Use of PET and PET/CT for Radiation Therapy Planning: IAEA expert report 2006–2007

Impact of mediastinal tumor burden and lymphatic spread in locally advanced non-small-cell lung cancer: A secondary analysis of the multicenter randomized PET-Plan trial

PURPOSE

The aim of this secondary analysis of the prospective randomized phase 2 PET-Plan trial (ARO-2009-09; NCT00697333) was to evaluate the impact of mediastinal tumor burden and lymphatic spread in patients with locally advanced non-small-cell lung cancer (NSCLC).

METHODS

All patients treated per protocol (n = 172) were included. Patients received isotoxically dose-escalated chemoradiotherapy up to a total dose of 60-74 Gy in 30-37 fractions, aiming as high as possible while adhering to normal tissue constraints. Radiation treatment (RT) planning was based on an 18F-FDG PET/CT targeting all lymph node (LN) stations containing CT positive LNs (i.e. short axis diameter > 10 mm), even if PET-negative (arm A) or targeting only LN stations containing PET-positive nodes (arm B). LN stations were classified into echelon 1 (ipsilateral hilum), 2 (ipsilateral station 4 and 7), and 3 (rest of the mediastinum, contralateral hilum). The endpoints were overall survival (OS), progression-free survival (PFS), and freedom from local progression (FFLP).

RESULTS

The median follow-up time (95 % confidence interval [CI]) was 41.1 (33.8 - 50.4) months. Patients with a high absolute number of PET-positive LN stations had worse OS (hazard ratio [HR] = 1.09; 95 % CI 0.99 - 1.18; p = 0.05) and PFS (HR = 1.12; 95 % CI 1.04 - 1.20; p = 0.003), irrespective of treatment arm allocation. The prescribed RT dose to the LNs did not correlate with any of the endpoints when considering all patients. However, in patients in arm B (i.e., PET-based selective nodal irradiation), prescribed RT dose to each LN station correlated significantly with FFLP (HR=0.45; 95 % CI 0.24-0.85; p = 0.01). Furthermore, patients with involvement of echelon 3 LN stations had worse PFS (HR = 2.22; 95 % CI 1.16-4.28; p = 0.02), also irrespective of allocation.

CONCLUSION

Mediastinal tumor burden and lymphatic involvement patterns influence outcome in patients treated with definitive chemoradiotherapy for locally advanced NSCLC. Higher dose to LNs did not improve OS, but did improve FFLP in patients treated with PET-based dose-escalated RT.

Current landscape of gastrointestinal radiation oncology in Spain: a multicenter real-life survey and comparison with key clinical guidelines

Background

The GI Tumors Workgroup, a division of the Spanish Society of Radiation Therapy, conducted a survey in December 2020 to assess the adherence of radiation oncologists in Spain to international guidelines for gastrointestinal tumors.

Materials and methods

Using Google Forms, we designed a survey covering treatments for esophageal, gastric, pancreatic, and rectal cancers.

Results

In esophageal cancer treatment, neoadjuvant chemoradiation was the standard in 76.7% of institutions. Radiation doses range from 41.1 to 50.4 Gy in conventional fractionation. Planning positron emission tomography-computed tomography (PET-CT) was performed in 83.3% of centers, and intensity-modulated radiation therapy/volumetric-arc radiation therapy (IMRT/VMAT) was the preferred technique in 86.7% of institutions. For gastric cancer, 71.4% followed perioperative chemotherapy guidelines. In the case of adjuvant radiotherapy, the majority prescribed 45-50.4 Gy, and 82.1% used IMRT/VMAT for treatment. For pancreas cancer, neoadjuvant chemotherapy followed by surgery in borderline resectable tumors and induction chemotherapy followed by radical radiotherapy for non-resectable tumors were the most frequent approaches. IMRT/VMAT was the primary technique. Locally advanced rectal cancer treatment is mainly based on neoadjuvant radiotherapy in all institutions. The preferred radiation doses typically range from 45 to 50 Gy in conventional fractionation. IMRT/VMAT was standard in most Institutions.

Conclusions

Spain's radiotherapy practices among respondents generally align with international guidelines for GI tumors highlighting Spain's commitment to evidence-based medical practice.

Clinical use of positron emission tomography for radiotherapy planning - Medical physics considerations

PET/CT imaging plays an increasing role in radiotherapy treatment planning. The aim of this article was to identify the major use cases and technical as well as medical physics challenges during integration of these data into treatment planning. Dedicated aspects, such as (i) PET/CT-based radiotherapy simulation, (ii) PET-based target volume delineation, (iii) functional avoidance to optimized organ-at-risk sparing and (iv) functionally adapted individualized radiotherapy are discussed in this article. Furthermore, medical physics aspects to be taken into account are summarized and presented in form of check-lists.

COMP Report: CPQR technical quality control guidelines for use of positron emission tomography/computed tomography in radiation treatment planning

Positron emission tomography with x-ray computed tomography (PET/CT) is increasingly being utilized for radiation treatment planning (RTP). Accurate delivery of RT therefore depends on quality PET/CT data. This study covers quality control (QC) procedures required for PET/CT for diagnostic imaging and incremental QC required for RTP. Based on a review of the literature, it compiles a list of recommended tests, performance frequencies, and tolerances, as well as references to documents detailing how to perform each test. The report was commissioned by the Canadian Organization of Medical Physicists as part of the Canadian Partnership for Quality Radiotherapy initiative.

PET/CT for Target Delineation of Lung Cancer Before Radiation Therapy

In clinical routine of patients suffering from lung cancer, radiotherapy/radiation oncology represents one of the therapeutic hallmarks in the multimodal treatment besides or in combination with other local treatments such as surgery, but also systemic treatments such as chemotherapy, tyrosine kinase, and immune check-point inhibitors. Conventional morphological imagings such as CT or MR are commonly used for staging, response assessment, but also for radiotherapy planning. However, advanced imaging techniques such as PET do continuously get increasing access to clinical routine overcoming limitations of standard imaging techniques by visualizing and quantifying molecular processes such as glucose metabolism, which is also of relevance for radiotherapy planning. This review article summarizes the current place of radiotherapy within the treatment regimens of patients with lung cancer and elucidates current concepts of standard morphological imaging for staging and radiotherapy planning. Moreover, the place of PET-based radiotherapy planning in a clinical context is presented and current methodological/technical advances that do comprise a potential role for radiotherapy planning in lung cancer patients are discussed.

Nasopharyngeal Carcinoma Radiomic Evaluation with Serial PET/CT: Exploring Features Predictive of Survival in Patients with Long-Term Follow-Up

PURPOSE

We aim determine the value of PET and CT radiomic parameters on survival with serial follow-up PET/CT in patients with nasopharyngeal carcinoma (NPC) for which curative intent therapy is undertaken.

METHODS

Patients with NPC and available pre-treatment as well as follow up PET/CT were included from 2005 to 2006 and were followed to 2021. Baseline demographic, radiological and outcome data were collected. Univariable Cox proportional hazard models were used to evaluate features from baseline and follow-up time points, and landmark analyses were performed for each time point.

