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Wang CX, Elganainy D, Zaid MM, Butner JD, Agrawal A, Nizzero S, Minsky BD, Holliday EB, Taniguchi CM, Smith GL, Koong AC, Herman JM, Das P, Maitra A, Wang H, Wolff RA, Katz MHG, Crane CH, Cristini V, Koay EJ. Mass Transport Model of Radiation Response: Calibration and Application to Chemoradiation for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2022; 114:163-172. [PMID: 35643254 PMCID: PMC10042520 DOI: 10.1016/j.ijrobp.2022.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/22/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The benefit of radiation therapy for pancreatic ductal adenocarcinoma (PDAC) remains unclear. We hypothesized that a new mechanistic mathematical model of chemotherapy and radiation response could predict clinical outcomes a priori, using a previously described baseline measurement of perfusion from computed tomography scans, normalized area under the enhancement curve (nAUC). METHODS AND MATERIALS We simplified an existing mass transport model that predicted cancer cell death by replacing previously unknown variables with averaged direct measurements from randomly selected pathologic sections of untreated PDAC. This allowed using nAUC as the sole model input to approximate tumor perfusion. We then compared the predicted cancer cell death to the actual cell death measured from corresponding resected tumors treated with neoadjuvant chemoradiation in a calibration cohort (n = 80) and prospective cohort (n = 25). After calibration, we applied the model to 2 separate cohorts for pathologic and clinical associations: targeted therapy cohort (n = 101), cetuximab/bevacizumab + radiosensitizing chemotherapy, and standard chemoradiation cohort (n = 81), radiosensitizing chemotherapy to 50.4 Gy in 28 fractions. RESULTS We established the relationship between pretreatment computed v nAUC to pathologically verified blood volume fraction of the tumor (r = 0.65; P = .009) and fractional tumor cell death (r = 0.97-0.99; P < .0001) in the calibration and prospective cohorts. On multivariate analyses, accounting for traditional covariates, nAUC independently associated with overall survival in all cohorts (mean hazard ratios, 0.14-0.31). Receiver operator characteristic analyses revealed discrimination of good and bad prognostic groups in the cohorts with area under the curve values of 0.64 to 0.71. CONCLUSIONS This work presents a new mathematical modeling approach to predict clinical response from chemotherapy and radiation for PDAC. Our findings indicate that oxygen/drug diffusion strongly influences clinical responses and that nAUC is a potential tool to select patients with PDAC for radiation therapy.
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Affiliation(s)
- Charles X Wang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, University of California Davis Medical Center, Sacramento, California
| | - Dalia Elganainy
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mohamed M Zaid
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph D Butner
- Mathematics in Medicine Program, Houston Methodist Research Institute, Houston, Texas
| | - Anshuman Agrawal
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sara Nizzero
- Mathematics in Medicine Program, Houston Methodist Research Institute, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cullen M Taniguchi
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Matthew H G Katz
- Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vittorio Cristini
- Mathematics in Medicine Program, Houston Methodist Research Institute, Houston, Texas; Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, Texas; Physiology, Biophysics, and Systems Biology Program, Graduate School of Medical Sciences, Weill Cornell Medicine, New York, New York
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Marks LB, Reinsberg SA, Yorke E, Moiseenko V. Why Do Both Mean Dose and V≥x Often Predict for Normal Tissue Outcomes? Adv Radiat Oncol 2022; 7:101039. [PMID: 36092989 PMCID: PMC9450075 DOI: 10.1016/j.adro.2022.101039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/19/2022] [Indexed: 11/15/2022] Open
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Khalil AA, Hau E, Gebski V, Grau C, Gee H, Nyeng TB, West K, Kramer S, Farlow D, Knap M, Møller DS, Hoffmann L, Farr KP. Personal innovative approach in radiation therapy of lung cancer- functional lung avoidance SPECT-guided (ASPECT) radiation therapy: a study protocol for phase II randomised double-blind clinical trial. BMC Cancer 2021; 21:940. [PMID: 34418994 PMCID: PMC8379730 DOI: 10.1186/s12885-021-08663-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/03/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) plays a key role in curative-intent treatment for locally advanced lung cancer. Radiation induced pulmonary toxicity can be significant for some patients and becomes a limiting factor for radiation dose, suitability for treatment, as well as post treatment quality of life and suitability for the newly introduced adjuvant immunotherapy. Modern RT techniques aim to minimise the radiation dose to the lungs, without accounting for regional distribution of lung function. Many lung cancer patients have significant regional differences in pulmonary function due to smoking and chronic lung co-morbidity. Even though reduction of dose to functional lung has shown to be feasible, the method of preferential functional lung avoidance has not been investigated in a randomised clinical trial. METHODS In this study, single photon emission computed tomography (SPECT/CT) imaging technique is used for functional lung definition, in conjunction with advanced radiation dose delivery method in randomised, double-blind trial. The study aims to assess the impact of functional lung avoidance technique on pulmonary toxicity and quality of life in patients receiving chemo-RT for lung cancer. Eligibility criteria are biopsy verified lung cancer, scheduled to receive (chemo)-RT with curative intent. Every patient will undergo a pre-treatment perfusion SPECT/CT to identify functional lung. At radiation dose planning, two plans will be produced for all patients on trial. Standard reference plan, without the use of SPECT imaging data, and functional avoidance plan, will be optimised to reduce the dose to functional lung within the predefined constraints. Both plans will be clinically approved. Patients will then be randomised in a 2:1 ratio to be treated according to either the functional avoidance or the standard plan. This study aims to accrue a total of 200 patients within 3 years. The primary endpoint is symptomatic radiation-induced lung toxicity, measured serially 1-12 months after RT. Secondary endpoints include: a quality of life and patient reported lung symptoms assessment, overall survival, progression-free survival, and loco-regional disease control. DISCUSSION ASPECT trial will investigate functional avoidance method of radiation delivery in clinical practice, and will establish toxicity outcomes for patients with lung cancer undergoing curative chemo-RT. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT04676828 . Registered 1 December 2020.
