1
|
Wu TC, Luterstein E, Neilsen BK, Goldman JW, Garon EB, Lee JM, Felix C, Cao M, Tenn SE, Low DA, Kupelian PA, Steinberg ML, Lee P. Accelerated Hypofractionated Chemoradiation Followed by Stereotactic Ablative Radiotherapy Boost for Locally Advanced, Unresectable Non-Small Cell Lung Cancer: A Nonrandomized Controlled Trial. JAMA Oncol 2024; 10:352-359. [PMID: 38206614 PMCID: PMC10784998 DOI: 10.1001/jamaoncol.2023.6033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/15/2023] [Indexed: 01/12/2024]
Abstract
Importance Intrathoracic progression remains the predominant pattern of failure in patients treated with concurrent chemoradiation followed by a consolidation immune checkpoint inhibitor for locally advanced, unresectable non-small cell lung cancer (NSCLC). Objective To determine the maximum tolerated dose (MTD) and use of hypofractionated concurrent chemoradiation with an adaptive stereotactic ablative radiotherapy (SABR) boost. Design, Setting, and Participants This was an early-phase, single-institution, radiation dose-escalation nonrandomized controlled trial with concurrent chemotherapy among patients with clinical stage II (inoperable/patient refusal of surgery) or III NSCLC (American Joint Committee on Cancer Staging Manual, seventh edition). Patients were enrolled and treated from May 2011 to May 2018, with a median patient follow-up of 18.2 months. Patients advanced to a higher SABR boost dose if dose-limiting toxic effects (any grade 3 or higher pulmonary, gastrointestinal, or cardiac toxic effects, or any nonhematologic grade 4 or higher toxic effects) occurred in fewer than 33% of the boost cohort within 90 days of follow-up. The current analyses were conducted from January to September 2023. Intervention All patients first received 4 Gy × 10 fractions followed by an adaptive SABR boost to residual metabolically active disease, consisting of an additional 25 Gy (low, 5 Gy × 5 fractions), 30 Gy (intermediate, 6 Gy × 5 fractions), or 35 Gy (high, 7 Gy × 5 fractions) with concurrent weekly carboplatin/paclitaxel. Main Outcome and Measure The primary outcome was to determine the MTD. Results Data from 28 patients (median [range] age, 70 [51-88] years; 16 [57%] male; 24 [86%] with stage III disease) enrolled across the low- (n = 10), intermediate- (n = 9), and high- (n = 9) dose cohorts were evaluated. The protocol-specified MTD was not exceeded. The incidences of nonhematologic acute and late (>90 days) grade 3 or higher toxic effects were 11% and 7%, respectively. No grade 3 toxic effects were observed in the intermediate-dose boost cohort. Two deaths occurred in the high-dose cohort. Two-year local control was 74.1%, 85.7%, and 100.0% for the low-, intermediate-, and high-dose cohorts, respectively. Two-year overall survival was 30.0%, 76.2%, and 55.6% for the low-, intermediate-, and high-dose cohorts, respectively. Conclusions and Relevance This early-phase, dose-escalation nonrandomized controlled trial showed that concurrent chemoradiation with an adaptive SABR boost to 70 Gy in 15 fractions with concurrent chemotherapy is a safe and effective regimen for patients with locally advanced, unresectable NSCLC. Trial Registration ClinicalTrials.gov Identifier: NCT01345851.
Collapse
Affiliation(s)
- Trudy C. Wu
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Beth K. Neilsen
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Edward B. Garon
- Department of Medicine, University of California, Los Angeles
| | - Jay M. Lee
- Division of Thoracic Surgery, Department of Surgery, University of California, Los Angeles
| | - Carol Felix
- Department of Radiation Oncology, University of California, Los Angeles
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles
| | - Stephen E. Tenn
- Department of Radiation Oncology, University of California, Los Angeles
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles
| | | | | | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles
- Now with Department of Radiation Oncology, City of Hope Orange County, Lennar Foundation Cancer Center, Irvine, California
| |
Collapse
|
2
|
Ajdari A, Liao Z, Mohan R, Wei X, Bortfeld T. Personalized mid-course FDG-PET based adaptive treatment planning for non-small cell lung cancer using machine learning and optimization. Phys Med Biol 2022; 67:10.1088/1361-6560/ac88b3. [PMID: 35947984 PMCID: PMC9579961 DOI: 10.1088/1361-6560/ac88b3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/10/2022] [Indexed: 11/12/2022]
Abstract
Objective. Traditional radiotherapy (RT) treatment planning of non-small cell lung cancer (NSCLC) relies on population-wide estimates of organ tolerance to minimize excess toxicity. The goal of this study is to develop a personalized treatment planning based on patient-specific lung radiosensitivity, by combining machine learning and optimization.Approach. Sixty-nine non-small cell lung cancer patients with baseline and mid-treatment [18]F-fluorodeoxyglucose (FDG)-PET images were retrospectively analyzed. A probabilistic Bayesian networks (BN) model was developed to predict the risk of radiation pneumonitis (RP) at three months post-RT using pre- and mid-treatment FDG information. A patient-specific dose modifying factor (DMF), as a surrogate for lung radiosensitivity, was estimated to personalize the normal tissue toxicity probability (NTCP) model. This personalized NTCP was then integrated into a NTCP-based optimization model for RT adaptation, ensuring tumor coverage and respecting patient-specific lung radiosensitivity. The methodology was employed to adapt the treatment planning of fifteen NSCLC patients.Main results. The magnitude of the BN predicted risks corresponded with the RP severity. Average predicted risk for grade 1-4 RP were 0.18, 0.42, 0.63, and 0.76, respectively (p< 0.001). The proposed model yielded an average area under the receiver-operating characteristic curve (AUROC) of 0.84, outperforming the AUROCs of LKB-NTCP (0.77), and pre-treatment BN (0.79). Average DMF for the radio-tolerant (RP grade = 1) and radiosensitive (RP grade ≥ 2) groups were 0.8 and 1.63,p< 0.01. RT personalization resulted in five dose escalation strategies (average mean tumor dose increase = 6.47 Gy, range = [2.67-17.5]), and ten dose de-escalation (average mean lung dose reduction = 2.98 Gy [0.8-5.4]), corresponding to average NTCP reduction of 15% [4-27].Significance. Personalized FDG-PET-based mid-treatment adaptation of NSCLC RT could significantly lower the RP risk without compromising tumor control. The proposed methodology could help the design of personalized clinical trials for NSCLC patients.
Collapse
Affiliation(s)
- Ali Ajdari
- Massachusetts General Hospital and Harvard Medical School, Department of Radiation Oncology, Division of Radiation BioPhysics, Boston, MA
| | - Zhongxing Liao
- University of Texas’ MD Anderson Cancer Center, Department of Radiation Oncology, Division of Radiation Oncology, Houston, TX
| | - Radhe Mohan
- University of Texas’ MD Anderson Cancer Center, Department of Radiation Physics, Division of Radiation Oncology, Houston, TX
| | - Xiong Wei
- University of Texas’ MD Anderson Cancer Center, Department of Radiation Oncology, Division of Radiation Oncology, Houston, TX
| | - Thomas Bortfeld
- Massachusetts General Hospital and Harvard Medical School, Department of Radiation Oncology, Division of Radiation BioPhysics, Boston, MA
| |
Collapse
|
3
|
Tambe NS, Pires IM, Moore CS, Wieczorek A, Upadhyay S, Beavis AW. Predicting personalised and progressive adaptive dose escalation to gross tumour volume using knowledge-based planning models for inoperable advanced-stage non-small cell lung cancer patients treated with volumetric modulated arc therapy. Biomed Phys Eng Express 2022; 8. [PMID: 35189613 DOI: 10.1088/2057-1976/ac56eb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/21/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Increased radiation doses could improve local control and overall survival of lung cancer patients, however, this could be challenging without exceeding organs at risk (OAR) dose constraints especially for patients with advanced-stage disease. Increasing OAR doses could reduce the therapeutic ratio and quality of life. It is therefore important to investigate methods to increase the dose to target volume without exceeding OAR dose constraints. METHODS Gross tumour volume (GTV) was contoured on synthetic computerised tomography (sCT) datasets produced using the Velocity adaptive radiotherapy software for eleven patients. The fractions where GTV volume decreased compared to that prior to radiotherapy (reference plan) were considered for personalised progressive dose escalation. The dose to the adapted GTV (GTVAdaptive) was increased until OAR doses were affected (as compared to the original clinical plan). Planning target volume (PTV) coverage was maintained for all plans. Doses were also escalated to the reference plan (GTVClinical) using the same method. Adapted, dose-escalated, plans were combined to estimate accumulated dose, D99 (dose to 99%) of GTVAdapted, PTV D99 and OAR doses and compared with those in the original clinical plans. Knowledge-based planning (KBP) model was developed to predict D99 of the adapted GTV with OAR doses and PTV coverage kept similar to the original clinical plans; prediction accuracy and model verification were performed using further data sets. RESULTS Compared to the original clinical plan, dose to GTV was significantly increased without exceeding OAR doses. Adaptive dose-escalation increased the average D99 to GTVAdaptive by 15.1Gy and 8.7Gy compared to the clinical plans. The KBP models were verified and demonstrated prediction accuracy of 0.4% and 0.7% respectively. CONCLUSION Progressive adaptive dose escalation can significantly increase the dose to GTV without increasing OAR doses or compromising dose to microscopic disease. This may increase overall survival without increasing toxicities.