RESULTS

Sixty patients were enrolled, and two-hundred and seventy-eight (278) PET/CT were at baseline and during follow-up. Thirty-eight percent (38%) were female, and sixty-two patients were male. All patients underwent curative radiation or chemoradiation therapy. The median follow-up was 11.72 years (1.26-14.86). Five-year and ten-year overall survivals (OSs) were 80.0% and 66.2%, and progression-free survival (PFS) was 90.0% and 74.4%. Time-dependent modelling suggested that, among others, PET gray-level zone length matrix (GLZLM) gray-level non-uniformity (GLNU) (HR 2.74 95% CI 1.06, 7.05) was significantly associated with OS. Landmark analyses suggested that CT parameters were most predictive at 15 month, whereas PET parameters were most predictive at time points 3, 6, 9 and 15 month.

CONCLUSIONS

This study with long-term follow up data on NPC suggests that mainly PET-derived radiomic features are predictive for OS but not PFS in a time-dependent evaluation. Furthermore, CT radiomic measures may predict OS and PFS best at initial and long-term follow-up time points and PET measures may be more predictive in the interval. These modalities are commonly used in NPC surveillance, and prospective validation should be considered.

Respiratory gated multistatic PET reconstructions to delineate radiotherapy target volume in patients with mobile lung tumors

BACKGROUND

PET-CT with ¹⁸F-FDG or other radiopharmaceuticals is a recommended tool to help the delineation of lung cancers candidate to radiotherapy. The motion artifacts caused by respiratory movements are reduced by 4D acquisitions. We introduced an extended reconstruction algorithm (multiple reconstruct register and average [multi-RRA]) which requires much shorter acquisition times than standard 4D PET-CT. Our aim was to evaluate the interest on multi-RRA images as an alternative of 3D and 4D PET-CT for the delineation of lung lesion.

METHODS

PET acquisitions synchronized to the respiratory signal were obtained in 18 patients with mobile lung tumors. We compared the tumor volumes delineated on Multi-RRA images to 3D and 4D PET-CT, considering the 4D CT as a reference. The tumor volumes were delineated and compared with topologic similarity indexes (Dice, Jaccard and overlap).

RESULTS

Twenty tumors were delineated. The volumes delineated with multi-RRA and 4D PET were not significantly different (mean difference of 0.2±0.7 mL). Comparison by pairs (Tukey-Kramer test) showed that 3D-PET volumes were significantly smaller than 4D-PET and multi-RRA volumes (P<0.001). Topologic similarity indexes with 4D-PET were slightly statistically higher with multi-RRA than with 3D-PET (Dice and Jaccard) or 4D-CT (Dice, Jaccard and Overlap).

CONCLUSIONS

The tumor volumes delineated on multi-RRA are similar to the volumes obtained with 4D PET, with shorter acquisition time.

Characterization of positioning uncertainties in PET-CT-MR trimodality solutions for radiotherapy

The purpose of this study was to evaluate the positioning uncertainties of two PET/CT‐MR imaging setups, C1 and C2. Because the PET/CT data were acquired on the same hybrid device with automatic image registration, experiments were conducted using CT‐MRI data. In C1, a transfer table was used, which allowed the patient to move from one imager to another while maintaining the same position. In C2, the patient stood up and was positioned in the same radiotherapy treatment position on each imager. The two setups provided a set of PET/CT and MR images. The accuracy of the registration software was evaluated on the CT‐MRI data of one patient using known translations and rotations of MRI data. The uncertainties on the two setups were estimated using a phantom and a cohort of 30 patients. The accuracy of the positioning uncertainties was evaluated using descriptive statistics and a t‐test to determine whether the mean shift significantly deviated from zero (p < 0.05) for each setup. The maximum registration errors were less than 0.97 mm and 0.6° for CT‐MRI registration. On the phantom, the mean total uncertainties were less than 2.74 mm and 1.68° for C1 and 1.53 mm and 0.33° for C2. For C1, the t‐test showed that the displacements along the z‐axis did not significantly deviate from zero (p = 0.093). For C2, significant deviations from zero were present for anterior‐posterior and superior‐inferior displacements. The mean total uncertainties were less than 4 mm and 0.42° for C1 and less than 1.39 mm and 0.27° for C2 in the patients. Furthermore, the t‐test showed significant deviations from zero for C1 on the anterior‐posterior and roll sides. For C2, there was a significant deviation from zero for the left‐right displacements.This study shows that transfer tables require careful evaluation before use in radiotherapy.

Joint EANM/SNMMI/ESTRO practice recommendations for the use of 2-[18F]FDG PET/CT external beam radiation treatment planning in lung cancer V1.0

PURPOSE

2-[18F]FDG PET/CT is of utmost importance for radiation treatment (RT) planning and response monitoring in lung cancer patients, in both non-small and small cell lung cancer (NSCLC and SCLC). This topic has been addressed in guidelines composed by experts within the field of radiation oncology. However, up to present, there is no procedural guideline on this subject, with involvement of the nuclear medicine societies.

METHODS

A literature review was performed, followed by a discussion between a multidisciplinary team of experts in the different fields involved in the RT planning of lung cancer, in order to guide clinical management. The project was led by experts of the two nuclear medicine societies (EANM and SNMMI) and radiation oncology (ESTRO).

RESULTS AND CONCLUSION

This guideline results from a joint and dynamic collaboration between the relevant disciplines for this topic. It provides a worldwide, state of the art, and multidisciplinary guide to 2-[18F]FDG PET/CT RT planning in NSCLC and SCLC. These practical recommendations describe applicable updates for existing clinical practices, highlight potential flaws, and provide solutions to overcome these as well. Finally, the recent developments considered for future application are also reviewed.

Modern Radiation Oncology: From IMRT to Particle Therapy—Present Status and the Days to Come

There has been tremendous technological development in the field of radiation oncology, mainly during the last few decades. Parallel advancements in imaging and accelerator technologies have contributed significantly to the same. Present-day radiation therapy is aimed at precision, in terms of physical accuracy of both its planning and delivery. This has been made possible by improvements in defining the target (use of various radiological and functional imaging modalities), advanced radiotherapy planning methods (intensity-modulated radiation therapy and recent emergence of particle therapy), and robust verification techniques (image-guided radiation therapy). These developments have enabled delivery of adequate tumoricidal doses conforming to the target, thereby improving disease control with reduced normal tissue toxicity in a wide range of malignancies. Elucidation of molecular pathways determining radioresistance or systemic effects of radiotherapy and strategies for therapeutic manipulation of the same are also being explored. Overall, we look forward to ensuring basic radiotherapy access to all patients, and precision radiation therapy to appropriate candidates (triaged by disease anatomy or biology and associated cost-effectiveness).

Radiotherapy planning of lymphomas: role of metabolic imaging with PET/CT

Accurate target delineation is an absolute requirement for modern radiotherapy planning. Historically, structural imaging modalities have been used for this purpose, but there is a considerable role for functional imaging with PET/CT to contribute in this area. PET/CT's role in radiotherapy planning is well established and its use is indispensable in the clinical management of the lymphomas, particularly Hodgkin Lymphoma. A crucial use of PET/CT is as a baseline scan for delineation of the initial lymphomatous involvement, since this will determine the contouring of the gross-, clinical- and planning-target volumes (GTV, CTV, PTV). This article reviews the principles of contemporary radiotherapy, examines the evidence for the contribution of PET/CT to radiotherapy planning in lymphoma and the practicalities and challenges of applying this powerful technology to this situation.