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Affiliation(s)
| | - Eric Hau
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney West Radiation Oncology Network, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW Australia
- Westmead Institute for Medical Research, Westmead, NSW Australia
| | - Val Gebski
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney West Radiation Oncology Network, Westmead, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, 2050 Australia
| | - Cai Grau
- Aarhus University Hospital, Aarhus, Denmark
| | - Harriet Gee
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney West Radiation Oncology Network, Westmead, Australia
- Westmead Institute for Medical Research, Westmead, NSW Australia
| | | | - Katrina West
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney West Radiation Oncology Network, Westmead, Australia
| | | | | | | | | | | | - Katherina P. Farr
- Aarhus University Hospital, Aarhus, Denmark
- Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
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Prior P, Awan MJ, Wilson JF, Li XA. Tumor Control Probability Modeling for Radiation Therapy of Keratinocyte Carcinoma. Front Oncol 2021; 11:621641. [PMID: 34079752 PMCID: PMC8165325 DOI: 10.3389/fonc.2021.621641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/23/2021] [Indexed: 12/02/2022] Open
Abstract
Summary Skin cancer patients may be treated definitively using radiation therapy (RT) with electrons, kilovoltage, or megavoltage photons depending on tumor stage and invasiveness. This study modeled tumor control probability (TCP) based on the pooled clinical outcome data of RT for primary basal and cutaneous squamous cell carcinomas (BCC and cSCC, respectively). Four TCP models were developed and found to be potentially useful in developing optimal treatment schemes based on recommended ASTRO 2020 Skin Consensus Guidelines for primary, keratinocyte carcinomas (i.e. BCC and cSCC). Background Radiotherapy (RT) with electrons or photon beams is an excellent primary treatment option for keratinocyte carcinoma (KC), particularly for non-surgical candidates. Our objective is to model tumor control probability (TCP) based on the pooled clinical data of primary basal and cutaneous squamous cell carcinomas (BCC and cSCC, respectively) in order to optimize treatment schemes. Methods Published reports citing crude estimates of tumor control for primary KCs of the head by tumor size (diameter: ≤2 cm and >2 cm) were considered in our study. A TCP model based on a sigmoidal function of biological effective dose (BED) was proposed. Three-parameter TCP models were generated for BCCs ≤2 cm, BCCs >2cm, cSCCs ≤2 cm, and cSCCs >2 cm. Equivalent fractionation schemes were estimated based on the TCP model and appropriate parameters. Results TCP model parameters for both BCC and cSCC for tumor sizes ≤2 cm and >2cm were obtained. For BCC, the model parameters were found to be TD50 = 56.62 ± 6.18 × 10-3 Gy, k = 0.14 ± 2.31 × 10−2 Gy−1 and L = 0.97 ± 4.99 × 10−3 and TD50 = 55.78 ± 0.19 Gy, k = 1.53 ± 0.20 Gy−1 and L = 0.94 ± 3.72 × 10−3 for tumor sizes of ≤2 cm and >2 cm, respectively. For SCC the model parameters were found to be TD50 = 56.81 ± 19.40 × 104 Gy, k = 0.13 ± 7.92 × 104 Gy−1 and L = 0.96 ± 1.31 × 10-2 and TD50 = 58.44 ± 0.30 Gy, k = 2.30 ± 0.43 Gy−1 and L = 0.91± 1.22 × 10−2 for tumors ≤2cm and >2 cm, respectively. The TCP model with the derived parameters predicts that radiation regimens with higher doses, such as increasing the number of fractions and/or dose per fraction, lead to higher TCP, especially for KCs >2 cm in size. Conclusion Four TCP models for primary KCs were developed based on pooled clinical data that may be used to further test the recommended kV and MV x-ray and electron RT regimens from the 2020 ASTRO guidelines. Increasing both number of fractions and dose per fraction may have clinically significant effects on tumor control for tumors >2 cm in size for both BCC and cSCC.
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Affiliation(s)
- Phillip Prior
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Musaddiq J Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - J Frank Wilson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
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Mohan V, Bruin NM, van de Kamer JB, Sonke JJ, Vogel WV. The increasing potential of nuclear medicine imaging for the evaluation and reduction of normal tissue toxicity from radiation treatments. Eur J Nucl Med Mol Imaging 2021; 48:3762-3775. [PMID: 33687522 PMCID: PMC8484246 DOI: 10.1007/s00259-021-05284-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
Radiation therapy is an effective treatment modality for a variety of cancers. Despite several advances in delivery techniques, its main drawback remains the deposition of dose in normal tissues which can result in toxicity. Common practices of evaluating toxicity, using questionnaires and grading systems, provide little underlying information beyond subjective scores, and this can limit further optimization of treatment strategies. Nuclear medicine imaging techniques can be utilised to directly measure regional baseline function and function loss from internal/external radiation therapy within normal tissues in an in vivo setting with high spatial resolution. This can be correlated with dose delivered by radiotherapy techniques to establish objective dose-effect relationships, and can also be used in the treatment planning step to spare normal tissues more efficiently. Toxicity in radionuclide therapy typically occurs due to undesired off-target uptake in normal tissues. Molecular imaging using diagnostic analogues of therapeutic radionuclides can be used to test various interventional protective strategies that can potentially reduce this normal tissue uptake without compromising tumour uptake. We provide an overview of the existing literature on these applications of nuclear medicine imaging in diverse normal tissue types utilising various tracers, and discuss its future potential.
