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Zhao Y, Haworth A, Rowshanfarzad P, Ebert MA. Focal Boost in Prostate Cancer Radiotherapy: A Review of Planning Studies and Clinical Trials. Cancers (Basel) 2023; 15:4888. [PMID: 37835581 PMCID: PMC10572027 DOI: 10.3390/cancers15194888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/28/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Focal boost radiotherapy was developed to deliver elevated doses to functional sub-volumes within a target. Such a technique was hypothesized to improve treatment outcomes without increasing toxicity in prostate cancer treatment. PURPOSE To summarize and evaluate the efficacy and variability of focal boost radiotherapy by reviewing focal boost planning studies and clinical trials that have been published in the last ten years. METHODS Published reports of focal boost radiotherapy, that specifically incorporate dose escalation to intra-prostatic lesions (IPLs), were reviewed and summarized. Correlations between acute/late ≥G2 genitourinary (GU) or gastrointestinal (GI) toxicity and clinical factors were determined by a meta-analysis. RESULTS By reviewing and summarizing 34 planning studies and 35 trials, a significant dose escalation to the GTV and thus higher tumor control of focal boost radiotherapy were reported consistently by all reviewed studies. Reviewed trials reported a not significant difference in toxicity between focal boost and conventional radiotherapy. Acute ≥G2 GU and late ≥G2 GI toxicities were reported the most and least prevalent, respectively, and a negative correlation was found between the rate of toxicity and proportion of low-risk or intermediate-risk patients in the cohort. CONCLUSION Focal boost prostate cancer radiotherapy has the potential to be a new standard of care.
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Affiliation(s)
- Yutong Zhao
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, WA 6000, Australia
| | - Martin A. Ebert
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- 5D Clinics, Claremont, WA 6010, Australia
- School of Medicine and Population Health, University of Wisconsin, Madison WI 53706, USA
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Gorovets D, Wibmer AG, Moore A, Lobaugh S, Zhang Z, Kollmeier M, McBride S, Zelefsky MJ. Local Failure after Prostate SBRT Predominantly Occurs in the PI-RADS 4 or 5 Dominant Intraprostatic Lesion. Eur Urol Oncol 2023; 6:275-281. [PMID: 35307323 PMCID: PMC9481979 DOI: 10.1016/j.euo.2022.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/07/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND A positive post-treatment prostate biopsy following definitive radiotherapy carries significant prognostic implications. OBJECTIVE To determine whether local recurrences after prostate stereotactic body radiation therapy (SBRT) are associated with the presence of and occur more commonly within the region of a PI-RADS 4 or 5 dominant intra-prostatic lesion (DIL) identified on pre-treatment multi-parametric magnetic resonance imaging (MRI). DESIGN, SETTING, AND PARTICIPANTS 247 patients with localized prostate cancer treated with SBRT at our institution from 2009-2018 underwent post-treatment biopsies (median time to biopsy: 2.2 years) to evaluate local control. INTERVENTIONS Prostate SBRT (median 40 Gy in 5 fractions). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS MRIs were read by a single diagnostic radiologist blinded to other patient characteristics and treatment outcomes. The DIL presence, size, location, and extent were then analyzed to determine associations with the post-treatment biopsy outcomes. RESULTS AND LIMITATIONS Among patients who underwent post-treatment biopsies, 39/247 (15.8%) were positive for Gleason-gradable prostate adenocarcinoma, of which 35/39 (90%) had a DIL initially present and 29/39 (74.4%) had a positive biopsy within the DIL. Factors independently associated with post-treatment biopsy outcomes included the presence of a DIL (OR 6.95; p = 0.001), radiographic T3 disease (OR 5.23, p < 0.001), SBRT dose ≥40 Gy (OR 0.26, p = 0.003), and use of androgen deprivation therapy (ADT; OR 0.28, p = 0.027). Among patients with a DIL (N = 149), the only factors associated with post-treatment biopsy outcomes included ≥50% percent cores positive (OR 2.4, p = 0.037), radiographic T3 disease (OR 4.04, p = 0.001), SBRT dose ≥40 Gy (OR 0.22, p < 0.001), and use of ADT (OR 0.21, p = 0.014). CONCLUSIONS Our results suggest that men with PI-RADS 4 or 5 DILs have a higher risk of local recurrence after prostate SBRT and that most recurrences are located within the DIL. PATIENT SUMMARY We found the presence of a dominant tumor on pre-treatment MRI was strongly associated with residual cancer within the prostate after SBRT and that most recurrences were within the dominant tumor.
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Affiliation(s)
- Daniel Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Andreas G Wibmer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Assaf Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stephanie Lobaugh
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer, New York, NY, USA
| | - Marisa Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Moerland MA, van Schelven LJ, van Lier A, Boskovic E, Peters M, van Son MJ, van der Voort van Zyp JRN, Lagendijk JJW. MR compatibility, safety and accuracy of the redesigned UMC Utrecht single needle implant device. Phys Med Biol 2021; 66. [PMID: 34010820 DOI: 10.1088/1361-6560/ac02d5] [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: 12/31/2020] [Accepted: 05/19/2021] [Indexed: 11/11/2022]
Abstract
Purpose. The Utrecht single needle implant device (SNID) was redesigned to increase needle insertion velocity. The purpose of this study is to evaluate the magnetic resonance compatibility, safety and accuracy of the implant device preparing its application in a patient study to investigate the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.Methods. Several experiments were performed to evaluate the mechanical and radiofrequency safety of the needle system, the magnetic field perturbation, the calibration of the implant device in the MR coordinate system, functioning of the implant device during imaging and accuracy of needle insertion.Results. Endurance experiments showed the mechanical safety of the needle system. Magnetic field perturbation was acceptable with induced image distortions smaller than 0.5 mm for clinical MR sequences. Calibration of the implant device in the MR coordinate system was reproducible with average error (mean±standard deviation) of 0.2 ± 0.4 mm, 0.1 ± 0.3 mm and 0.6 ± 0.6 mm in thex,y- andz- direction, respectively. The RF safety measurement showed for clinical MR imaging sequences maximum temperature rises of 0.2 °C at the entry and tip points of the needle. Simultaneous functioning of the implant device and imaging is possible albeit with some intensity band artifacts in the fast field echo images. Finally, phantom measurements showed deviations amounting 2.5-3.6 mm measured as target-to-needle distance at a depth of 12 cm.Conclusions. This preclinical evaluation showed that the MR compatibility, safety and accuracy of the redesigned UMC Utrecht SNID allow its application in a patient study on the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.
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Affiliation(s)
- M A Moerland
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - L J van Schelven
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, The Netherlands
| | - A van Lier
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - E Boskovic
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, The Netherlands
| | - M Peters
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - M J van Son
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | | | - J J W Lagendijk
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
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Wang Q, Pérez-Carrillo GJG, Ponisio MR, LaMontagne P, Dahiya S, Marcus DS, Milchenko M, Shimony J, Liu J, Chen G, Salter A, Massoumzadeh P, Miller-Thomas MM, Rich KM, McConathy J, Benzinger TLS, Wang Y. Heterogeneity Diffusion Imaging of gliomas: Initial experience and validation. PLoS One 2019; 14:e0225093. [PMID: 31725772 PMCID: PMC6855653 DOI: 10.1371/journal.pone.0225093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 10/29/2019] [Indexed: 12/05/2022] Open
Abstract
Objectives Primary brain tumors are composed of tumor cells, neural/glial tissues, edema, and vasculature tissue. Conventional MRI has a limited ability to evaluate heterogeneous tumor pathologies. We developed a novel diffusion MRI-based method—Heterogeneity Diffusion Imaging (HDI)—to simultaneously detect and characterize multiple tumor pathologies and capillary blood perfusion using a single diffusion MRI scan. Methods Seven adult patients with primary brain tumors underwent standard-of-care MRI protocols and HDI protocol before planned surgical resection and/or stereotactic biopsy. Twelve tumor sampling sites were identified using a neuronavigational system and recorded for imaging data quantification. Metrics from both protocols were compared between World Health Organization (WHO) II and III tumor groups. Cerebral blood volume (CBV) derived from dynamic susceptibility contrast (DSC) perfusion imaging was also compared with the HDI-derived perfusion fraction. Results The conventional apparent diffusion coefficient did not identify differences between WHO II and III tumor groups. HDI-derived slow hindered diffusion fraction was significantly elevated in the WHO III group as compared with the WHO II group. There was a non-significantly increasing trend of HDI-derived tumor cellularity fraction in the WHO III group, and both HDI-derived perfusion fraction and DSC-derived CBV were found to be significantly higher in the WHO III group. Both HDI-derived perfusion fraction and slow hindered diffusion fraction strongly correlated with DSC-derived CBV. Neither HDI-derived cellularity fraction nor HDI-derived fast hindered diffusion fraction correlated with DSC-derived CBV. Conclusions Conventional apparent diffusion coefficient, which measures averaged pathology properties of brain tumors, has compromised accuracy and specificity. HDI holds great promise to accurately separate and quantify the tumor cell fraction, the tumor cell packing density, edema, and capillary blood perfusion, thereby leading to an improved microenvironment characterization of primary brain tumors. Larger studies will further establish HDI’s clinical value and use for facilitating biopsy planning, treatment evaluation, and noninvasive tumor grading.