Prognostic value of metabolic signature on 18F-FDG uptake in breast cancer patients after radiotherapy

Radiotherapy (RT) is a major modality of postoperative treatment in breast cancer. The maximal standardized value (SUVmax) is ¹⁸FDG-PET/CT derived parameter that reported to be a valuable prognostic factor in cancer patients. Herein, we aimed to identify a prognostic gene signature associated with glucose uptake for breast cancer patients after RT by leveraging the mRNA expression profiling on public datasets. The glucose uptake signature was constructed using the single sample gene set enrichment analysis (ssGSEA) algorithm and evaluated in GSE21217 where SUVmax value was measured by PET-CT directly. The prognostic value was validated in three post-RT breast cancer cohorts (GSE103744, NKI, and FUSCC databases). The patients were stratified into glucose uptake signature score-high and low groups. Patients with a higher score had worse survival than those with a lower score. Mechanistically, the glucose uptake signature was calculated in each cell type of a single-cell RNA-seq database from five breast cancer patients. Glucose uptake signature score was significantly elevated in the malignant epithelial cells compared with normal ones. The immunosuppression markers including PDCD1, TIGIT, LAG3, and HAVCR2 were significantly upregulated in the T cells bearing a high glucose uptake signature score. Collectively, our results demonstrated the potential prognostic value of a glucose uptake signature in the post-RT breast cancer patients.

Prospective Evaluation of the First Integrated Positron Emission Tomography/Dual-Energy Computed Tomography System in Patients With Lung Cancer

PURPOSE

The aim of this pilot study was to prospectively evaluate the first integrated positron emission tomography (PET)/dual-energy computed tomography (DECT) system performance in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

In this single-center, prospective trial, consecutive patients with NSCLC referred for a PET study between May 2017 and June 2018 were enrolled. All patients received contrast-enhanced imaging on a clinical PET/DECT system. Data analysis included PET-based standard uptake values (SUVmax) and DECT-based iodine densities of tumor masses, lymph nodes, and distant metastases. Results were analyzed using correlation tests and receiver operating characteristics curves.

RESULTS

The study population was composed of 21 patients (median age 62 y, 14 male patients). A moderate positive correlation was found between iodine density values (2.2 mg/mL) and SUVmax (10.5) in tumor masses (ρ=0.53, P<0.01). Iodine density values (2.3 mg/mL) and SUVmax (5.4) of lymph node metastases showed a weak positive correlation (ρ=0.23, P=0.14). In addition, iodine quantification analysis provided no added value in differentiating between pathologic and nonpathologic lymph nodes with an area under the curve (AUC) of 0.55 using PET-based SUVmax as the reference standard. A weak positive correlation was observed between iodine density (2.2 mg/mL) and SUVmax in distant metastases (14.9, ρ=0.23, P=0.52).

CONCLUSIONS

The application of an integrated PET/DECT system in lung cancer might provide additional insights in the assessment of tumor masses. However, the added value of iodine density quantification for the evaluation of lymph nodes and distant metastases seems limited.

Increasing Demand on Human Capital and Resource Utilization in Radiation Therapy: The Past Decade

PURPOSE

To quantify the change resource utilization in radiation therapy in the context of advancing technologies and techniques over the last decade.

METHODS AND MATERIALS

Prospectively, the time to complete radiation therapy workflow tasks was captured between January 1, 2020, and December 31, 2020. The institutional task workflows are specific to each technique and broadly organized into 4 categories: 3-dimenstional conformal radiation therapy, intensity modulated radiation therapy, volumetric modulated arc therapy simple, and volumetric modulated arc therapy complex. These discipline-specific task times were used to quantify a resource utilization factor, which is the median time taken to complete all tasks for each category divided by the median time for 3-dimensional conformal radiation therapy treatments. Retrospectively, all plans treated between January 1, 2012, and December 31, 2019, were quantified and categorized. The resource factor was applied to determine resource utilization. For context, institutional staffing levels were captured across the same decade for medical dosimetrists, medical physicists, and radiation oncologists.

RESULTS

This analysis includes 30,229 patient plans in the retrospective data set and 4747 patient plans in the prospective data set. This analysis demonstrates that over this period, patient numbers increased by approximately 45%, whereas time-based human resources increased by almost 150%. The resource allocation factors for 3-dimenstional conformal radiation therapy, intensity modulated radiation therapy, volumetric modulated arc therapy simple, and volumetric arc therapy complex were 1.0, 2.4, 2.9, and 4.3, respectively. Across the 3 disciplines, staffing levels increased from 15 to 17 (13%) for medical dosimetrists, from 10 to 13 (30%) for medical physicists, and from 16 to 23 (44%) for radiation oncologists.

CONCLUSIONS

This work demonstrates the increase in resource utilization due to the introduction of advanced technologies and changes in radiation therapy techniques over the past decade. Human resource utilization is the predominant factor and should be considered with increasing patient volume for operational planning.

FDG-PET/CT and MR imaging for target volume delineation in rectal cancer radiotherapy treatment planning: a systematic review

Aim:

The aim of this systematic review was to synthesise and summarise evidence surrounding the clinical use of fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) and magnetic resonance imaging (MRI) for target volume delineation (TVD) in rectal cancer radiotherapy planning.

Methods:

PubMed, EMBASE, Cochrane library, CINAHL, Web of Science and Scopus databases and other sources were systematically queried using keywords and relevant synonyms. Eligible full-text studies were assessed for methodological quality using the QUADAS-2 tool.

Results:

Eight of the 1448 studies identified met the inclusion criteria. Findings showed that MRI significantly delineate larger tumour volumes (TVs) than FDG-PET/CT while diffusion-weighted magnetic resonance imaging (DW-MRI) defined smaller gross tumour volumes (GTVs) compared to T2 weighted-Magnetic Resonance Image. CT-based GTVs were found to be larger compared to FDG-PET/CT. FDG-PET/CT also identified new lesions in 15–17% patients and TVs extending outside the routinely used clinical standard CT TV in 29–83% patients. Between observers, delineated volumes were similar and consistent between MRI sequences, whereas interobserver agreement was significantly improved with FDG-PET/CT than CT.

Conclusion:

FDG-PET/CT and DW-MRI appear to delineate smaller rectal TVs and show improved interobserver variability. Overall, this study provides valuable insights into the amount of attention in the research literature that has been paid to imaging for TVD in rectal cancer.

Value of PET imaging for radiation therapy

This comprehensive review written by experts in their field gives an overview on the current status of incorporating positron emission tomography (PET) into radiation treatment planning. Moreover, it highlights ongoing studies for treatment individualisation and per-treatment tumour response monitoring for various primary tumours. Novel tracers and image analysis methods are discussed. The authors believe this contribution to be of crucial value for experts in the field as well as for policy makers deciding on the reimbursement of this powerful imaging modality.

Value of PET imaging for radiation therapy

This comprehensive review written by experts in their field gives an overview on the current status of incorporating positron emission tomography (PET) into radiation treatment planning. Moreover, it highlights ongoing studies for treatment individualisation and per-treatment tumour response monitoring for various primary tumours. Novel tracers and image analysis methods are discussed. The authors believe this contribution to be of crucial value for experts in the field as well as for policy makers deciding on the reimbursement of this powerful imaging modality.