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Affiliation(s)
- V Mohan
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - N M Bruin
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J B van de Kamer
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - J-J Sonke
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Vicente E, Modiri A, Kipritidis J, Hagan A, Yu K, Wibowo H, Yan Y, Owen DR, Matuszak MM, Mohindra P, Timmerman R, Sawant A. Functionally weighted airway sparing (FWAS): a functional avoidance method for preserving post-treatment ventilation in lung radiotherapy. Phys Med Biol 2020; 65:165010. [PMID: 32575096 DOI: 10.1088/1361-6560/ab9f5d] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recent changes to the guidelines for screening and early diagnosis of lung cancer have increased the interest in preserving post-radiotherapy lung function. Current investigational approaches are based on spatially mapping functional regions and generating regional avoidance plans that preferentially spare highly ventilated/perfused lung. A potentially critical, yet overlooked, aspect of functional avoidance is radiation injury to peripheral airways, which serve as gas conduits to and from functional lung regions. Dose redistribution based solely on regional function may cause irreparable damage to the 'supply chain'. To address this deficiency, we propose the functionally weighted airway sparing (FWAS) method. FWAS (i) maps the bronchial pathways to each functional sub-lobar lung volume; (ii) assigns a weighting factor to each airway based on the relative contribution of the sub-volume to overall lung function; and (iii) creates a treatment plan that aims to preserve these functional pathways. To evaluate it, we used four cases from a retrospective cohort of SAbR patients treated for lung cancer. Each patient's airways were auto-segmented from a diagnostic-quality breath-hold CT using a research virtual bronchoscopy software. A ventilation map was generated from the planning 4DCT to map regional lung function. For each terminal airway, as resolved by the segmentation software, the total ventilation within the sub-lobar volume supported by that airway was estimated and used as a function-based weighting factor. Upstream airways were weighted based on the cumulative volumetric ventilation supported by corresponding downstream airways. Using a previously developed model for airway radiosensitivity, dose constraints were determined for each airway corresponding to a <5% probability of airway collapse. Airway dose constraints, ventilation scores, and clinical dose constraints were input to a swarm optimization-based inverse planning engine to create a 3D conformal SAbR plan (CRT). The FWAS plans were compared to the patients' prescribed CRT clinical plans and the inverse-optimized clinical plans. Depending on the size and location of the tumour, the FWAS plan showed superior preservation of ventilation due to airflow preservation through open pathways (i.e. cumulative ventilation score from the sub-lobar volumes of open pathways). Improvements ranged between 3% and 23%, when comparing to the prescribed clinical plans, and between 3% and 35%, when comparing to the inverse-optimized clinical plans. The three plans satisfied clinical requirements for PTV coverage and OAR dose constraints. These initial results suggest that by sparing pathways to high-functioning lung subregions it is possible to reduce post-SAbR loss of respiratory function.
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Affiliation(s)
- E Vicente
- University of Maryland School of Medicine, Baltimore, MD, United States of America
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Palma G, Monti S, Conson M, Pacelli R, Cella L. Normal tissue complication probability (NTCP) models for modern radiation therapy. Semin Oncol 2019; 46:210-218. [PMID: 31506196 DOI: 10.1053/j.seminoncol.2019.07.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
Mathematical models of normal tissue complication probability (NTCP) able to robustly predict radiation-induced morbidities (RIM) play an essential role in the identification of a personalized optimal plan, and represent the key to maximizing the benefits of technological advances in radiation therapy (RT). Most modern RT techniques pose, however, new challenges in estimating the risk of RIM. The aim of this report is to schematically review NTCP models in the framework of advanced radiation therapy techniques. Issues relevant to hypofractionated stereotactic body RT and ion beam therapy are critically reviewed. Reirradiation scenarios for new or recurrent malignances and NTCP are also illustrated. A new phenomenological approach to predict RIM is suggested.
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Affiliation(s)
- Giuseppe Palma
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Serena Monti
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Laura Cella
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy.
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Sharifi H, McDonald GC, Lee JK, Ajlouni MI, Chetty IJ, Zhong H. Four-dimensional computed tomography-based biomechanical measurements of pulmonary function and their correlation with clinical outcome for lung stereotactic body radiation therapy patients. Quant Imaging Med Surg 2019; 9:1278-1287. [PMID: 31448213 PMCID: PMC6685808 DOI: 10.21037/qims.2019.07.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/30/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Functional image guided radiotherapy allows for the delivery of an equivalent dose to tumor targets while sparing high ventilation lung tissues. In this study, we investigate whether radiation dose to functional lung is associated with clinical outcome for stereotactic body radiation therapy (SBRT) patients. METHODS Four-dimensional computed tomography (4DCT) images were used to assess lung function. Deformable image registration (DIR) was performed from the end-inhale phase to the end-exhale phase with resultant displacement vectors used to calculate ventilation maps. In addition to the Jacobian-based ventilation we introduce a volumetric variation method (Rv) based on a biomechanical finite element method (FEM), to assess lung ventilation. Thirty NSCLC patients, treated with SBRT, were evaluated in this study. 4DCT images were used to calculate both Jacobian and Rv-based ventilation images. Areas under the receiver operating characteristic curve (AUC) were used to assess the predictive power of functional metrics. Metrics were calculated over the whole lung as well as high and low ventilated regions. RESULTS Ventilation in dose regions between 1 and 5 Gy had higher AUC values compared to other dose regions. Rv based ventilation imaging method also showed to be less spatially variant and less heterogeneous, and the resultant Rv metrics had higher AUC values for predicting grade 2+ dyspnea. CONCLUSIONS Low dose delivered to high ventilation areas may also increase the risk of compromised pulmonary function. Rv based ventilation images could be useful for the prediction of clinical toxicity for lung SBRT patients.