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Affiliation(s)
- Qing Wang
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | | | - Maria Rosana Ponisio
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Pamela LaMontagne
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Daniel S. Marcus
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Mikhail Milchenko
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Joshua Shimony
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jingxia Liu
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Gengsheng Chen
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Amber Salter
- Department of Biostatistics, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Parinaz Massoumzadeh
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Michelle M. Miller-Thomas
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Keith M. Rich
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jonathan McConathy
- Department of Radiology, Division of Molecular Imaging and Therapeutics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Tammie L. S. Benzinger
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Yong Wang
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, United States of America
- * E-mail:
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Lee J, Carver E, Feldman A, Pantelic MV, Elshaikh M, Wen N. Volumetric and Voxel-Wise Analysis of Dominant Intraprostatic Lesions on Multiparametric MRI. Front Oncol 2019; 9:616. [PMID: 31334128 PMCID: PMC6624674 DOI: 10.3389/fonc.2019.00616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction: Multiparametric MR imaging (mpMRI) has shown promising results in the diagnosis and localization of prostate cancer. Furthermore, mpMRI may play an important role in identifying the dominant intraprostatic lesion (DIL) for radiotherapy boost. We sought to investigate the level of correlation between dominant tumor foci contoured on various mpMRI sequences. Methods: mpMRI data from 90 patients with MR-guided biopsy-proven prostate cancer were obtained from the SPIE-AAPM-NCI Prostate MR Classification Challenge. Each case consisted of T2-weighted (T2W), apparent diffusion coefficient (ADC), and Ktrans images computed from dynamic contrast-enhanced sequences. All image sets were rigidly co-registered, and the dominant tumor foci were identified and contoured for each MRI sequence. Hausdorff distance (HD), mean distance to agreement (MDA), and Dice and Jaccard coefficients were calculated between the contours for each pair of MRI sequences (i.e., T2 vs. ADC, T2 vs. Ktrans, and ADC vs. Ktrans). The voxel wise spearman correlation was also obtained between these image pairs. Results: The DILs were located in the anterior fibromuscular stroma, central zone, peripheral zone, and transition zone in 35.2, 5.6, 32.4, and 25.4% of patients, respectively. Gleason grade groups 1-5 represented 29.6, 40.8, 15.5, and 14.1% of the study population, respectively (with group grades 4 and 5 analyzed together). The mean contour volumes for the T2W images, and the ADC and Ktrans maps were 2.14 ± 2.1, 2.22 ± 2.2, and 1.84 ± 1.5 mL, respectively. Ktrans values were indistinguishable between cancerous regions and the rest of prostatic regions for 19 patients. The Dice coefficient and Jaccard index were 0.74 ± 0.13, 0.60 ± 0.15 for T2W-ADC and 0.61 ± 0.16, 0.46 ± 0.16 for T2W-Ktrans. The voxel-based Spearman correlations were 0.20 ± 0.20 for T2W-ADC and 0.13 ± 0.25 for T2W-Ktrans. Conclusions: The DIL contoured on T2W images had a high level of agreement with those contoured on ADC maps, but there was little to no quantitative correlation of these results with tumor location and Gleason grade group. Technical hurdles are yet to be solved for precision radiotherapy to target the DILs based on physiological imaging. A Boolean sum volume (BSV) incorporating all available MR sequences may be reasonable in delineating the DIL boost volume.
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Affiliation(s)
- Joon Lee
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Eric Carver
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Aharon Feldman
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Milan V Pantelic
- Department of Radiology, Henry Ford Health System, Detroit, MI, United States
| | - Mohamed Elshaikh
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
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Olsson LE, Johansson M, Zackrisson B, Blomqvist LK. Basic concepts and applications of functional magnetic resonance imaging for radiotherapy of prostate cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 9:50-57. [PMID: 33458425 PMCID: PMC7807726 DOI: 10.1016/j.phro.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/27/2018] [Accepted: 02/08/2019] [Indexed: 12/30/2022]
Abstract
Recently, the interest to integrate magnetic resonance imaging (MRI) in radiotherapy for prostate cancer has increased considerably. MRI can contribute in all steps of the radiotherapy workflow from diagnosis, staging, and target definition to treatment follow-up. Of particular interest is the ability of MRI to provide a wide range of functional measures. The complexity of MRI as an imaging modality combined with the growing interest of the application to prostate cancer radiotherapy, emphasize the need for dedicated education within the radiation oncology community. In this context, an overview of the most common as well as a few upcoming functional MR imaging techniques is presented: the basic methodology and measurement is described, the link between the functional measures and the underlying biology is established, and finally relevant applications of functional MRI useful for prostate cancer radiotherapy are given.
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Affiliation(s)
- Lars E Olsson
- Department of Medical Radiation Physics, Translational Medicine, Lund University, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
| | | | | | - Lennart K Blomqvist
- Department of Radiology, Molecular Medicine and Surgery, Karolinska University, Sweden
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Sun Y, Reynolds HM, Wraith D, Williams S, Finnegan ME, Mitchell C, Murphy D, Haworth A. Voxel-wise prostate cell density prediction using multiparametric magnetic resonance imaging and machine learning. Acta Oncol 2018; 57:1540-1546. [PMID: 29698083 DOI: 10.1080/0284186x.2018.1468084] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are currently no methods to estimate cell density in the prostate. This study aimed to develop predictive models to estimate prostate cell density from multiparametric magnetic resonance imaging (mpMRI) data at a voxel level using machine learning techniques. MATERIAL AND METHODS In vivo mpMRI data were collected from 30 patients before radical prostatectomy. Sequences included T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced imaging. Ground truth cell density maps were computed from histology and co-registered with mpMRI. Feature extraction and selection were performed on mpMRI data. Final models were fitted using three regression algorithms including multivariate adaptive regression spline (MARS), polynomial regression (PR) and generalised additive model (GAM). Model parameters were optimised using leave-one-out cross-validation on the training data and model performance was evaluated on test data using root mean square error (RMSE) measurements. RESULTS Predictive models to estimate voxel-wise prostate cell density were successfully trained and tested using the three algorithms. The best model (GAM) achieved a RMSE of 1.06 (± 0.06) × 103 cells/mm2 and a relative deviation of 13.3 ± 0.8%. CONCLUSION Prostate cell density can be quantitatively estimated non-invasively from mpMRI data using high-quality co-registered data at a voxel level. These cell density predictions could be used for tissue classification, treatment response evaluation and personalised radiotherapy.
