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Park CKS, Warner NS, Kaza E, Sudhyadhom A. Optimization and validation of low-field MP2RAGE T 1 mapping on 0.35T MR-Linac: Toward adaptive dose painting with hypoxia biomarkers. Med Phys 2024. [PMID: 39140821 DOI: 10.1002/mp.17353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/18/2024] [Accepted: 07/27/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Stereotactic MR-guided Adaptive Radiation Therapy (SMART) dose painting for hypoxia has potential to improve treatment outcomes, but clinical implementation on low-field MR-Linac faces substantial challenges due to dramatically lower signal-to-noise ratio (SNR) characteristics. While quantitative MRI and T1 mapping of hypoxia biomarkers show promise, T1-to-noise ratio (T1NR) optimization at low fields is paramount, particularly for the clinical implementation of oxygen-enhanced (OE)-MRI. The 3D Magnetization Prepared (2) Rapid Gradient Echo (MP2RAGE) sequence stands out for its ability to acquire homogeneous T1-weighted contrast images with simultaneous T1 mapping. PURPOSE To optimize MP2RAGE for low-field T1 mapping; conduct experimental validation in a ground-truth phantom; establish feasibility and reproducibility of low-field MP2RAGE acquisition and T1 mapping in healthy volunteers. METHODS The MP2RAGE optimization was performed to maximize the contrast-to-noise ratio (CNR) of T1 values in white matter (WM) and gray matter (GM) brain tissues at 0.35T. Low-field MP2RAGE images were acquired on a 0.35T MR-Linac (ViewRay MRIdian) using a multi-channel head coil. Validation of T1 mapping was performed with a ground-truth Eurospin phantom, containing inserts of known T1 values (400-850 ms), with one and two average (1A and 2A) MP2RAGE scans across four acquisition sessions, resulting in eight T1 maps. Mean (± SD) T1 relative error, T1NR, and intersession coefficient of variation (CV) were determined. Whole-brain MP2RAGE scans were acquired in 5 healthy volunteers across two sessions (A and B) and T1 maps were generated. Mean (± SD) T1 values for WM and GM were determined. Whole-brain T1 histogram analysis was performed, and reproducibility was determined with the CV between sessions. Voxel-by-voxel T1 difference maps were generated to evaluate 3D spatial variation. RESULTS Low-field MP2RAGE optimization resulted in parameters: MP2RAGETR of 3250 ms, inversion times (TI1/TI2) of 500/1200 ms, and flip angles (α1/α2) of 7/5°. Eurospin T1 maps exhibited a mean (± SD) relative error of 3.45% ± 1.30%, T1NR of 20.13 ± 5.31, and CV of 2.22% ± 0.67% across all inserts. Whole-brain MP2RAGE images showed high anatomical quality with clear tissue differentiation, resulting in mean (± SD) T1 values: 435.36 ± 10.01 ms for WM and 623.29 ± 14.64 ms for GM across subjects, showing excellent concordance with literature. Whole-brain T1 histograms showed high intrapatient and intersession reproducibility with characteristic intensity peaks consistent with voxel-level WM and GM T1 values. Reproducibility analysis revealed a CV of 0.46% ± 0.31% and 0.35% ± 0.18% for WM and GM, respectively. Voxel-by-voxel T1 difference maps show a normal 3D spatial distribution of noise in WM and GM. CONCLUSIONS Low-field MP2RAGE proved effective in generating accurate, reliable, and reproducible T1 maps with high T1NR in phantom studies and in vivo feasibility established in healthy volunteers. While current work is focused on refining the MP2RAGE protocol to enable clinically efficient OE-MRI, this study establishes a foundation for TOLD T1 mapping for hypoxia biomarkers. This advancement holds the potential to facilitate a paradigm shift toward MR-guided biological adaptation and dose painting by leveraging 3D hypoxic spatial distributions and improving outcomes in conventionally challenging-to-treat cancers.