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Affiliation(s)
- Hoda Sharifi
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
- Department of Physics, Oakland University, Rochester, MI, USA
| | - Gary C. McDonald
- Department of Mathematics and Statistics, Oakland University, Rochester, MI, USA
| | - Joon Kyu Lee
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Munther I. Ajlouni
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Indrin J. Chetty
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
- Department of Physics, Oakland University, Rochester, MI, USA
| | - Hualiang Zhong
- Department of Physics, Oakland University, Rochester, MI, USA
- Department of Radiation Oncology, Medical College of Wisconsin, Madison, WI, USA
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Palma G, Monti S, Buonanno A, Pacelli R, Cella L. PACE: A Probabilistic Atlas for Normal Tissue Complication Estimation in Radiation Oncology. Front Oncol 2019; 9:130. [PMID: 30918837 PMCID: PMC6424876 DOI: 10.3389/fonc.2019.00130] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/13/2019] [Indexed: 12/23/2022] Open
Abstract
In radiation oncology, the need for a modern Normal Tissue Complication Probability (NTCP) philosophy to include voxel-based evidence on organ radio-sensitivity (RS) has been acknowledged. Here a new formalism (Probabilistic Atlas for Complication Estimation, PACE) to predict radiation-induced morbidity (RIM) is presented. The adopted strategy basically consists in keeping the structure of a classical, phenomenological NTCP model, such as the Lyman-Kutcher-Burman (LKB), and replacing the dose distribution with a collection of RIM odds, including also significant non-dosimetric covariates, as input of the model framework. The theory was first demonstrated in silico on synthetic dose maps, classified according to synthetic outcomes. PACE was then applied to a clinical dataset of thoracic cancer patients classified for lung fibrosis. LKB models were trained for comparison. Overall, the obtained learning curves showed that the PACE model outperformed the LKB and predicted synthetic outcomes with an accuracy >0.8. On the real patients, PACE performance, evaluated by both discrimination and calibration, was significantly higher than LKB. This trend was confirmed by cross-validation. Furthermore, the capability to infer the spatial pattern of underlying RS map for the analyzed RIM was successfully demonstrated, thus paving the way to new perspectives of NTCP models as learning tools.
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Affiliation(s)
- Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
| | | | - Amedeo Buonanno
- Department of Engineering, University of Campania Luigi Vanvitelli, Aversa, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
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Modeling radiation pneumonitis of pulmonary stereotactic body radiotherapy: The impact of a local dose–effect relationship for lung perfusion loss. Radiother Oncol 2019; 132:142-147. [DOI: 10.1016/j.radonc.2018.12.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/06/2018] [Accepted: 12/16/2018] [Indexed: 12/25/2022]
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Functional lung imaging in radiation therapy for lung cancer: A systematic review and meta-analysis. Radiother Oncol 2018; 129:196-208. [PMID: 30082143 DOI: 10.1016/j.radonc.2018.07.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/14/2018] [Accepted: 07/18/2018] [Indexed: 12/25/2022]
Abstract
RATIONALE Advanced imaging techniques allow functional information to be derived and integrated into treatment planning. METHODS A systematic review was conducted with the primary objective to evaluate the ability of functional lung imaging to predict risk of radiation pneumonitis. Secondary objectives were to evaluate dose-response relationships on post treatment functional imaging and assess the utility in including functional lung information into treatment planning. A structured search for publications was performed following PRISMA guidelines and registered on PROSPERO. RESULTS 814 articles were screened against review criteria and 114 publications met criteria. Methods of identifying functional lung included using CT, MRI, SPECT and PET to image ventilation or perfusion. Six studies compared differences between functional and anatomical lung imaging at predicting radiation pneumonitis. These found higher predictive values using functional lung imaging. Twenty-one studies identified a dose-response relationship on post-treatment functional lung imaging. Nineteen planning studies demonstrated the ability of functional lung optimised planning techniques to spare regions of functional lung. Meta-analysis of these studies found that mean (95% CI) functional volume receiving 20 Gy was reduced by 4.2% [95% CI: 2.3: 6.0] and mean lung dose by 2.2 Gy [95% CI: 1.2: 3.3] when plans were optimised to spare functional lung. There was significant variation between publications in the definition of functional lung. CONCLUSION Functional lung imaging may have potential utility in radiation therapy planning and delivery, although significant heterogeneity was identified in approaches and reporting. Recommendations have been made based on the available evidence for future functional lung trials.
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Defraene G, La Fontaine M, van Kranen S, Reymen B, Belderbos J, Sonke JJ, De Ruysscher D. Radiation-Induced Lung Density Changes on CT Scan for NSCLC: No Impact of Dose-Escalation Level or Volume. Int J Radiat Oncol Biol Phys 2018; 102:642-650. [PMID: 30244882 DOI: 10.1016/j.ijrobp.2018.06.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/23/2018] [Accepted: 06/20/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Dose-escalation for patients with non-small cell lung cancer (NSCLC) in the positron emission tomography (PET)-boost trial (NCT01024829) exposes portions of normal lung tissue to high radiation doses. The relationship between lung parenchyma dose and density changes on computed tomography (CT) was analyzed. MATERIALS AND METHODS The CT scans of 59 patients with stage IB to III NSCLC, randomized between a boost to the whole primary tumor and an integrated boost to its 50% SUVmax (maximum standardized uptake value) volume. Patients were treated with concurrent or sequential chemoradiation or radiation only. Deformable registration mapped the 3-month follow-up CT to the planning CT. Hounsfield unit differences (ΔHU) were extracted to assess lung parenchyma density changes. Equivalent dose in 2 Gy fractions (EQD2)-ΔHU response was described sigmoidally, and regional response variation was studied by polar analysis. Prognostic factors of ΔHU were obtained through generalized linear modeling. RESULTS Saturation of ΔHU was observed above 60 Gy. No interaction was found between boost dose distribution (D1cc and V70Gy) and ΔHU at lower doses. ΔHU was lowest peripherally from the tumor and peaked posteriorly at 3 cm from the tumor border (3.1 HU/Gy). Right lung location was an independent risk factor for ΔHU (P = .02). CONCLUSIONS No apparent increase of lung density changes at 3-month follow-up was observed above 60 Gy EQD2 for patients with NSCLC treated with (concurrent or sequential chemo) radiation. The mild response observed peripherally in the lung parenchyma might be exploited in plan optimization routines minimizing lung damage.