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Affiliation(s)
- Yu Sun
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Hayley M. Reynolds
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Darren Wraith
- Institute of Health and Biomedical Innovation Queensland University of Technology, Brisbane, Australia
| | - Scott Williams
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Mary E. Finnegan
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Catherine Mitchell
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Declan Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Annette Haworth
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- School of Physics, The University of Sydney, Sydney, Australia
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Towards intrinsic R2* imaging in the prostate at 3 and 7 tesla. Magn Reson Imaging 2017; 42:16-21. [DOI: 10.1016/j.mri.2017.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/26/2017] [Accepted: 04/30/2017] [Indexed: 12/17/2022]
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Damkjær S, Thomsen JB, Petersen SI, Bangsgaard JP, M. Petersen P, Vogelius IR, Aznar MC. A modeling study of functional magnetic resonance imaging to individualize target definition of seminal vesicles for external beam radiotherapy. Acta Oncol 2017; 56:799-805. [PMID: 28293971 PMCID: PMC5425627 DOI: 10.1080/0284186x.2017.1300684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/24/2017] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pre-treatment magnetic resonance imaging (MRI) can give patient-specific evaluation of suspected pathologically involved volumes in the seminal vesicles (SV) in prostate cancer patients. By targeting this suspicious volume we hypothesize that radiotherapy is more efficient without introducing more toxicity. In this study we evaluate the concept of using MRI-defined target volumes in terms of tumor control probability (TCP) and rectal normal tissue complication probability (NTCP). MATERIAL AND METHODS Twenty-one high-risk prostate cancer patients were included. Pre-treatment CT images, T2 weighted (T2w) MRI and two multi-parametric MRI were acquired. Overlap between a suspicious volume in the SV observed on T2w images and a suspicious volume observed on either multi-parametric MRI was assumed to reflect a true malignant region (named 'MRI positive'). In addition the entire SV on the CT-scan was delineated. Three treatment plans of 2 Gy ×39 fractions were generated per patient: one covering the MRI positive volume in SV and prostate with margin of 11 mm to the MRI positive in the SV and two plans covering prostate and SV using 11 and 7 mm SV margin, respectively. All plans were prescribed the same PTV mean dose. Rectal NTCP grade ≥2 was evaluated with the Lyman-Kutcher-Burman model and TCP was estimated by a logistic model using the combined MRI positive volume in SV and prostate as region-of-interest. RESULTS Fourteen of twenty-one patients were classified as MRI positive, six of which had suspicious volumes in all three MRI modalities. On average TCP for the plan covering prostate and the MRI positive volume was 3% higher (up to 11%) than the two other plans which was statistically significant. The increased TCP was obtained without increasing rectal NTCP grade ≥2. CONCLUSIONS Using functional MRI for individualized target delineation in the SV may improve the treatment outcome in radiotherapy of prostate cancer without increasing the rectal toxicity.
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Affiliation(s)
- Sidsel Damkjær
- Department of Oncology, Section of Radiotherapy, RigshospitaletCopenhagenDenmark
| | - Jakob B. Thomsen
- Department of Oncology, Section of Radiotherapy, RigshospitaletCopenhagenDenmark
| | - Svetlana I. Petersen
- Department of Oncology, Section of Radiotherapy, RigshospitaletCopenhagenDenmark
| | | | - Peter M. Petersen
- Department of Oncology, Section of Radiotherapy, RigshospitaletCopenhagenDenmark
| | - Ivan R. Vogelius
- Department of Oncology, Section of Radiotherapy, RigshospitaletCopenhagenDenmark
| | - Marianne C. Aznar
- Clinical Trial Service Unit – Nuffield Department of Population Health, University of OxfordOxfordUK
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Kumar S, Rai R, Moses D, Choong C, Holloway L, Vinod SK, Liney G. MRI in radiotherapy for lung cancer: A free-breathing protocol at 3T. Pract Radiat Oncol 2017; 7:e175-e183. [DOI: 10.1016/j.prro.2016.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/12/2016] [Accepted: 10/14/2016] [Indexed: 01/22/2023]
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Thorwarth D, Notohamiprodjo M, Zips D, Müller AC. Personalized precision radiotherapy by integration of multi-parametric functional and biological imaging in prostate cancer: A feasibility study. Z Med Phys 2017; 27:21-30. [DOI: 10.1016/j.zemedi.2016.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/18/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
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12
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Pathmanathan AU, Alexander EJ, Huddart RA, Tree AC. The delineation of intraprostatic boost regions for radiotherapy using multimodality imaging. Future Oncol 2016; 12:2495-2511. [PMID: 27322113 DOI: 10.2217/fon-2016-0129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dose escalation to the prostate improves tumor control but at the expense of increased rectal toxicity. Modern imaging can be used to detect the most common site of recurrence, the intraprostatic lesion (IPL), which has led to the concept of focusing dose escalation to the IPL in order to improve the therapeutic ratio. Imaging must be able to detect lesions with adequate sensitivity and specificity to accurately delineate the IPL. This information must be carefully integrated into the radiotherapy planning process to ensure the dose is targeted to the IPL. This review will consider the role and challenges of multiparametric MRI and PET computed tomography in delineating a tumor boost to be delivered by external beam radiotherapy.
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Affiliation(s)
| | - Emma J Alexander
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
| | - Robert A Huddart
- The Institute of Cancer Research, 123 Old Brompton Road, London, SW7 3RP, UK
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
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13
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Guo L, Wang G, Feng Y, Yu T, Guo Y, Bai X, Ye Z. Diffusion and perfusion weighted magnetic resonance imaging for tumor volume definition in radiotherapy of brain tumors. Radiat Oncol 2016; 11:123. [PMID: 27655356 PMCID: PMC5031292 DOI: 10.1186/s13014-016-0702-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 09/13/2016] [Indexed: 12/12/2022] Open
Abstract
Accurate target volume delineation is crucial for the radiotherapy of tumors. Diffusion and perfusion magnetic resonance imaging (MRI) can provide functional information about brain tumors, and they are able to detect tumor volume and physiological changes beyond the lesions shown on conventional MRI. This review examines recent studies that utilized diffusion and perfusion MRI for tumor volume definition in radiotherapy of brain tumors, and it presents the opportunities and challenges in the integration of multimodal functional MRI into clinical practice. The results indicate that specialized and robust post-processing algorithms and tools are needed for the precise alignment of targets on the images, and comprehensive validations with more clinical data are important for the improvement of the correlation between histopathologic results and MRI parameter images.
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Affiliation(s)
- Lu Guo
- Department of Biomedical Engineering, Tianjin University, Tianjin, 300072, China
| | - Gang Wang
- Department of Biomedical Engineering, Tianjin University, Tianjin, 300072, China
| | - Yuanming Feng
- Department of Biomedical Engineering, Tianjin University, Tianjin, 300072, China. .,Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China. .,Department of Radiation Oncology, East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA.
| | - Tonggang Yu
- Department of Radiology, Huashan hospital, Fudan University, Shanghai, 200040, China
| | - Yu Guo
- Department of Biomedical Engineering, Tianjin University, Tianjin, 300072, China
| | - Xu Bai
- Department of Radiology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China
| | - Zhaoxiang Ye
- Department of Radiology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060, China
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14
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Abstract
CLINICAL/METHODICAL ISSUE The aim of magnetic resonance imaging (MRI) guided radiotherapy is high precision in treatment delivery. With new developments it is possible to focus the high dose irradiation on the tumor while sparing the surrounding tissue. The achievements in precision of the treatment planning and delivery warrant equally precise tumor definition. STANDARD RADIOLOGICAL METHODS In conventional radiation therapy it is necessary to carry out a planning computed tomography (CT). For many tumors there is also need for an additional morphological MRI because of more accurate tumor definition. In standard radiotherapy the tumor volume is irradiated with a homogeneous dose. METHODICAL INNOVATIONS The aim of functional multiparametric MRI is to visualize and quantify biological, physiological and pathological processes at the cellular and molecular levels. Based on this information it is possible to elucidate tumor biology and identify subvolumes of more aggressive behavior. They are often radiotherapy-resistant, leading to tumor recurrence thus requiring further dose escalation. The concept of inhomogeneous tumor irradiation according to its biological behavior is called dose painting. PERFORMANCE Dose painting is technically feasible. The expected clinical benefit is motivated by selective treatment adaptations based on biological tumor characteristics. Tumors show variable response to therapy underlining the need for individual treatment plans. This approach may lead not only to higher local control but also to better sparing of normal surrounding tissue. ACHIEVEMENTS With the clinical implementation of dose painting, improvements in the therapeutic outcome can be expected. PRACTICAL RECOMMENDATIONS Due to the existing technical challenges, extensive collaboration between radiation oncologists, radiologists, medical physicists and radiation biologists is needed.