Collapse
Affiliation(s)
- Nilesh S Tambe
- Radiation Physics Department, Hull University Teaching Hospitals NHS Trust, Queens Centre For Oncology And Haematology, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Isabel M Pires
- Biomedical Sciences, University of Hull, Cottingham Road,, Hardy Building,, Hull, Kingston upon Hull, HU6 7RX, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Craig Steven Moore
- Medical Physics, Hull University Teaching Hospitals NHS Trust, Queens Centre, Castle Hill Hospital, Cottingham, Hull, HU16 5LH, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Andrzej Wieczorek
- Hull University Teaching Hospitals NHS Trust, Department of Clinical Oncology, The Queen's Centre, Cottingham, Hull, Kingston upon Hull, HU3 2JZ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Sunil Upadhyay
- Clinical Oncology Department, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital,, Queen's Centre for Oncology and Hematology, Castle Road, Cottingham, Kingston upon Hull, HU16 5JQ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Andrew W Beavis
- Department of Radiotherapy Physics, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Hull, Kingston upon Hull, HU3 2JZ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| |
Collapse
|
4
|
Hoegen P, Lang C, Akbaba S, Häring P, Splinter M, Miltner A, Bachmann M, Stahl-Arnsberger C, Brechter T, El Shafie RA, Weykamp F, König L, Debus J, Hörner-Rieber J. Cone-Beam-CT Guided Adaptive Radiotherapy for Locally Advanced Non-small Cell Lung Cancer Enables Quality Assurance and Superior Sparing of Healthy Lung. Front Oncol 2020; 10:564857. [PMID: 33363005 PMCID: PMC7756078 DOI: 10.3389/fonc.2020.564857] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/04/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate the potential of cone-beam-CT (CB-CT) guided adaptive radiotherapy (ART) for locally advanced non-small cell lung cancer (NSCLC) for sparing of surrounding organs-at-risk (OAR). Materials and Methods In 10 patients with locally advanced NSCLC, daily CB-CT imaging was acquired during radio- (n = 4) or radiochemotherapy (n = 6) for simulation of ART. Patients were treated with conventionally fractionated intensity-modulated radiotherapy (IMRT) with total doses of 60–66 Gy (pPlan) (311 fraction CB-CTs). OAR were segmented on every daily CB-CT and the tumor volumes were modified weekly depending on tumor changes. Doses actually delivered were recalculated on daily images (dPlan), and voxel-wise dose accumulation was performed using a deformable registration algorithm. For simulation of ART, treatment plans were adapted using the new contours and re-optimized weekly (aPlan). Results CB-CT showed continuous tumor regression of 1.1 ± 0.4% per day, leading to a residual gross tumor volume (GTV) of 65.3 ± 13.4% after 6 weeks of radiotherapy (p = 0.005). Corresponding PTVs decreased to 83.7 ± 7.8% (p = 0.005). In the actually delivered plans (dPlan), both conformity (p = 0.005) and homogeneity (p = 0.059) indices were impaired compared to the initial plans (pPlan). This resulted in higher actual lung doses than planned: V20Gy was 34.6 ± 6.8% instead of 32.8 ± 4.9% (p = 0.066), mean lung dose was 19.0 ± 3.1 Gy instead of 17.9 ± 2.5 Gy (p = 0.013). The generalized equivalent uniform dose (gEUD) of the lung was 18.9 ± 3.1 Gy instead of 17.8 ± 2.5 Gy (p = 0.013), leading to an increased lung normal tissue complication probability (NTCP) of 15.2 ± 13.9% instead of 9.6 ± 7.3% (p = 0.017). Weekly plan adaptation enabled decreased lung V20Gy of 31.6 ± 6.2% (−3.0%, p = 0.007), decreased mean lung dose of 17.7 ± 2.9 Gy (−1.3 Gy, p = 0.005), and decreased lung gEUD of 17.6 ± 2.9 Gy (−1.3 Gy, p = 0.005). Thus, resulting lung NTCP was reduced to 10.0 ± 9.5% (−5.2%, p = 0.005). Target volume coverage represented by conformity and homogeneity indices could be improved by weekly plan adaptation (CI: p = 0.007, HI: p = 0.114) and reached levels of the initial plan (CI: p = 0.721, HI: p = 0.333). Conclusion IGRT with CB-CT detects continuous GTV and PTV changes. CB-CT-guided ART for locally advanced NSCLC is feasible and enables superior sparing of healthy lung at high levels of plan conformity.
Collapse
Affiliation(s)
- Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Clemens Lang
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Mainz University Hospital, Mainz, Germany
| | - Peter Häring
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mona Splinter
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annette Miltner
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marion Bachmann
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Thomas Brechter
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
5
|
Grewal AS, Min EJ, Long Q, Grewal SK, Jain V, Levin WP, Cengel KA, Swisher-McClure S, Aggarwal C, Bauml JM, Singh A, Ciunci C, Cohen RB, Langer C, Feigenberg SJ, Berman AT. Early Tumor and Nodal Response in Patients with Locally Advanced Non-Small Cell Lung Carcinoma Predict for Oncologic Outcomes in Patients Treated with Concurrent Proton Therapy and Chemotherapy. Int J Radiat Oncol Biol Phys 2019; 106:358-368. [PMID: 31654783 DOI: 10.1016/j.ijrobp.2019.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/04/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE There are no established imaging biomarkers that predict response during chemoradiation for patients with locally advanced non-small cell lung carcinoma. At our institution, proton therapy (PT) patients undergo repeat computed tomography (CT) simulations twice during radiation. We hypothesized that tumor regression measured on these scans would separate early and late responders and that early response would translate into better outcomes. METHODS AND MATERIALS Patients underwent CT simulations before starting PT (CT0) and between weeks 1 to 3 (CT1) and weeks 4 to 7 (CT2) of PT. Primary tumor volume (TVR) and nodal volume (NVR) reduction were calculated at CT1 and CT2. Based on recursive partitioning analysis, early response at CT1 and CT2 was defined as ≥20% and ≥40%, respectively. Locoregional and overall progression-free survival (PFS), distant metastasis-free survival, and overall survival by response status were measured using Kaplan-Meier analysis. RESULTS Ninety-seven patients with locally advanced non-small cell lung carcinoma underwent definitive PT to a median dose of 66.6 Gy with concurrent chemotherapy. Median TVR and NVR at CT1 were 19% (0-79%) and 19% (0-75%), respectively. At CT2, they were 33% (2-98%) and 35% (0-89%), respectively. With a median follow-up of 25 months, the median overall survival and PFS for the entire cohort was 24.9 and 13.2 months, respectively. Compared with patients with TVR and NVR <20% at T1 and <40% at T2, patients with TVR and NVR ≥20% at CT1 and ≥40% at CT2 had improved median locoregional PFS (27.15 vs 12.97 months for TVR ≥40% vs <40%, P < .01, and 25.67 vs 12.09 months for NVR ≥40% vs <40%, P < .01) and median PFS (22.7 vs 9.2 months, P < .01, and 20.3 vs 7.9 months, P < .01), confirmed on multivariate Cox regression analysis. CONCLUSIONS Significantly improved outcomes in patients with early responses to therapy, as measured by TVR and NVR, were seen. Further study is warranted to determine whether treatment intensification will improve outcomes in slow-responding patients.
Collapse
Affiliation(s)
- Amardeep S Grewal
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eun Jeong Min
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Qi Long
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sharonjit K Grewal
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Varsha Jain
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Bauml
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aditi Singh
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine Ciunci
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corey Langer
- Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
6
|
Greater reduction in mid-treatment FDG-PET volume may be associated with worse survival in non-small cell lung cancer. Radiother Oncol 2018; 132:241-249. [PMID: 30389239 DOI: 10.1016/j.radonc.2018.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/17/2018] [Accepted: 10/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This study tested the hypotheses that 1) changes in mid-treatment fluorodeoxyglucose (FDG)-positron emission tomography (PET) parameters are predictive of overall survival (OS) and 2) mid-treatment FDG-PET-adapted treatment has the potential to improve survival in patients with non-small cell lung cancer (NSCLC). MATERIAL AND METHODS Patients with stage I-III NSCLC requiring daily fractionated radiation were eligible. FDG-PET-CT scans were obtained prior to and mid-treatment with radiotherapy at 40-50 Gy. The normalized maximum standardized uptake value (NSUVmax), normalized mean SUV (NSUVmean), PET-metabolic tumor volume (MTV), total lesion glycolysis (TLG), and computed tomography-based gross tumor volume (CT-GTV) were consistently measured for all patients. The primary study endpoint was OS. RESULTS The study is comprised of 102 patients who received 3-dimensional conformal radiotherapy, among whom 30 patients who received mid-treatment PET-adapted dose escalation radiotherapy. All PET-CT parameters decreased significantly (P < 0.001) mid-treatment, with greater reductions in FDG-volumetric parameters compared to FDG-activity factors. Mid-treatment changes in MTV (P = 0.053) and TLG (P = 0.021) were associated with OS, while changes in NSUVmax, NSUVmean, and CT-GTV were not (all Ps>0.1). Patients receiving conventional radiation (60-70 Gy) with MTV reductions greater than the mean had a median survival of 14 months, compared to those with MTV reductions less than the mean who had a median survival of 22 months. By contrast, patients receiving mid-treatment PET-adapted radiation with MTV reductions greater than the mean had a median survival of 33 months, compared to those with MTV reductions less than the mean who had a median survival of 19 months. Overall, PET-adapted treatment resulted in a 19% better 5-year survival than conventional radiation. CONCLUSION Changes in mid-treatment PET-volumetric parameters were significantly associated with survival in NSCLC. A greater reduction in the mid-treatment MTV was associated with worse survival in patients treated with standard radiation, but with better survival in patients who received mid-treatment PET-adapted treatment.
Collapse
|
7
|
Zhang P, Yorke E, Mageras G, Rimner A, Sonke JJ, Deasy JO. Validating a Predictive Atlas of Tumor Shrinkage for Adaptive Radiotherapy of Locally Advanced Lung Cancer. Int J Radiat Oncol Biol Phys 2018; 102:978-986. [PMID: 30061006 DOI: 10.1016/j.ijrobp.2018.05.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/10/2018] [Accepted: 05/20/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE To cross-validate and expand a predictive atlas that can estimate geometric patterns of lung tumor shrinkage during radiation therapy using data from 2 independent institutions and to model its integration into adaptive radiation therapy (ART) for enhanced dose escalation. METHODS AND MATERIALS Data from 22 patients at a collaborating institution were obtained to cross-validate an atlas, originally created with 12 patients, for predicting patterns of tumor shrinkage during radiation therapy. Subsequently, the atlas was expanded by integrating all 34 patients. Each study patient was selected via a leave-one-out scheme and was matched with a subgroup of the remaining 33 patients based on similarity measures of tumor volume and surroundings. The spatial distribution of residual tumor was estimated by thresholding the superimposed shrinkage patterns in the subgroup. A Bayesian method was also developed to recalibrate the prediction using the tumor observed on the midcourse images. Finally, in a retrospective predictive treatment planning (PTP) study, at the initial planning stage, the predicted residual tumors were escalated to the highest achievable dose while maintaining the original prescription dose to the remainder of the tumor. The PTP approach was compared isotoxically to ART that replans with midcourse imaging and to PTP-ART with the recalibrated prediction. RESULTS Predictive accuracy (true positive plus true negative ratios based on predicted and actual residual tumor) were comparable across institutions, 0.71 versus 0.73, and improved to 0.74 with an expanded atlas including 2 institutions. Recalibration further improved accuracy to 0.76. PTP increased the mean dose to the actual residual tumor by an averaged 6.3Gy compared to ART. CONCLUSION A predictive atlas found to perform well across institutions and benefit from more diversified shrinkage patterns and tumor locations. Elevating tumoricidal dose to the predicted residual tumor throughout the entire treatment course could improve the efficacy and efficiency of treatment compared to ART with midcourse replanning.