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Affiliation(s)
- Gilles Defraene
- Department of Oncology, Experimental Radiation Oncology, KU Leuven-University of Leuven, Belgium.
| | - Matthew La Fontaine
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon van Kranen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bart Reymen
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dirk De Ruysscher
- Department of Oncology, Experimental Radiation Oncology, KU Leuven-University of Leuven, Belgium; Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiation Oncology (Maastro Clinic), GROW School for Developmental Biology and Oncology, Maastricht, The Netherlands
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Modeling Patient-Specific Dose-Function Response for Enhanced Characterization of Personalized Functional Damage. Int J Radiat Oncol Biol Phys 2018; 102:1265-1275. [PMID: 30108006 DOI: 10.1016/j.ijrobp.2018.05.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Functional-guided radiation therapy (RT) plans have the potential to limit damage to normal tissue and reduce toxicity. Although functional imaging modalities have continued to improve, a limited understanding of the functional response to radiation and its application to personalized therapy has hindered clinical implementation. The purpose of this study was to retrospectively model the longitudinal, patient-specific dose-function response in non-small cell lung cancer patients treated with RT to better characterize the expected functional damage in future, unknown patients. METHODS AND MATERIALS Perfusion single-photon emission computed tomography/computed tomography scans were obtained at baseline (n = 81), midtreatment (n = 74), 3 months post-treatment (n = 51), and 1 year post-treatment (n = 26) and retrospectively analyzed. Patients were treated with conventionally fractionated RT or stereotactic body RT. Normalized perfusion single-photon emission computed tomography voxel intensity was used as a surrogate for local lung function. A patient-specific logistic model was applied to each individual patient's dose-function response to characterize functional reduction at each imaging time point. Patient-specific model parameters were averaged to create a population-level logistic dose-response model. RESULTS A significant longitudinal decrease in lung function was observed after RT by analyzing the voxelwise change in normalized perfusion intensity. Generated dose-function response models represent the expected voxelwise reduction in function, and the associated uncertainty, for an unknown patient receiving conventionally fractionated RT or stereotactic body RT. Differential treatment responses based on the functional status of the voxel at baseline suggest that initially higher functioning voxels are damaged at a higher rate than lower functioning voxels. CONCLUSIONS This study modeled the patient-specific dose-function response in patients with non-small cell lung cancer during and after radiation treatment. The generated population-level dose-function response models were derived from individual patient assessment and have the potential to inform functional-guided treatment plans regarding the expected functional lung damage. This type of patient-specific modeling approach can be applied broadly to other functional response analyses to better capture intrapatient dependencies and characterize personalized functional damage.
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Farr KP, Khalil AA, Møller DS, Bluhme H, Kramer S, Morsing A, Grau C. Time and dose-related changes in lung perfusion after definitive radiotherapy for NSCLC. Radiother Oncol 2017; 126:307-311. [PMID: 29203289 DOI: 10.1016/j.radonc.2017.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/04/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE To examine radiation-induced changes in regional lung perfusion per dose level in 58 non-small-cell lung cancer (NSCLC) patients treated with intensity-modulated radiotherapy (IMRT). MATERIAL AND METHODS NSCLC patients receiving chemo-radiotherapy (RT) of minimum 60 Gy were included prospectively in the study. Lung perfusion single-photon emission computed tomography (SPECT/CT) was performed before and serially after RT. Changes (relative to baseline, %) in regional lung perfusion were correlated with regional dose. Toxicity outcome was radiation pneumonitis (RP) CTC grades 2-5. RESULTS Perfusion changes were associated with dose. Dose-dependent reduction in regional perfusion was observed at 3, 6 and 12 months of follow-up. Relative perfusion loss per dose bin was 4% at 1 month, 14% at 3 months, 13% at 6 months and 21% at 12 months after RT. In patients with RP, perfusion reduction was larger in high dose lung regions, compared to those without RP. Low dose regions, on the contrary, revealed perfusion gain in the patients with RP. CONCLUSION Progressive dose dependent perfusion loss is manifested on SPECT up to 12 months following IMRT. These findings suggest that the dynamic change in perfusion may have prognostic value in predicting radiation pneumonitis in NSCLC patients treated with IMRT.
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Affiliation(s)
| | - Azza A Khalil
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Ditte S Møller
- Department of Medical Physics, Aarhus University Hospital, Denmark
| | - Henrik Bluhme
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Denmark
| | - Stine Kramer
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Denmark
| | - Anni Morsing
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Denmark
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Overview of the Novel and Improved Pulmonary Ventilation-Perfusion Imaging Applications in the Era of SPECT/CT. AJR Am J Roentgenol 2016; 207:1307-1315. [PMID: 27726408 DOI: 10.2214/ajr.15.15071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In this article, we describe the concepts of ventilation-perfusion planar, SPECT, and SPECT/CT and outline the advantages of integrated ventilation-perfusion SPECT/CT over planar imaging. We present an overview of the traditional and new applications of ventilation-perfusion scintigraphy. CONCLUSION SPECT/CT has improved the diagnostic accuracy of ventilation-perfusion imaging and opened the door for a new spectrum of applications.
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A survey of changing trends in modelling radiation lung injury in mice: bringing out the good, the bad, and the uncertain. J Transl Med 2016; 96:936-49. [PMID: 27479087 DOI: 10.1038/labinvest.2016.76] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 05/10/2016] [Accepted: 06/04/2016] [Indexed: 12/22/2022] Open
Abstract
Within this millennium there has been resurgence in funding and research dealing with animal models of radiation-induced lung injury to identify and establish predictive biomarkers and effective mitigating agents that are applicable to humans. Most have been performed on mice but there needs to be assurance that the emphasis on such models is not misplaced. We therefore considered it timely to perform a comprehensive appraisal of the literature dealing with radiation lung injury of mice and to critically evaluate the validity and clinical relevance of the research. A total of 357 research papers covering the period of 1970-2015 were extensively reviewed. Whole thorax irradiation (WTI) has become the most common treatment for studying lung injury in mice and distinct trends were seen with regard to the murine strain, radiation dose, intended pathology investigated, length of study, and assays. Recently, the C57BL/6 strain has been increasingly used in the majority of these studies with the notion that they are susceptible to pulmonary fibrosis. Nonetheless, many of these investigations depend on animal survival as the primary end point and neglect the importance of radiation pneumonitis and the anomaly of lethal pleural effusions. A relatively large variation in survival times of C5BL/6 mice is also seen among different institutions pointing to the need for standardization of radiation treatments and environmental conditions. An analysis of mitigating drug treatments is complicated by the fact that the majority of studies are limited to the C57BL/6 strain with a premature termination of the experiments and do not establish whether the treatment actually prevents or simply delays the progression of radiation injury. This survey of the literature has pointed to several improvements that need to be considered in establishing a reliable preclinical murine model of radiation lung injury. The lethality end point should also be used cautiously and with greater emphasis on other assays such as non-invasive lung functional and imaging monitoring in order to quantify specific pulmonary injury that can be better extrapolated to radiation toxicity encountered in our own species.