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Affiliation(s)
- P Georg
- EBG MedAustron GmbH, Marie-Curie-Straße 5, 2700, Wiener Neustadt, Österreich. .,Christian Doppler Labor für die Medizinische Strahlenforschung, Medizinische Universität Wien, Wien, Österreich.
| | - P Andrzejewski
- Christian Doppler Labor für die Medizinische Strahlenforschung, Medizinische Universität Wien, Wien, Österreich.,Abteilung für medizinische Strahlenphysik, Univ. Klinik für Strahlentherapie, Medizinische Universität Wien, Wien, Österreich
| | - K Pinker
- Christian Doppler Labor für die Medizinische Strahlenforschung, Medizinische Universität Wien, Wien, Österreich.,Abteilung für molekulare Bildgebung, Univ. Klinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Wien, Österreich
| | - D Georg
- Christian Doppler Labor für die Medizinische Strahlenforschung, Medizinische Universität Wien, Wien, Österreich.,Abteilung für medizinische Strahlenphysik, Univ. Klinik für Strahlentherapie, Medizinische Universität Wien, Wien, Österreich
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15
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Lai YL, Wu CY, Chao KSC. Biological imaging in clinical oncology: radiation therapy based on functional imaging. Int J Clin Oncol 2016; 21:626-632. [PMID: 27384183 DOI: 10.1007/s10147-016-1000-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/29/2016] [Indexed: 12/25/2022]
Abstract
Radiation therapy is one of the most effective tools for cancer treatment. In recent years, intensity-modulated radiation therapy has become increasingly popular in that target dose-escalation can be done while sparing adjacent normal tissues. For this reason, the development of measures to pave the way for accurate target delineation is of great interest. With the integration of functional information obtained by biological imaging with radiotherapy, strategies using advanced biological imaging to visualize metabolic pathways and to improve therapeutic index and predict treatment response are discussed in this article.
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Affiliation(s)
- Yo-Liang Lai
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Yi Wu
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - K S Clifford Chao
- China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
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16
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Troost EG, Thorwarth D, Oyen WJ. Imaging-Based Treatment Adaptation in Radiation Oncology. J Nucl Med 2015; 56:1922-9. [DOI: 10.2967/jnumed.115.162529] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/22/2015] [Indexed: 12/13/2022] Open
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17
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Thorwarth D. Functional imaging for radiotherapy treatment planning: current status and future directions-a review. Br J Radiol 2015; 88:20150056. [PMID: 25827209 PMCID: PMC4628531 DOI: 10.1259/bjr.20150056] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In recent years, radiotherapy (RT) has been subject to a number of technological innovations. Today, RT is extremely flexible, allowing irradiation of tumours with high doses, whilst also sparing normal tissues from doses. To make use of these additional degrees of freedom, integration of functional image information may play a key role (i) for better staging and tumour detection, (ii) for more accurate RT target volume delineation, (iii) to assess functional information about biological characteristics and individual radiation resistance and (iv) to apply personalized dose prescriptions. In this article, we discuss the current status and future directions of different clinically available functional imaging modalities; CT, MRI, positron emission tomography (PET) as well as the hybrid imaging techniques PET/CT and PET/MRI and their potential for individualized RT.
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Affiliation(s)
- D Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
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18
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de Boer J, Wolf AL, Szeto YZ, van Herk M, Sonke JJ. Dynamic Collimator Angle Adjustments During Volumetric Modulated Arc Therapy to Account for Prostate Rotations. Int J Radiat Oncol Biol Phys 2015; 91:1009-16. [DOI: 10.1016/j.ijrobp.2014.11.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 10/22/2014] [Accepted: 11/12/2014] [Indexed: 11/25/2022]
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19
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Review of potential improvements using MRI in the radiotherapy workflow. Z Med Phys 2015; 25:210-20. [PMID: 25779877 DOI: 10.1016/j.zemedi.2014.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 09/20/2014] [Accepted: 11/25/2014] [Indexed: 12/29/2022]
Abstract
The goal of modern radiotherapy is to deliver a lethal amount of dose to tissue volumes that contain a significant amount of tumour cells while sparing surrounding unaffected or healthy tissue. Online image guided radiotherapy with stereotactic ultrasound, fiducial-based planar X-ray imaging or helical/conebeam CT has dramatically improved the precision of radiotherapy, with moving targets still posing some methodical problems regarding positioning. Therefore, requirements for precise target delineation and identification of functional body structures to be spared by high doses become more evident. The identification of areas of relatively radioresistant cells or areas of high tumor cell density is currently under development. This review outlines the state of the art of MRI integration into treatment planning and its importance in follow up and the quantification of biological effects. Finally the current state of the art of online imaging for patient positioning will be outlined and indications will be given what the potential of integrated radiotherapy/online MRI systems is.
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20
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Lagendijk JJW, Raaymakers BW, Van den Berg CAT, Moerland MA, Philippens ME, van Vulpen M. MR guidance in radiotherapy. Phys Med Biol 2014; 59:R349-69. [PMID: 25322150 DOI: 10.1088/0031-9155/59/21/r349] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Jan J W Lagendijk
- Department of Radiotherapy, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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21
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Crook J, Ots A, Gaztañaga M, Schmid M, Araujo C, Hilts M, Batchelar D, Parker B, Bachand F, Milette MP. Ultrasound-planned high-dose-rate prostate brachytherapy: Dose painting to the dominant intraprostatic lesion. Brachytherapy 2014; 13:433-41. [PMID: 24958556 DOI: 10.1016/j.brachy.2014.05.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/07/2014] [Accepted: 05/01/2014] [Indexed: 11/27/2022]
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22
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Alber M, Thorwarth D. Multi-modality functional image guided dose escalation in the presence of uncertainties. Radiother Oncol 2014; 111:354-9. [PMID: 24880742 DOI: 10.1016/j.radonc.2014.04.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/22/2014] [Accepted: 04/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE In order to increase local tumour control by radiotherapy without increasing toxicity, it appears promising to harness functional imaging (FI) to guide dose to sub-volumes of the target with a high tumour load and perhaps de-escalate dose to low risk volumes, in order to maximise the efficiency of the deposited radiation dose. METHODS AND MATERIALS A number of problems have to be solved to make focal dose escalation (FDE) efficient and safe: (1) how to combine ambiguous information from multiple imaging modalities; (2) how to take into account uncertainties of FI based tissue classification; (3) how to account for geometric uncertainties in treatment delivery; (4) how to add complementary FI modalities to an existing scheme. A generic optimisation concept addresses these points and is explicitly designed for clinical efficacy and for lowering the implementation threshold to FI-guided FDE. It combines classic tumour control probability modelling with a multi-variate logistic regression model of FI accuracy and an uncomplicated robust optimisation method. RESULTS Its key elements are (1) that dose is deposited optimally when it achieves equivalent expected effect everywhere in the target volume and (2) that one needs to cap the certainty about the absence of tumour anywhere in the target region. For illustration, an example of a PET/MR-guided FDE in prostate cancer is given. CONCLUSIONS FDE can be safeguarded against FI uncertainties, at the price of a limit on the sensible dose escalation.