Collapse
Affiliation(s)
- Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, NY.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, NY
| | - Gig Mageras
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York City, NY
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, NY
| |
Collapse
|
8
|
Lazzeroni M, Uhrdin J, Carvalho S, van Elmpt W, Lambin P, Dasu A, Wersäll P, Toma-Dasu I. Evaluation of third treatment week as temporal window for assessing responsiveness on repeated FDG-PET-CT scans in Non-Small Cell Lung Cancer patients. Phys Med 2018. [DOI: 10.1016/j.ejmp.2018.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
9
|
Jiang C, Han S, Chen W, Ying X, Wu H, Zhu Y, Shi G, Sun X, Xu Y. A retrospective study of shrinking field radiation therapy during chemoradiotherapy in stage III non-small cell lung cancer. Oncotarget 2018; 9:12443-12451. [PMID: 29552324 PMCID: PMC5844760 DOI: 10.18632/oncotarget.23849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 10/26/2017] [Indexed: 12/25/2022] Open
Abstract
Background and purpose: This retrospective study aimed to investigate the feasibility of shrinking field radiotherapy during chemoradiotherapy in non-small cell lung cancer (NSCLC). Patients and methods Ninety-seven patients with stage III NSCLC who achieved a good response to chemoradiation were analyzed. Computed tomography was performed after 40-50 Gy dose radiation to evaluate curative effect. Patients in the shrinking field group underwent resimulation CT scans and shrinking field radiotherapy. Acute symptomatic irradiation-induced pneumonia (ASIP), progression patterns and survival were assessed. Results Of the 97 patients who achieved response after a median total dose of 60 Gy, fifty patients received shrinking field radiotherapy. The incidence of acute symptomatic irradiation-induced pneumonia tended to be lower for the shrinking field group (18.0% vs. 23.4%, P = 0.51). The rate of disease progression was significantly higher in the non-shrinking than shrinking field group (95.7% vs. 66.0%, P < 0.001). Compared to the non-shrinking field group, the shrinking field group had similar overall survival (30.0 vs. 30.0 months, P = 0.58) but significantly better median progression-free survival (14.0 vs. 11.0 months, P = 0.006). Conclusions Shrinking field radiotherapy during chemoradiotherapy in stage III non-small cell lung cancer seems safe with acceptable toxicities and relapse, and potentially spares normal tissues and enables dose escalation. Prospective trials are warranted.
Collapse
Affiliation(s)
- Chenxue Jiang
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Shuiyun Han
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Wucheng Chen
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Xiaozhen Ying
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - He Wu
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Yaoyao Zhu
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Guodong Shi
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Xiaojiang Sun
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| | - Yaping Xu
- First Clinical Medical School, Wenzhou Medical University, Wenzhou, PR China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, PR China
| |
Collapse
|
10
|
Predictive and prognostic value of tumor volume and its changes during radical radiotherapy of stage III non-small cell lung cancer : A systematic review. Strahlenther Onkol 2017; 194:79-90. [PMID: 29030654 DOI: 10.1007/s00066-017-1221-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/19/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Lung cancer remains the leading cause of cancer-related mortality worldwide. Stage III non-small cell lung cancer (NSCLC) includes heterogeneous presentation of the disease including lymph node involvement and large tumour volumes with infiltration of the mediastinum, heart or spine. In the treatment of stage III NSCLC an interdisciplinary approach including radiotherapy is considered standard of care with acceptable toxicity and improved clinical outcome concerning local control. Furthermore, gross tumour volume (GTV) changes during definitive radiotherapy would allow for adaptive replanning which offers normal tissue sparing and dose escalation. METHODS A literature review was conducted to describe the predictive value of GTV changes during definitive radiotherapy especially focussing on overall survival. The literature search was conducted in a two-step review process using PubMed®/Medline® with the key words "stage III non-small cell lung cancer" and "radiotherapy" and "tumour volume" and "prognostic factors". RESULTS After final consideration 17, 14 and 9 studies with a total of 2516, 784 and 639 patients on predictive impact of GTV, GTV changes and its impact on overall survival, respectively, for definitive radiotherapy for stage III NSCLC were included in this review. Initial GTV is an important prognostic factor for overall survival in several studies, but the time of evaluation and the value of histology need to be further investigated. GTV changes during RT differ widely, optimal timing for re-evaluation of GTV and their predictive value for prognosis needs to be clarified. The prognostic value of GTV changes is unclear due to varying study qualities, re-evaluation time and conflicting results. CONCLUSION The main findings were that the clinical impact of GTV changes during definitive radiotherapy is still unclear due to heterogeneous study designs with varying quality. Several potential confounding variables were found and need to be considered for future studies to evaluate GTV changes during definitive radiotherapy with respect to treatment outcome.
Collapse
|
11
|
Cremonesi M, Gilardi L, Ferrari ME, Piperno G, Travaini LL, Timmerman R, Botta F, Baroni G, Grana CM, Ronchi S, Ciardo D, Jereczek-Fossa BA, Garibaldi C, Orecchia R. Role of interim 18F-FDG-PET/CT for the early prediction of clinical outcomes of Non-Small Cell Lung Cancer (NSCLC) during radiotherapy or chemo-radiotherapy. A systematic review. Eur J Nucl Med Mol Imaging 2017; 44:1915-1927. [PMID: 28681192 DOI: 10.1007/s00259-017-3762-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Non-Small Cell Lung Cancer (NSCLC) is characterized by aggressiveness and includes the majority of thorax malignancies. The possibility of early stratification of patients as responsive and non-responsive to radiotherapy with a non-invasive method is extremely appealing. The distribution of the Fluorodeoxyglucose (18F-FDG) in tumours, provided by Positron-Emission-Tomography (PET) images, has been proved to be useful to assess the initial staging of the disease, recurrence, and response to chemotherapy and chemo-radiotherapy (CRT). OBJECTIVES In the last years, particular efforts have been focused on the possibility of using ad interim 18F-FDG PET (FDGint) to evaluate response already in the course of radiotherapy. However, controversial findings have been reported for various malignancies, although several results would support the use of FDGint for individual therapeutic decisions, at least in some pathologies. The objective of the present review is to assemble comprehensively the literature concerning NSCLC, to evaluate where and whether FDGint may offer predictive potential. METHODS Several searches were completed on Medline and the Embase database, combining different keywords. Original papers published in the English language from 2005 to 2016 with studies involving FDGint in patients affected by NSCLC and treated with radiation therapy or chemo-radiotherapy only were chosen. RESULTS Twenty-one studies out of 970 in Pubmed and 1256 in Embase were selected, reporting on 627 patients. CONCLUSION Certainly, the lack of univocal PET parameters was identified as a major drawback, while standardization would be required for best practice. In any case, all these papers denoted FDGint as promising and a challenging examination for early assessment of outcomes during CRT, sustaining its predictivity in lung cancer.
Collapse
Affiliation(s)
- Marta Cremonesi
- Radiation Research Unit, European Institute of Oncology, Milano, Italy.
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, Milano, Italy
| | | | - Gaia Piperno
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | | | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Francesca Botta
- Medical Physics Unit, European Institute of Oncology, Milano, Italy
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milano, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, Milano, Italy
| | - Sara Ronchi
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Delia Ciardo
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | | | - Roberto Orecchia
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy.,Department of Medical Imaging and Radiation Sciences, European Institute of Oncology, Milano, Italy
| |
Collapse
|
12
|
Late-Course Adaptive Adjustment Based on Metabolic Tumor Volume Changes during Radiotherapy May Reduce Radiation Toxicity in Patients with Non-Small Cell Lung Cancer. PLoS One 2017; 12:e0170901. [PMID: 28125698 PMCID: PMC5268643 DOI: 10.1371/journal.pone.0170901] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/12/2017] [Indexed: 12/19/2022] Open
Abstract
To reduce the high risk of radiation toxicity and enhance the quality of life of patients with non-small cell lung cancer (NSCLC), we quantified the metabolic tumor volumes (MTVs) from baseline to the late-course of radiotherapy (RT) by fluorodeoxyglucose positron emission tomography computerized tomography (FDG PET-CT) and discussed the potential benefit of late-course adaptive plans rather than original plans by dose volume histogram (DVH) comparisons. Seventeen patients with stage II-III NSCLC who were treated with definitive conventionally fractionated RT were eligible for this prospective study. FDG PET-CT scans were acquired within 1 week before RT (pre-RT) and at approximately two-thirds of the total dose during-RT (approximately 40 Gy). MTVs were taken as gross tumor volumes (GTVs) that included the primary tumor and any involved hilar or mediastinal lymph nodes. An original plan based on the baseline MTVs and adaptive plans based on observations during-RT MTVs were generated for each patient. The DVHs for lung, heart, esophagus and spinal cord were compared between the original plans and composite plans at 66 Gy. At the time of approximately 40 Gy during-RT, MTVs were significantly reduced in patients with NSCLC (pre-RT 136.2±82.3 ml vs. during-RT 64.7±68.0 ml, p = 0.001). The composite plan of the original plan at 40 Gy plus the adaptive plan at 26 Gy resulted in better DVHs for all the organs at risk that were evaluated compared to the original plan at 66 Gy (p<0.05), including V5, V10, V15, V20, V25, V30 and the mean dose of total lung, V10, V20, V30, V40, V50, V60 and the mean dose of heart, V35, V40, V50, V55, V60, the maximum dose and mean dose of the esophagus, and the maximum dose of the spinal-cord. PET-MTVs were reduced significantly at the time of approximately 40 Gy during-RT. Late course adaptive radiotherapy may be an effective way to reduce the dose volume to the organs at risk, thus reducing radiation toxicity in patients with NSCLC.
