideal indication of RT for patients with RPLS still remains to be determined.
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Affiliation(s)
- Paul Sargos
- Department of Radiotherapy, Institut Bergonie, 229 cours de l'Argonne, 33076 Bordeaux, France.
| | - Eberhard Stoeckle
- Department of Surgery, Institut Bergonie, 229 cours de l'Argonne, 33076 Bordeaux, France
| | - Anne Ducassou
- Department of Radiotherapy, Institut Claudius Regaud- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Antoine Giraud
- Clinical and Epidemiological Research Unit, INSERM CIC1401, Institut Bergonié, Comprehensive Cancer Center, F-33000 Bordeaux, France
| | - Augustin Mervoyer
- Department of Radiotherapy, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Antoine Italiano
- Department of Medical Oncology, Institut Bergonie, 229 cours de l'Argonne, 33076 Bordeaux, France
| | - Sabrina Albert
- Clinical and Epidemiological Research Unit, INSERM CIC1401, Institut Bergonié, Comprehensive Cancer Center, F-33000 Bordeaux, France
| | - Gwenael Ferron
- Department of Surgical Oncology, INSERM CRCT19 (Oncogenesis of Sarcoma), Institut Claudius Regaud- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Carine Bellera
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene team, UMR 1219, F-33000 Bordeaux, France; Inserm CIC1401, Clinical and Epidemiological Research Unit, Institut Bergonié, Comprehensive Cancer Center, F-33000 Bordeaux, France.
| | - Guy Kantor
- Department of Radiotherapy, Institut Bergonie, 229 cours de l'Argonne, 33076 Bordeaux, France
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023. [DOI: doi.org/10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 09/03/2023] Open
Abstract
AbstractIntroductionCorrelations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter‐provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy.MethodsTen radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter‐provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3).ResultsThe bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter‐provider agreement for bowel bag compared with bladder and rectum.ConclusionInter‐provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of Oncology University Hospital Centre Mother Teresa Tirana Albania
| | - Kevin Kauweloa
- Department of Radiation Oncology Queen's Medical Centre Honolulu Hawaii USA
| | | | - Andrew C. Hoover
- Department of Radiation Oncology University of Kansas Cancer Centre, Kansas University Medical Centre Kansas City Kansas USA
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Zhang Z, Yu S, Peng F, Tan Z, Zhang L, Li D, Yang P, Peng Z, Li X, Fang C, Wang Y, Liu Y. Advantages and robustness of partial VMAT with prone position for neoadjuvant rectal cancer evaluated by CBCT-based offline adaptive radiotherapy. Radiat Oncol 2023; 18:102. [PMID: 37330508 DOI: 10.1186/s13014-023-02285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/18/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND AND PURPOSE This study aims to explore the advantages and robustness of the partial arc combined with prone position planning technique for radiotherapy in rectal cancer patients. Adaptive radiotherapy is recalculated and accumulated on the synthesis CT (sCT) obtained by deformable image registration between planning CT and cone beam CT (CBCT). Full and partial volume modulation arc therapy (VMAT) with the prone position on gastrointestinal and urogenital toxicity, based on the probability of normal tissue complications (NTCP) model in rectal cancer patients were evaluated. MATERIALS AND METHODS Thirty-one patients were studied retrospectively. The contours of different structures were outlined in 155 CBCT images. First, full VMAT (F-VMAT) and partial VMAT (P-VMAT) planning techniques were designed and calculated using the same optimization constraints for each individual patient. The Acuros XB (AXB) algorithm was used in order to generate more realistic dose distributions and DVH, considering the air cavities. Second, the Velocity 4.0 software was used to fuse the planning CT and CBCT to obtain the sCT. Then, the AXB algorithm was used in the Eclipse 15.6 software to conduct re-calculation based on the sCT to obtain the corresponding dose. Furthermore, the NTCP model was used to analyze its radiobiological side effects on the bladder and the bowel bag. RESULTS With a CTV coverage of 98%, when compared with F-VMAT, P-VMAT with the prone position technique can effectively reduce the mean dose of the bladder and the bowel bag. The NTCP model showed that the P-VMAT combined with the prone planning technique resulted in a significantly lower complication probability of the bladder (1.88 ± 2.08 vs 1.62 ± 1.41, P = 0.041) and the bowel bag (1.28 ± 1.70 vs 0.95 ± 1.52, P < 0.001) than the F-VMAT. In terms of robustness, P-VMAT was more robust than F-VMAT, considering that less dose and NTCP variation was observed in the CTV, bladder and bowel bag. CONCLUSION This study analyzed the advantages and robustness of the P-VMAT in the prone position from three aspects, based on the sCT fused by CBCT. Whether it is in regards to dosimetry, radiobiological effects or robustness, P-VMAT in the prone position has shown comparative advantages.
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Affiliation(s)
- Zhe Zhang
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Shou Yu
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Feng Peng
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhibo Tan
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lei Zhang
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Daming Li
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Pengfei Yang
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhaoming Peng
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xin Li
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China
- Shenzhen-Peking University, Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| | - Chunfeng Fang
- Department of Radiation Oncology, Hebei Yizhou Cancer Hospital, Zhuozhou, China
| | - Yuenan Wang
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China.
| | - Yajie Liu
- Department of Radiation Oncology, Peking University Shenzhen Hospital, Shenzhen, China.
- Shenzhen-Peking University, Hong Kong University of Science and Technology Medical Center, Shenzhen, China.
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12
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Trivellato S, Caricato P, Pellegrini R, Montanari G, Daniotti MC, Bordigoni B, Faccenda V, Panizza D, Meregalli S, Bonetto E, Arcangeli S, De Ponti E. Comprehensive dosimetric and clinical evaluation of lexicographic optimization-based planning for cervical cancer. Front Oncol 2022; 12:1041839. [PMID: 36465394 PMCID: PMC9709287 DOI: 10.3389/fonc.2022.1041839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/25/2022] [Indexed: 11/01/2023] Open
Abstract
AIM In this study, a not yet commercially available fully-automated lexicographic optimization (LO) planning algorithm, called mCycle (Elekta AB, Stockholm, Sweden), was validated for cervical cancer. MATERIAL AND METHODS Twenty-four mono-institutional consecutive treatment plans (50 Gy/25 fx) delivered between November 2019 and April 2022 were retrospectively selected. The automatic re-planning was performed by mCycle, implemented in the Monaco TPS research version (v5.59.13), in which the LO and Multicriterial Optimization (MCO) are coupled with Monte Carlo calculation. mCycle optimization follows an a priori assigned priority list, the so-called Wish List (WL), representing a dialogue between the radiation oncologist and the planner, setting hard constraints and following objectives. The WL was tuned on a patient subset according to the institution's clinical protocol to obtain an optimal plan in a single optimization. This robust WL was then used to automatically re-plan the remaining patients. Manual plans (MP) and mCycle plans (mCP) were compared in terms of dose distributions, complexity (modulation complexity score, MCS), and delivery accuracy (perpendicular diode matrices, gamma analysis-passing ratio, PR). Their clinical acceptability was assessed through the blind choice of two radiation oncologists. Finally, a global quality score index (SI) was defined to gather into a single number the plan evaluation process. RESULTS The WL tuning requested four patients. The 20 automated re-planning tasks took three working days. The median optimization and calculation time can be estimated at 4 h and just over 1 h per MP and mCP, respectively. The dose comparison showed a comparable organ-at-risk spare. The planning target volume coverage increased (V95%: MP 98.0% [95.6-99.3]; mCP 99.2%[89.7-99.9], p >0.05). A significant increase has been registered in MCS (MP 0.29 [0.24-0.34]; mCP 0.26 [0.23-0.30], p <0.05) without affecting delivery accuracy (PR (3%/3mm): MP 97.0% [92.7-99.2]; mCP 97.1% [95.0-98.6], p >0.05). In the blind choice, all mCP results were clinically acceptable and chosen over MP in more than 75% of cases. The median SI score was 0.69 [0.41-0.84] and 0.73 [0.51-0.82] for MP and mCP, respectively (p >0.05). CONCLUSIONS mCycle plans were comparable to clinical manual plans, more complex but accurately deliverable and registering a similar SI. Automated plans outperformed manual plans in blinded clinical choice.
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Affiliation(s)
- Sara Trivellato
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Paolo Caricato
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | | | - Gianluca Montanari
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Denis Panizza
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Sofia Meregalli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Elisa Bonetto
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Long-Term Follow-Up Results of Adjuvant Intensity-Modulated Radiotherapy with Concurrent Paclitaxel and Cisplatin in High-Risk Endometrial Cancer Patients. JOURNAL OF ONCOLOGY 2022; 2022:4621240. [PMID: 36268278 PMCID: PMC9578806 DOI: 10.1155/2022/4621240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/18/2022]
Abstract
Purpose. The purpose of this study was to retrospectively review the outcomes of patients with high-risk endometrial cancer treated with adjuvant radiotherapy with concurrent paclitaxel and cisplatin (TP). Methods. Patients with endometrial cancer who underwent radical surgery were screened between Jan 2005 and Dec 2018. Patients with high-risk factors who received adjuvant chemoradiotherapy were included in the study. High risks included stage I, endometrioid-type grade 3 with deep myometrial invasion or lymphovascular space invasion (or both), endometrioid-type stage II to IVa, or stage I to III with serous or clear cell histology. The adjuvant treatment regimen included one cycle of TP chemotherapy, followed by pelvic intensity-modulated radiotherapy (IMRT) with concurrent TP, followed by an additional one cycle of TP. Failure free survival (FFS) and overall survival (OS) were estimated. Patterns of recurrence and occurrence of adverse events were described. Results. A total of 450 patients with high-risk endometrial cancer were screened, 231 of whom were included in this study. After a median follow-up of 70 months, the 5-year OS was 94.7%, and the 6-year OS was 91.8%. The 5-y and 6-y FFS were 90.8% and 87.9%, respectively, which were related to stage (
). A total of 14 patients experienced tumor recurrence, including 7 pelvic recurrence and 7 distant metastases. Seven patients died, all due to tumor progression. A total of 164 patients (71%) completed the prescribed course of treatment. A total of 205 patients had adverse events, 46 patients (20%) had grade 1, 92 patients (40%) had grade 2, 49 patients (21%) had grade 3, and 18 patients (8%) had grade 4. There were 83 nonhematologic and 122 hematologic toxicities (26 grade 3 and 18 grade 4). Conclusion. Adjuvant pelvic radiotherapy combined with synchronous TP chemotherapy can achieve excellent long-term survival for high-risk endometrial cancer patients. Moreover, this combination therapy has good safety and feasibility, which is worthy of further study and verification.