Evaluation of Hybrid PET/MRI for Gross Tumor Volume (GTV) Delineation in Colorectal Cancer Liver Metastases Radiotherapy

Purpose

Hybrid PET/MRI has been increasingly incorporated into the practice of radiation oncologists since it contains both anatomical and biological data and may bring about personalized radiation plans for each patient. The objective of this study was to evaluate the feasibility of GTV delineation from hybrid PET/MRI compared with that from current-practice MRI during radiotherapy planning in patients with colorectal liver metastases.

Patients and Methods

Twenty-four patients (thirty lesions) with colorectal liver metastases were prospectively enrolled in this study. Three physicians delineated the target volume with the most popular delineating methods-the visual method. First of all, differences among the three observers were assessed. The difference and correlation of GTV values obtained by MRI, PET, and hybrid PET/MRI were subjected to statistical analysis afterwards. Finally, the dice similarity coefficient (DSC) was calculated to assess the spatial overlap. Based on the value of DSC, we also evaluate the correlation between DSC and tumor size. GTV-MRI was set as a reference.

Results

There was no significant difference among observers in GTV-MRI (F=0.118, p=0.889), GTV-PET (F=0.070, p=0.933) and GTV-PET/MRI (F=0.40, p=0.961). 83.33% of GTV-PET/MRI and 63.33% of GTV-PET were larger than the reference GTV-MRI. Statistical analysis revealed that GTV-PET/MRI (p<0.001) and GTV-PET (p<0.05) diverged statistically significantly from GTV-MRI. GTV-PET (r=0.992, p<0.001) and GTV-PET/MRI (r=0.997, p<0.001) were significantly related to GTV-MRI. The average DSC value between GTV-MRI and GTV-PET was 0.51 (range 0-0.90) and that between GTV-MRI and GTV-PET/MRI was 0.72 (range 0.42-0.90). There was a positive correlation between the DSC and GTV-MRI (r=0.851, p<0.05).

Conclusion

With the database used, there is good agreement among observers. Hybrid PET/MRI in colorectal liver metastases radiotherapy may affect the GTV delineation. Moreover, the overlap degree between GTV-MRI and GTV-PET/MRI is higher and increases with volume.

Evolving target volume concepts in locally advanced non-small cell lung cancer

Radiotherapy (RT) target volume concepts for locally advanced lung cancer have been under discussion for years. Although they may be as important as treatment doses, many aspects of them are still based on conventions, which, due to the paucity of prospective data, rely on long-term practice or on clinical knowledge and experience (e.g., on patterns of spread or recurrence). However, in recent years, large improvements have been made in medical imaging and molecular imaging methods have been implemented, which are of great interest in RT. For lung cancer, in recent years, 18F-fluoro-desoxy-glucose (FDG)-positron-emission tomography (PET)/computed tomography (CT) has shown a superior diagnostic accuracy as compare to conventional imaging and has become an indispensable standard tool for diagnostic workup, staging and response assessment. This offers the chance to optimize target volume concepts in relation to modern imaging. While actual recommendations as the EORTC or ESTRO-ACROP guidelines already include imaging standards, the recently published PET-Plan trial prospectively investigated conventional versus imaging guided target volumes in relation to patient outcome. The results of this trial may help to further refine standards. The current review gives a practical overview on procedures for pre-treatment imaging and target volume delineation in locally advanced non-small cell lung cancer (NSCLC) in synopsis of the procedures established by the PET-Plan trial with the actual EORTC and ACROP guidelines.

EANM/SNMMI practice guideline for [18F]FDG PET/CT external beam radiotherapy treatment planning in uterine cervical cancer v1.0

PURPOSE

The aim of this EANM / SNMMI Practice Guideline with ESTRO endorsement is to provide general information and specific considerations about [18F]FDG PET/CT in advanced uterine cervical cancer for external beam radiotherapy planning with emphasis on staging and target definition, mostly in FIGO stages IB3-IVA and IVB, treated with curative intention.

METHODS

Guidelines from related fields, relevant literature and leading experts have been consulted during the development of this guideline. As this field is rapidly evolving, this guideline cannot be seen as definitive, nor is it a summary of all existing protocols. Local variations should be taken into consideration when applying this guideline.

CONCLUSION

The background, common clinical indications, qualifications and responsibilities of personnel, procedure / specifications of the examination, documentation / reporting and equipment specifications, quality control and radiation safety in imaging is discussed with an emphasis on the multidisciplinary approach.

Monte Carlo simulation and performance assessment of GE Discovery 690 VCT positron emission tomography/computed tomography scanner

The aim of this study is to simulate GE Discovery 690 VCT positron emission tomography/computed tomography (PET/CT) scanner using Geant4 Application for Tomographic Emission (GATE) simulation package (version 8). Then, we assess the performance of scanner by comparing measured and simulated parameter results. Detection system and geometry of PET scanner that consists of 13,824 LYSO crystals designed in 256 blocks and 24 ring detectors were modeled. In order to achieve a precise model, we verified scanner model. Validation was based on a comparison between simulation data and experimental results obtained with this scanner in the same situation. Parameters used for validation were sensitivity, spatial resolution, and contrast. Image quality assessment was done based on comparing the contrast recovery coefficient (CRC) of simulated and measured images. The findings demonstrate that the mean difference between simulated and measured sensitivity is <7%. The simulated spatial resolution agreed to within <5.5% of the measured values. Contrast results had a slight divergence within the range below 4%. The image quality validation study demonstrated an acceptable agreement in CRC for 8:1 and 2:1 source-to-background activity ratio. Validated performance parameters showed good agreement between experimental data and simulated results and demonstrated that GATE is a valid simulation tool for simulating this scanner model. The simulated model of this scanner can be used for future studies regarding optimization of image reconstruction algorithms and emission acquisition protocols.

FDG-PET Radiomics for Response Monitoring in Non-Small-Cell Lung Cancer Treated with Radiation Therapy

Simple Summary

In this study, we strive to identify clinically relevant image feature (IF) changes during chemoradiation in patients with non-small-cell lung cancer (NSCLC) to be able to predict tumor responses in an early stage of treatment. All patients underwent static (3D) and respiratory-gated 4D PET/CT scans before treatment and a 3D scan during or after treatment. Our proposed method rejects IF changes due to intrinsic variability such as noise, resolution and movement through breathing. The IF variability observed across 4D PET is employed as a patient individualized normalization factor to emphasize statistically relevant IF changes during treatment.

Abstract

The aim of this study is to identify clinically relevant image feature (IF) changes during chemoradiation and evaluate their efficacy in predicting treatment response. Patients with non-small-cell lung cancer (NSCLC) were enrolled in two prospective trials (STRIPE, PET-Plan). We evaluated 48 patients who underwent static (3D) and retrospectively-respiratory-gated 4D PET/CT scans before treatment and a 3D scan during or after treatment. Our proposed method rejects IF changes due to intrinsic variability. The IF variability observed across 4D PET is employed as a patient individualized normalization factor to emphasize statistically relevant IF changes during treatment. Predictions of overall survival (OS), local recurrence (LR) and distant metastasis (DM) were evaluated. From 135 IFs, only 17 satisfied the required criteria of being normally distributed across 4D PET and robust between 3D and 4D images. Changes during treatment in the area-under-the-curve of the cumulative standard-uptake-value histogram (δ_AUCCSH) within primary tumor discriminated (AUC = 0.87, Specificity = 0.78) patients with and without LR. The resulted prognostic model was validated with a different segmentation method (AUC = 0.83) and in a different patient cohort (AUC = 0.63). The quantification of tumor FDG heterogeneity by δ_AUCCSH during chemoradiation correlated with the incidence of local recurrence and might be recommended for monitoring treatment response in patients with NSCLC.