Collapse
|
13
|
Zhang P, Rimner A, Yorke E, Hu Y, Kuo L, Apte A, Lockney N, Jackson A, Mageras GS, Deasy JO. A geometric atlas to predict lung tumor shrinkage for radiotherapy treatment planning. Phys Med Biol 2017; 62:702-714. [PMID: 28072571 PMCID: PMC5503804 DOI: 10.1088/1361-6560/aa54f9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
To develop a geometric atlas that can predict tumor shrinkage and guide treatment planning for non-small-cell lung cancer. To evaluate the impact of the shrinkage atlas on the ability of tumor dose escalation. The creation of a geometric atlas included twelve patients with lung cancer who underwent both planning CT and weekly CBCT for radiotherapy planning and delivery. The shrinkage pattern from the original pretreatment to the residual posttreatment tumor was modeled using a principal component analysis, and used for predicting the spatial distribution of the residual tumor. A predictive map was generated by unifying predictions from each individual patient in the atlas, followed by correction for the tumor's surrounding tissue distribution. Sensitivity, specificity, and accuracy of the predictive model for classifying voxels inside the original gross tumor volume were evaluated. In addition, a retrospective study of predictive treatment planning (PTP) escalated dose to the predicted residual tumor while maintaining the same level of predicted complication rates for a clinical plan delivering uniform dose to the entire tumor. The effect of uncertainty on the predictive model's ability to escalate dose was also evaluated. The sensitivity, specificity and accuracy of the predictive model were 0.73, 0.76, and 0.74, respectively. The area under the receiver operating characteristic curve for voxel classification was 0.87. The Dice coefficient and mean surface distance between the predicted and actual residual tumor averaged 0.75, and 1.6 mm, respectively. The PTP approach allowed elevation of PTV D95 and mean dose to the actual residual tumor by 6.5 Gy and 10.4 Gy, respectively, relative to the clinical uniform dose approach. A geometric atlas can provide useful information on the distribution of resistant tumors and effectively guide dose escalation to the tumor without compromising the organs at risk complications. The atlas can be further refined by using more patient data sets.
Collapse
Affiliation(s)
- Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Yuchi Hu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Licheng Kuo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Natalie Lockney
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Gig S Mageras
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| |
Collapse
|
14
|
Zhong H, Siddiqui SM, Movsas B, Chetty IJ. Evaluation of adaptive treatment planning for patients with non-small cell lung cancer. Phys Med Biol 2017; 62:4346-4360. [PMID: 28072395 DOI: 10.1088/1361-6560/aa586f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of this study was to develop metrics to evaluate uncertainties in deformable dose accumulation for patients with non-small cell lung cancer (NSCLC). Initial treatment plans (primary) and cone-beam CT (CBCT) images were retrospectively processed for seven NSCLC patients, who showed significant tumor regression during the course of treatment. Each plan was developed with IMRT for 2 Gy × 33 fractions. A B-spline-based DIR algorithm was used to register weekly CBCT images to a reference image acquired at fraction 21 and the resultant displacement vector fields (DVFs) were then modified using a finite element method (FEM). The doses were calculated on each of these CBCT images and mapped to the reference image using a tri-linear dose interpolation method, based on the B-spline and FEM-generated DVFs. Contours propagated from the planning image were adjusted to the residual tumor and OARs on the reference image to develop a secondary plan. For iso-prescription adaptive plans (relative to initial plans), mean lung dose (MLD) was reduced, on average from 17.3 Gy (initial plan) to 15.2, 14.5 and 14.8 Gy for the plans adapted using the rigid, B-Spline and FEM-based registrations. Similarly, for iso-toxic adaptive plans (considering MLD relative to initial plans) using the rigid, B-Spline and FEM-based registrations, the average doses were 69.9 ± 6.8, 65.7 ± 5.1 and 67.2 ± 5.6 Gy in the initial volume (PTV1), and 81.5 ± 25.8, 77.7 ± 21.6, and 78.9 ± 22.5 Gy in the residual volume (PTV21), respectively. Tumor volume reduction was correlated with dose escalation (for isotoxic plans, correlation coefficient = 0.92), and with MLD reduction (for iso-fractional plans, correlation coefficient = 0.85). For the case of the iso-toxic dose escalation, plans adapted with the B-Spline and FEM DVFs differed from the primary plan adapted with rigid registration by 2.8 ± 1.0 Gy and 1.8 ± 0.9 Gy in PTV1, and the mean difference between doses accumulated using the B-spline and FEM DVF's was 1.1 ± 0.6 Gy. As a dose mapping-induced energy change, energy defect in the tumor volume was 20.8 ± 13.4% and 4.5 ± 2.4% for the B-spline and FEM-based dose accumulations, respectively. The energy defect of the B-Spline-based dose accumulation is significant in the tumor volume and highly correlated to the difference between the B-Spline and FEM-accumulated doses with their correlation coefficient equal to 0.79. Adaptive planning helps escalate target dose and spare normal tissue for patients with NSCLC, but deformable dose accumulation may have a significant loss of energy in regressed tumor volumes when using image intensity-based DIR algorithms. The metric of energy defect is a useful tool for evaluation of adaptive planning accuracy for lung cancer patients.
Collapse
|
15
|
Agrawal S, Kumar S, Maurya AK. Potential for adaptive dose escalation in radiotherapy for patients with locally advanced non-small-cell lung cancer in a low mid income setting. Br J Radiol 2017; 90:20140234. [PMID: 27897060 DOI: 10.1259/bjr.20140234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the effect of tumour volume regression on adaptive treatment planning, reduction in doses to organs at risk (OARs) and dose escalation. METHODS 20 patients undergoing radical chemoradiotherapy were imaged in the fifth week of radiotherapy (CT_45) to evaluate differences in tumour volume regression between concurrent and sequential chemoradiotherapy. Replanning was carried out in the CT_45 in those with >20% regression (n = 10) and evaluated for change in target coverage indices (the coverage index and external volume index) and doses to the OAR [mean lung dose, V20 and V5 of whole and ipsilateral lung (MLDWL, V20WL, V5WL, MLDIL, V20IL, V5IL); mean oesophagus dose, V50oesophagus; and maximum spinal cord doses]. The feasibility of maximum dose escalation was explored keeping the limit of the OAR below their tolerance limits. RESULTS Tumour regression was higher with concurrent chemoradiotherapy as compared with sequential chemoradiotherapy (p = 0.02). With the adaptive plan, the mean coverage index improved from 0.96 (±0.14) to 1.29 (±0.36), the mean external volume index changed from 1.39(±0.60) to 1.41(±0.56) and the reduction in doses to the OARs were MLDWL 10.6%, V20WL 1.3%, V5WL 1.2%, MLDIL 6.6%, V20IL 1.5%, V5IL 2.3%, mean oesophagus dose 7%, V50oesophagus 31% and maximum cord dose 0.35%. Dose escalation was possible in four patients in CT_45. CONCLUSION There is 35% reduction in tumour volume with chemoradiotherapy at 45 Gy which allows improvement in conformality, reduction in doses to the OARs and dose escalation in 40% of patients. Advances in knowledge: This article emphasizes that adaptive planning with a single diagnostic scan at 45 Gy has the potential for improvement of radiotherapy planning indices, dose escalation while respecting the dose to the OAR. This simple strategy can be helpful in radiotherapy planning upto 60 Gy in 40% of the patients of locally advanced non-small-cell lung cancer in countries with limited resources.
Collapse
Affiliation(s)
- Sushma Agrawal
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sunil Kumar
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil K Maurya
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
16
|
van den Bosch M, Öllers M, Reymen B, van Elmpt W. Automatic selection of lung cancer patients for adaptive radiotherapy using cone-beam CT imaging. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2017. [DOI: 10.1016/j.phro.2017.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
17
|
Cui Y, Bowsher J, Cai J, Yin FF. Impact of moving target on measurement accuracy in 3D and 4D PET imaging-a phantom study. Adv Radiat Oncol 2016; 2:94-100. [PMID: 28740918 PMCID: PMC5514228 DOI: 10.1016/j.adro.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/28/2016] [Accepted: 12/02/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the impact of tumor motion on maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) measurements in both 3-dimensional and respiratory-correlated, 4-dimensional positron emission tomography (PET) imaging. We also evaluated the effect of implementing different attenuation correction methods in 4-dimensional PET image reconstruction on SUVmax and MTV. METHODS AND MATERIALS An anthropomorphic thorax phantom with a spherical ball as a surrogate for a tumor was used. Different types of motion were imposed on the ball to mimic a patient's breathing motion. Three-dimensional PET imaging of the phantom without tumor motion was performed and used as the reference. The ball was then set in motion with different breathing motion traces and imaged with both 3- and 4-dimensional PET methods. The clinical 4-dimensional PET imaging protocol was modified so that 3 different types of attenuation correction images were used for reconstructions: the same free-breathing computed tomography (CT) for all PET phases, the same average intensity projection CT for all PET phases, and 4-dimensional CT for phase-matched attenuation correction. Tumor SUVmax and MTV values that were measured from the moving phantom were compared with the reference values. RESULTS SUVmax that was measured in 3-dimensional PET imaging was different from the reference value by 20.4% on average for the motions that were investigated; this difference decreased to 2.6% with 4-dimensional PET imaging. The measurement of MTV in 4-dimensional PET also showed a similar magnitude of reduction of deviation compared with 3-dimensional PET. Four-dimensional PET with use of phase-matched 4-dimensional CT for attenuation correction showed less variation in SUVmax and MTV among phases compared with 4-dimensional PET with free-breathing CT or average intensity projection CT for attenuation correction. CONCLUSIONS Four-dimensional PET imaging reduces the impact of motion on measured SUVmax and MTV when compared with 3-dimensional PET imaging. Clinical 4-dimensional PET imaging protocols should consider phase-matched 4-dimensional CT imaging for attenuation correction to achieve more accurate measurements.