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A contouring strategy and reference atlases for the full abdominopelvic bowel bag on treatment planning and cone beam computed tomography images. Adv Radiat Oncol 2022; 7:101031. [PMID: 36092988 PMCID: PMC9450071 DOI: 10.1016/j.adro.2022.101031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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Cheng YK, Kuo SH, Yen HH, Wu JH, Chen YC, Huang MY. The prognostic significance of pretreatment squamous cell carcinoma antigen levels in cervical cancer patients treated by concurrent chemoradiation therapy and a comparison of dosimetric outcomes and clinical toxicities between tomotherapy and volumetric modulated arc therapy. Radiat Oncol 2022; 17:91. [PMID: 35549962 PMCID: PMC9097430 DOI: 10.1186/s13014-022-02063-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/02/2022] [Indexed: 12/05/2022] Open
Abstract
Background To analyze the prognostic factors associated with stage IB-IVA cervical cancer in patients who underwent concurrent chemoradiation therapy (CCRT) and to compare the clinical toxicities and dosimetric parameters of organs at risk between the different radiotherapy techniques. Methods This retrospective study enrolled 93 patients with stage IB-IVA cervical cancer who underwent definitive CCRT between April 2009 and December 2017. Nine patients (9.7%) received 3DCRT, 43 patients (46.2%) underwent VMAT, and 41 patients (44.1%) received tomotherapy, and all of them followed by brachytherapy using a 2D planning technique. The treatment outcomes and related prognostic factors were analyzed. We also compared the clinical toxicities and dosimetric parameters between the different techniques used for the last 30 patients. Results With a median follow-up of 52.0 months, the 5-year overall survival (OS), progression-free survival (PFS), locoregional recurrence–free survival (LRRFS), and distant metastases–free survival (DMFS) were analyzed. In a Cox proportional hazards regression model, pretreatment SCC Ag > 10 ng/mL was a significant prognostic factor for PFS (hazard ratio [HR] 2.20; 95% confidence interval [CI] 1.03–4.70; P = 0.041), LRRFS (HR, 3.48; 95% CI 1.07–11.26; P = 0.038), and DMFS (HR 2.80; 95% CI 1.02–7.67; P = 0.045). Increasing the rectal volume receiving a radiation dose exceeding 30 Gy (V30 of rectum; odds ratio [OR] 1.15; 95% CI 1.10–1.30; P = 0.03) was associated with a higher possibility of ≥ Grade 2 acute radiation therapy (RT)-related diarrhea. The median rectal V30 values were 56.4%, 97.5%, and 86.5% for tomotherapy, 3-dimensional conformal radiation therapy (3DCRT), and volumetric modulated arc therapy (VMAT), respectively (P < 0.001). In addition, the chance of experiencing ≥ Grade 2 acute diarrhea were 10.0%, 66.7%, and 54.5% for tomotherapy, 3DCRT, and VMAT, respectively (P = 0.029). Conclusions Patients with pretreatment SCC Ag ≤ 10 ng/mL have better PFS, LRRFS, and DMFS than those with pretreatment SCC Ag > 10 ng/mL. The rectal V30 is a significant predictor of severe acute diarrhea. Tomotherapy significantly decreased the rectal V30, reducing the severity of acute RT-related diarrhea during external beam RT. Trial registration This study was approved by the institutional review board at Kaohsiung Medical University Hospital. The registration number is KMUHIRB-E(I)-20190054 and retrospectively registered on 2019/3.
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Affiliation(s)
- Yuan-Kai Cheng
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shih-Hsun Kuo
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Heng-Hsuan Yen
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jing-Hu Wu
- Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chieh Chen
- Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. .,Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. .,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan.
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Wang G, Wang W, Jin H, Dong H, Chen W, Li X, Bai S, Li G, Chen W, Li L, Chen J. Effect of Abdominal Circumference on the Irradiated Bowel Volume in Pelvic Radiotherapy for Rectal Cancer Patients: Implications for the Radiotherapy-Related Intestinal Toxicity. Front Oncol 2022; 12:843704. [PMID: 35280741 PMCID: PMC8904399 DOI: 10.3389/fonc.2022.843704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background To effectively reduce the irradiated bowel volume so as to reduce intestinal toxicity from pelvic radiotherapy, treatment in the prone position with a full bladder on a belly board is widely used in pelvic radiotherapy for rectal cancer patients. However, the clinical applicable condition of this radiotherapy mode is unclear. The aim of this study was to preliminarily identify patients who were not eligible for this radiotherapy mode by analyzing the effect of abdominal circumference on the irradiated bowel volume. Methods From May 2014 to September 2019, 179 patients with locally advanced rectal cancer were retrospectively reviewed in our center. All patients received pelvic radiotherapy. Weight, height, AC, and body mass index (BMI) were used as the research objects, and the irradiated bowel volume at different dose levels (V10, V20, V30, V40, V50) was selected as the outcome variable. Multivariate linear regression and sensitivity analyses were used to evaluate the correlation between AC and irradiated bowel volume. Generalized additive model (GAM) and piecewise linear regression were used to further analyze the possible nonlinear relationship between them. Results Among the four body size indicators, AC showed a negative linear correlation with the irradiated bowel volume, which was the most significant and stable. In adjuvant radiotherapy patients, we further discovered the threshold effect between AC and irradiated bowel volume, as AC was greater than the inflection point (about 71 cm), irradiated bowel volume decreased rapidly with the increase in AC. t-test showed that in patients with small AC (<71 cm), the irradiated bowel volume was significantly higher than that of patients with medium-large AC (≥71 cm). Especially in patients with adjuvant radiotherapy, the mean irradiated bowel volume of patients with small AC was the highest in this study. Compared with adjuvant radiotherapy, in neoadjuvant radiotherapy, the mean difference of irradiated bowel volume between patients with medium-large AC and those with small AC was larger. Conclusion AC is an independent factor influencing the irradiated bowel volume and has a strong negative linear correlation with it. Patients with small AC may not benefit from this common mode of radiotherapy, especially in adjuvant radiotherapy.
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Affiliation(s)
| | - Wenling Wang
- Department of Abdominal Oncology, The Affiliated Hospital of Guizhou Medical University, The Affiliated Cancer Hospital of Guizhou Medical University, Guiyang, China
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17
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Abstract
Dose constraints are essential for performing dosimetry, especially for intensity modulation and for radiotherapy under stereotaxic conditions. We present the update of the recommendations of the French society of oncological radiotherapy for the use of these doses in classical current practice but also for reirradiation.
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Affiliation(s)
- G Noël
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France.
| | - D Antoni
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
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18
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Lübeck Christiansen R, Dysager L, Rønn Hansen C, Robenhagen Jensen H, Schytte T, Junker Nyborg C, Smedegaard Bertelsen A, Nielsen Agergaard S, Mahmood F, Hansen S, Hansen O, Brink C, Bernchou U. Online adaptive radiotherapy potentially reduces toxicity for high-risk prostate cancer treatment. Radiother Oncol 2021; 167:165-171. [PMID: 34923034 DOI: 10.1016/j.radonc.2021.12.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE With daily, MR-guided online adapted radiotherapy (MRgART) it may be possible to reduce the PTV in pelvic RT. This study investigated the potential reduction in normal tissue complication probability (NTCP) of MRgART compared to standard radiotherapy for high-risk prostate cancer. MATERIALS AND METHODS Twenty patients treated with 78 Gy to the prostate and 56 Gy to elective pelvic lymph nodes were included. VMAT plans were generated with standard clinical PTV margins. Additionally to the planning MR, patients had three MRI scans during treatment to simulate an MRgART. A reference plan with PTV margins determined for MRgART was created per patient and adapted to each of the following MRs. Adapted plans were warped to the planning MR for dose accumulation. The standard plan was rigidly registered to each adaptation MR before it was warped to the planning MR for dose accumulation. Dosimetric impact was compared by DVH analysis and potential clinical effects were assessed by NTCP modeling. RESULTS MRgART yielded statistically significant lower doses for the bladder wall, rectum and peritoneal cavity, compared to the standard RT, which translated into reduced median risks of urine incontinence (ΔNTCP 2.8%), urine voiding pain (ΔNTCP 2.8%) and acute gastrointestinal toxicity (ΔNTCP 17.4%). Mean population accumulated doses were as good or better for all investigated OAR when planned for MRgART as standard RT. CONCLUSION Online adapted radiotherapy may reduce the dose to organs at risk in high-risk prostate cancer patients, due to reduced PTV margins. This potentially translates to significant reductions in the risks of acute and late adverse effects.
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Affiliation(s)
- Rasmus Lübeck Christiansen
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital.
| | - Lars Dysager
- Department of Oncology, Odense University Hospital
| | - Christian Rønn Hansen
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | | | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark; Department of Oncology, Odense University Hospital
| | | | | | | | - Faisal Mahmood
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | | | - Olfred Hansen
- Department of Clinical Research, University of Southern Denmark; Department of Oncology, Odense University Hospital
| | - Carsten Brink
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | - Uffe Bernchou
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
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19
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Mell LK. Trials and tribulations of bone marrow sparing radiotherapy for cervical cancer. Radiother Oncol 2021; 167:78-80. [PMID: 34896460 DOI: 10.1016/j.radonc.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, United States.
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20
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Wang D, Wang W, Liu X, Ren K, Liang Y, Zhu Q, Zhang F, Hu K. A modified delineation method of para-aortic nodal clinical target volume in patients with locally advanced cervical cancer. Cancer Med 2021; 11:28-39. [PMID: 34783168 PMCID: PMC8704148 DOI: 10.1002/cam4.4418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To validate the nodal center coverage (NCC) of the three mainstream delineation methods of para-aortic nodal clinical target volume (CTV) and propose a modified delineation method of para-aortic nodal CTV in prophylactic extended-field irradiation (EFI) of cervical cancer. METHODS A total of 106 patients with para-aortic lymph nodes (PALNs) identified on PET/CT were included at Peking Union Medical College Hospital between 2011 and 2020. PALNs were classified as left lateral para-aortic (LLPA), aorto-caval (AC), and right para-caval (RPC). Distances from the nodal center to the aorta and inferior vena cava (IVC) were measured. The NCC of the three mainstream delineation methods of para-aortic nodal CTV (CTV-K, CTV-S, and CTV-D) and a modified CTV (CTV-M) was calculated. Radiotherapy plans were created based on 4 CTVs for 10 selected patients who received prophylactic EFI. The chi-squared test and the Student's t-test were performed. RESULTS We identified 344 PALNs (216 LLPA, 101 AC, and 27 RPC) in 106 patients. Mean distance from the nodal center to the aorta was 9.6 mm in the LLPA and 7 mm in the AC and from the nodal center to the IVC was 5.6 mm in the AC and 5.6 mm in the RPC. CTV-D improved the NCC of 98% compared with 92% for CTV-K (p = 0.002) and 95% for CTV-S (p = 0.046). CTV-M provided the same satisfactory NCC as CTV-D (97% vs. 98%, p = 0.485). The V50Gy to the duodenum, the Dmean to the bilateral kidneys, and the V45Gy to the small bowel were significantly lower on the CTV-M-based plan than on the CTV-D-based plan (p = 0.001, 0.011, and 0.001, respectively). CONCLUSION CTV-D provided more satisfactory NCC than CTV-K and CTV-S. CTV-M provided the same satisfactory NCC as CTV-D and reduced the dose to the critical structures.