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Petr J, Platzek I, Seidlitz A, Mutsaerts HJ, Hofheinz F, Schramm G, Maus J, Beuthien-Baumann B, Krause M, van den Hoff J. Early and late effects of radiochemotherapy on cerebral blood flow in glioblastoma patients measured with non-invasive perfusion MRI. Radiother Oncol 2016; 118:24-8. [DOI: 10.1016/j.radonc.2015.12.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/08/2015] [Accepted: 12/11/2015] [Indexed: 11/28/2022]
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Nestle U, Belderbos J. Cons: should a medically inoperable patient with a T2N0M0 non-small cell lung cancer central in the lung hilus be treated using stereotactic body radiotherapy? Transl Lung Cancer Res 2015; 4:623-6. [PMID: 26629432 DOI: 10.3978/j.issn.2218-6751.2015.08.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ursula Nestle
- 1 Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany ; 2 German Cancer Consortium (DKTK), Heidelberg (partner site Freiburg), Germany ; 3 Department of Radiation Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - José Belderbos
- 1 Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany ; 2 German Cancer Consortium (DKTK), Heidelberg (partner site Freiburg), Germany ; 3 Department of Radiation Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Wang H, Feng M, Jackson A, Ten Haken RK, Lawrence TS, Cao Y. Local and Global Function Model of the Liver. Int J Radiat Oncol Biol Phys 2015; 94:181-188. [PMID: 26700712 DOI: 10.1016/j.ijrobp.2015.09.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 09/21/2015] [Accepted: 09/28/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE To develop a local and global function model in the liver based on regional and organ function measurements to support individualized adaptive radiation therapy (RT). METHODS AND MATERIALS A local and global model for liver function was developed to include both functional volume and the effect of functional variation of subunits. Adopting the assumption of parallel architecture in the liver, the global function was composed of a sum of local function probabilities of subunits, varying between 0 and 1. The model was fit to 59 datasets of liver regional and organ function measures from 23 patients obtained before, during, and 1 month after RT. The local function probabilities of subunits were modeled by a sigmoid function in relating to MRI-derived portal venous perfusion values. The global function was fitted to a logarithm of an indocyanine green retention rate at 15 minutes (an overall liver function measure). Cross-validation was performed by leave-m-out tests. The model was further evaluated by fitting to the data divided according to whether the patients had hepatocellular carcinoma (HCC) or not. RESULTS The liver function model showed that (1) a perfusion value of 68.6 mL/(100 g · min) yielded a local function probability of 0.5; (2) the probability reached 0.9 at a perfusion value of 98 mL/(100 g · min); and (3) at a probability of 0.03 [corresponding perfusion of 38 mL/(100 g · min)] or lower, the contribution to global function was lost. Cross-validations showed that the model parameters were stable. The model fitted to the data from the patients with HCC indicated that the same amount of portal venous perfusion was translated into less local function probability than in the patients with non-HCC tumors. CONCLUSIONS The developed liver function model could provide a means to better assess individual and regional dose-responses of hepatic functions, and provide guidance for individualized treatment planning of RT.
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Affiliation(s)
- Hesheng Wang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Mary Feng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Randall K Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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Farr KP, Møller DS, Khalil AA, Kramer S, Morsing A, Grau C. Loss of lung function after chemo-radiotherapy for NSCLC measured by perfusion SPECT/CT: Correlation with radiation dose and clinical morbidity. Acta Oncol 2015. [PMID: 26203930 DOI: 10.3109/0284186x.2015.1061695] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The purpose of the study was to assess dose and time dependence of radiotherapy (RT)-induced changes in regional lung function measured with single photon emission computed tomography (SPECT) of the lung and relate these changes to the symptomatic endpoint of radiation pneumonitis (RP) in patients treated for non-small cell lung cancer (NSCLC). MATERIAL AND METHODS NSCLC patients scheduled to receive curative RT of minimum 60 Gy were included prospectively in the study. Lung perfusion SPECT/CT was performed before and three months after RT. Reconstructed SPECT/CT data were registered to treatment planning CT. Dose to the lung was segmented into regions corresponding to 0-5, 6-20, 21-40, 41-60 and > 60 Gy. Changes (%) in regional lung perfusion before and after RT were correlated with regional dose and symptomatic RP (CTC grade 2-5) outcome. RESULTS A total of 58 patients were included, of which 45 had three-month follow-up SPECT/CT scans. Analysis showed a statistically significant dose-dependent reduction in regional perfusion at three-month follow-up. The largest population composite perfusion loss was in 41-60 Gy (42.2%) and > 60 Gy (41.7%) dose bins. Lung regions receiving low dose of 0-5 Gy and 6-20 Gy had corresponding perfusion increase (-7.2% and -6.1%, respectively). Regional perfusion reduction was different in patients with and without RP with the largest difference in 21-40 Gy bin (p = 0.02), while for other bins the difference did not reach statistical significance. The risk of symptomatic RP was higher for the patients with perfusion reduction after RT (p = 0.02), with the relative risk estimate of 3.6 (95% CI 1.1-12). CONCLUSION Perfusion lung function changes in a dose-dependent manner after RT. The severity of radiation-induced lung symptoms is significantly correlated with SPECT perfusion changes. Perfusion reduction early after RT is associated with a high risk of later development of symptomatic RP.