Collapse
Affiliation(s)
- Yunfeng Cui
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - James Bowsher
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jing Cai
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
18
|
Adaptive Dose Escalation using Serial Four-dimensional Positron Emission Tomography/Computed Tomography Scans during Radiotherapy for Locally Advanced Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2016; 28:e199-e205. [PMID: 27637725 DOI: 10.1016/j.clon.2016.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/20/2016] [Accepted: 06/24/2016] [Indexed: 11/23/2022]
Abstract
AIMS Computed tomography (CT)-based radiotherapy dose escalation for locally advanced non-small cell lung cancer (LA-NSCLC) has had limited success. In this planning study, we investigated the potential for adaptive dose escalation using respiratory-gated 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography scans (4DPET/4DCT) acquired before and during a course of chemoradiotherapy (CRT). MATERIALS AND METHODS We prospectively enrolled patients with LA-NSCLC receiving curative intent CRT. Radiotherapy was delivered using intensity-modulated radiotherapy (IMRT) using the week 0 4DCT scan. Three alternative, dose-escalated IMRT plans were developed offline based on the week 0, 2 and 4 4DPET/4DCT scans. The FDG-avid primary (PET-T) and nodal disease (PET-N) volumes defined by the 50% of maximum standard uptake value threshold were dose escalated to as high as possible while respecting organ at risk constraints. RESULTS Thirty-two patients were recruited, 27 completing all scans. Twenty-five patients (93%) were boosted successfully above the clinical plan doses at week 0, 23 (85%) at week 2 and 20 (74%) at week 4. The median dose received by 95% of the planning target volume (D95) at week 0, 2 and 4 to PET-T were 74.4 Gy, 75.3 Gy and 74.1 Gy and to PET-N were 74.3 Gy, 71.0 Gy and 69.5 Gy. CONCLUSIONS Using 18F-FDG-4DPET/4DCT, it is feasible to dose escalate both primary and nodal disease in most patients. Choosing week 0 images to plan a course with an integrated boost to PET-avid disease allows for more patients to be successfully dose escalated with the highest boost dose.
Collapse
|
19
|
Kelsey CR, Christensen JD, Chino JP, Adamson J, Ready NE, Perez BA. Adaptive planning using positron emission tomography for locally advanced lung cancer: A feasibility study. Pract Radiat Oncol 2016; 6:96-104. [DOI: 10.1016/j.prro.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 12/25/2022]
|
20
|
Personalized Radiation Therapy (PRT) for Lung Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 890:175-202. [DOI: 10.1007/978-3-319-24932-2_10] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
21
|
Mehmood Q, Sun A, Becker N, Higgins J, Marshall A, Le LW, Vines DC, McCloskey P, Ford V, Clarke K, Yap M, Bezjak A, Bissonnette JP. Predicting Radiation Esophagitis Using 18F-FDG PET During Chemoradiotherapy for Locally Advanced Non-Small Cell Lung Cancer. J Thorac Oncol 2015; 11:213-21. [PMID: 26718880 DOI: 10.1016/j.jtho.2015.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/09/2015] [Accepted: 10/10/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Treatment of locally advanced non-small cell lung cancer with chemoradiotherapy (CRT) is limited by development of toxicity in normal tissue, including radiation esophagitis (RE). Increasingly, (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is being used for adaptive planning. Our aim was to assess changes in esophageal FDG uptake during CRT and relate the changes to the onset and severity of RE. METHODS This prospective study in patients with stage II-III non-small cell lung cancer involved serial four-dimensional computed tomography and PET scans during CRT (60-74Gy). RE was recorded weekly using the Common Terminology Criteria for Adverse Events (v4.0), and imaging was performed at weeks 0, 2, 4, and 7. Changes in the esophagus's peak standard uptake value (SUVpeak) were analyzed for each time point and correlated with grade of RE using the Wilcoxon rank-sum test. The volume of esophagus receiving 50 Gy (V50) and volume of esophagus receiving 60 Gy (V60) were correlated with the development of RE, and the C-statistic (area under the curve [AUC]) was calculated to measure predictivity of grade 3 RE. RESULTS RE developed in 20 of 27 patients (74%), with grade 3 reached in 6 (22%). A significant percentage increase in SUVpeak in the patients with RE was noted at week 4 (p = 0.01) and week 7 (p = 0.03). For grade 3 RE, a significant percentage increase in SUVpeak was noted at week 2 (p = 0.01) and week 7 (p = 0.03) compared with that for less than grade 3 RE. Median V50 (46.3%) and V60 (33.4%) were significantly higher in patients with RE (p = 0.04). The AUC measurements suggested that the percentage change in SUVpeak at week 2 (AUC = 0.69) and V50 (AUC = 0.67) and V60 (AUC = 0.66) were similarly predictive of grade 3 RE. CONCLUSIONS Serial FDG-PET images during CRT show significant increases in SUVpeak for patients in whom RE develops. The changes at week 2 may predict those at risk for the development of grade 3 RE and may be informative for adaptive planning and early intervention.
Collapse
Affiliation(s)
- Qurrat Mehmood
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Alexander Sun
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada.
| | - Nathan Becker
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Jane Higgins
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Andrea Marshall
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Douglass C Vines
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada
| | - Paula McCloskey
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Victoria Ford
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Katy Clarke
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Mei Yap
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Andrea Bezjak
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Jean-Pierre Bissonnette
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| |
Collapse
|
22
|
Jentsch C, Beuthien-Baumann B, Troost EGC, Shakirin G. Validation of functional imaging as a biomarker for radiation treatment response. Br J Radiol 2015; 88:20150014. [PMID: 26083533 DOI: 10.1259/bjr.20150014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Major advances in radiotherapy techniques, increasing knowledge of tumour biology and the ability to translate these advances into new therapeutic approaches are important goals towards more individualized cancer treatment. With the development of non-invasive functional and molecular imaging techniques such as positron emission tomography (PET)-CT scanning and MRI, there is now a need to evaluate potential new biomarkers for tumour response prediction, for treatment individualization is not only based on morphological criteria but also on biological tumour characteristics. The goal of individualization of radiotherapy is to improve treatment outcome and potentially reduce chronic treatment toxicity. This review gives an overview of the molecular and functional imaging modalities of tumour hypoxia and tumour cell metabolism, proliferation and perfusion as predictive biomarkers for radiation treatment response in head and neck tumours and in lung tumours. The current status of knowledge on integration of PET/CT/MRI into treatment management and bioimage-guided adaptive radiotherapy are discussed.
Collapse
Affiliation(s)
- C Jentsch
- 1 OncoRay-National Centre for Radiation Research in Oncology, Dresden, Germany.,2 Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden,Helmholtz-Zentrum Dresden-Rossendorf, Germany.,3 German Cancer Consortium (DKTK) Dresden, Germany
| | - B Beuthien-Baumann
- 1 OncoRay-National Centre for Radiation Research in Oncology, Dresden, Germany.,3 German Cancer Consortium (DKTK) Dresden, Germany.,4 Institute of Radiation Oncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - E G C Troost
- 1 OncoRay-National Centre for Radiation Research in Oncology, Dresden, Germany.,2 Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden,Helmholtz-Zentrum Dresden-Rossendorf, Germany.,3 German Cancer Consortium (DKTK) Dresden, Germany.,4 Institute of Radiation Oncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | | |
Collapse
|
23
|
The Evolving Role of Molecular Imaging in Non–Small Cell Lung Cancer Radiotherapy. Semin Radiat Oncol 2015; 25:133-42. [DOI: 10.1016/j.semradonc.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
24
|
Ostheimer C, Bache M, Güttler A, Reese T, Vordermark D. Prognostic information of serial plasma osteopontin measurement in radiotherapy of non-small-cell lung cancer. BMC Cancer 2014; 14:858. [PMID: 25416631 PMCID: PMC4251866 DOI: 10.1186/1471-2407-14-858] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 10/24/2014] [Indexed: 12/24/2022] Open
Abstract
Background Circulating baseline levels of the plasma-protein osteopontin (OPN) have been suggested as a prognostic indicator in chemotherapy and surgery for lung cancer. However, the role of this hypoxia-related protein in radiotherapy of lung cancer is unclear. We previously demonstrated the prognostic effect of baseline OPN plasma levels which was increased by co-detection with other hypoxia-related proteins in the radical radiotherapy of non-small-cell lung cancer (NSCLC). This prospective clinical study investigated whether serial OPN measurements during and after curative-intent radiotherapy for NSCLC provide additional or superior prognostic information. Methods Sixty-nine patients with inoperable NSCLC were prospectively enrolled (55 M0, 14 M1). OPN plasma levels were measured before (t0), at the end (t1) and four weeks after radiotherapy (t2) by ELISA, compared between M0 and M1 patients and correlated with clinicopathological parameters. OPN levels were monitored over time and correlated with prognosis in M0-stage patients treated by radical 66-Gy radiotherapy ± chemotherapy. Results Pre-treatment OPN levels were associated with T stage (p = .03), lung function (p = .002), weight loss (p = .01), tumor volume (p = .02) and hemoglobin concentration (p = 04). M1 patients had significantly elevated OPN levels at all time points (p < .001). Patients with increasing OPN levels after radiotherapy had inferior freedom from relapse (p = .008), overall survival (p = .004) and disease-free survival (p = .001) compared to patients with stable or decreasing OPN levels. The risk of relapse in patients with increasing or stable OPN levels after radiotherapy was increased by a factor of 2.9 (p = .01). Patients with increasing post-treatment OPN levels had a 3.1-fold increased risk of death (p = .003). In an exploratory multivariate model, post-treatment OPN level changes but not absolute baseline OPN levels remained an independent prognostic factor for overall survival (p = .002) with a 3.6-fold increased risk of death, as well as N stage (p = .006). Conclusions Our results suggest that OPN level changes over time, particularly post-treatment, may yield additional prognostic information in curative-intent radiotherapy of NSCLC.