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Affiliation(s)
- Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang Ren
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongguang Liang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qizhen Zhu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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21
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Bojechko C, Nelson T, Simpson D, Moiseenko V. Assessment of predictive indicators of acute gastrointestinal toxicity using in vivo transmission images. Med Phys 2021; 48:8152-8162. [PMID: 34664718 DOI: 10.1002/mp.15304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/08/2021] [Accepted: 10/09/2021] [Indexed: 11/12/2022] Open
Abstract
PURPOSE For pelvic and abdominal treatments, excess dose to the bowel can result in acute toxicities. Current estimates of bowel toxicity are based on pre-treatment dose-volume histogram data. However, the actual dose the bowel receives depends on interfraction variations, such as patient anatomy changes. We propose a method to model bowel toxicities, incorporating in vivo patient information using transit electronic portal imaging device (EPID) images. METHODS AND MATERIALS For 63 patients treated to the lower thorax, abdomen, or pelvis on the Varian Halcyon, weekly chart review was performed to obtain incidences of grade 2 or higher toxicity, RTOG scale. Twenty patients presented with acute gastrointestinal (GI) toxicity. All patients were treated with conventional fractionation. For each treatment plan, the absolute volume dose-volume histogram of the bowel was exported and analyzed. Additionally, for each fraction of treatment, in vivo EPID images were collected and used to estimate the change in radiation transmission during the course of treatment. A logistic model was used to test correlations between acute GI toxicity and bowel dosimetric parameters as well as metrics obtained from in vivo image measurements. After performing the fit to the in vivo EPID data, the bootstrap resampling method was used to create confidence intervals. In vivo EPID image metrics from an additional 42 patients treated to the lower thorax, abdomen, or pelvis were used to validate the logistic model fit. RESULTS The incidence of toxicity versus the volume of 40 Gy to the bowel space was fitted with a logistic function, which was superior to an average model (p < 0.0001) and agrees with previously published models. For the initial in vivo EPID data, the incidence of toxicity versus the sum of in vivo transmission measurements showed marginal significance after 15 fractions (p = 0.10) of treatment and a significance of p = 0.038 is seen at the 20th fraction, when compared to an average model. For the validation data set, the logistic model of the in vivo transmission measurement after 20 fractions was superior to the average model (p = 0.043), with the model falling within the 68% confidence interval of the fit of the initial data set. CONCLUSIONS Dose-volume constraints to reduce the incidence of acute GI toxicity have been validated. The presented novel EPID transmission-based metric can be used to identify GI toxicity as patients progress through treatment.
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Affiliation(s)
- Casey Bojechko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Tyler Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Daniel Simpson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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22
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Nilsson MP, Gunnlaugsson A, Johnsson A, Scherman J. Dosimetric and Clinical Predictors for Acute and Late Gastrointestinal Toxicity Following Chemoradiotherapy of Locally Advanced Anal Cancer. Clin Oncol (R Coll Radiol) 2021; 34:e35-e44. [PMID: 34598844 DOI: 10.1016/j.clon.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/04/2021] [Accepted: 09/16/2021] [Indexed: 11/03/2022]
Abstract
AIMS To analyse dosimetric and clinical predictors for acute and late gastrointestinal toxicity following chemoradiotherapy of anal cancer. MATERIALS AND METHODS Consecutive patients with locally advanced (T2 ≥4 cm - T4 or N+) anal cancer were selected from an institutional database (n = 114). All received intensity-modulated radiotherapy with concomitant 5-fluorouracil and mitomycin C. Gastrointestinal toxicity was retrospectively graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and bowel cavity, small bowel and large bowel were contoured. Dosimetric and clinical variables were tested for associations with acute grade ≥3 gastrointestinal toxicity and late grade ≥2 gastrointestinal toxicity using the Mann-Whitney test, area under receiver operating characteristic curve (AUC) and logistic regression. RESULTS The median follow-up was 40 months. Acute grade ≥3 gastrointestinal toxicity was seen in 51 (44.7%) of the patients; late grade ≥2 gastrointestinal toxicity was seen in 36 of the patients (39.6% of 91 patients with >1 year recurrence-free follow-up). Bowel cavity V30Gy was the best dosimetric predictor for acute gastrointestinal toxicity (AUC 0.633; P = 0.02). Large bowel V20Gy was the best dosimetric predictor for late gastrointestinal toxicity (AUC 0.698; P = 0.001) but showed no association with acute gastrointestinal toxicity. In multivariate logistic regression, increasing age was significantly associated with acute gastrointestinal toxicity; smoking and large bowel V20Gy were significantly associated with late gastrointestinal toxicity. Patients who experienced acute grade ≥3 gastrointestinal toxicity were not at an increased risk of late grade ≥2 gastrointestinal toxicity (odds ratio 1.3; P = 0.55). CONCLUSIONS Factors of importance for acute and late gastrointestinal toxicity were not the same. Bowel cavity V30Gy is a good metric to use for the prediction of acute gastrointestinal toxicity, but the results of our study indicate that individual large and small bowel loops need to be contoured for better prediction of late gastrointestinal toxicity. The role of the large bowel as an important organ at risk for late gastrointestinal toxicity merits further research.
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Affiliation(s)
- M P Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - A Gunnlaugsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - A Johnsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - J Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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23
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Jang H, Park J, Artz M, Zhang Y, Ricci JC, Huh S, Johnson PB, Kim MH, Chun M, Oh YT, Noh OK, Park HJ. Effective Organs-at-Risk Dose Sparing in Volumetric Modulated Arc Therapy Using a Half-Beam Technique in Whole Pelvic Irradiation. Front Oncol 2021; 11:611469. [PMID: 34490075 PMCID: PMC8416480 DOI: 10.3389/fonc.2021.611469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although there are some controversies regarding whole pelvic radiation therapy (WPRT) due to its gastrointestinal and hematologic toxicities, it is considered for patients with gynecological, rectal, and prostate cancer. To effectively spare organs-at-risk (OAR) doses using multi-leaf collimator (MLC)'s optimal segments, potential dosimetric benefits in volumetric modulated arc therapy (VMAT) using a half-beam technique (HF) were investigated for WPRT. METHODS While the size of a fully opened field (FF) was decided to entirely include a planning target volume in all beam's eye view across arc angles, the HF was designed to use half the FF from the isocenter for dose optimization. The left or the right half of the FF was alternatively opened in VMAT-HF using a pair of arcs rotating clockwise and counterclockwise. Dosimetric benefits of VMAT-HF, presented with dose conformity, homogeneity, and dose-volume parameters in terms of modulation complex score, were compared to VMAT optimized using the FF (VMAT-FF). Consequent normal tissue complication probability (NTCP) by reducing the irradiated volumes was evaluated as well as dose-volume parameters with statistical analysis for OAR. Moreover, beam-on time and MLC position precision were analyzed with log files to assess plan deliverability and clinical applicability of VMAT-HF as compared to VMAT-FF. RESULTS While VMAT-HF used 60%-70% less intensity modulation complexity than VMAT-FF, it showed superior dose conformity. The small intestine and colon in VMAT-HF showed a noticeable reduction in the irradiated volumes of up to 35% and 15%, respectively, at an intermediate dose of 20-45 Gy. The small intestine showed statistically significant dose sparing at the volumes that received a dose from 15 to 45 Gy. Such a dose reduction for the small intestine and colon in VMAT-HF presented a significant NTCP reduction from that in VMAT-FF. Without sacrificing the beam delivery efficiency, VMAT-HF achieved effective OAR dose reduction in dose-volume histograms. CONCLUSIONS VMAT-HF led to deliver conformal doses with effective gastrointestinal-OAR dose sparing despite using less modulation complexity. The dose of VMAT-HF was delivered with the same beam-on time with VMAT-FF but precise MLC leaf motions. The VMAT-HF potentially can play a valuable role in reducing OAR toxicities associated with WPRT.
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Affiliation(s)
- Hyunsoo Jang
- Department of Radiation Oncology, Dongguk University College of Medicine, Gyeongju, South Korea
| | - Jiyeon Park
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | - Mark Artz
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | - Yawei Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | - Jacob C. Ricci
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL, United States
| | - Soon Huh
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | - Perry B. Johnson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | - Mi-Hwa Kim
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Mison Chun
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Young-Taek Oh
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - O Kyu Noh
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Hae-Jin Park
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
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24
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Jadon R, Hanna L, Parsons P, Staffurth J. Dose-Volume Predictors for Patient-reported Late Diarrhoea, Faecal Incontinence and Urgency after Pelvic Radiotherapy. Clin Oncol (R Coll Radiol) 2021; 33:536-545. [PMID: 33875359 DOI: 10.1016/j.clon.2021.03.011] [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: 07/15/2020] [Revised: 02/09/2021] [Accepted: 03/15/2021] [Indexed: 11/30/2022]
Abstract
AIMS Pelvic radiotherapy adds significantly to the curative treatment of many pelvic malignancies. However, this cure comes at a cost for many patients, where late bowel toxicities, such as faecal incontinence, urgency and diarrhoea, adversely affect quality of life. Despite the implementation of advanced radiotherapy techniques in many centres, there are deficiencies in our knowledge of how to make best use of these techniques to minimise these late toxicities, with dose-volume constraints specifically for late effects needing definition. The aims of this study were to establish dose-volume predictors for patient-reported late bowel toxicities and derive constraints for clinical use to reduce the risk of these toxicities. MATERIALS AND METHODS All radiotherapy patients treated in our institution between 2012 and 2014 for gynaecological and urological cancers (bladder, prostate where pelvic nodes are treated) were identified. Patients were sent patient-reported toxicity questionnaires at 12 and 24 months after treatment. Planning computed tomography scans were retrospectively contoured with different definitions of bowel as organs at risk (OARs). Dose-volume data for each OAR were collected and predictors of these toxicities found using multivariate analysis. For those dose-volume predictors found to be significant on multivariate analysis, statistically significant and clinically relevant dose-volume constraints were derived. Furthermore, data collected were used to validate constraints from published studies. RESULTS Faecal urgency, incontinence and diarrhoea rates were found in 52, 23.5 and 18.7% of the 203 patients included at 12 months following radiotherapy. Dose-volume parameters for sigmoid colon and large bowel were significant for these toxicities, and constraints for these OARs were derived, which are promising. A previously published constraint for bowel loops was validated with our data. CONCLUSIONS The sigmoid colon and large bowel are important OARs for the development of faecal urgency, incontinence and diarrhoea. Promising constraints for these OARs were derived, which require further validation before prospective clinical use.