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Affiliation(s)
- Markus Alber
- Department of Oncology, Aarhus University, Denmark.
| | - Daniela Thorwarth
- Department for Radiation Oncology, Eberhard Karls University Tübingen, Germany
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23
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Potential interest of developing an integrated boost dose escalation for stereotactic irradiation of primary prostate cancer. Phys Med 2014; 30:320-5. [DOI: 10.1016/j.ejmp.2013.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 09/19/2013] [Accepted: 09/23/2013] [Indexed: 12/31/2022] Open
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24
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Borren A, Groenendaal G, Moman MR, Boeken Kruger AE, van Diest PJ, van Vulpen M, Philippens MEP, van der Heide UA. Accurate prostate tumour detection with multiparametric magnetic resonance imaging: dependence on histological properties. Acta Oncol 2014; 53:88-95. [PMID: 24041257 DOI: 10.3109/0284186x.2013.837581] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND To benefit most of focal treatment of prostate tumours, detection with high precision of all tumour voxels is needed. Although diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) have good diagnostic performance, perfect tumour detection is challenging. In this study, we investigated the variation in prostate tissue characteristics Gleason score (GS), cell density (CD) and microvessel density (MVD) to explain the limitations in tumour voxel detection with a MRI-based logistic regression model. MATERIAL AND METHODS Twelve radical prostatectomy patients underwent a pre-operative 3.0T DWI and DCE-MRI exam. The MRI scans were used to calculate voxel-wise tumour probability with a logistic regression model for the peripheral zone (PZ) of the prostate. Tumour probability maps were correlated and validated with whole-mount histology. Additionally, from the whole-mount histological sections CD, MVD and GS were retrieved for every single voxel. GS, CD and MVD of true- and false-positive voxels and of true- and false-negative voxels were compared using Mann-Whitney U-tests. RESULTS False-negative tumour voxels had significantly lower CD and MVD (p < 0.0001) and were similar to non-tumour PZ. True-positive detected tumour voxels had high CDs and MVDs (p < 0.0001). In addition, tumour voxels with higher GS showed a trend towards more frequent detection (p = 0.06). Tumour voxels with GS ≥ 3 + 4 showed higher CD and MVD compared to tumour voxels with GS 3 + 3 (p < 0.0001). CONCLUSION Tumour voxels with low CD and MVD resemble healthy tissue and are limiting tumour voxel detection using DWI and DCE-MRI. Nevertheless, the most aggressive tumour voxels, containing high CD, MVD and GS, are more likely to be detected and can therefore be treated with high dose using focal therapy or focal boosting.
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Affiliation(s)
- Alie Borren
- Department of Radiotherapy, University Medical Center Utrecht , The Netherlands
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25
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Mason J, Al-Qaisieh B, Bownes P, Wilson D, Buckley DL, Thwaites D, Carey B, Henry A. Multi-parametric MRI-guided focal tumor boost using HDR prostate brachytherapy: a feasibility study. Brachytherapy 2013; 13:137-45. [PMID: 24268487 DOI: 10.1016/j.brachy.2013.10.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 09/25/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE This study investigates the feasibility of delivering focal boost dose to tumor regions, identified with multi-parametric MRI, in high-dose-rate prostate brachytherapy. METHODS AND MATERIALS T2-weighted, diffusion-weighted, and dynamic-contrast-enhanced MRI were acquired the day before treatment and analyzed retrospectively for 15 patients. Twelve patients had hormone therapy before the MRI scan. The tumor was delineated on MRI by a radiologist and registered to treatment planning transrectal ultrasound images. A margin based on analysis of delineation and registration uncertainties was applied to create a focal boost planning target volume (F-PTV). Delivered treatment plans were compared with focal boost plans optimized to increase F-PTV dose as much as allowed by urethral and rectal dose constraints. RESULTS Tumors were delineated in all patients with volumes 0.4-23.0cc. The margin for tumor delineation and image registration uncertainties was estimated to be 4.5 mm. For F-PTV, the focal boost treatment plans increased median D90 from 17.6 to 20.9 Gy and median V150 from 27.3% to 75.9%. CONCLUSIONS MRI-guided high-dose-rate prostate brachytherapy focal tumor boost is feasible-tumor regions can be identified even after hormone therapy, and focal boost dose can be delivered without violating urethral and rectal dose constraints.
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Affiliation(s)
- Josh Mason
- Medical Physics, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust; Division of Medical Physics, University of Leeds.
| | - Bashar Al-Qaisieh
- Medical Physics, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
| | - Peter Bownes
- Medical Physics, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
| | - Dan Wilson
- Medical Physics, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
| | | | - David Thwaites
- Division of Medical Physics, University of Leeds; Institute of Medical Physics, School of Physics, University of Sydney, Australia
| | - Brendan Carey
- Radiology, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
| | - Ann Henry
- Clinical Oncology, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
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26
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Borren A, Moman MR, Groenendaal G, Boeken Kruger AE, van Diest PJ, van der Groep P, van der Heide UA, van Vulpen M, Philippens MEP. Why prostate tumour delineation based on apparent diffusion coefficient is challenging: an exploration of the tissue microanatomy. Acta Oncol 2013; 52:1629-36. [PMID: 23621751 DOI: 10.3109/0284186x.2013.787164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Focal boosting of prostate tumours to improve outcome, requires accurate tumour delineation. For this, the apparent diffusion coefficient (ADC) derived from diffusion-weighted MR imaging (DWI) seems a useful tool. On voxel level, the relationship between ADC and histological presence of tumour is, however, ambiguous. Therefore, in this study the relationship between ADC and histological variables was investigated on voxel level to understand the strengths and limitations of DWI for prostate tumour delineation. MATERIAL AND METHODS Twelve radical prostatectomy patients underwent a pre-operative 3.0T DWI exam and the ADC was calculated. From whole-mount histological sections cell density and glandular area were retrieved for every voxel. The distribution of all variables was described for tumour, peripheral zone (PZ) and central gland (CG) on regional and voxel level. Correlations between variables and differences between regions were calculated. RESULTS Large heterogeneity of ADC on voxel level was observed within tumours, between tumours and between patients. This heterogeneity was reflected by the distribution of cell density and glandular area. On regional level, tumour was different from PZ having higher cell density (p = 0.007), less glandular area (p = 0.017) and lower ADCs (p = 0.017). ADC was correlated with glandular area (r = 0.402) and tumour volume (r = -0.608), but not with Gleason score. ADC tended to decrease with increasing cell density (r = -0.327, p = 0.073). On voxel level, correlations between ADC and histological variables varied among patients, for cell density ranging from r = -0.439 to r = 0.261 and for glandular area from r = 0.593 to r = 0.207. CONCLUSIONS The variation in ADC can to a certain extent be explained by the variation in cell density and glandular area. The ADC is highly heterogeneous, which reflects the heterogeneity of malignant and benign prostate tissue. This heterogeneity might however obscure small tumours or parts of tumours. Therefore, DWI has to be used in the context of multiparametric MRI.
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Affiliation(s)
- Alie Borren
- Department of Radiotherapy, University Medical Center Utrecht , Utrecht , The Netherlands
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27
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Rusten E, Rødal J, Bruland ØS, Malinen E. Biologic targets identified from dynamic 18FDG-PET and implications for image-guided therapy. Acta Oncol 2013; 52:1378-83. [PMID: 23981046 DOI: 10.3109/0284186x.2013.813071] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The outcome of biologic image-guided radiotherapy depends on the definition of the biologic target. The purpose of the current work was to extract hyperperfused and hypermetabolic regions from dynamic positron emission tomography (D-PET) images, to dose escalate either region and to discuss implications of such image guided strategies. METHODS Eleven patients with soft tissue sarcomas were investigated with D-PET. The images were analyzed using a two-compartment model producing parametric maps of perfusion and metabolic rate. The two image series were segmented and exported to a treatment planning system, and biological target volumes BTVper and BTVmet (perfusion and metabolism, respectively) were generated. Dice's similarity coefficient was used to compare the two biologic targets. Intensity-modulated radiation therapy (IMRT) plans were generated for a dose painting by contours regime, where planning target volume (PTV) was planned to 60 Gy and BTV to 70 Gy. Thus, two separate plans were created for each patient with dose escalation of either BTVper or BTVmet. RESULTS BTVper was somewhat smaller than BTVmet (209 ± 170 cm(3) against 243 ± 143 cm(3), respectively; population-based mean and s.d.). Dice's coefficient depended on the applied margin, and was 0.72 ± 0.10 for a margin of 10 mm. Boosting BTVper resulted in mean dose of 69 ± 1.0 Gy to this region, while BTVmet received 67 ± 3.2 Gy. Boosting BTVmet gave smaller dose differences between the respective non-boost DVHs (such as D98). CONCLUSIONS Dose escalation of one of the BTVs results in a partial dose escalation of the other BTV as well. If tumor aggressiveness is equally pronounced in hyperperfused and hypermetabolic regions, this should be taken into account in the treatment planning.