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Affiliation(s)
- Katherina P Farr
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
| | - Ditte S Møller
- b Department of Medical Physics , Aarhus University Hospital , Aarhus C , Denmark
| | - Azza A Khalil
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
| | - Stine Kramer
- c Department of Nuclear Medicine and PET Centre , Aarhus University Hospital , Aarhus C , Denmark
| | - Anni Morsing
- c Department of Nuclear Medicine and PET Centre , Aarhus University Hospital , Aarhus C , Denmark
| | - Cai Grau
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
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21
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Impact of dose on lung ventilation change calculated from 4D-CT using deformable image registration in lung cancer patients treated with SBRT. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13566-015-0200-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Siva S, Hardcastle N, Kron T, Bressel M, Callahan J, MacManus MP, Shaw M, Plumridge N, Hicks RJ, Steinfort D, Ball DL, Hofman MS. Ventilation/Perfusion Positron Emission Tomography--Based Assessment of Radiation Injury to Lung. Int J Radiat Oncol Biol Phys 2015; 93:408-17. [PMID: 26275510 DOI: 10.1016/j.ijrobp.2015.06.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/11/2015] [Accepted: 06/02/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate (68)Ga-ventilation/perfusion (V/Q) positron emission tomography (PET)/computed tomography (CT) as a novel imaging modality for assessment of perfusion, ventilation, and lung density changes in the context of radiation therapy (RT). METHODS AND MATERIALS In a prospective clinical trial, 20 patients underwent 4-dimensional (4D)-V/Q PET/CT before, midway through, and 3 months after definitive lung RT. Eligible patients were prescribed 60 Gy in 30 fractions with or without concurrent chemotherapy. Functional images were registered to the RT planning 4D-CT, and isodose volumes were averaged into 10-Gy bins. Within each dose bin, relative loss in standardized uptake value (SUV) was recorded for ventilation and perfusion, and loss in air-filled fraction was recorded to assess RT-induced lung fibrosis. A dose-effect relationship was described using both linear and 2-parameter logistic fit models, and goodness of fit was assessed with Akaike Information Criterion (AIC). RESULTS A total of 179 imaging datasets were available for analysis (1 scan was unrecoverable). An almost perfectly linear negative dose-response relationship was observed for perfusion and air-filled fraction (r(2)=0.99, P<.01), with ventilation strongly negatively linear (r(2)=0.95, P<.01). Logistic models did not provide a better fit as evaluated by AIC. Perfusion, ventilation, and the air-filled fraction decreased 0.75 ± 0.03%, 0.71 ± 0.06%, and 0.49 ± 0.02%/Gy, respectively. Within high-dose regions, higher baseline perfusion SUV was associated with greater rate of loss. At 50 Gy and 60 Gy, the rate of loss was 1.35% (P=.07) and 1.73% (P=.05) per SUV, respectively. Of 8/20 patients with peritumoral reperfusion/reventilation during treatment, 7/8 did not sustain this effect after treatment. CONCLUSIONS Radiation-induced regional lung functional deficits occur in a dose-dependent manner and can be estimated by simple linear models with 4D-V/Q PET/CT imaging. These findings may inform future studies of functional lung avoidance using V/Q PET/CT.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia.
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Mathias Bressel
- Department of Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Jason Callahan
- Centre for Molecular Imaging, Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Michael P MacManus
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Mark Shaw
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Nikki Plumridge
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Rodney J Hicks
- Centre for Molecular Imaging, Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Australia
| | - Daniel Steinfort
- Department of Medicine, University of Melbourne, Parkville, Australia; Department of Cancer Medicine, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - David L Ball
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Michael S Hofman
- Centre for Molecular Imaging, Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Australia
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Hardcastle N, Hofman MS, Hicks RJ, Callahan J, Kron T, MacManus MP, Ball DL, Jackson P, Siva S. Accuracy and Utility of Deformable Image Registration in (68)Ga 4D PET/CT Assessment of Pulmonary Perfusion Changes During and After Lung Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 93:196-204. [PMID: 26279034 DOI: 10.1016/j.ijrobp.2015.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 04/29/2015] [Accepted: 05/08/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Measuring changes in lung perfusion resulting from radiation therapy dose requires registration of the functional imaging to the radiation therapy treatment planning scan. This study investigates registration accuracy and utility for positron emission tomography (PET)/computed tomography (CT) perfusion imaging in radiation therapy for non-small cell lung cancer. METHODS (68)Ga 4-dimensional PET/CT ventilation-perfusion imaging was performed before, during, and after radiation therapy for 5 patients. Rigid registration and deformable image registration (DIR) using B-splines and Demons algorithms was performed with the CT data to obtain a deformation map between the functional images and planning CT. Contour propagation accuracy and correspondence of anatomic features were used to assess registration accuracy. Wilcoxon signed-rank test was used to determine statistical significance. Changes in lung perfusion resulting from radiation therapy dose were calculated for each registration method for each patient and averaged over all patients. RESULTS With B-splines/Demons DIR, median distance to agreement between lung contours reduced modestly by 0.9/1.1 mm, 1.3/1.6 mm, and 1.3/1.6 mm for pretreatment, midtreatment, and posttreatment (P < .01 for all), and median Dice score between lung contours improved by 0.04/0.04, 0.05/0.05, and 0.05/0.05 for pretreatment, midtreatment, and posttreatment (P < .001 for all). Distance between anatomic features reduced with DIR by median 2.5 mm and 2.8 for pretreatment and midtreatment time points, respectively (P = .001) and 1.4 mm for posttreatment (P > .2). Poorer posttreatment results were likely caused by posttreatment pneumonitis and tumor regression. Up to 80% standardized uptake value loss in perfusion scans was observed. There was limited change in the loss in lung perfusion between registration methods; however, Demons resulted in larger interpatient variation compared with rigid and B-splines registration. CONCLUSIONS DIR accuracy in the data sets studied was variable depending on anatomic changes resulting from radiation therapy; caution must be exercised when using DIR in regions of low contrast or radiation pneumonitis. Lung perfusion reduces with increasing radiation therapy dose; however, DIR did not translate into significant changes in dose-response assessment.