PET-Based Volumetric Biomarkers for Risk Stratification of Non-Small Cell Lung Cancer Patients

Despite the recent advances in lung cancer biology, molecular pathology, and treatment, this malignancy remains the leading cause of cancer-related death worldwide and non-small cell lung cancer (NSCLC) is the most common form found at diagnosis. Accurate staging of the disease is a fundamental prognostic factor that correctly predicts progression-free (PFS) and overall survival (OS) of NSCLC patients. However, outcome of patients within each TNM staging group can change widely highlighting the need to identify additional prognostic biomarkers to better stratify patients on the basis of risk. 18F-FDG PET/CT plays an essential role in staging, evaluation of treatment response, and tumoral target delineation in NSCLC patients. Moreover, a number of studies showed the prognostic role of imaging parameters derived from PET images, such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG). These parameters represent three-dimensional PET-based measurements providing information on both tumor volume and metabolic activity and previous studies reported their ability to predict OS and PFS of NSCLC patients. This review will primarily focus on the studies that showed the prognostic and predictive role of MTV and TLG in NSCLC patients, addressing also their potential utility in the new era of immunotherapy of NSCLC.

Quantitative PET Imaging and Clinical Parameters as Predictive Factors for Patients With Cervical Carcinoma: Implications of a Prediction Model Generated Using Multi-Objective Support Vector Machine Learning

Purpose:

Quantitative features from pre-treatment positron emission tomography (PET) have been used to predict treatment outcomes for patients with cervical carcinoma. The purpose of this study is to use quantitative PET imaging features and clinical parameters to construct a multi-objective machine learning predictive model.

Materials/Methods:

Seventy-five patients with stage IB2-IVA disease treated at our institution from 2009–2012 were analyzed. Models predicting locoregional and distant failure were generated using clinical parameters (age, race, stage, histology, tumor size, nodal status) and imaging features (12 textural, 9 intensity, 8 geometric features, 2 additional imaging features) from pre-treatment PET. Model features were selected based on a multi-objective evolutionary algorithm to maximize specificity given a fixed moderately high sensitivity using support vector machine learning methods. Model 1 used clinical parameters only (C), Model 2 used imaging features only (I), and Model 3 used clinical and imaging features (C+I). Sensitivity, specificity, area under a receiver-operating characteristic curve (AUC), and p-values were compared to assess ability to predict locoregional and distant failure.

Results:

C+I had the highest performance for both locoregional failure (AUC 0.84, p < 0.01; specificity: 0.86; sensitivity: 0.79) and distant failure (AUC 0.75, p < 0.01; specificity: 0.75; sensitivity: 0.75).

Conclusions:

Based on a moderately high fixed sensitivity and optimized for specificity, the model using both clinical parameters and imaging features (C+I) had the best performance in predicting both locoregional failure and distant failure.

Critical Re-Evaluation of a Failure Mode Effect Analysis in a Radiation Therapy Department After 10 Years

PURPOSE

Failure mode effect analysis (FMEA) is a proactive methodology that allows one to analyze a process, regardless of whether an adverse event occurs. In our radiation therapy (RT) department, a first FMEA was performed in 2009. In this paper we critically re-evaluate the RT process after 10 years and present it in terms of a lesson learned.

METHODS AND MATERIALS

A working group (WG), led by a qualified clinical risk engineer, which included radiation oncologists, physicists, a radiation therapist, and a nurse, evaluated the possible failure modes (FMs) of the RT process. For each FM, the estimated frequency of occurrence (O, range 1-4), the expected severity of the damage (S, range 1-5), and the detectability lack (D, range 1-4) were scored. A risk priority number (RPN) was obtained as RPN = OxSxD. The data were compared with the 2009 edition.

RESULTS

In the 2020 analysis, 67 FMs were identified (27 in the 2009 series). The absolute risk values of the previous 3 highest FMs were generally reduced. The patient identification risk (highest value in the 2009 analysis) was reduced from 48.0 to 6.9, becoming the 51st RPN score, thanks to a patient barcode recognition within the bunker. The 2020 highest risk values regarded: (i-2020) the patient's inadequate recollection and reporting of his/her medical history (ie, anamnesis) during the first medical examination and (ii-2020) the incorrect interpretation of tumor and normal tissue in computed tomography images. The WG proposed corrective actions.

CONCLUSIONS

In this single institution experience, the 10-year FMEA analysis showed a reduction in the previous higher RPN values thanks to the corrective actions taken. The new FMs and subsequent RPNs reveal the need for a continuous iterative improvement process.

Imaging for Target Delineation in Head and Neck Cancer Radiotherapy

The definition of tumor involved volumes in patients with head and neck cancer poses great challenges with the increasing use of highly conformal radiotherapy techniques eg, volumetric modulated arc therapy and intensity modulated proton therapy. The risk of underdosing the tumor might increase unless great care is taken in the process. The information gained from imaging is increasing with both PET and MRI becoming readily available for the definition of targets. The information gained from these techniques is indeed multidimensional as one often acquire data on eg, metabolism, diffusion, and hypoxia together with anatomical and structural information. Nevertheless, much work remains to fully exploit the available information on a patient-specific level. Multimodality target definition in radiotherapy is a chain of processes that must be individually scrutinized, optimized and quality assured. Any uncertainties or errors in image acquisition, reconstruction, interpretation, and delineation are systematic errors and hence will potentially have a detrimental effect on the entire radiotherapy treatment and hence; the chance of cure or the risk of unnecessary side effects. Common guidelines and procedures create a common minimum standard and ground for evaluation and development. In Denmark, the treatment of head and neck cancer is organized within the multidisciplinary Danish Head and Neck Cancer Group (DAHANCA). The radiotherapy quality assurance group of DAHANCA organized a workshop in January 2020 with participants from oncology, radiology, and nuclear medicine from all centers in Denmark, treating patients with head and neck cancer. The participants agreed on a national guideline on imaging for target delineation in head and neck cancer radiotherapy, which has been approved by the DAHANCA group. The guidelines are available in the Supplementary. The use of multimodality imaging is being recommended for the planning of all radical treatments with a macroscopic tumor. 2-[¹⁸F]FDG-PET/CT should be available, preferable in the treatment position. The recommended MRI sequences are T1, T2 with and without fat suppression, and T1 with contrast enhancement, preferable in the treatment position. The interpretation of clinical information, including thorough physical examination as well as imaging, should be done in a multidisciplinary setting with an oncologist, radiologist, and nuclear medicine specialist.