Collapse
Affiliation(s)
- Christian Ostheimer
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Klinik und Poliklinik für Strahlentherapie, Martin Luther Universitaet Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097 Halle (Saale), Germany.
| | | | | | | | | |
Collapse
|
25
|
Shi X, Meng X, Sun X, Xing L, Yu J. PET/CT imaging-guided dose painting in radiation therapy. Cancer Lett 2014; 355:169-75. [PMID: 25218590 DOI: 10.1016/j.canlet.2014.07.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/17/2014] [Accepted: 07/26/2014] [Indexed: 12/23/2022]
Abstract
Application of functional imaging to radiotherapy (RT) is a rapidly expanding field with the development of new modalities and techniques. Functional imaging of PET in conjunction with RT provides new avenues towards the clinical application of dose painting - a new RT strategy delivering optimized dose redistribution according to the functional imaging information to further improve tumour control. Two prototypical strategies of dose painting are reviewed: dose painting by contours (DPBC) and dose painting by numbers (DPBN). DPBN set a linear correlation of the boost dose and image intensity of this same voxel while homogeneous dose is given to the subvolume contoured by a threshold created in PET images in DPBC. Both comply with strict organs at risk (OAR) constraints and are alternatives for boosting subvolumes in clinical practice. This review focuses on the rationale, target validation, dose prescription verification and evaluation and recent clinical achievements in the field of integrating PET imaging into RT treatment planning. Further research is necessary in order to investigate unresolved problems in its routine clinical application thoroughly.
Collapse
Affiliation(s)
- Xiaorong Shi
- Department of Radiation Oncology, Key Laboratory of Radiation Oncology of Shandong Province, Shandong Cancer Hospital, Shandong University, Jinan, Shandong Province, China; Department of Oncology, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shanxi Province, China
| | - Xue Meng
- Department of Radiation Oncology, Key Laboratory of Radiation Oncology of Shandong Province, Shandong Cancer Hospital, Shandong University, Jinan, Shandong Province, China
| | - Xindong Sun
- Department of Radiation Oncology, Key Laboratory of Radiation Oncology of Shandong Province, Shandong Cancer Hospital, Shandong University, Jinan, Shandong Province, China
| | - Ligang Xing
- Department of Radiation Oncology, Key Laboratory of Radiation Oncology of Shandong Province, Shandong Cancer Hospital, Shandong University, Jinan, Shandong Province, China
| | - Jinming Yu
- Department of Radiation Oncology, Key Laboratory of Radiation Oncology of Shandong Province, Shandong Cancer Hospital, Shandong University, Jinan, Shandong Province, China.
| |
Collapse
|
26
|
Everitt SJ, Ball DL, Hicks RJ, Callahan J, Plumridge N, Collins M, Herschtal A, Binns D, Kron T, Schneider M, MacManus M. Differential 18F-FDG and 18F-FLT Uptake on Serial PET/CT Imaging Before and During Definitive Chemoradiation for Non–Small Cell Lung Cancer. J Nucl Med 2014; 55:1069-74. [DOI: 10.2967/jnumed.113.131631] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/10/2014] [Indexed: 11/16/2022] Open
|
27
|
Rosenzweig KE, Sura S. Image-Guided Radiation Therapy. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
28
|
Dubray B, Thureau S, Nkhali L, Modzelewski R, Doyeux K, Ruan S, Vera P. FDG-PET imaging for radiotherapy target volume definition in lung cancer. Ing Rech Biomed 2014. [DOI: 10.1016/j.irbm.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
29
|
Zhang P, Yorke E, Hu YC, Mageras G, Rimner A, Deasy JO. Predictive treatment management: incorporating a predictive tumor response model into robust prospective treatment planning for non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2013; 88:446-52. [PMID: 24315562 DOI: 10.1016/j.ijrobp.2013.10.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/23/2013] [Accepted: 10/28/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE We hypothesized that a treatment planning technique that incorporates predicted lung tumor regression into optimization, predictive treatment planning (PTP), could allow dose escalation to the residual tumor while maintaining coverage of the initial target without increasing dose to surrounding organs at risk (OARs). METHODS AND MATERIALS We created a model to estimate the geometric presence of residual tumors after radiation therapy using planning computed tomography (CT) and weekly cone beam CT scans of 5 lung cancer patients. For planning purposes, we modeled the dynamic process of tumor shrinkage by morphing the original planning target volume (PTVorig) in 3 equispaced steps to the predicted residue (PTVpred). Patients were treated with a uniform prescription dose to PTVorig. By contrast, PTP optimization started with the same prescription dose to PTVorig but linearly increased the dose at each step, until reaching the highest dose achievable to PTVpred consistent with OAR limits. This method is compared with midcourse adaptive replanning. RESULTS Initial parenchymal gross tumor volume (GTV) ranged from 3.6 to 186.5 cm(3). On average, the primary GTV and PTV decreased by 39% and 27%, respectively, at the end of treatment. The PTP approach gave PTVorig at least the prescription dose, and it increased the mean dose of the true residual tumor by an average of 6.0 Gy above the adaptive approach. CONCLUSIONS PTP, incorporating a tumor regression model from the start, represents a new approach to increase tumor dose without increasing toxicities, and reduce clinical workload compared with the adaptive approach, although model verification using per-patient midcourse imaging would be prudent.
Collapse
Affiliation(s)
- Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yu-Chi Hu
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Gig Mageras
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| |
Collapse
|
30
|
Karam SD, Horne ZD, Hong RL, McRae D, Duhamel D, Nasr NM. Dose escalation with stereotactic body radiation therapy boost for locally advanced non small cell lung cancer. Radiat Oncol 2013; 8:179. [PMID: 23842112 PMCID: PMC3720211 DOI: 10.1186/1748-717x-8-179] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/28/2013] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Low survival outcomes have been reported for the treatment of locally advanced non small cell lung cancer (LA-NSCLC) with the standard of care treatment of concurrent chemoradiation (cCRT). We present our experience of dose escalation using stereotactic body radiosurgery (SBRT) following conventional cCRT for patients with LA-NSCLC. METHODS Sixteen patients with a median age of 67.5 treated with fractionated SBRT from 2010 to 2012 were retrospectively analyzed. Nine (56%) of the patients had stage IIIB, 6 (38%) has stage IIIA, and 1 (6%) had recurrent disease. Majority of the patients (63%) presented with N2 disease. All patients had a PET CT for treatment planning. Patients received conventional cCRT to a median dose of 50.40 Gy (range 45-60) followed by an SBRT boost with an average dose of 25 Gy (range 20-30) given over 5 fractions. RESULTS With a median follow-up of 14 months (range, 1-14 months), 1-year overall survival (OS), progression free survival (PFS), local control (LC), regional control (RC), and distant control (DC) rates were, 78%, 42%, 76%, 79%, and 71%, respectively. Median times to disease progression and regional failure were 10 months and 18 months, respectively. On univariate analysis, advanced age and nodal status were worse prognostic factors of PFS (p < 0.05). Four patients developed radiation pneumonitis and one developed hemoptysis. Treatment was interrupted in one patient who required hospitalization due to arrhythmias and pneumonia. CONCLUSION Risk adaptive dose escalation with SBRT following external beam radiotherapy is possible and generally tolerated treatment option for patients with LA-NSCLC.
Collapse
|
31
|
Weiss E, Fatyga M, Wu Y, Dogan N, Balik S, Sleeman W, Hugo G. Dose escalation for locally advanced lung cancer using adaptive radiation therapy with simultaneous integrated volume-adapted boost. Int J Radiat Oncol Biol Phys 2013; 86:414-9. [PMID: 23523321 PMCID: PMC3665644 DOI: 10.1016/j.ijrobp.2012.12.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 11/21/2012] [Accepted: 12/11/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE To test the feasibility of a planned phase 1 study of image-guided adaptive radiation therapy in locally advanced lung cancer. METHODS AND MATERIALS Weekly 4-dimensional fan beam computed tomographs (4D FBCT) of 10 lung cancer patients undergoing concurrent chemoradiation therapy were used to simulate adaptive radiation therapy: After an initial intensity modulated radiation therapy plan (0-30 Gy/2 Gy), adaptive replanning was performed on week 2 (30-50 Gy/2 Gy) and week 4 scans (50-66 Gy/2 Gy) to adjust for volume and shape changes of primary tumors and lymph nodes. Week 2 and 4 clinical target volumes (CTV) were deformably warped from the initial planning scan to adjust for anatomical changes. On the week 4 scan, a simultaneous integrated volume-adapted boost was created to the shrunken primary tumor with dose increases in 5 0.4-Gy steps from 66 Gy to 82 Gy in 2 scenarios: plan A, lung isotoxicity; plan B, normal tissue tolerance. Cumulative dose was assessed by deformably mapping and accumulating biologically equivalent dose normalized to 2 Gy-fractions (EQD2). RESULTS The 82-Gy level was achieved in 1 in 10 patients in scenario A, resulting in a 13.4-Gy EQD2 increase and a 22.1% increase in tumor control probability (TCP) compared to the 66-Gy plan. In scenario B, 2 patients reached the 82-Gy level with a 13.9 Gy EQD2 and 23.4% TCP increase. CONCLUSIONS The tested image-guided adaptive radiation therapy strategy enabled relevant increases in EQD2 and TCP. Normal tissue was often dose limiting, indicating a need to modify the present study design before clinical implementation.
Collapse
Affiliation(s)
- Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA 23298, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Mac Manus MP, Hicks RJ. The role of positron emission tomography/computed tomography in radiation therapy planning for patients with lung cancer. Semin Nucl Med 2012; 42:308-19. [PMID: 22840596 DOI: 10.1053/j.semnuclmed.2012.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Positron emission tomography (PET)/computed tomography (CT) has rapidly assumed a critical role in the management of patients with locoregionally advanced lung cancers who are candidates for definitive radiation therapy (RT). Definitive RT is given with curative intent, but can only be successful in patients without distant metastasis and if all gross tumor is contained within the treated volume. An increasing body of evidence supports the use of PET-based imaging for selection of patients for both surgery and definitive RT. Similarly, the use of PET/CT images for accurate target volume definition in lung cancer is a dynamic area of research. Most available evidence on PET staging of lung cancer relates to non-small cell lung cancer (NSCLC). In general clinical use, (18)F-fluorodeoxyglucose (FDG) is the primary radiopharmaceutical useful in NSCLC. Other tracers, including proliferation markers and hypoxia tracers, may have significant roles in future. Much of the FDG-PET literature describing the impact of PET on actual patient management has concerned candidates for surgical resection. In the few prospective studies where PET was used for staging and patient selection in NSCLC candidates for definitive RT, 25%-30% of patients were denied definitive RT, generally because PET detected unsuspected advanced locoregional or distant metastatic disease. PET/CT and CT findings are often discordant in NSCLC but studies with clinical-pathological correlation always show that PET-assisted staging is more accurate than conventional assessment. In all studies in which "PET-defined" and "non-PET-defined" RT target volumes were compared, there were major differences between PET and non-PET volumes. Therefore, in cases where PET-assisted and non-PET staging are different and biopsy confirmation is unavailable, it is rational to use the most accurate modality (namely PET/CT) to define the target volume. The use of PET/CT in patient selection and target volume definition is likely to lead to improvements in outcome for patients with NSCLC.