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Affiliation(s)
- R Jadon
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK; Department of Clinical Oncology, Addenbrooke's Hospital, Cambridge, UK.
| | - L Hanna
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - P Parsons
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK
| | - J Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK; School of Medicine, Institute of Cancer and Genetics, Cardiff University, Velindre Cancer Centre, Cardiff, UK
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25
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Berger T, Godart J, Jagt T, Vittrup AS, Fokdal LU, Lindegaard JC, Kibsgaard Jensen NB, Zolnay A, Reijtenbagh D, Trnkova P, Tanderup K, Hoogeman M. Dosimetric Impact of Intrafraction Motion in Online-Adaptive Intensity Modulated Proton Therapy for Cervical Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1580-1587. [PMID: 33227442 DOI: 10.1016/j.ijrobp.2020.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/23/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE A method was recently developed for online-adaptive intensity modulated proton therapy (IMPT) in patients with cervical cancer. The advantage of this approach, relying on the use of tight margins, is challenged by the intrafraction target motion. The purpose of this study was to evaluate the dosimetric effect of intrafraction motion on the target owing to changes in bladder filling in patients with cervical cancer treated with online-adaptive IMPT. METHODS AND MATERIALS In 10 patients selected to have large uterus motion induced by bladder filling, the intrafraction anatomic changes were simulated for several prefraction durations for online (automated) contouring and planning. For each scenario, the coverage of the primary target was evaluated with margins of 2.5 and 5 mm. RESULTS Using a 5- mm planning target volume margin, median accumulated D98% was greater than 42.75 GyRBE1.1 (95% of the prescribed dose) in the case of a prefraction duration of 5 and 10 minutes. For a prefraction duration of 15 minutes, this parameter deteriorated to 42.6 GyRBE1.1. When margins were reduced to 2.5 mm, only a 5-minute duration resulted in median target D98% above 42.75 GyRBE1.1. In addition, smaller bladders were found to be associated with larger dose degradations compared with larger bladders. CONCLUSIONS This study indicates that intrafraction anatomic changes can have a substantial dosimetric effect on target coverage in an online-adaptive IMPT scenario for patients subject to large uterus motion. A margin of 5 mm was sufficient to compensate for the intrafraction motion due to bladder filling for up to 10 minutes of prefraction time. However, compensation for the uncertainties that were disregarded in this study, by using margins or robust optimization, is also required. Furthermore, a large bladder volume restrains intrafraction target motion and is recommended for treating patients in this scenario. Assuming that online-adaptive IMPT remains beneficial as long as narrow margins are used (5 mm or below), this study demonstrates its feasibility with regard to intrafraction motion.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Jérémy Godart
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Thyrza Jagt
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | | | | | | | | | - Andras Zolnay
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Dominique Reijtenbagh
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Petra Trnkova
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands; Holland PTC, Delft, The Netherlands
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Mischa Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands; Holland PTC, Delft, The Netherlands
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Hundvin JA, Fjellanger K, Pettersen HES, Nygaard B, Revheim K, Sulen TH, Ekanger C, Hysing LB. Clinical iterative model development improves knowledge-based plan quality for high-risk prostate cancer with four integrated dose levels. Acta Oncol 2021; 60:237-244. [PMID: 33030972 DOI: 10.1080/0284186x.2020.1828619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Manual volumetric modulated arc therapy (VMAT) treatment planning for high-risk prostate cancer receiving whole pelvic radiotherapy (WPRT) with four integrated dose levels is complex and time consuming. We have investigated if the radiotherapy planning process and plan quality can be improved using a well-tuned model developed through a commercial system for knowledge-based planning (KBP). MATERIAL AND METHODS Treatment plans from 69 patients treated for high-risk prostate cancer with manually planned VMAT were used to develop an initial KBP model (RapidPlan, RP). Prescribed doses were 50, 60, 67.5, and 72.5 Gy in 25 fractions to the pelvic lymph nodes, prostate and seminal vesicles, prostate gland, and prostate tumour(s), respectively. This RP model was in clinical use from July 2019 to February 2020, producing another set of 69 clinically delivered treatment plans for a new patient group, which were used to develop a second RP model. Both models were validated on an independent group of 40 patients. Plan quality was compared by D 98% and the Paddick conformity index for targets, mean dose (D mean) and generalised equivalent uniform dose (gEUD) for bladder, bowel bag and rectum, and number of monitor units (MU). RESULTS Target coverage and conformity was similar between manually created and RP treatment plans. Compared to the manually created treatment plans, the final RP model reduced average D mean and gEUD with 2.7 Gy and 1.3 Gy for bladder, 1.2 Gy and 0.9 Gy for bowel bag, and 2.7 Gy and 0.8 Gy for rectum, respectively (p < .05). For rectum, the interpatient variation (i.e., 95% confidence interval) of DVHs was reduced by 23%. CONCLUSION KBP improved plan quality and consistency among treatment plans for high-risk prostate cancer. Model tuning using KBP-based clinical plans further improved model outcome.
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Affiliation(s)
| | - Kristine Fjellanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Britt Nygaard
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kari Revheim
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Turid Husevåg Sulen
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Christian Ekanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv Bolstad Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
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Rectal Dose Is the Other Dosimetric Factor in Addition to Small Bowel for Prediction of Acute Diarrhea during Postoperative Whole-Pelvic Intensity-Modulated Radiotherapy in Gynecologic Patients. Cancers (Basel) 2021; 13:cancers13030497. [PMID: 33525461 PMCID: PMC7865679 DOI: 10.3390/cancers13030497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Although the small bowel volume effect for acute diarrhea during radiotherapy has been investigated, no study has reported the influence of rectal dose. We analyzed 108 patients undergoing intensity-modulated radiotherapy after hysterectomy. Acute diarrhea was defined as onset during radiotherapy based on Common Terminology Criteria for Adverse Events (CTCAE) version 3. Both small bowel and rectum dosimetric parameters affected Grade 2 to 3 diarrhea. The high-dose volume effects on the small bowel still play an important role in postoperative intensity-modulated radiotherapy. This is the first large cohort study to demonstrate the role of both IMRT dosimetric factors of the rectum and the small bowel in acute diarrhea in gynecological patients with a previous hysterectomy. A small bowel volume of 39.6 Gy < 60 mL and a mean rectal dose of <32.75 Gy are suggested as constraints to treatment planning. Abstract We studied the association of rectal dose with acute diarrhea in patients with gynecologic malignancies undergoing whole-pelvic (WP) intensity-modulated radiotherapy (IMRT). From June 2006 to April 2019, 108 patients with previous hysterectomy who underwent WP IMRT were enrolled in this cohort study. WP irradiation of 39.6–45 Gy/22–25 fractions was initially delivered to the patients. Common Terminology Criteria for Adverse Events (CTCAE) version 3 was used to evaluate acute diarrhea during radiotherapy. Small bowel volume at different levels of isodose curves (Vn%) and mean rectal dose (MRD) were measured for statistical analysis. The multivariate analysis showed that the MRD ≥ 32.75 Gy (p = 0.005) and small bowel volume of 100% prescribed (V100%) ≥ 60 mL (p = 0.008) were independent factors of Grade 2 or higher diarrhea. The cumulative incidence of Grade 2 or higher diarrhea at 39.6 Gy were 70.5%, 42.2%, and 15.0% (p < 0.001) in patients with both high (V100% ≥ 60 mL and MRD ≥ 32.75 Gy), either high, and both low volume-dose factors, respectively. Strict constraints for the rectum/small bowel or image-guided radiotherapy to reduce these doses are suggested.
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Buranaporn P, Dankulchai P, Jaikuna T, Prasartseree T. Relation between DIR recalculated dose based CBCT and GI and GU toxicity in postoperative prostate cancer patients treated with VMAT. Radiother Oncol 2021; 157:8-14. [PMID: 33418004 DOI: 10.1016/j.radonc.2020.12.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the relationship between deformable image registration (DIR) recalculated dose on cone beam computed tomography (CBCT) and gastrointestinal and genitourinary toxicity in postoperative prostate cancer patients treated with volumetric modulated arc therapy and its actual delivered dose. MATERIAL AND METHODS A total of 114 patients were retrospectively studied. Delineation of rectum and bladder was performed on each CBCT image. Actual delivered dose on CBCT available fraction was recalculated using DIR. Dosimetric parameters of rectum and bladder were then evaluated by Quantitative Analyses of Normal Tissue Effects in the Clinic study. Differences in mean volume between patients with grade 0-1 and grade 2-5 CTCAEv5.0 toxicities were compared. Relationship between toxicity and radiation volume was analyzed using logit analysis. RESULTS Significant differences between the actual and planned dose-volume were observed in nearly all doses of rectum. High-grade acute rectal toxicity was significantly associated with planned dose-volume in V50 and V75, and actual dose in all doses. High-grade chronic rectal toxicity was significantly associated with all planned and actual rectal dose-volume parameters. There was no significant association between all dose-volume parameters and acute or chronic bladder toxicity. CONCLUSION Significant differences between actual and planned dose-volume, and significant association between actual dose-volume and acute rectal toxicity, but not planned dose-volume suggests that actual dose-volume may more precisely reflect toxicity due to daily variation in the rectum during the treatment course. Adaptive planning should be considered as a novel approach for reducing toxicity.