A modern review of the uncertainties in volumetric imaging of respiratory-induced target motion in lung radiotherapy

Radiotherapy has become a critical component for the treatment of all stages and types of lung cancer, often times being the primary gateway to a cure. However, given that radiation can cause harmful side effects depending on how much surrounding healthy tissue is exposed, treatment of the lung can be particularly challenging due to the presence of moving targets. Careful implementation of every step in the radiotherapy process is absolutely integral for attaining optimal clinical outcomes. With the advent and now widespread use of stereotactic body radiation therapy (SBRT), where extremely large doses are delivered, accurate, and precise dose targeting is especially vital to achieve an optimal risk to benefit ratio. This has largely become possible due to the rapid development of image-guided technology. Although imaging is critical to the success of radiotherapy, it can often be plagued with uncertainties due to respiratory-induced target motion. There has and continues to be an immense research effort aimed at acknowledging and addressing these uncertainties to further our abilities to more precisely target radiation treatment. Thus, the goal of this article is to provide a detailed review of the prevailing uncertainties that remain to be investigated across the different imaging modalities, as well as to highlight the more modern solutions to imaging motion and their role in addressing the current challenges.

Precision Radiotherapy: 18F-FDG PET-based radiotherapy planning in Head and Neck cancers

Precision medicine is gaining importance in this era of molecular imaging where the molecular features of a disease can be noninvasively assessed and treated with personalized medicine. This is especially suited for head and neck cancers (HNCa). Early stage HNCa are ideally managed with radiotherapy (RT) or surgery. Head and neck (HN) is a complex region and its tumors respond to RT differently due to dissimilar structures and moving organs such as tongue. Radiation oncologists are always in the process of trying and investigating newer RT techniques in order to achieve precise and targetted therapy to tumour/s. One such innovation is Intensity modulated RT (IMRT) using 3 Dimensional conformal RT (3DCRT). This 3DCRT resizes the radiation beams to match the shape of the tumor. Such focused dose escalation may improve local control in HNCa. Image guided RT in conjunction with IMRT is the most advanced form of RT planning being used these days. Simulation computerized tomography (CT) images are usually incorporated into RT planning module. But limitations of CT such as poor soft tissue contrast than magnetic resonance imaging and inability to clearly define solid / cystic / necrotic areas and viable tumour exist. Functional imaging such as Positron Emission Tomography (PET) has established its superiority over CT in delineating the actual site and extent of HN tumors. A combination of IMRT with BTV (Biological Tumour Volume) may be the most ideal technique to deliver a homogeneous radiation boost to tumour. This review shall discuss PET based RT planning, challenges, practical tips, and how to optimize therapy with the least side effects to the normal surrounding tissues.

Impact of positron emission tomography with computed tomography for image-guided radiotherapy

Therapeutic effectiveness in radiotherapy is partly related to correct staging of the disease and then precise therapeutic targeting. Positron emission tomography (PET) allows the stage of many cancers to be determined and therefore is essential before deciding on radiation treatment. The definition of the therapeutic target is essential to obtain correct tumour control and limit side effects. The part of adaptive radiotherapy remains to be defined, but PET by its functional nature makes it possible to define the prognosis of many cancers and to consider radiotherapy adapted to the initial response allowing an increase over the entire metabolic volume, or targeted at a subvolume at risk per dose painting, or with a decrease in the dose in case of good response at interim assessment.

Treatment patterns and survival after 18F-fluorodeoxyglucose positron emission tomography/computed tomography-guided local consolidation therapy for oligometastatic non-small cell lung cancer: a two-center propensity score-matched analysis

Purpose

In this retrospective study, we evaluated the treatment patterns and survival after positron emission tomography-computed tomography (PET/CT)-guided local consolidation therapy (LCT) for oligometastatic non-small cell lung cancer (NSCLC).

Methods

We reviewed the medical records of Chinese patients with oligometastatic stage IV non-small cell lung cancer (≤ 5 metastases) who had undergone PET/CT and were eligible for systemic therapy at two centers between May 2005 and August 2019. Propensity score matching (1:1) was used to reduce selection bias and imbalanced distribution of confounding factors.

Results

We identified 84 eligible patients and used propensity scores to create well-matched groups of 35 patients who did or did not undergo LCT. Among all patients, the 1-year overall survival (OS) rate was 47.6% and the 2-year OS rate was 22.6%. Relative to the group that did not receive LCT, the LCT group had a significantly higher OS rate (13 months vs. 7 months, p = 0.002). The two groups had similar incidences and classifications of LCT-related side effects. In multivariable analysis, LCT was found to be strongly associated with a favorable OS (hazard ratio: 0.508, 95% confidence interval: 0.311–0.828, p = 0.001).

Conclusion

We concluded that LCT was significantly associated with improved clinical outcomes among the Chinese patients with oligometastatic NSCLC who were eligible for systemic treatment and could undergo PET/CT evaluation.

Radiotherapy Planning and Molecular Imaging in Lung Cancer

INTRODUCTION

In patients suitable for radical chemoradiotherapy for lung cancer, 18F-FDGPET/ CT is a proposed management to improve the accuracy of high dose radiotherapy. However, there is a high rate of locoregional failure in patients with locally advanced non-small cell lung cancer (NSCLC), probably due to the fact that standard dosing may not be effective in all patients. The aim of the present review was to address some criticisms associated with the radiotherapy image-guided in NSCLC.

MATERIALS AND METHODS

A systematic literature search was conducted. Only published articles that met the following criteria were included: articles, only original papers, radiopharmaceutical ([18F]FDG and any tracer other than [18F]FDG), target, only specific for lung cancer radiotherapy planning, and experimental design (eventually "in vitro" studies were excluded). Peer-reviewed indexed journals, regardless of publication status (published, ahead of print, in press, etc.) were included. Reviews, case reports, abstracts, editorials, poster presentations, and publications in languages other than English were excluded. The decision to include or exclude an article was made by consensus and any disagreement was resolved through discussion.

RESULTS

Hundred eligible full-text articles were assessed. Diverse information is now available in the literature about the role of FDG and new alternative radiopharmaceuticals for the planning of radiotherapy in NSCLC. In particular, the role of alternative technologies for the segmentation of FDG uptake is essential, although indeterminate for RT planning. The pros and cons of the available techniques have been extensively reported.

CONCLUSION

PET/CT has a central place in the planning of radiotherapy for lung cancer and, in particular, for NSCLC assuming a substantial role in the delineation of tumor volume. The development of new radiopharmaceuticals can help overcome the problems related to the disadvantage of FDG to accumulate also in activated inflammatory cells, thus improving tumor characterization and providing new prognostic biomarkers.

Molecular Imaging in Photon Radiotherapy

Nowadays, more than ever before, the treatment of cancer patients requires an interdisciplinary approach more than ever. Radiation therapy (RT) has become an indispensable pillar of cancer treatment early on, offering a local, curative treatment option and symptom control in palliative cases.

Metachronous mediastinal and lung metastases from head and neck cancer: A case series, literature review and considerations for treatment

Metachronous mediastinal and lung metastases (MMLM), important sources of morbidity and mortality, in people with head and neck cancer (HNC) have received little attention. Between 1980 and 2004, 37 patients with treated HNC and MMLM diagnosed on follow-up imaging (with histological confirmation in 14 cases) were identified. The median interval from diagnosis of HNC to the appearance of MMLM was 14.5 months. The overall median survival was 4 months, and the 1-year crude survival rate (CSR) was 16%. A meaningful difference in the 1-year CSRs between the palliative radiation treated and untreated subjects (39% and 4%, respectively, p < 0.01) was observed. Because associated costs of health care utilization are considerable, and yet survival is limited, optimum management of MMLM-HNC with improvement of prognosis remains a challenge.