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Affiliation(s)
- Espen Rusten
- Department of Physics, University of Oslo , Oslo , Norway
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28
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Rischke HC, Nestle U, Fechter T, Doll C, Volegova-Neher N, Henne K, Scholber J, Knippen S, Kirste S, Grosu AL, Jilg CA. 3 Tesla multiparametric MRI for GTV-definition of Dominant Intraprostatic Lesions in patients with Prostate Cancer--an interobserver variability study. Radiat Oncol 2013; 8:183. [PMID: 23875672 PMCID: PMC3828667 DOI: 10.1186/1748-717x-8-183] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/20/2013] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To evaluate the interobserver variability of gross tumor volume (GTV) - delineation of Dominant Intraprostatic Lesions (DIPL) in patients with prostate cancer using published MRI criteria for multiparametric MRI at 3 Tesla by 6 different observers. MATERIAL AND METHODS 90 GTV-datasets based on 15 multiparametric MRI sequences (T2w, diffusion weighted (DWI) and dynamic contrast enhanced (DCE)) of 5 patients with prostate cancer were generated for GTV-delineation of DIPL by 6 observers. The reference GTV-dataset was contoured by a radiologist with expertise in diagnostic imaging of prostate cancer using MRI. Subsequent GTV-delineation was performed by 5 radiation oncologists who received teaching of MRI-features of primary prostate cancer before starting contouring session. GTV-datasets were contoured using Oncentra Masterplan® and iplan® Net. For purposes of comparison GTV-datasets were imported to the Artiview® platform (Aquilab®), GTV-values and the similarity indices or Kappa indices (KI) were calculated with the postulation that a KI > 0.7 indicates excellent, a KI > 0.6 to < 0.7 substantial and KI > 0.5 to < 0.6 moderate agreement. Additionally all observers rated difficulties of contouring for each MRI-sequence using a 3 point rating scale (1 = easy to delineate, 2 = minor difficulties, 3 = major difficulties). RESULTS GTV contouring using T2w (KI-T2w = 0.61) and DCE images (KI-DCE = 0.63) resulted in substantial agreement. GTV contouring using DWI images resulted in moderate agreement (KI-DWI = 0.51). KI-T2w and KI-DCE was significantly higher than KI-DWI (p = 0.01 and p = 0.003). Degree of difficulty in contouring GTV was significantly lower using T2w and DCE compared to DWI-sequences (both p < 0.0001). Analysis of delineation differences revealed inadequate comparison of functional (DWI, DCE) to anatomical sequences (T2w) and lack of awareness of non-specific imaging findings as a source of erroneous delineation. CONCLUSIONS Using T2w and DCE sequences at 3 Tesla for GTV-definition of DIPL in prostate cancer patients by radiation oncologists with knowledge of MRI features results in substantial agreement compared to an experienced MRI-radiologist, but for radiotherapy purposes higher KI are desirable, strengthen the need for expert surveillance. DWI sequence for GTV delineation was considered as difficult in application.
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Affiliation(s)
- Hans Christian Rischke
- Department of Radiation Oncology, University of Freiburg, Robert Koch Str. 3, 79106 Freiburg, Germany.
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29
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Van den Bergh L, Isebaert S, Koole M, Oyen R, Joniau S, Lerut E, Deroose C, De Keyzer F, Van Poppel H, Haustermans K. Does 11C-choline PET-CT contribute to multiparametric MRI for prostate cancer localisation? Strahlenther Onkol 2013; 189:789-95. [DOI: 10.1007/s00066-013-0359-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/25/2013] [Indexed: 11/30/2022]
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30
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Bohoslavsky R, Witte MG, Janssen TM, van Herk M. Probabilistic objective functions for margin-less IMRT planning. Phys Med Biol 2013; 58:3563-80. [PMID: 23640114 DOI: 10.1088/0031-9155/58/11/3563] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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31
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Li B, Du Y, Yang H, Huang Y, Meng J, Xiao D. Magnetic resonance imaging for prostate cancer clinical application. Chin J Cancer Res 2013; 25:240-9. [PMID: 23592906 DOI: 10.3978/j.issn.1000-9604.2013.03.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 12/14/2012] [Indexed: 01/16/2023] Open
Abstract
As prostate cancer is a biologically heterogeneous disease for which a variety of treatment options are available, the major objective of prostate cancer imaging is to achieve more precise disease characterization. In clinical practice, magnetic resonance imaging (MRI) is one of the imaging tools for the evaluation of prostate cancer, the fusion of MRI or dynamic contrast-enhanced MRI (DCE-MRI) with magnetic resonance spectroscopic imaging (MRSI) is improving the evaluation of cancer location, size, and extent, while providing an indication of tumor aggressiveness. This review summarizes the role of MRI in the application of prostate cancer and describes molecular MRI techniques (including MRSI and DCE-MRI) for aiding prostate cancer management.
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Affiliation(s)
- Bing Li
- Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China ; Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
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Pommer T, Falk M, Poulsen PR, Keall PJ, O'Brien RT, Petersen PM, Munck af Rosenschöld P. Dosimetric benefit of DMLC tracking for conventional and sub-volume boosted prostate intensity-modulated arc radiotherapy. Phys Med Biol 2013; 58:2349-61. [PMID: 23492899 DOI: 10.1088/0031-9155/58/7/2349] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study investigated the dosimetric impact of uncompensated motion and motion compensation with dynamic multileaf collimator (DMLC) tracking for prostate intensity modulated arc therapy. Two treatment approaches were investigated; a conventional approach with a uniform radiation dose to the target volume and an intraprostatic lesion (IPL) boosted approach with an increased dose to a subvolume of the prostate. The impact on plan quality of optimizations with a leaf position constraint, which limited the distance between neighbouring adjacent MLC leaves, was also investigated. Deliveries were done with and without DMLC tracking on a linear acceleration with a high-resolution MLC. A cylindrical phantom containing two orthogonal diode arrays was used for dosimetry. A motion platform reproduced six patient-derived prostate motion traces, with the average displacement ranging from 1.0 to 8.9 mm during the first 75 s. A research DMLC tracking system was used for real-time motion compensation with optical monitoring for position input. The gamma index was used for evaluation, with measurements with a static phantom or the planned dose as reference, using 2% and 2 mm gamma criteria. The average pass rate with DMLC tracking was 99.9% (range 98.7-100%, measurement as reference), whereas the pass rate for untracked deliveries decreased distinctly as the average displacement increased, with an average pass rate of 61.3% (range 32.7-99.3%). Dose-volume histograms showed that DMLC tracking maintained the planned dose distributions in the presence of motion whereas traces with >3 mm average displacement caused clear plan degradation for untracked deliveries. The dose to the rectum and bladder had an evident dependence on the motion direction and amplitude for untracked deliveries, and the dose to the rectum was slightly increased for IPL boosted plans compared to conventional plans for anterior motion with large amplitude. In conclusion, optimization using a leaf position constraint had minimal dosimetric effect, DMLC tracking improved the target and normal tissue dose distributions compared to no tracking for target motion >3 mm, with the DMLC tracking distributions showing generally good agreement between the planned and delivered doses.