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Affiliation(s)
- Panyapat Buranaporn
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pittaya Dankulchai
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Tanwiwat Jaikuna
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tissana Prasartseree
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Loo M, Martinez-Gomez C, Khalifa J, Angeles MA, Chira C, Piram L, Martin E, Malavaud B, Ferron G, Graff-Cailleaud P. Laparoscopic closure of the pouch of Douglas by a peritoneal running suture. A minimally invasive and prosthetic-free technique to prevent excessive dose delivery to the small bowel during pelvic irradiation for prostate cancer. Clin Transl Radiat Oncol 2021; 26:71-78. [PMID: 33313426 PMCID: PMC7721662 DOI: 10.1016/j.ctro.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Prostate radiotherapy relies on the delivery of high doses that can be obstructed when a small bowel loop descends in the pelvis. We present a laparoscopic minimally invasive prosthetic-free technique closing the Douglas' pouch with a peritoneal running suture to cordon off the bowel from the pelvis and hence allow optimal irradiation. MATERIALS AND METHODS Prostate cancer patients referred for radiotherapy and whose planning-CT revealed a bowel loop trapped in the pelvis were proposed the procedure, followed by a new planning-CT. This proof-of-concept study reports postoperative follow-up and dosimetric benefits. RESULTS The procedure was performed in ten patients (2016-2020) as a same-day surgery for nine. Median operative time was 34 min (range 22-50) and no relevant intraoperative complication occurred. The third patient of the series presented a small bowel hernia through the peritoneal suture at the 15th postoperative day requiring a laparotomic desincarceration without major consequences. Regarding the small bowel, median D1cc (dose to 1 cc) was 65.5 Gy and 55.5 Gy (p = 0.005) before and after procedure. Median V60 (volume receiving ≥60 Gy) was 10.2 cc and 0.0 cc (p = 0.005). In the immediate vicinity of the small bowel (5 mm), median D1cc was 68.3 Gy and 57.7 Gy (p = 0.005). Radiotherapy was safely delivered to all patients. CONCLUSION Laparoscopic closure of the Douglas' pouch by a peritoneal suture is an efficient technique to cordon off inconvenient ectopic small bowel loops. It prevents excessive bowel irradiation and hence facilitates curative prostate radiotherapy. The technique could be applied to other pelvic malignancies.
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Affiliation(s)
- Maxime Loo
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Carlos Martinez-Gomez
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
- INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, 2 Avenue Hubert Curien, 31100 Toulouse, France
| | - Jonathan Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
- INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, 2 Avenue Hubert Curien, 31100 Toulouse, France
| | - Martina-Aida Angeles
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Ciprian Chira
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Lucie Piram
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Elodie Martin
- Department of Biostatistics, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Bernard Malavaud
- Department of Urology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
| | - Gwenaël Ferron
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
- INSERM CRCT Team 19, ONCOSARC-Oncogenesis of Sarcomas, 2 Avenue Hubert Curien, 31100 Toulouse, France
| | - Pierre Graff-Cailleaud
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, 1, avenue Irène Joliot-Curie, 31100 Toulouse, France
- Department of Radiation Oncology, Institut Curie, 25 rue d'Ulm, 75005 Paris
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Abraham AG, Usmani N, Warkentin B, Thai J, Yun J, Ghosh S, Cheung W, Xu Y, Nijjar T, Severin D, Tankel K, Fairchild A, Joseph K. Dosimetric Parameters Predicting Late Small Bowel Toxicity in Patients With Rectal Cancer Receiving Neoadjuvant Chemoradiation. Pract Radiat Oncol 2020; 11:e70-e79. [PMID: 32771626 DOI: 10.1016/j.prro.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to identify dosimetric parameters that predict late small bowel (SB) toxicity after neoadjuvant long course chemoradiation (CRT) for rectal cancer. METHODS AND MATERIALS Four hundred eighty-six consecutive patients with locally advanced rectal cancers (clinical T3/T4 or N1/N2) who received CRT followed by surgery and had dosimetric data available for analysis were included in this study. The dose-volume relationship between small bowel irradiation and late small bowel toxicity was evaluated and a mathematical model to predict for late SB toxicity was derived. RESULTS Among the 486 patients with a median follow-up of 60 months from completion of radiation, 36 (7.4%) patients experienced ≥ grade 2 and 21 (4.3%) developed ≥ grade 3 late SB toxicity. A statistically significant association between the development of grade ≥3 late small bowel toxicity and the volume of small bowel irradiated was found at each dose level from 5 to 40 Gy (P < .001 for all dose volumes) in 5 Gy intervals. The average SB volume for patients who experienced grade ≥2 SB toxicity was 2149.9 cm3 and the average SB volume for patients who experienced grade ≥3 SB toxicity was 2179.9 cm3. The predicted V30 for a 5% risk for grade ≥2 SB toxicity was 101.5 cm3 and for grade ≥3 SB toxicity was 201.5 cm3. The volume of small bowel receiving at least 30 Gy (V30) was most strongly associated with grade ≥3 SB toxicity. CONCLUSIONS This study demonstrates the significant dose-volume relationship between volume of small bowel receiving 30 Gy (V30 Gy) and late grade ≥3 SB toxicity. When planning CRT for patients with rectal cancer, restricting V30 to <200 cm3 will be a useful guideline to minimize the 5 year grade ≥3 late SB toxicity to <5%.
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Affiliation(s)
| | - Nawaid Usmani
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Brad Warkentin
- Department of Oncology, Cross Cancer Institute, Edmonton, Canada
| | - JoAnn Thai
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Jihyun Yun
- Department of Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Sunita Ghosh
- Department of Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Winson Cheung
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Yuan Xu
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tirath Nijjar
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Diane Severin
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Keith Tankel
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Alysa Fairchild
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Kurian Joseph
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada.
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Reijtenbagh DMW, Godart J, Mens JWM, Heijkoop ST, Heemsbergen WD, Hoogeman MS. Patient-reported acute GI symptoms in locally advanced cervical cancer patients correlate with rectal dose. Radiother Oncol 2020; 148:38-43. [PMID: 32311599 DOI: 10.1016/j.radonc.2020.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE To investigate relationships between patient-reported acute gastro-intestinal symptoms in a locally advanced cervical cancer (LACC) prospective cohort and clinical and dosimetric parameters, while also taking spatial dose into account. MATERIAL AND METHODS A total of 103 patients was included, receiving radiotherapy based on a plan-library-based plan-of-the-day protocol, combined either with concurrent chemotherapy or with neo-adjuvant chemotherapy and concomitant hyperthermia. Toxicity endpoints were extracted from questionnaires sent out weekly during treatment and regularly in the acute phase after treatment. Endpoints were defined for symptoms concerning obstipation, diarrhea, fecal leakage, bowel cramps and rectal bleeding. Dose surface maps were constructed for the rectum. Clinical parameters and dosimetric parameters of the bowel bag and rectum were collected for all patients. RESULTS The use of concomitant chemotherapy and an increase in Planning Target Volume (PTV) resulted in a significant increase in reported diarrhea. The dose-volume parameters V5Gy-V25Gy of the rectum were found to be significant, unlike dose-volume parameters of the bowel bag. Additionally, a significantly higher dose to the inferior part of the rectum was found for patients reporting diarrhea. No significance was reached for fecal leakage and bowel cramps. CONCLUSION The significance of results for patients reporting diarrhea symptoms found for PTV volume indicates a potential benefit for a plan-of-the-day protocol. Additionally, the results suggest that a reduction of inferior rectum dose could decrease patient-reported diarrhea symptoms, while the administration of concomitant chemotherapy appears to lead to radiosensitizing effects that increase these symptoms.
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Affiliation(s)
| | - Jeremy Godart
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Jan-Willem M Mens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Sabrina T Heijkoop
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Mischa S Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands.
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Berger T, Seppenwoolde Y, Pötter R, Assenholt MS, Lindegaard JC, Nout RA, de Leeuw A, Jürgenliemk-Schulz I, Tan LT, Georg D, Kirisits C, Dumas I, Nesvacil N, Swamidas J, Hudej R, Lowe G, Hellebust TP, Menon G, Fokdal L, Tanderup K. Importance of Technique, Target Selection, Contouring, Dose Prescription, and Dose-Planning in External Beam Radiation Therapy for Cervical Cancer: Evolution of Practice From EMBRACE-I to II. Int J Radiat Oncol Biol Phys 2019; 104:885-894. [PMID: 30904706 DOI: 10.1016/j.ijrobp.2019.03.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/05/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the evolution of external beam radiation therapy (EBRT) from EMBRACE-I (general guidelines for EBRT) to the initial phase of the EMBRACE-II study (detailed protocol for EBRT). METHODS AND MATERIALS EMBRACE-I enrolled 1416 locally advanced cervical cancer patients treated with chemoradiation including image-guided adaptive brachytherapy during 2008 to 2015. From March 2016 until March 2018, 153 patients were enrolled in the ongoing EMBRACE-II study, which involves a comprehensive detailed strategy and accreditation procedure for EBRT target contouring, treatment planning, and image guidance. EBRT planning target volumes (PTVs), treated volumes (V43 Gy), and conformity index (CI; V43 Gy/PTV) were evaluated in both studies and compared. RESULTS For EMBRACE-I, conformal radiation therapy (60% of patients) or intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT; 40%) was applied with 45 to 50 Gy over 25 to 30 fractions to the elective clinical target volume (CTV). For pelvic CTVs (82%), median PTV and V43 Gy volumes were 1549 and 2390 mL, respectively, and CI was 1.54. For pelvic plus paraortic nodal (PAN) CTVs (15%), median PTV and V43 Gy volumes were 1921 and 2895 mL, and CI was 1.51. For pelvic CTVs treated with 45 to 46 Gy, the use of conformal radiation therapy was associated with a median V43 Gy volume that was 546 mL larger than with IMRT/VMAT. For pelvic CTVs treated with IMRT, the use of a dose prescription ≥48 Gy was associated with a median V43 Gy volumes that was 428 mL larger than with a dose prescription of 45 to 46 Gy. For EMBRACE-II, all patients were treated with: IMRT/VMAT, daily IGRT, 45 Gy over 25 fractions for the elective CTV, and simultaneously integrated boost for pathologic lymph nodes. For pelvic CTVs (61%), median PTV and V43 Gy volumes were 1388 and 1418 mL, and CI was 1.02. For pelvic plus PAN CTVs (32%), median PTV and V43 Gy volumes were 1720 and 1765 mL, and CI was 1.03. From EMBRACE-I to initial II, median V43 Gy was decreased by 972 mL (41%) and 1130 mL (39%), and median CI decreased from 1.54 to 1.02 and 1.51 to 1.03 for pelvic and pelvic plus PAN irradiation, respectively. CONCLUSIONS Application of IMRT/VMAT, IGRT, and a 45-Gy dose provides the potential of higher conformality inducing significant reduction of treated volume. Adherence to a detailed protocol including comprehensive accreditation, as in EMBRACE-II, reduces considerably V43 Gy and V50 Gy and improves conformality and interinstitutional consistency.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Denmark.