Guidance on the use of PET for treatment planning in radiotherapy clinical trials

The aim of this article is to propose meaningful guidance covering the practical and technical issues involved when planning or conducting clinical trials involving positron emission tomography (PET)-guided radiotherapy. The complexity of imaging requirements will depend on the study aims, design and PET methods used. Where PET is used to adapt radiotherapy, a high level of accuracy and reproducibility is required to ensure effective and safe treatment delivery. The guidance in this document is intended to assist researchers designing clinical trials involving PET-guided radiotherapy to provide sufficient information about the appropriate methods to complete PET-CT imaging to a consistent standard at participating centres. The guidance is divided into six categories: application of PET in radiotherapy, resource requirements, quality assurance, imaging protocol design, data management and image processing. Each section provides an overview of the recent literature to support the specific recommendations. This guidance builds on previous recommendations from the National Cancer Research Institute PET Research Network and has been produced in collaboration with the National Radiotherapy Trials Quality Assurance Group.

Task Group 174 Report: Utilization of [18 F]Fluorodeoxyglucose Positron Emission Tomography ([18 F]FDG-PET) in Radiation Therapy

The use of positron emission tomography (PET) in radiation therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning, and response assessment. The most common radiotracer is ¹⁸ F-fluorodeoxyglucose ([¹⁸ F]FDG), a glucose analog with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [¹⁸ F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning, and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between interpatient scans and intrapatient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [¹⁸ F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [¹⁸ F]FDG-PET for RT.

Positron emission tomography with computed tomography imaging (PET/CT) for the radiotherapy planning definition of the biological target volume: PART 2

AIM

Positron Emission Tomography with Computed Tomography (PET/CT) has been proven to be useful in the definition of Radiotherapy (RT) target volume. In this regard, the present expert review summarizes existing data for pancreas, prostate, gynecological and rectum/anal cancer.

METHODS

A comprehensive search of published original article was made, based on SCOPUS and PubMed database, selecting the paper that evaluated the role of PET/CT in the definition of RT volume.

RESULTS

FDG-PET has an important and promising role for pancreatic cancer. Choline PET/CT could be useful for identifying high-risk volumes for prostate cancer; while PSMA PET/CT is still under evaluation. FDG PET/CT in gynecological cancers has been shown to impact external-beam RT planning. The role of FDG-PET for Gross Tumor volume identification is crucial, representing a useful and powerful tool for anal and rectal cancer.

CONCLUSION

Taken together, molecular and functional imaging approaches offer a major step to individualize radiotherapeutic approach.

PET/MRI-guided GTV delineation during radiotherapy planning in patients with squamous cell carcinoma of the tongue

Purpose

The aim of the study was to evaluate the usefulness and accuracy of 18-fluorine-labeled fluorodeoxyglucose (PET) and magnetic resonance imaging (MRI) hybrid in gross tumor volume (GTV) delineation during radiotherapy planning in patients with carcinoma of the tongue.

Methods

Ten patients with squamous cell carcinoma (SCC) of the tongue underwent computed tomography (CT) and PET/MRI examination. The GTV for primary tumor and lymph nodes (nGTV) were defined on CT (GTV-CT) and compared to GTVs obtained from PET (GTV-PET) and MRI (GTV-MRI) images. Two methods of GTV determination were used: visual interpretation of CT, PET (GTV-PET_vis) and MRI images and quantitative automatic method (Syngovia, Siemens) based on a chosen threshold value (20%, 30%, 40%, 50%) of standardized uptake values (SUV_max) from PET examination (GTV-PET_20%, GTV-PET_30%, etc.). Statistical analysis of differences in GTV values obtained from CT, PET and MRI studies was performed. GTV-CT was used as a reference.

Results

In all, 80% of GTV-MRI and 40% of GTV-PET_vis were larger than GTV-CT. Respectively, 20% of GTV-MRI and 60% of GTV-PET_vis were smaller than GTV-CT. Taking into account all threshold measurements, 70% of volumes were smaller than GTV-CT. GTV-PET_30% were the most closely related volumes to GTV-CT from all threshold methods in 50% of patients. GTV-PET_vis generated the most similar volumes in relation to GTV-CT from all PET measurements. Statistical analysis confirmed those results. Compared to nGTV-CT, 70% of nGTV-MRI and 20% of nGTV-PET_vis were larger. The remaining nGTV-MRI and nGTV-PET_vis measurements were smaller than nGTV-CT. Measurements of all thresholds nGTVs were smaller than nGTV-CTV in 52.5% of cases. nGTV-PET_20% were the most closely related volumes to nGTV-CT in 40% of the cases. Statistical analysis showed that nGTV-PET_20% (p = 0.0468), nGTV-PET_vis (p = 0.0166), and nGTV-PET_50% (p = 0.0166) diverge significantly from nGTV-CT results. nGTV-MRI (p = 0.1141), nGTV-PET_30% (p = 0.2845), and nGTV-PET_40% (p = 0.5076) were significantly related with nGTV-CT.

Conclusion

Combination of PET/MRI provides more information during target tumor mass delineation in radiotherapy planning of patients with SCC of the tongue than other standard imaging methods. The most frequently matching threshold value was 30% of SUV_max for primary tumor delineation and 30–40% of SUV_max for nGTV determination.

Electronic supplementary material

The online version of this article (10.1007/s00066-019-01480-3) contains supplementary material, which is available to authorized users.

ICORG 06-35: a prospective evaluation of PET-CT scan in patients with non-operable or non-resectable non-small cell lung cancer treated by radical 3-dimensional conformal radiation therapy: a phase II study

BACKGROUND

Radiotherapy (RT) is a key treatment modality in the curative treatment of patients with non-small cell lung cancer (NSCLC). Incorrect definition of the gross, or clinical, target volume is a common source of error which can lead to a reduced probability of tumour control.

OBJECTIVE

This was a pilot and a phase II study. The pilot evaluated the technical feasibility of integrating positron emission tomography-computed tomography (PET-CT) fusion. The primary outcome of the phase II study was to evaluate the safety of PET-CT scan-based RT by evaluating the rate of loco-regional recurrence outside the PET-CT planning target volume (PTV) but within conventional 3-D PTV.

METHODS

Patients underwent standard post-treatment follow-up, including repeated three monthly CT scans of the thorax. In case of loco-regional recurrence, three categories were considered, with only extra-PET scan PTV and intra-CT scan PTV recurrences considered as a failure. Our hypothesis was that the rate of these events would be < 10%.

RESULTS

Twelve patients were recruited; the study closed early due to poor recruitment. The primary endpoint of the pilot was met; it was feasible to deliver a PET-CT-based plan to ≥ 60% of patients. Two patients had intra-PET scan PTV recurrences, six had extra-PET scan PTV and extra-CT, and three patients had both. Another patient had extra-PET scan PTV and extra-CT as well as extra-PET scan PTV and intra-CT scan PTV recurrence.

CONCLUSION/ADVANCES IN KNOWLEDGE

PET-based planning has the potential to reduce radiation treatment volumes because of the avoidance of mediastinal lymph nodes that are PET negative.