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Affiliation(s)
- Tobias Pommer
- Radiation Medicine Research Center, Department of Radiation Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Girometti R, Bazzocchi M, Como G, Brondani G, Del Pin M, Frea B, Martinez G, Zuiani C. Negative predictive value for cancer in patients with “Gray-Zone” PSA level and prior negative biopsy: Preliminary results with multiparametric 3.0 tesla MR. J Magn Reson Imaging 2012; 36:943-950. [DOI: 10.1002/jmri.23703] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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van der Heide UA, Houweling AC, Groenendaal G, Beets-Tan RGH, Lambin P. Functional MRI for radiotherapy dose painting. Magn Reson Imaging 2012; 30:1216-23. [PMID: 22770686 DOI: 10.1016/j.mri.2012.04.010] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 03/26/2012] [Accepted: 04/01/2012] [Indexed: 02/07/2023]
Abstract
Modern radiation therapy techniques are exceptionally flexible in the deposition of radiation dose in a target volume. Complex distributions of dose can be delivered reliably, so that the tumor is exposed to a high dose, whereas nearby healthy structures can be avoided. As a result, an increase in curative dose is no longer invariably associated with an increased level of toxicity. This modern technology can be exploited further by modulating the required dose in space so as to match the variation in radiation sensitivity in the tumor. This approach is called dose painting. For dose painting to be effective, functional imaging techniques are essential to identify regions in a tumor that require a higher dose. Several techniques are available in nuclear medicine and radiology. In recent years, there has been a considerable research effort concerning the integration of magnetic resonance imaging (MRI) into the external radiotherapy workflow motivated by the superior soft tissue contrast as compared to computed tomography. In MRI, diffusion-weighted MRI reflects the cell density of tissue and thus may indicate regions with a higher tumor load. Dynamic contrast-enhanced MRI reflects permeability of the microvasculature and blood flow, correlated to the oxygenation of the tumor. These properties have impact on its radiation sensitivity. New questions must be addressed when these techniques are applied in radiation therapy: scanning in treatment position requires alternative solutions to the standard patient setup in the choice of receive coils compared to a diagnostic department. This standard positioning also facilitates repeated imaging. The geometrical accuracy of MR images is critical for high-precision radiotherapy. In particular, when multiparametric functional data are used for dose painting, quantification of functional parameters at a high spatial resolution becomes important. In this review, we will address these issues and describe clinical developments in MRI-guided dose painting.
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Affiliation(s)
- Uulke A van der Heide
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands.
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35
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Urethra sparing – potential of combined Nickel–Titanium stent and intensity modulated radiation therapy in prostate cancer. Radiother Oncol 2012; 103:256-60. [DOI: 10.1016/j.radonc.2011.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 11/20/2011] [Accepted: 11/22/2011] [Indexed: 11/21/2022]
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36
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Groenendaal G, van Vulpen M, Pereboom SR, Poelma-Tap D, Korporaal JG, Monninkhof E, van der Heide UA. The effect of hormonal treatment on conspicuity of prostate cancer: Implications for focal boosting radiotherapy. Radiother Oncol 2012; 103:233-8. [PMID: 22265733 DOI: 10.1016/j.radonc.2011.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 09/23/2011] [Accepted: 12/17/2011] [Indexed: 11/26/2022]
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Abdellatif A, Craig J, Jensen M, Mulligan M, Mosalaei H, Bauman G, Chen J, Wong E. Experimental assessments of intrafractional prostate motion on sequential and simultaneous boost to a dominant intraprostatic lesion. Med Phys 2012; 39:1505-17. [DOI: 10.1118/1.3685586] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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YAMAZOE S, TAKAHARA T, SHIMIZU K, OUCHI K, MOGAMI T, HARADA J, FUKUDA K. Diffusion-weighted Imaging with Relative Signal Intensity Statistical Thresholding for Delineating Prostate Cancer Tumors. Magn Reson Med Sci 2012; 11:1-8. [DOI: 10.2463/mrms.11.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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39
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Groenendaal G, Borren A, Moman MR, Monninkhof E, van Diest PJ, Philippens MEP, van Vulpen M, van der Heide UA. Pathologic validation of a model based on diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging for tumor delineation in the prostate peripheral zone. Int J Radiat Oncol Biol Phys 2011; 82:e537-44. [PMID: 22197085 DOI: 10.1016/j.ijrobp.2011.07.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 06/20/2011] [Accepted: 07/18/2011] [Indexed: 01/12/2023]
Abstract
PURPOSE For focal boost strategies in the prostate, the robustness of magnetic resonance imaging-based tumor delineations needs to be improved. To this end we developed a statistical model that predicts tumor presence on a voxel level (2.5×2.5×2.5 mm3) inside the peripheral zone. Furthermore, we show how this model can be used to derive a valuable input for radiotherapy treatment planning. METHODS AND MATERIALS The model was created on 87 radiotherapy patients. For the validation of the voxelwise performance of the model, an independent group of 12 prostatectomy patients was used. After model validation, the model was stratified to create three different risk levels for tumor presence: gross tumor volume (GTV), high-risk clinical target volume (CTV), and low-risk CTV. RESULTS The model gave an area under the receiver operating characteristic curve of 0.70 for the prediction of tumor presence in the prostatectomy group. When the registration error between magnetic resonance images and pathologic delineation was taken into account, the area under the curve further improved to 0.89. We propose that model outcome values with a high positive predictive value can be used to define the GTV. Model outcome values with a high negative predictive value can be used to define low-risk CTV regions. The intermediate outcome values can be used to define a high-risk CTV. CONCLUSIONS We developed a logistic regression with a high diagnostic performance for voxelwise prediction of tumor presence. The model output can be used to define different risk levels for tumor presence, which in turn could serve as an input for dose planning. In this way the robustness of tumor delineations for focal boost therapy can be greatly improved.
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Affiliation(s)
- Greetje Groenendaal
- Department of Radiotherapy, University Medical Center, Utrecht, The Netherlands.
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Lips IM, van der Heide UA, Haustermans K, van Lin ENJT, Pos F, Franken SPG, Kotte ANTJ, van Gils CH, van Vulpen M. Single blind randomized phase III trial to investigate the benefit of a focal lesion ablative microboost in prostate cancer (FLAME-trial): study protocol for a randomized controlled trial. Trials 2011; 12:255. [PMID: 22141598 PMCID: PMC3286435 DOI: 10.1186/1745-6215-12-255] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 12/05/2011] [Indexed: 11/12/2022] Open
Abstract
Background The treatment results of external beam radiotherapy for intermediate and high risk prostate cancer patients are insufficient with five-year biochemical relapse rates of approximately 35%. Several randomized trials have shown that dose escalation to the entire prostate improves biochemical disease free survival. However, further dose escalation to the whole gland is limited due to an unacceptable high risk of acute and late toxicity. Moreover, local recurrences often originate at the location of the macroscopic tumor, so boosting the radiation dose at the macroscopic tumor within the prostate might increase local control. A reduction of distant metastases and improved survival can be expected by reducing local failure. The aim of this study is to investigate the benefit of an ablative microboost to the macroscopic tumor within the prostate in patients treated with external beam radiotherapy for prostate cancer. Methods/Design The FLAME-trial (Focal Lesion Ablative Microboost in prostatE cancer) is a single blind randomized controlled phase III trial. We aim to include 566 patients (283 per treatment arm) with intermediate or high risk adenocarcinoma of the prostate who are scheduled for external beam radiotherapy using fiducial markers for position verification. With this number of patients, the expected increase in five-year freedom from biochemical failure rate of 10% can be detected with a power of 80%. Patients allocated to the standard arm receive a dose of 77 Gy in 35 fractions to the entire prostate and patients in the experimental arm receive 77 Gy to the entire prostate and an additional integrated microboost to the macroscopic tumor of 95 Gy in 35 fractions. The secondary outcome measures include treatment-related toxicity, quality of life and disease-specific survival. Furthermore, by localizing the recurrent tumors within the prostate during follow-up and correlating this with the delivered dose, we can obtain accurate dose-effect information for both the macroscopic tumor and subclinical disease in prostate cancer. The rationale, study design and the first 50 patients included are described. Trial registration This study is registered at ClinicalTrials.gov: NCT01168479
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Affiliation(s)
- Irene M Lips
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Thwaites DI, Malicki J. Physics and technology in ESTRO and in Radiotherapy and Oncology: past, present and into the 4th dimension. Radiother Oncol 2011; 100:327-32. [PMID: 21962819 DOI: 10.1016/j.radonc.2011.09.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 09/21/2011] [Indexed: 12/11/2022]
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Mueller-Lisse UG, Mueller-Lisse UL, Zamecnik P, Schlemmer HPW, Scherr MK. [Diffusion-weighted MRI of the prostate]. Radiologe 2011; 51:205-14. [PMID: 21328048 DOI: 10.1007/s00117-010-2061-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Diffusion-weighted magnetic resonance imaging (DWI) can complement MRI of the prostate in the detection and localization of prostate cancer, particularly after previous negative biopsy. A total of 13 original reports and 2 reviews published in 2010 demonstrate that prostate cancer can be detected by DWI due to its increased cell density and decreased diffusiveness, either qualitatively in DWI images or quantitatively by means of the apparent diffusion coefficient (ADC). In the prostate, the ADC is influenced by the strength of diffusion weighting, localization (peripheral or transitional zone), presence of prostatitis or hemorrhage and density and differentiation of prostate cancer cells. Mean differences between healthy tissue of the peripheral zone and prostate cancer appear to be smaller for ADC than for the (choline + creatine)/citrate ratio in MR spectroscopy. Test quality parameters vary greatly between different studies but appear to be slightly better for combined MRI and DWI than for MRI of the prostate alone. Clinical validation of DWI of the prostate requires both increased technical conformity and increased numbers of patients in clinical studies.