| | - Yvette Seppenwoolde
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | | | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Astrid de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Li Tee Tan
- Departments of Oncology, Radiology and Gynae-oncology, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Trust, United Kingdom
| | - Dietmar Georg
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Isabelle Dumas
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | - Nicole Nesvacil
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Jamema Swamidas
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Navi Mumbai, India
| | - Robert Hudej
- Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia
| | - Gerry Lowe
- Cancer Centre, Mount Vernon Hospital, London, United Kingdom
| | - Taran Paulsen Hellebust
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway
| | - Geetha Menon
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Visser J, de Boer P, Crama KF, van Kesteren Z, Rasch CRN, Stalpers LJA, Bel A. Dosimetric comparison of library of plans and online MRI-guided radiotherapy of cervical cancer in the presence of intrafraction anatomical changes. Radiat Oncol 2019; 14:126. [PMID: 31300000 PMCID: PMC6624982 DOI: 10.1186/s13014-019-1322-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/18/2019] [Indexed: 12/05/2022] Open
Abstract
Background Online magnetic resonance imaging (MRI)-guided radiotherapy of cervical cancer has the potential to further reduce dose to organs at risk (OAR) as compared to a library of plans (LOP) approach. This study presents a dosimetric comparison of an MRI-guided strategy with a LOP strategy taking intrafraction anatomical changes into account. Methods The 14 patients included in this study were treated with chemo radiation at our institute and received weekly MRIs after informed consent. The MRI-guided strategy consisted of treatment plans created on the weekly sagittal MRI with 3 mm and 5 mm planning target volume (PTV) margin for clinical target volume (CTV) cervix-uterus (MRI_3mm and MRI_5mm). The plans for the LOP strategy were based on interpolations of CTV cervix-uterus on pretreatment full and empty bladder scans. Dose volume histogram (DVH) parameters were compared for targets and OARs as delineated on the weekly transversal MRI, which was acquired on average 10 min after the sagittal MRI. Results For the MRI_5mm strategy D98% of the high-risk CTV was at least 95% for all weekly MRIs of all patients, while for the LOP and MRI_3mm strategy this requirement was not satisfied for at least one weekly MRI for 1 and 3 patients, respectively. The average reduction of the volume of the reference dose (95% of the prescribed dose) as compared to the LOP strategy was 464 cm3 for the MRI_3mm strategy, and 422 cm3 for the MRI_5mm strategy. The bowel bag constraint V40Gy < 350 cm3 was violated for 13 patients for the LOP strategy and for 5 patients for both MRI_3mm and MRI_5mm strategy. Conclusions With online MRI-guided radiotherapy of cervical cancer considerable sparing of OARs can be achieved. If a new treatment plan can be generated and delivered within 10 min, an online MRI-guided strategy with a 5 mm PTV margin for CTV cervix-uterus is sufficient to account for intrafraction anatomical changes. Trial registration NL44492.018.13. Electronic supplementary material The online version of this article (10.1186/s13014-019-1322-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Visser
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| | - P de Boer
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Present Address: Radiotherapeutisch Instituut Friesland, Borniastraat 36, Leeuwarden, the Netherlands
| | - K F Crama
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Z van Kesteren
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Present Address: Department of Radiation Oncology, Leiden University Medical Center, University of Leiden, Albinusdreef 2, Leiden, The Netherlands
| | - L J A Stalpers
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - A Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Berger T, Fokdal LU, Assenholt MS, Jensen NB, Petersen JB, Nyvang L, Korreman S, Lindegaard JC, Tanderup K. Robustness of elective lymph node target coverage with shrinking Planning Target Volume margins in external beam radiotherapy of locally advanced cervical cancer. Phys Imaging Radiat Oncol 2019; 11:9-15. [PMID: 33458270 PMCID: PMC7807569 DOI: 10.1016/j.phro.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/06/2019] [Accepted: 06/06/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Image-Guidance decreases set-up uncertainties, which may allow for Planning Target Volume (PTV) margins reduction. This study evaluates the robustness of the elective lymph node target coverage to translational and rotational set-up errors in combination with shrinking PTV margins and determines the gain for the Organs At Risk (OARs). MATERIAL AND METHODS Ten cervix cancer patients who underwent external beam radiotherapy with 45 Gy/25Fx were analysed. Daily Image-Guidance was based on bony registration of Cone Beam CT (CBCT) to planning CT (pCT) and daily couch correction (translation and yaw). On each pCT, four Volumetric Modulated Arc Therapy dose-plans were generated with PTV margins of 0, 3, 5 and 8 mm. The elective clinical target volume (CTV-E) was propagated from daily CBCTs to the pCT to evaluate daily CTV-E dose. Additional systematic translational isocenter shifts of 2 mm were simulated. D98% (dose received by 98% of the volume of interest) and D99.9% were extracted from each CTV-E for all dose-plans and scenarios. Total dose was accumulated by Dose-Volume Histogram addition. The dosimetric impact of PTV margin reduction on the OARs was evaluated through V30Gy (volume included within the 30 Gy isodose), V40Gy and body V43Gy. RESULTS When decreasing the PTV margin from 5 to 0 mm, bowel V30Gy was decreased by 13% (from 247 cm3 to 214 cm3), body V43Gy by 19% (from 1462 cm3 to 1188 cm3) and PTV by 39% (from 1416 to 870 cm3). The dosimetric impact of combined systematic shifts and residual rotations on the elective target with a 0 mm PTV margin was a decrease of D98% (mean ± SD) from 44.1 Gy ± 0.4 Gy to 43.7 Gy ± 0.8 Gy and a minimum of 42.4 Gy. CONCLUSION PTV margin reduction from 5 to 0 mm induced significant OARs dosimetric gains while elective target coverage remained robust to positioning uncertainties.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Lars U. Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Lars Nyvang
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Stine Korreman
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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The Effect of Body Mass Index and Weight Change on Late Gastrointestinal Toxicity in Locally Advanced Cervical Cancer Treated With Intensity-modulated Radiotherapy. Int J Gynecol Cancer 2019; 28:1377-1386. [PMID: 29994908 DOI: 10.1097/igc.0000000000001312] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the effects of body mass index (BMI) and weight change during radiotherapy on the development of toxicity in patients with locally advanced cervical cancer (LACC) treated with intensity-modulated radiotherapy (IMRT). METHODS A total of 245 patients were analyzed after undergoing definitive IMRT treatment between 2004 and 2015 for stage IB2 to stage IVA LACC. The patients were divided into 3 groups: underweight (BMI <18.5 kg/m), normal weight (BMI 18.5-24.9 kg/m), and overweight (BMI ≥25.0 kg/m). The relationships between toxicity, clinical factors, and the bowel dose-volume histogram were analyzed. V45 indicated the bowel volume that received a radiation dose of 45 Gy. RESULTS The median follow-up period was 63 months. The V45 was similar among the 3 groups. The 5-year rates of grade 3 or higher late gastrointestinal toxicities were 18.6%, 4.0%, and 4.2% for the underweight, normal weight, and overweight groups, respectively (P = 0.002). In the multivariable analysis, underweight (hazard ratio, 13.99; 95% confidence interval, 3.22-60.82; P < 0.001) and weight loss (> -5%) (hazard ratio, 5.91; 95% confidence interval, 1.75-19.98; P = 0.004) were significant predictors of grade 3 or higher-grade late gastrointestinal toxicities. CONCLUSION A BMI of less than 18.5 kg/m and weight loss (> -5%) were associated with a higher risk of grade ≥3 or higher late gastrointestinal toxicity in patients with LACC treated with definitive IMRT. Future research on the development of a standardized and structured approach to improve the therapeutic ratio for the supportive care of patients with LACC is needed.
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Hoover A, Gunan Ganju R, TenNapel M, Chen A. Visceral adipose ratio as a novel predictor for acute bowel toxicity in patients receiving pelvic radiation: Preliminary dosimetric analysis and clinical validation. J Med Imaging Radiat Oncol 2019; 63:408-414. [DOI: 10.1111/1754-9485.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/04/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew Hoover
- Department of Radiation Oncology University of Kansas Cancer Center Kansas University Medical Center Kansas City Kansas USA
| | - Rohit Gunan Ganju
- Department of Radiation Oncology University of Kansas Cancer Center Kansas University Medical Center Kansas City Kansas USA
| | - Mindi TenNapel
- Department of Radiation Oncology University of Kansas Cancer Center Kansas University Medical Center Kansas City Kansas USA
| | - Allen Chen
- Department of Radiation Oncology University of Kansas Cancer Center Kansas University Medical Center Kansas City Kansas USA
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van de Schoot AJ, van den Wollenberg W, Carbaat C, de Ruiter P, Nowee ME, Pos F, van Triest B, Sonke JJ, Janssen TM. Evaluation of plan quality in radiotherapy planning with an MR-linac. Phys Imaging Radiat Oncol 2019; 10:19-24. [PMID: 33458263 PMCID: PMC7807609 DOI: 10.1016/j.phro.2019.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND & PURPOSE Clinical introduction of magnetic resonance (MR)-guided radiotherapy involves treatment planning while taking into account machine-specific characteristics. Our aim was to investigate the feasibility of high-quality MR-linac treatment planning for an MR-linac and to benchmark MR-linac plan quality (IMRT) against current clinical practice (VMAT). MATERIALS & METHODS Data of eight rectal and eight prostate cancer patients, who received radiotherapy on a conventional CBCT-integrated linac, were selected. Clinically acquired CTs and associated delineations of target volumes and organs-at-risk (OARs) were used for MR-linac treatment planning in Monaco. To investigate treatment planning software bias 'quasi MR-linac plans' were generated in Pinnacle3 by mimicking MR-linac specific beam characteristics. MR-linac, quasi MR-linac, and clinical plans were compared and differences in target and OAR doses assessed. Differences in plan complexity were determined by the number of segments and monitor units. RESULTS Compared to clinical plans, MR-linac plans showed a statistically significant decrease in plan homogeneity, an increase in PTV Dmean (prostate: 0.6 Gy; rectum: 0.8 Gy) and D1% (prostate: 1.9 Gy; rectum: 2.0 Gy), and increases in OAR dose. Quasi MR-linac plans were comparable to MR-linac plans with respect to OAR dose and plan homogeneity. For rectal cancer an increase was seen in PTV Dmean (0.12 Gy) and D1% (0.5 Gy) compared to regular MR-linac plans. All created plans were clinically equivalent to current clinical practice. CONCLUSIONS This study demonstrates the feasibility of creating high-quality MR-linac treatment plans. The results supported the clinical introduction of an MR-linac.