How rapid advances in imaging are defining the future of precision radiation oncology

Imaging has an essential role in the planning and delivery of radiotherapy. Recent advances in imaging have led to the development of advanced radiotherapy techniques—including image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy and proton beam therapy. The optimal use of imaging might enable higher doses of radiation to be delivered to the tumour, while sparing normal surrounding tissues. In this article, we review how the integration of existing and novel forms of computed tomography, magnetic resonance imaging and positron emission tomography have transformed tumour delineation in the radiotherapy planning process, and how these advances have the potential to allow a more individualised approach to the cancer therapy. Recent data suggest that imaging biomarkers that assess underlying tumour heterogeneity can identify areas within a tumour that are at higher risk of radio-resistance, and therefore potentially allow for biologically focussed dose escalation. The rapidly evolving concept of adaptive radiotherapy, including artificial intelligence, requires imaging during treatment to be used to modify radiotherapy on a daily basis. These advances have the potential to improve clinical outcomes and reduce radiation-related long-term toxicities. We outline how recent technological advances in both imaging and radiotherapy delivery can be combined to shape the future of precision radiation oncology.

Polyphosphoester-Based Nanocarrier for Combined Radio-Photothermal Therapy of Breast Cancer

Recently, clinical research on tumor therapy has gradually shifted from traditional monotherapy toward combination therapy as tumors are complex, diverse, and heterogeneous. Combination therapy may be essential for achieving the optimized treatment efficacy of tumors through distinct tumor-inhibiting mechanisms. At the same time, nanocarriers are emerging as an excellent strategy for delivering both drugs simultaneously. This work presents utilization of a polyphosphoester-based nanocarrier (NP_IR/Cur) to achieve the codelivery of hydrophobic photothermal agent IR-780 and radiosensitizer curcumin (Cur). The IR-780 and curcumin coencapsulated NP_IR/Cur exhibited adequate drug loading, a prolonged blood half-life, enhanced passive tumor homing, and improved curcumin bioavailability as well as combined therapeutic functions. Briefly, NP_IR/Cur could not only achieve effective thermal ablation through the conversion of near-infrared light to heat, but also give rise to a significant boosted local radiation dose to trigger promoted radiation damages, thus resulting in enhanced tumor cell growth inhibition. In conclusion, the as-prepared NP_IR/Cur manifested excellent performance in facilitating combined photothermal and radiation therapy, thus expanding the application range of PPE-based carriers in nanomedicine, and also prompting exploration of their potential for other effective combination therapies.

The Path Toward PET-Guided Radiation Therapy for Glioblastoma in Laboratory Animals: A Mini Review

Glioblastoma is the most aggressive and malignant primary brain tumor in adults. Despite the current state-of-the-art treatment, which consists of maximal surgical resection followed by radiation therapy, concomitant, and adjuvant chemotherapy, progression remains rapid due to aggressive tumor characteristics. Several new therapeutic targets have been investigated using chemotherapeutics and targeted molecular drugs, however, the intrinsic resistance to induced cell death of brain cells impede the effectiveness of systemic therapies. Also, the unique immune environment of the central nervous system imposes challenges for immune-based therapeutics. Therefore, it is important to consider other approaches to treat these tumors. There is a well-known dose-response relationship for glioblastoma with increased survival with increasing doses, but this effect seems to cap around 60 Gy, due to increased toxicity to the normal brain. Currently, radiation treatment planning of glioblastoma patients relies on CT and MRI that does not visualize the heterogeneous nature of the tumor, and consequently, a homogenous dose is delivered to the entire tumor. Metabolic imaging, such as positron-emission tomography, allows to visualize the heterogeneous tumor environment. Using these metabolic imaging techniques, an approach called dose painting can be used to deliver a higher dose to the tumor regions with high malignancy and/or radiation resistance. Preclinical studies are required for evaluating the benefits of novel radiation treatment strategies, such as PET-based dose painting. The aim of this review is to give a brief overview of promising PET tracers that can be evaluated in laboratory animals to bridge the gap between PET-based dose painting in glioblastoma patients.

[Chemoradiation for oesophageal cancer: A critical review of the literature]

Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4Gy to 45Gy for a preoperative strategy or 50 to 50.4Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.

Effect of PET/CT standardized uptake values on complete response to treatment before definitive chemoradiotherapy in stage III non-small cell lung cancer

PURPOSE

The standard treatment for patients with stage III non-small cell lung cancer (NSCLC), unsuitable for resection and with good performance, is definitive radiotherapy with cisplatin-based chemotherapy. Our aim is to evaluate the effect of the maximum value of standardized uptake values (SUVmax) of the primary tumor in positron emission tomography-computed tomography (PET/CT) before treatment on complete response (CR) and overall survival.

METHODS

The data of 73 stage III NSCLC patients treated with concurrent definitive chemoradiotherapy (CRT) between 2008 and 2017 and had PET/CT staging in the pretreatment period were evaluated. ROC curve analysis was performed to determine the ideal cut-off value of pretreatment SUVmax to predict CR.

RESULTS

Median age was 58 years (range 27-83 years) and 66 patients were male (90.4%). Median follow-up time was 18 months (range 3-98 months); median survival was 23 months. 1-year overall survival (OS) rate and 5-year OS rate were 72 and 19%, respectively. Median progression-free survival (PFS) was 9 months; 1-year PFS rate and 5-year PFS rate were 38 and 19%, respectively. The ideal cut-off value of pretreatment SUVmax that predicted the complete response of CRT was 12 in the ROC analysis [AUC 0.699 (0.550-0.833)/P < 0.01] with a sensitivity of 83%, and specificity of 55%. In patients with SUVmax < 12, CR rate was 60%, while, in patients with SUV ≥ 12, it was only 19% (P = 0.002). Median OS was 26 months in patients with pretreatment SUVmax < 12, and 21 months in patients with SUVmax ≥ 12 (HR = 2.93; 95% CI 17.24-28.75; P = 0.087). CR rate of the whole patient population was 26%, and it was the only factor that showed a significant benefit on survival in both univariate and multivariate analyses.

CONCLUSION

Pretreatment SUVmax of the primary tumor in PET/CT may predict CR in stage III NSCLC patients who were treated with definitive CRT. Having clinical CR is the only positive predictive factor for prolonged survival.

The developing role of FDG PET imaging for prognostication and radiotherapy target volume delineation in non-small cell lung cancer

Advancements in functional imaging technology have allowed new possibilities in contouring of target volumes, monitoring therapy, and predicting treatment outcome in non-small cell lung cancer (NSCLC). Consequently, the role of ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) has expanded in the last decades from a stand-alone diagnostic tool to a versatile instrument integrated with computed tomography (CT), with a prominent role in lung cancer radiotherapy. This review outlines the most recent literature on developments in FDG PET imaging for prognostication and radiotherapy target volume delineation (TVD) in NSCLC. We also describe the challenges facing the clinical implementation of these developments and present new ideas for future research.

Lung Cancer: Posttreatment Imaging: Radiation Therapy and Imaging Findings

Over the last few decades, advances in radiation therapy technology have markedly improved radiation delivery. Advancements in treatment planning with the development of image-guided radiotherapy and techniques such as proton therapy, allow precise delivery of high doses of radiation conformed to the tumor. These advancements result in improved locoregional control while reducing radiation dose to surrounding normal tissue. The radiologic manifestations of these techniques can differ from radiation induced lung disease seen with traditional radiation therapy. Awareness of these radiologic manifestations and correlation with radiation treatment plans are important to differentiate expected radiation induced lung injury from recurrence, infection and drug toxicity.