Collapse
Affiliation(s)
- Michael P Mac Manus
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | | |
Collapse
|
33
|
Guckenberger M, Kavanagh A, Partridge M. Combining advanced radiotherapy technologies to maximize safety and tumor control probability in stage III non-small cell lung cancer. Strahlenther Onkol 2012; 188:894-900. [PMID: 22933031 DOI: 10.1007/s00066-012-0161-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 05/16/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND The goal of the current study was to investigate the tumor control probability (TCP) of advanced radiotherapy technologies for stage III non-small cell lung cancer (NSCLC) and to evaluate potential interplay effects between their applications. MATERIALS AND METHODS Three-dimensional conformal radiotherapy (3D-CRT) with conventionally fractionated doses of 66 Gy served as reference for 13 patients with stage III NSCLC. Isotoxic dose escalation relative to the corresponding 3D-CRT plans was performed for three technologies and their combinations: intensity-modulated radiotherapy (IMRT), IMRT with a simultaneous integrated boost (IMRT-SIB) of 10% to the gross tumor volume (GTV), and adaptive re-planning twice during the treatment course (ART). All analyses were based on accumulated dose distributions using deformable image registration of CT images, which were acquired weekly during the treatment course. RESULTS IMRT reduced the mean lung dose (MLD) by 5.6% ± 3.8% compared to 3D-CRT. ART resulted in lung sparing of 7.9% ± 4.8% and 9.2% ± 3.9% in 3D-CRT and IMRT planning, respectively. IMRT and ART escalated the irradiation dose by 6.6% ± 3.2% and 8.8% ± 6.3%, respectively, which was not statistically different. For the 7 patients with the largest GTVs, IMRT-SIB was superior to IMRT and ART with dose escalation of 11.9% ± 3.7%. The combination of ART, IMRT, and SIB achieved maximum dose escalation in all 13 patients by 17.1% ± 5.4% on average, which increased TCP from 19.9% ± 7.0 to 37.1% ± 10.1%. Adaptive re-planning was required to continuously conform the escalated and hypofractionated SIB doses to the shrinking tumor. CONCLUSION Combining advanced radiotherapy technologies is considered as a safe and effective strategy to maximize local tumor control probability in stage III NSCLC.
Collapse
Affiliation(s)
- M Guckenberger
- Department of Radiation Oncology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | | | | |
Collapse
|
34
|
Louvel G, Cazoulat G, Chajon E, Le Maître A, Simon A, Henry O, Bensadoun RJ, de Crevoisier R. [Image-guided and adaptive radiotherapy]. Cancer Radiother 2012; 16:423-9. [PMID: 22920086 DOI: 10.1016/j.canrad.2012.07.177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 06/28/2012] [Accepted: 07/09/2012] [Indexed: 11/18/2022]
Abstract
Image-guided radiotherapy (IGRT) aims to take into account anatomical variations occurring during irradiation by visualization of anatomical structures. It may consist of a rigid registration of the tumour by moving the patient, in case of prostatic irradiation for example. IGRT associated with intensity-modulated radiotherapy (IMRT) is strongly recommended when high-dose is delivered in the prostate, where it seems to reduce rectal and bladder toxicity. In case of significant anatomical deformations, as in head and neck tumours (tumour shrinking and decrease in volume of the salivary glands), replanning appears to be necessary, corresponding to the adaptive radiotherapy. This should ideally be "monitored" and possibly triggered based on a calculation of cumulative dose, session after session, compared to the initial planning dose, corresponding to the concept of dose-guided adaptive radiotherapy. The creation of "planning libraries" based on predictable organ positions (as in cervical cancer) is another way of adaptive radiotherapy. All of these strategies still appear very complex and expensive and therefore require stringent validation before being routinely applied.
Collapse
Affiliation(s)
- G Louvel
- Département de radiothérapie, centre Eugène-Marquis, Rennes, France
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Massaccesi M, Calcagni ML, Spitilli MG, Cocciolillo F, Pelligrò F, Bonomo L, Valentini V, Giordano A. ¹⁸F-FDG PET-CT during chemo-radiotherapy in patients with non-small cell lung cancer: the early metabolic response correlates with the delivered radiation dose. Radiat Oncol 2012; 7:106. [PMID: 22781363 PMCID: PMC3410758 DOI: 10.1186/1748-717x-7-106] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/10/2012] [Indexed: 12/25/2022] Open
Abstract
Background To evaluate the metabolic changes on 18 F-fluoro-2-deoxyglucose positron emission tomography integrated with computed tomography (18 F-FDG PET-CT) performed before, during and after concurrent chemo-radiotherapy in patients with locally advanced non-small cell lung cancer (NSCLC); to correlate the metabolic response with the delivered radiation dose and with the clinical outcome. Methods Twenty-five NSCLC patients candidates for concurrent chemo-radiotherapy underwent 18 F-FDG PET-CT before treatment (pre-RT PET-CT), during the third week (during-RT PET-CT) of chemo-radiotherapy, and 4 weeks from the end of chemo-radiotherapy (post-RT PET-CT). The parameters evaluated were: the maximum standardized uptake value (SUVmax) of the primary tumor, the SUVmax of the lymph nodes, and the Metabolic Tumor Volume (MTV). Results SUVmax of the tumor and MTV significantly (p=0.0001, p=0.002, respectively) decreased earlier during the third week of chemo-radiotherapy, with a further reduction 4 weeks from the end of treatment (p<0.0000, p<0.0002, respectively). SUVmax of lymph nodes showed a trend towards a reduction during chemo-radiotherapy (p=0.06) and decreased significantly (p=0.0006) at the end of treatment. There was a significant correlation (r=0.53, p=0.001) between SUVmax of the tumor measured at during-RT PET-CT and the total dose of radiotherapy reached at the moment of the scan. Disease progression free survival was significantly (p=0.01) longer in patients with complete metabolic response measured at post-RT PET-CT. Conclusions In patients with locally advanced NSCLC, 18 F-FDG PET-CT performed during and after treatment allows early metabolic modifications to be detected, and for this SUVmax is the more sensitive parameter. Further studies are needed to investigate the correlation between the metabolic modifications during therapy and the clinical outcome in order to optimize the therapeutic strategy. Since the metabolic activity during chemo-radiotherapy correlates with the cumulative dose of fractionated radiotherapy delivered at the moment of the scan, special attention should be paid to methodological aspects, such as the radiation dose reached at the time of PET.
Collapse
|
36
|
Chang CF, Rashtian A, Gould MK. The use and misuse of positron emission tomography in lung cancer evaluation. Clin Chest Med 2012; 32:749-62. [PMID: 22054883 DOI: 10.1016/j.ccm.2011.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article discusses the potential benefits and limitations of positron emission tomography (PET) for characterizing lung nodules, staging the mediastinum, identifying occult distant metastasis, determining prognosis and treatment response, guiding plans for radiation therapy, restaging during and after treatment, and selecting targets for tissue sampling. The key findings from the medical literature are presented regarding the capabilities and fallibilities of PET in lung cancer evaluation, including characterization of pulmonary nodules and staging in patients with known or suspected non-small-cell lung cancer. The discussion is limited to PET imaging with fluorodeoxyglucose.
Collapse
Affiliation(s)
- Ching-Fei Chang
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD Room 723, Los Angeles, CA 90033, USA
| | | | | |
Collapse
|
37
|
Rossier C, Dunet V, Matzinger O, Prior J. TEP/TDM en radiothérapie : indications et perspectives. Cancer Radiother 2012; 16:152-63. [DOI: 10.1016/j.canrad.2012.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 01/24/2012] [Accepted: 02/02/2012] [Indexed: 12/12/2022]
|
38
|
Yaromina A, Krause M, Baumann M. Individualization of cancer treatment from radiotherapy perspective. Mol Oncol 2012; 6:211-21. [PMID: 22381063 DOI: 10.1016/j.molonc.2012.01.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 01/21/2012] [Accepted: 01/23/2012] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy is today used in about 50% of all cancer patients, often in multidisciplinary approaches. With major advance in radiotherapy techniques, increasing knowledge on tumor genetics and biology and the continuous introduction of specifically targeted drugs into combined radio-oncological treatment schedules, individualization of radiotherapy is of high priority to further improve treatment outcomes, i.e. to increase long-term tumor cure and/or to reduce chronic treatment toxicity. This review gives an overview on the importance of predictive biomarkers for the field of radiation oncology. The current status of knowledge on potential biomarkers of tumor hypoxia, tumor cell metabolism, DNA repair, cancer stem cells and biomarkers for combining radiotherapy with inhibition of the epidermal growth factor receptor using monoclonal antibodies is described.