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Affiliation(s)
| | - Wouter van den Wollenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Casper Carbaat
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Peter de Ruiter
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Marlies E. Nowee
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Floris Pos
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Baukelien van Triest
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Tomas M. Janssen
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Kozak MM, Koenig JL, von Eyben R, Kidd EA. Less Than Whole Uterus Irradiation for Locally Advanced Cervical Cancer Maintains Locoregional Control and Decreases Radiation Dose to Bowel. Pract Radiat Oncol 2019; 9:e164-e171. [DOI: 10.1016/j.prro.2018.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/26/2018] [Accepted: 10/22/2018] [Indexed: 11/29/2022]
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Gleeson I, Rose C, Spurrell J. Dosimetric comparison of helical tomotherapy and VMAT for anal cancer: A single institutional experience. Med Dosim 2019; 44:e32-e38. [PMID: 30639142 DOI: 10.1016/j.meddos.2018.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 11/17/2022]
Abstract
To compare the dosimetric results of helical tomotherapy (HT) and volumetric arc therapy (VMAT) in the treatment of anal cancer. Plans were created for 20 (n = 20) patients treated for anal cancer using HT and 2 arc VMAT. Dosimetric comparison was assessed for doses to targets and organs at risk (small bowel, bladder, external genitalia, and femoral heads). Delivery time and dosimetric verification results were also compared. HT showed a higher V95% for both primary and nodal targets (V95% increase by 0.5% to 1.3%; p = ≤0.05). No differences were seen in V105%, V107%, or V110 % between techniques. HT provided better sparing of the small bowel for dose levels V30, V35, and V40 (p = 0.005, 0.001, and 0.030), but was similar at higher doses. Similarly HT provided better bladder dose at V35 only (p = 0.020). Doses to femoral heads and genitalia were similar. Delivery time was higher for the HT plans (4.58 ± 1.1 min) than VMAT (3.13 ± 0.2 minutes) (p = 0.011). Dose verification results were 99.5 ± 0.9% and 100 ± 0% (HT, n = 6) vs 95.0 ± 3.1% and 99.2 ± 0.8% (VMAT, n = 20) for global gamma criteria 3%/3 mm and 4%/4 mm, respectively. Both HT and VMAT produced high quality plans that frequently met most of the dose objectives apart from genitalia V20, V40, bladder V35, and V50. Although absolute dose differences were small, the PTV V95%, small bowel V30, V35, and V40 and bladder V35 were statistically better in the HT plans. VMAT provided a shorter delivery time by 1.45 minutes; however, our HT plans were more likely to pass tighter plan dose verification criteria than VMAT.
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Affiliation(s)
- Ian Gleeson
- Department of Medical Physics, Addenbrooke's Hospital, Cambridge, CB20QQ, UK.
| | - Christopher Rose
- Department of Medical Physics, Addenbrooke's Hospital, Cambridge, CB20QQ, UK.
| | - Joshua Spurrell
- Department of Medical Physics, Addenbrooke's Hospital, Cambridge, CB20QQ, UK.
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40
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The impact of daily bladder filling on small bowel dose for intensity modulated radiation therapy for cervical cancer. Med Dosim 2019; 44:102-106. [DOI: 10.1016/j.meddos.2018.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 01/03/2023]
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41
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Dapper H, Oechsner M, Münch S, Borm K, Peeken J, Mayinger M, Combs SE, Habermehl D. Dosimetric analysis and comparison of reduced longitudinal cranial margins of VMAT-IMRT of rectal cancer. Radiat Oncol 2018; 13:169. [PMID: 30189877 PMCID: PMC6127934 DOI: 10.1186/s13014-018-1120-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background The cranial border of the target volume (TV) in rectal cancer patients treated with neoadjuvant chemoradiation (nCRT) is mostly defined at the level of L5/S1. However, current studies have shown that relapse cranially of the target volume after neoadjuvant nCRT and surgery is very rare. A reduction of cranial TV margins could be reasonable to reduce toxicity to the organs at risk (OAR). In this study we compared the dose distribution to the OAR for different cranial longitudinal margins using a dose-volume histogram (DVH) analysis. Methods Ten patients with loco regional advanced rectal cancer were analysed retrospectively. All patients were planned for Volumetric Arc Therapy Radiation Therapy (VMAT). Next to the original PTV (PTV0), three new planning target volumes (PTV) were defined for each patient: The PTV0 reduced by 1 cm, 2 cm and 3 cm on cranial extension. For each PTV a treatment plan with a total dose of 50.4 Gy with daily doses of 1.8 Gy was calculated. Dose to the OAR were evaluated and compared. Results For the bone marrow, the small bowel and the peritoneal space all clinically relevant relative dose parameters (V10-V50) as well as the Dmedian could be significantly reduced with every cranial target volume reduction of 1 cm. For V10 of the peritoneal space the dose could be nearly halved with a 3 cm shortened TV. After TV reduction of 3 cm also for the urinary bladder a significant dose reduction of the Dmedian could be achieved. Conclusions Considering the very low recurrence rates in the TME and IMRT era, the distribution patterns of these relapses as well as the relevant side effects of nCRT, we would agree with existing recommendations of reduction of the cranial target volume in nCRT treated rectal cancer patients.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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Tamaki T, Hirai R, Igari M, Kumazaki Y, Noda SE, Suzuki Y, Kato S. Dosimetric comparison of three-dimensional conformal radiotherapy versus volumetric-arc radiotherapy in cervical cancer treatment: applying the central-shielding principle to modern technology. JOURNAL OF RADIATION RESEARCH 2018; 59:639-648. [PMID: 30053184 PMCID: PMC6151642 DOI: 10.1093/jrr/rry054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Indexed: 05/05/2023]
Abstract
This study evaluated the feasibility of applying volumetric-arc radiotherapy (VMAT) in standard curative radiotherapy for non-bulky cervical cancer using the central-shielding principle. Whole-pelvis irradiation of 20 Gy and central-shielding pelvis irradiation of 30 Gy, both in 2 Gy fractions, were created using 3D conformal radiotherapy (3DCRT) with a standard midline block or VMAT. Composite dose distributions and DVH parameters were compared first in a simple phantom model and then in 10 clinical cases of Stage I-II cervical cancer. Whole-pelvis clinical target volumes (CTVs) were created from published guidelines for primary disease and lymph node regions, and CTVs for central-shielding irradiation were created by subtracting uterus corpus and 4 cm-wide regions centered at the cervical canal and vagina. In a phantom model, VMAT provided adequate dose coverage to the PTVs without excessive doses to the rectum or bladder compared with the 3DCRT plan. In the clinical cases, VMAT plans resulted in slightly but significantly better coverage of PTVs. The DVH parameters for the rectum and bladder were equivalent or lower for VMAT plans compared with the 3DCRT plans. In the bowel, V30Gy, V40Gy, and V50Gy were significantly lower in VMAT plans compared with in the 3DCRT plans (47.6% vs 61.0%, 29.8% vs 56.2% and 6.8% vs 21.1%, respectively). Based on these results, VMAT may be used in external-beam radiotherapy for early-stage cervical cancer by adopting the principle of central-shielding pelvis irradiation. Furthermore, VMAT is likely to reduce doses to the small bowel and may reduce gastrointestinal toxicities for these patients.
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Affiliation(s)
- Tomoaki Tamaki
- Department of Radiation Oncology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, Japan
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
- Corresponding author. Department of Radiation Oncology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima 960–1295 Japan. Tel: +81-24-547-1630; Fax: +81-24-547-1631;
| | - Ryuta Hirai
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
| | - Mitsunobu Igari
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
| | - Yu Kumazaki
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
| | - Shin-ei Noda
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
| | - Yoshiyuki Suzuki
- Department of Radiation Oncology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397–1 Yamane, Hidaka, Saitama, Japan
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Prone Positioning on a Belly Board Decreases Rectal and Bowel Doses in Pelvic Intensity-Modulated Radiation Therapy (IMRT) for Prostate Cancer. Pathol Oncol Res 2018; 25:995-1002. [PMID: 29882196 DOI: 10.1007/s12253-018-0436-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022]
Abstract
The presence of normal tissues in the irradiated volume limits dose escalation during pelvic radiotherapy (RT) for prostate cancer. Supine and prone positions on a belly board were compared by analyzing the exposure of organs at risk (OARs) using intensity modulated RT (IMRT). The prospective trial included 55 high risk, localized or locally advanced prostate cancer patients, receiving definitive image-guided RT. Computed tomography scanning for irradiation planning was carried out in both positions. Gross tumor volume, clinical and planning target volumes (PTV) and OARs were delineated, defining subprostatic and periprostatic rectal subsegments. At the height of the largest antero-posterior (AP) diameter of the prostate, rectal diameters and distance from the posterior prostate wall were measured. IMRT plans were generated. Normal tissue exposure and structure volumes were compared between supine and prone plans using paired t-test. In the volumes of the prostate, PTV, colon and small bowel, no significant differences were found. In prone position, all rectal volumes, diameters, and rectum-prostate distance were significantly higher, the irradiated colon and small bowel volume was lower in dose ranges of 20-40 Gy, and the exposure to all rectal segments was more favorable in 40-75 Gy dose ranges. No significant difference was found in the exposure of other OARs. Prone positioning on a belly board is an appropriate positioning method aiming rectum and bowel protection during pelvic IMRT of prostate cancer. The relative reduction in rectal exposure might be a consequence of the slight departure between the prostate and rectal wall.
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Intensity-modulated radiotherapy for whole pelvis irradiation in prostate cancer: A dosimetric and plan robustness study between photons and protons. Tech Innov Patient Support Radiat Oncol 2018; 6:11-19. [PMID: 32095573 PMCID: PMC7033791 DOI: 10.1016/j.tipsro.2018.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/16/2018] [Accepted: 02/22/2018] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the dosimetric impact and plan robustness of using Pencil Beam Scanning (PBS) in patients that requires prophylactic pelvic lymph nodes (PLNs) irradiation for prostate cancer. Material and methods Five intermediate to high-risk prostate patients previously treated using volumetric modulated arc therapy (VMAT), were selected for this study. Comparative proton radiotherapy plans were generated, where a three-field intensity modulated proton therapy (IMPT) plan was for the phase 1 planning target volume (PTV1) with PLNs. A technique with two posterior oblique fields using single field uniform dose (SFUD) was used for phase 2 (PTV2) volume, that comprises of the prostate and proximal seminal vesicles (Pro + proxSVs). Plan evaluation was performed on PTV coverage and dose to the organs at risk (OARs) using VMAT plans as a baseline (BL). Robust analysis on clinical target volume (CTV) coverage for the PBS plans was simulated with a 3 and 5 mm setup errors and a 3.5% range uncertainty. Results For target coverage, PTV1 and PTV2 showed negligible differences with a comparable homogeneity index (HI) values for both modalities. Proton plans produced a statistically significant lower mean dose to the bladder (32.5 Gy(RBE) vs. 46.5 Gy) and rectum (33.6 Gy(RBE) vs. 42.7 Gy). Dose to the bladder and rectum was equivalent at the high dose region. For the bowel cavity, the mean dose for proton plans were 45% lower compared to VMAT plans. Similarly, proton plans were able to achieve an overall reduction in integral dose for both treatment phase. CTV coverage remained high with all the simulated setup and range errors. Conclusions Proposed beam geometries for PTV1 and PTV2 proton plans presented good treatment accuracy with similar target coverage as the VMAT plans. Better sparing of OARs was achieved at the low-medium dose region for the proton plans.