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Affiliation(s)
- U G Mueller-Lisse
- Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Innenstadt, Ziemssenstrasse 1, Munich, Germany.
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Maggio A, Fiorino C, Mangili P, Cozzarini C, de Cobelli F, Cattaneo GM, Rancati T, Maschio AD, Muzio ND, Calandrino R. Feasibility of safe ultra-high (EQD(2)>100 Gy) dose escalation on dominant intra-prostatic lesions (DILs) by Helical Tomotheraphy. Acta Oncol 2011; 50:25-34. [PMID: 21174609 DOI: 10.3109/0284186x.2010.530688] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE to verify the possibility of using Helical Tomotherapy to safely escalate dose to single or multiple highly radioresistant dominant intra-prostatic lesions (DILs) as assessed by functional magnetic resonance imaging (MRI). MATERIAL in seven intermediate/high risk patients, T2WI, T1WI and DWI MRI imaging showed evidence of one DIL in four patients and two DILs in three patients in the peripheral zone of the prostate. The planning strategy was to deliver median doses of 80, 90, 100 and 120 Gy to PTVDIL while delivering 71.4 Gy/28 fractions (EQD(2)=75 Gy) to the remaining portion of PTV. A higher priority was assigned to rectal constraints relative to DIL coverage. Rectal NTCP calculations were performed using the most recently available model data. RESULTS the median dose to DIL could safely be escalated to at least 100 Gy (EQD(2,α/β=10)=113 Gy) without violating safe constraints for the organs at risk. Typical rectal NTCP values were around or below 1-3% for G3 toxicity and 5-7% for G2-G3 toxicity. For the 100 Gy DIL dose boost strategy, mean D95% of DIL and PTVDIL were 98.8 Gy and 86.7 Gy, respectively. The constraints for bladder, urethra and femoral heads were always respected. CONCLUSIONS IGRT by Helical Tomotherapy may permit the safe escalation of EQD(2,α/β=10) to at least 113 Gy to DILs without significantly increasing rectal NTCP compared to plans without dose escalation. A Phase I-II clinical study is warranted.
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Affiliation(s)
- Angelo Maggio
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
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Haack S, Pedersen EM, Jespersen SN, Kallehauge JF, Lindegaard JC, Tanderup K. Apparent diffusion coefficients in GEC ESTRO target volumes for image guided adaptive brachytherapy of locally advanced cervical cancer. Acta Oncol 2010; 49:978-83. [PMID: 20831485 DOI: 10.3109/0284186x.2010.500619] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE T2 weighted MRI is recommended for image guided adaptive brachytherapy (IGABT) in cervical cancer. Diffusion weighted imaging (DWI) and the derived apparent diffusion coefficient (ADC) may add additional biological information on tumour cell density. The purpose of this study was to evaluate the distribution of the ADC within target volumes as recommended by GEC-ESTRO: Gross Tumour Volume at BT (GTV(BT)), High-Risk Clinical Tumour Volume (HR-CTV) and Intermediate-Risk Clinical Target Volume (IR-CTV) and to evaluate the change of diffusion between fractions of IGABT. MATERIAL AND METHODS Fifteen patients with locally advanced cervical cancer were examined by MRI before their first (BT1) and second (BT2) fraction of IGABT, resulting in a total of 30 MR examinations including both T2 weighted and DWI sequences. The Apparent Diffusion Coefficient (ADC) was calculated by use of three levels of b-values (0, 600, 1000 s/mm(2)). ADC maps were constructed and fused with the GEC ESTRO target contours. The mean ADC value within each target volume was calculated. Furthermore, volumes of low diffusion (ADC(low)) were defined based on an ADC threshold of 1.2 × 10(-3) mm(2)/s, and overlap with target volumes was evaluated. Change of ADC level in target volumes and change of ADC(low) volume from BT1 to BT2 was also evaluated. RESULTS The mean ADC was significantly lower in GTV(BT) than in HR-CTV (p<0.001) which again was significantly lower than in IR-CTV (p<0.001). There was no significant change of the ADC(low) volume or ADC level within each target structure between BT1 and BT2 (p=0.242). All three GEC-ESTRO volumes contained volumes with low diffusion. The GTV(BT) contained 37.2% volume of low diffusion, HR-CTV 20.3% and IR-CTV 10.8%. CONCLUSION With DWI we were able to find a significant difference in ADC-values for the three different GEC ESTRO targets. This supports the assumption that the target volumes used for dose prescription in IGABT contain tissues with different characteristics, with the tumour (GTV(BT)) being the volume with the lowest diffusion. No significant changes were found from BT1 to BT2 indicating that changes of ADC level and volumes are stable at the time of BT. Further studies are needed to evaluate the role of DWI in target contouring and dose prescription for IGABT.
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MESH Headings
- Brachytherapy/methods
- Carcinoma, Adenosquamous/diagnostic imaging
- Carcinoma, Adenosquamous/pathology
- Carcinoma, Adenosquamous/radiotherapy
- Carcinoma, Squamous Cell/diagnostic imaging
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Diffusion
- Diffusion Magnetic Resonance Imaging/methods
- Diffusion Magnetic Resonance Imaging/standards
- Disease Progression
- Dose Fractionation, Radiation
- Female
- Guidelines as Topic
- Humans
- Image Processing, Computer-Assisted/methods
- Image Processing, Computer-Assisted/standards
- Models, Theoretical
- Neoplasm Staging
- Organ Size
- Radiation Dosage
- Radiography
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy Planning, Computer-Assisted/standards
- Tumor Burden
- Uterine Cervical Neoplasms/diagnostic imaging
- Uterine Cervical Neoplasms/pathology
- Uterine Cervical Neoplasms/radiotherapy
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Affiliation(s)
- Søren Haack
- Department of Clinical Engineering, Aarhus University Hospital, Skejby, Aarhus, Denmark.
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Abstract
"Dose-painting" radiotherapy allows for a heterogeneous delivery of radiation within the tumour volume by targeting radioresistant areas defined by functional imaging. Within gross tumour volume, it is possible to define one or more target volumes based on biology (biological target volume [BTV]) and to apply a strategy of intensity modulated radiation therapy (IMRT) that will deliver a higher dose to these regions. In this review of the literature, we will highlight the biological elements responsible for radioresistance, and how to image them, then we will detail the radiotherapy techniques necessary for this approach, before presenting clinical results in various situations (head and neck tumours, prostate, brain tumours, etc.). Despite many difficulties that make dose-painting IMRT unusable in routine nowadays, biology-guided radiation therapy represents one of the major pathways of development of radiotherapy in the coming years.
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