Collapse
Affiliation(s)
- Ala Yaromina
- Department of Radiation Oncology, OncoRay-National Center for Radiation Research in Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | | |
Collapse
|
39
|
Kepka L, Baumann M. Radiotherapy in small cell lung cancer: Limited volumes in limited disease and adding thoracic radiotherapy in extended disease? Radiother Oncol 2012; 102:165-7. [DOI: 10.1016/j.radonc.2012.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/11/2012] [Indexed: 12/25/2022]
|
40
|
Serial assessment of FDG-PET FDG uptake and functional volume during radiotherapy (RT) in patients with non-small cell lung cancer (NSCLC). Radiother Oncol 2012; 102:251-7. [DOI: 10.1016/j.radonc.2011.07.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 06/15/2011] [Accepted: 07/23/2011] [Indexed: 11/23/2022]
|
41
|
Ding XP, Zhang J, Li BS, Li HS, Wang ZT, Yi Y, Sun HF, Wang DQ. Feasibility of Shrinking Field Radiation Therapy through 18F-FDG PET/CT after 40 Gy for Stage III Non-Small Cell Lung Cancers. Asian Pac J Cancer Prev 2012; 13:319-323. [DOI: 10.7314/apjcp.2012.13.1.319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
42
|
Das SK, Ten Haken RK. Functional and molecular image guidance in radiotherapy treatment planning optimization. Semin Radiat Oncol 2011; 21:111-8. [PMID: 21356479 DOI: 10.1016/j.semradonc.2010.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Functional and molecular imaging techniques are increasingly being developed and used to quantitatively map the spatial distribution of parameters, such as metabolism, proliferation, hypoxia, perfusion, and ventilation, onto anatomically imaged normal organs and tumor. In radiotherapy optimization, these imaging modalities offer the promise of increased dose sparing to high-functioning subregions of normal organs or dose escalation to selected subregions of the tumor as well as the potential to adapt radiotherapy to functional changes that occur during the course of treatment. The practical use of functional/molecular imaging in radiotherapy optimization must take into cautious consideration several factors whose influences are still not clearly quantified or well understood including patient positioning differences between the planning computed tomography and functional/molecular imaging sessions, image reconstruction parameters and techniques, image registration, target/normal organ functional segmentation, the relationship governing the dose escalation/sparing warranted by the functional/molecular image intensity map, and radiotherapy-induced changes in the image intensity map over the course of treatment. The clinical benefit of functional/molecular image guidance in the form of improved local control or decreased normal organ toxicity has yet to be shown and awaits prospective clinical trials addressing this issue.
Collapse
Affiliation(s)
- Shiva K Das
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | | |
Collapse
|
43
|
Stephans K, Khouri A, Machtay M. The Role of PET in the Evaluation, Treatment, and Ongoing Management of Lung Cancer. PET Clin 2011; 6:265-74. [DOI: 10.1016/j.cpet.2011.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
44
|
van Loon J, Offermann C, Ollers M, van Elmpt W, Vegt E, Rahmy A, Dingemans AMC, Lambin P, De Ruysscher D. Early CT and FDG-metabolic tumour volume changes show a significant correlation with survival in stage I-III small cell lung cancer: a hypothesis generating study. Radiother Oncol 2011; 99:172-5. [PMID: 21571382 DOI: 10.1016/j.radonc.2011.03.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 03/07/2011] [Accepted: 03/27/2011] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many patients with stage I-III small cell lung cancer (SCLC) experience disease progression short after the completion of concurrent chemoradiotherapy (CRT). The purpose of the current study was to evaluate whether CT or FDG metabolic response early after the start of chemotherapy, but before the beginning of chest RT, is predictive for survival in SCLC. METHODS Fifteen stage I-III SCLC patients treated with concurrent CRT with an FDG-PET and CT scan available before the start of chemotherapy and after or during the first cycle of chemotherapy, but before the start of radiotherapy, were selected. The metabolic volume (MV) was defined both within the primary tumour and in the involved nodal stations using the 40% (MV40) and 50% (MV50) threshold of the maximum SUV. Metabolic and CT response was assessed by the relative change in MV and CT volume, respectively, between both time points. The association between response and overall survival (OS) was analysed by univariate cox regression analysis. The minimum follow-up was 18 months. RESULTS Reductions in MV40 and MV50 were -36±38% (126.4 to 68.7cm(3)) and -44±38% (90.2 to 27.8cm(3)), respectively. The median CT volume reduction was -40±64% (190.6 to 113.8cm(3)). MV40 and MV50 changes showed a significant association with survival (HR=1.02, 95% CI: 1.00-1.04 (p=0.042); HR=1.02, 95% CI: 1.00-1.04 (p=0.048), respectively), indicating a 2% increase in survival probability for 1% reduction in metabolic volume. The CT volume change was also significantly correlated with survival (HR=1.01, 95% CI: 1.00-1.03, p=0.007). CONCLUSIONS This hypothesis generating study shows that both the early CT and the MV changes show a significant correlation with survival in SCLC. A prospective study is planned in a larger patient cohort to allow multivariate analysis, with the final aim to select patients early during treatment that could benefit from dose intensification or alternative treatment.
Collapse
Affiliation(s)
- Judith van Loon
- Department of Radiation Oncology, Maastricht University Medical Centre, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Bentzen SM, Gregoire V. Molecular imaging-based dose painting: a novel paradigm for radiation therapy prescription. Semin Radiat Oncol 2011; 21:101-10. [PMID: 21356478 PMCID: PMC3052283 DOI: 10.1016/j.semradonc.2010.10.001] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Dose painting is the prescription of a nonuniform radiation dose distribution to the target volume based on functional or molecular images shown to indicate the local risk of relapse. Two prototypical strategies for implementing this novel paradigm in radiation oncology are reviewed: subvolume boosting and dose painting by numbers. Subvolume boosting involves the selection of a "target within the target," defined by image segmentation on the basis of the quantitative information in the image or morphologically, and this is related to image-based target volume selection and delineation. Dose painting by numbers is a voxel-level prescription of dose based on a mathematical transformation of the image intensity of individual pixels. The quantitative use of images to decide both where and how to delivery radiation therapy in an individual case is also called theragnostic imaging. Dose painting targets are imaging surrogates for cellular or microenvironmental phenotypes associated with poor radioresponsiveness. In this review, the focus is on the following positron emission tomography tracers: FDG and choline as surrogates for tumor burden, fluorothymidine as a surrogate for proliferation (or cellular growth fraction) and hypoxia-sensitive tracers, including [(18)F] fluoromisonidazole, EF3, EF5, and (64)Cu-labeled copper(II) diacetyl-di(N(4)-methylthiosemicarbazone) as surrogates of cellular hypoxia. Research advances supporting the clinicobiological rationale for dose painting are reviewed as are studies of the technical feasibility of optimizing and delivering realistic dose painted radiation therapy plans. Challenges and research priorities in this exciting research field are defined and a possible design for a randomized clinical trial of dose painting is presented.
Collapse
Affiliation(s)
- Søren M Bentzen
- Departments of Human Oncology, Medical Physics, Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI 53792, USA.
| | | |
Collapse
|
46
|
Stephans K, Khouri A, Machtay M. The Role of PET in the Evaluation, Treatment, and Ongoing Management of Lung Cancer. PET Clin 2011; 6:177-84. [DOI: 10.1016/j.cpet.2011.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
47
|
van Loon J, van Baardwijk A, Boersma L, Ollers M, Lambin P, De Ruysscher D. Therapeutic implications of molecular imaging with PET in the combined modality treatment of lung cancer. Cancer Treat Rev 2011; 37:331-43. [PMID: 21320756 DOI: 10.1016/j.ctrv.2011.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 01/13/2011] [Accepted: 01/21/2011] [Indexed: 12/23/2022]
Abstract
Molecular imaging with PET, and certainly integrated PET-CT, combining functional and anatomical imaging, has many potential advantages over anatomical imaging alone in the combined modality treatment of lung cancer. The aim of the current article is to review the available evidence regarding PET with FDG and other tracers in the combined modality treatment of locally advanced lung cancer. The following topics are addressed: tumor volume definition, outcome prediction and the added value of PET after therapy, and finally its clinical implications and future perspectives. The additional value of FDG-PET in defining the primary tumor volume has been established, mainly in regions with atelectasis or post-treatment effects. Selective nodal irradiation (SNI) of FDG-PET positive nodal stations is the preferred treatment in NSCLC, being safe and leading to decreased normal tissue exposure, providing opportunities for dose escalation. First results in SCLC show similar results. FDG-uptake on the pre-treatment PET scan is of prognostic value. Data on the value of pre-treatment FDG-uptake to predict response to combined modality treatment are conflicting, but the limited data regarding early metabolic response during treatment do show predictive value. The FDG response after radical treatment is of prognostic significance. FDG-PET in the follow-up has potential benefit in NSCLC, while data in SCLC are lacking. Radiotherapy boosting of radioresistant areas identified with FDG-PET is subject of current research. Tracers other than (18)FDG are promising for treatment response assessment and the visualization of intra-tumor heterogeneity, but more research is needed before they can be clinically implemented.
Collapse
Affiliation(s)
- Judith van Loon
- Maastricht University Medical Centre, Department of Radiation Oncology, MAASTRO Clinic, GROW Research Institute, The Netherlands.
| | | | | | | | | | | |
Collapse
|
48
|
Dewalle-Vignion AS, Betrouni N, Lopes R, Huglo D, Stute S, Vermandel M. A new method for volume segmentation of PET images, based on possibility theory. IEEE TRANSACTIONS ON MEDICAL IMAGING 2011; 30:409-423. [PMID: 20952337 DOI: 10.1109/tmi.2010.2083681] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
18F-fluorodeoxyglucose positron emission tomography (18FDG PET) has become an essential technique in oncology. Accurate segmentation and uptake quantification are crucial in order to enable objective follow-up, the optimization of radiotherapy planning, and therapeutic evaluation. We have designed and evaluated a new, nearly automatic and operator-independent segmentation approach. This incorporated possibility theory, in order to take into account the uncertainty and inaccuracy inherent in the image. The approach remained independent of PET facilities since it did not require any preliminary calibration. Good results were obtained from phantom images [percent error =18.38% (mean) ± 9.72% (standard deviation)]. Results on simulated and anatomopathological data sets were quantified using different similarity measures and showed the method was efficient (simulated images: Dice index =82.18% ± 13.53% for SUV =2.5 ). The approach could, therefore, be an efficient and robust tool for uptake volume segmentation, and lead to new indicators for measuring volume of interest activity.
Collapse
|
49
|
van Elmpt W, Öllers M, van Herwijnen H, den Holder L, Vercoulen L, Wouters M, Lambin P, De Ruysscher D. Volume or Position Changes of Primary Lung Tumor During (Chemo-)Radiotherapy Cannot Be Used as a Surrogate for Mediastinal Lymph Node Changes: The Case for Optimal Mediastinal Lymph Node Imaging During Radiotherapy. Int J Radiat Oncol Biol Phys 2011; 79:89-95. [DOI: 10.1016/j.ijrobp.2009.10.059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 10/08/2009] [Accepted: 10/23/2009] [Indexed: 11/15/2022]
|
50
|
Physical radiotherapy treatment planning based on functional PET/CT data. Radiother Oncol 2010; 96:317-24. [DOI: 10.1016/j.radonc.2010.07.012] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 07/12/2010] [Accepted: 07/13/2010] [Indexed: 11/18/2022]
|