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Affiliation(s)
- Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia.
| | - Michael S Hofman
- Molecular Imaging, Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Rodney J Hicks
- Molecular Imaging, Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jason Callahan
- Molecular Imaging, Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Tomas Kron
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia; The Sir Peter MacCallum Department of Oncology, Melbourne University, Victoria, Australia
| | - Michael P MacManus
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia; The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - David L Ball
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia; The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Price Jackson
- Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Australia
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Siva S, Thomas R, Callahan J, Hardcastle N, Pham D, Kron T, Hicks RJ, MacManus MP, Ball DL, Hofman MS. High-resolution pulmonary ventilation and perfusion PET/CT allows for functionally adapted intensity modulated radiotherapy in lung cancer. Radiother Oncol 2015; 115:157-62. [PMID: 25935743 DOI: 10.1016/j.radonc.2015.04.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/12/2015] [Accepted: 04/19/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE To assess the utility of functional lung avoidance using IMRT informed by four-dimensional (4D) ventilation/perfusion (V/Q) PET/CT. MATERIALS AND METHODS In a prospective clinical trial, patients with non-small cell lung cancer (NSCLC) underwent 4D-V/Q PET/CT scanning before 60Gy of definitive chemoradiation. Both "highly perfused" (HPLung) and "highly ventilated" (HVLung) lung volumes were delineated using a 70th centile SUV threshold, and a "ventilated lung volume" (VLung) was created using a 50th centile SUV threshold. For each patient four IMRT plans were created, optimised to the anatomical lung, HPLung, HVLung and VLung volumes, respectively. Improvements in functional dose volumetrics when optimising to functional volumes were assessed using mean lung dose (MLD), V5, V10, V20, V30, V40, V50 and V60 parameters. RESULTS The study cohort consisted of 20 patients with 80 IMRT plans. Plans optimised to HPLung resulted in a significant reduction of functional MLD by a mean of 13.0% (1.7Gy), p=0.02. Functional V5, V10 and V20 were improved by 13.2%, 7.3% and 3.8% respectively (p-values<0.04). There was no significant sparing of dose to functional lung when adapting to VLung or HVLung. Plan quality was highly consistent with a mean PTV D95 and D5 ranging from 60.8Gy to 61.0Gy and 63.4Gy to 64.5Gy, respectively, and mean conformity and heterogeneity index ranging from 1.11 to 1.17 and 0.94 to 0.95, respectively. CONCLUSION IMRT plans adapted to perfused but not ventilated lung on 4D-V/Q PET/CT allowed for reduced dose to functional lung whilst maintaining consistent plan quality.
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Affiliation(s)
- Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Australia
| | - Roshini Thomas
- Department of Radiotherapy Services, Peter MacCallum Cancer Centre, Australia
| | - Jason Callahan
- Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Australia
| | | | - Daniel Pham
- Department of Radiotherapy Services, Peter MacCallum Cancer Centre, Australia
| | - Tomas Kron
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Department of Physical Sciences, Peter MacCallum Cancer Centre, Australia
| | - Rodney J Hicks
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Australia
| | - Michael P MacManus
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Australia
| | - David L Ball
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Australia
| | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia; Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Australia
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van Elmpt W, Zegers CML, Das M, De Ruysscher D. Imaging techniques for tumour delineation and heterogeneity quantification of lung cancer: overview of current possibilities. J Thorac Dis 2014; 6:319-27. [PMID: 24688776 DOI: 10.3978/j.issn.2072-1439.2013.08.62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/21/2013] [Indexed: 01/05/2023]
Abstract
Imaging techniques for the characterization and delineation of primary lung tumours and lymph nodes are a prerequisite for adequate radiotherapy. Numerous imaging modalities have been proposed for this purpose, but only computed tomography (CT) and FDG-PET have been implemented in clinical routine. Hypoxia PET, dynamic contrast-enhanced CT (DCE-CT), dual energy CT (DECT) and (functional) magnetic resonance imaging (MRI) hold promise for the future. Besides information on the primary tumour, these techniques can be used for quantification of tissue heterogeneity and response. In the future, treatment strategies may be designed which are based on imaging techniques to optimize individual treatment.
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Affiliation(s)
- Wouter van Elmpt
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Catharina M L Zegers
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Marco Das
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Dirk De Ruysscher
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
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Alpha/Beta Ratio for Normal Lung Tissue as Estimated From Lung Cancer Patients Treated With Stereotactic Body and Conventionally Fractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2014; 88:224-8. [DOI: 10.1016/j.ijrobp.2013.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/27/2013] [Accepted: 10/09/2013] [Indexed: 11/23/2022]
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Time evolution of regional CT density changes in normal lung after IMRT for NSCLC. Radiother Oncol 2013; 109:89-94. [PMID: 24060177 DOI: 10.1016/j.radonc.2013.08.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/20/2013] [Accepted: 08/25/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE This study investigates the clinical radiobiology of radiation induced lung disease in terms of regional computed tomography (CT) density changes following intensity modulated radiotherapy (IMRT) for non-small-cell lung cancer (NSCLC). METHODS A total of 387 follow-up CT scans in 131 NSCLC patients receiving IMRT to a prescribed dose of 60 or 66 Gy in 2 Gy fractions were analyzed. The dose-dependent temporal evolution of the density change was analyzed using a two-component model, a superposition of an early, transient component and a late, persistent component. RESULTS The CT density of healthy lung tissue was observed to increase significantly (p<0.0001) for all dose levels after IMRT. The time evolution and the size of the density signal depend on the local delivered dose. The transient component of the density signal was found to peak in the range of 3-4 months, while the density tends to stabilize at times >12 months. CONCLUSIONS The radiobiology of lung injury may be analyzed in terms of CT density change. The initial transient change in density is consistent with radiation pneumonitis, while the subsequent stabilization of the density is consistent with pulmonary fibrosis.
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