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45
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Frelinghuysen M, Schillemans W, Hol L, Verhoef C, Hoogeman M, Nuyttens JJ. Acute toxicity of the bowel after stereotactic robotic radiotherapy for abdominopelvic oligometastases. Acta Oncol 2018; 57:480-484. [PMID: 28920500 DOI: 10.1080/0284186x.2017.1378432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM To correlate dose-volume histogram (DVH) parameters with appearance of grade ≥2 acute and late gastrointestinal toxicity of stereotactic body radiotherapy (SBRT) in patients with abdominopelvic solitary or oligometastatic disease outside the liver. MATERIAL AND METHODS Acute and late bowel toxicity of 84 abdominopelvic oligometastatic patients was registered. A logistic regression was performed between different DVH parameters and presence of grade ≥2 acute and late toxicity. A Normal Tissue Complication Probability (NTCP) model was built with significant parameters to determine complication probabilities (CP). RESULTS Thirteen (15%) of 84 patients experienced of grade ≥2 acute toxicity, while 8 (10%) reported late toxicity complications. A significant relationship was found for EQD2 (V30Gy, V40Gy, V50Gy and V65Gy) and grade ≥2 acute toxicity. Dmax and D2 were not significant. Late grade ≥2 toxicity was not significantly correlated with any DVH parameter. According to our NTCP model for V40Gy, an irradiated bowel volume of 10 cm3 of V40Gy resulted in CP of grade ≥2 acute toxicity of less than 10%. Local control was 87% at 2 years and 82% at 5 years. Overall survival was 61% at 2 years and 32% at 5 years. CONCLUSIONS After SBRT for abdominopelvic oligometastases, in general, the presence of acute and late toxicity was low. A significant relationship was found for V30Gy, V40Gy, V50Gy and V65Gy and grade ≥2 acute toxicity. We estimated acute complication probabilities per volume of irradiated bowel by V40Gy and V50Gy.
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Affiliation(s)
- Michael Frelinghuysen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wilco Schillemans
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Erasmus MC, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost Jan Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Chuong MD, Hartsell W, Larson G, Tsai H, Laramore GE, Rossi CJ, Wilkinson JB, Kaiser A, Vargas C. Minimal toxicity after proton beam therapy for prostate and pelvic nodal irradiation: results from the proton collaborative group REG001-09 trial. Acta Oncol 2018; 57:368-374. [PMID: 29034790 DOI: 10.1080/0284186x.2017.1388539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Proton beam therapy (PBT) reduces normal organ dose compared to intensity modulated radiation therapy (IMXT) for prostate cancer patients who receive pelvic radiation therapy. It is not known whether this dosimetric advantage results in less gastrointestinal (GI) and genitourinary (GU) toxicity than would be expected from IMXT. MATERIAL AND METHODS We evaluated treatment parameters and toxicity outcomes for non-metastatic prostate cancer patients who received pelvic radiation therapy and enrolled on the PCG REG001-09 trial. Patients who received X-ray therapy and/or brachytherapy were excluded. Of 3210 total enrolled prostate cancer patients, 85 received prostate and pelvic radiation therapy exclusively with PBT. Most had clinically and radiographically negative lymph nodes although 6 had pelvic nodal disease and one also had para-aortic involvement. Pelvic radiation therapy was delivered using either 2 fields (opposed laterals) or 3 fields (opposed laterals and a posterior beam). Median pelvic dose was 46.9 GyE (range 39.7-56) in 25 fractions (range 24-30). Median boost dose to the prostate +/- seminal vesicles was 30 GyE (range 20-41.4) in 16 fractions (range 10-24). RESULTS Median follow-up was 14.5 months (range 2.8-49.2). Acute grade 1, 2, and 3 GI toxicity rates were 16.4, 2.4, 0%, respectively. Acute grade 1, 2, and 3 GU toxicity rates were 60, 34.1, 0%, respectively. CONCLUSIONS Prostate cancer patients who receive pelvic radiation therapy using PBT experience significantly less acute GI toxicity than is expected using IMXT. Further investigation is warranted to confirm whether this favorable acute GI toxicity profile is related to small bowel sparing from PBT.
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Affiliation(s)
- Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute at Baptist Health South Florida, Miami, FL, USA
| | - William Hartsell
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, USA
| | - Gary Larson
- ProCure Proton Therapy Center Oklahoma City, Oklahoma City, OK, USA
| | - Henry Tsai
- ProCure Proton Therapy Center New Jersey, Somerset, NJ, USA
| | - George E. Laramore
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | | | - J. Ben Wilkinson
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, LA, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
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Verges R, Giraldo A, Seoane A, Toral E, Ruiz MC, Pons A, Giralt J. Does ITV vaginal procedure ensure dosimetric coverage during IMRT of post-operative gynaecological tumours without instructions concerning rectal filling? Rep Pract Oncol Radiother 2018; 23:136-142. [DOI: 10.1016/j.rpor.2018.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/09/2017] [Accepted: 01/22/2018] [Indexed: 11/28/2022] Open
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de Boer P, van de Schoot AJAJ, Westerveld H, Smit M, Buist MR, Bel A, Rasch CRN, Stalpers LJA. Target tailoring and proton beam therapy to reduce small bowel dose in cervical cancer radiotherapy : A comparison of benefits. Strahlenther Onkol 2018; 194:255-263. [PMID: 29101415 PMCID: PMC5847034 DOI: 10.1007/s00066-017-1224-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 10/05/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of the study was to investigate the potential clinical benefit from both target tailoring by excluding the tumour-free proximal part of the uterus during image-guided adaptive radiotherapy (IGART) and improved dose conformity based on intensity-modulated proton therapy (IMPT). METHODS The study included planning CTs from 11 previously treated patients with cervical cancer with a >4-cm tumour-free part of the proximal uterus on diagnostic magnetic resonance imaging (MRI). IGART and robustly optimised IMPT plans were generated for both conventional target volumes and for MRI-based target tailoring (where the non-invaded proximal part of the uterus was excluded), yielding four treatment plans per patient. For each plan, the V15Gy, V30Gy, V45Gy and Dmean for bladder, sigmoid, rectum and bowel bag were compared, and the normal tissue complication probability (NTCP) for ≥grade 2 acute small bowel toxicity was calculated. RESULTS Both IMPT and MRI-based target tailoring resulted in significant reductions in V15Gy, V30Gy, V45Gy and Dmean for bladder and small bowel. IMPT reduced the NTCP for small bowel toxicity from 25% to 18%; this was further reduced to 9% when combined with MRI-based target tailoring. In four of the 11 patients (36%), NTCP reductions of >10% were estimated by IMPT, and in six of the 11 patients (55%) when combined with MRI-based target tailoring. This >10% NTCP reduction was expected if the V45Gy for bowel bag was >275 cm3 and >200 cm3, respectively, during standard IGART alone. CONCLUSIONS In patients with cervical cancer, both proton therapy and MRI-based target tailoring lead to a significant reduction in the dose to surrounding organs at risk and small bowel toxicity.
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Affiliation(s)
- Peter de Boer
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Agustinus J A J van de Schoot
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Henrike Westerveld
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mark Smit
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marrije R Buist
- Department of Gynaecology and Obstetrics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Kim A, Karotki A, Presutti J, Gonzales G, Wong S, Chu W. The effect of prone and supine treatment positions for the pre-operative treatment of rectal cancer on organ-at-risk sparing and setup reproducibility using volumetric modulated arc therapy. Radiat Oncol 2017; 12:180. [PMID: 29202879 PMCID: PMC5715653 DOI: 10.1186/s13014-017-0918-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/04/2017] [Indexed: 02/02/2023] Open
Abstract
Background and purpose To compare organ-at-risk doses and setup reproducibility using the prone and supine orientations in volumetric modulated arc therapy (VMAT) for rectal cancer. Materials and methods Seventeen consecutive rectal cancer patients undergoing preoperative radiation were selected and setup in either the prone (N = 8) or supine (N = 9) position. All patients were treated using posteriorly-applied VMAT. Bladder and small bowel dose and cone beam CT (CBCT) reproducibility metrics were retrospectively collected. Results Dose metrics for bladder and small bowel did not show significant differences between the prone and supine orientations. The prone data had a trend for smaller irradiated volumes than supine for the small bowel at lower doses—V20 (prone: 135 ± 99 cm3; supine: 201 ± 162 cm3) and V30 (prone: 78 ± 71 cm3; supine: 105 ± 106 cm3). At higher doses, the trend reversed as exemplified by the small bowel V50.4 (prone: 20 ± 28 cm3; supine: 10 ± 14 cm3). CBCT data showed that rotational errors in pitch and roll were significantly larger for the prone vs. supine orientation (pitch: 2.0° ± 1.3° vs. 0.8° ± 1.1° p < 0.001; roll: 1.0° ± 0.9° vs. 0.3° ± 0.5°, p < 0.001). Conclusions Bladder and small bowel doses were not significantly different when comparing VMAT plans developed for the prone and supine orientations. The supine orientation demonstrated improved setup reproducibility.
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Affiliation(s)
- Anthony Kim
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Aliaksandr Karotki
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Joe Presutti
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Glen Gonzales
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Shun Wong
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - William Chu
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
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Nováková E, Heijkoop S, Quint S, Zolnay A, Mens J, Godart J, Heijmen B, Hoogeman M. What is the optimal number of library plans in ART for locally advanced cervical cancer? Radiother Oncol 2017; 125:470-477. [DOI: 10.1016/j.radonc.2017.08.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/24/2017] [Accepted: 08/19/2017] [Indexed: 10/18/2022]
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