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Affiliation(s)
- Claire Keun Sun Park
- Division of Physics and Biophysics, Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Noah Stanley Warner
- Division of Physics and Biophysics, Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Harvard-MIT Health Sciences and Technology, Harvard Medical School, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Evangelia Kaza
- Division of Physics and Biophysics, Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Atchar Sudhyadhom
- Division of Physics and Biophysics, Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Russo L, Charles-Davies D, Bottazzi S, Sala E, Boldrini L. Radiomics for clinical decision support in radiation oncology. Clin Oncol (R Coll Radiol) 2024; 36:e269-e281. [PMID: 38548581 DOI: 10.1016/j.clon.2024.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 02/14/2024] [Accepted: 03/08/2024] [Indexed: 07/09/2024]
Abstract
Radiomics is a promising tool for the development of quantitative biomarkers to support clinical decision-making. It has been shown to improve the prediction of response to treatment and outcome in different settings, particularly in the field of radiation oncology by optimising the dose delivery solutions and reducing the rate of radiation-induced side effects, leading to a fully personalised approach. Despite the promising results offered by radiomics at each of these stages, standardised methodologies, reproducibility and interpretability of results are still lacking, limiting the potential clinical impact of these tools. In this review, we briefly describe the principles of radiomics and the most relevant applications of radiomics at each stage of cancer management in the framework of radiation oncology. Furthermore, the integration of radiomics into clinical decision support systems is analysed, defining the challenges and offering possible solutions for translating radiomics into a clinically applicable tool.
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Affiliation(s)
- L Russo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Radiologiche ed Ematologiche. Università Cattolica Del Sacro Cuore, Rome, Italy.
| | - D Charles-Davies
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - S Bottazzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - E Sala
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Radiologiche ed Ematologiche. Università Cattolica Del Sacro Cuore, Rome, Italy
| | - L Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Schlachter M, Peters S, Camenisch D, Putora PM, Bühler K. Exploration of overlap volumes for radiotherapy plan evaluation with the aim of healthy tissue sparing. Comput Biol Med 2023; 166:107523. [PMID: 37778212 DOI: 10.1016/j.compbiomed.2023.107523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/17/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE Development of a novel interactive visualization approach for the exploration of radiotherapy treatment plans with a focus on overlap volumes with the aim of healthy tissue sparing. METHODS We propose a visualization approach to include overlap volumes in the radiotherapy treatment plan evaluation process. Quantitative properties can be interactively explored to identify critical regions and used to steer the visualization for a detailed inspection of candidates. We evaluated our approach with a user study covering the individual visualizations and their interactions regarding helpfulness, comprehensibility, intuitiveness, decision-making and speed. RESULTS A user study with three domain experts was conducted using our software and evaluating five data sets each representing a different type of cancer and location by performing a set of tasks and filling out a questionnaire. The results show that the visualizations and interactions help to identify and evaluate overlap volumes according to their physical and dose properties. Furthermore, the task of finding dose hot spots can also benefit from our approach. CONCLUSIONS The results indicate the potential to enhance the current treatment plan evaluation process in terms of healthy tissue sparing.
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Affiliation(s)
- Matthias Schlachter
- VRVis Zentrum für Virtual Reality und Visualisierung Forschungs-GmbH, Vienna, Austria.
| | - Samuel Peters
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Daniel Camenisch
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Katja Bühler
- VRVis Zentrum für Virtual Reality und Visualisierung Forschungs-GmbH, Vienna, Austria
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Abstract
Hypoxia (oxygen deprivation) occurs in most solid malignancies, albeit with considerable heterogeneity. Hypoxia is associated with an aggressive cancer phenotype by promotion of genomic instability, evasion of anti-cancer therapies including radiotherapy and enhancement of metastatic risk. Therefore, hypoxia results in poor cancer outcomes. Targeting hypoxia to improve cancer outcomes is an attractive therapeutic strategy. Hypoxia-targeted dose painting escalates radiotherapy dose to hypoxic sub-volumes, as quantified and spatially mapped using hypoxia imaging. This therapeutic approach could overcome hypoxia-induced radioresistance and improve patient outcomes without the need for hypoxia-targeted drugs. This article will review the premise and underpinning evidence for personalized hypoxia-targeted dose painting. It will present data on relevant hypoxia imaging biomarkers, highlight the challenges and potential benefit of this approach and provide recommendations for future research priorities in this field. Personalized hypoxia-based radiotherapy de-escalation strategies will also be addressed.
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Affiliation(s)
- Ahmed Salem
- Department of Anatomy, Physiology and Biochemistry, Faculty of Medicine, Hashemite University, Zarqa, Jordan; Division of Cancer Sciences, University of Manchester, Manchester, UK.
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Sminia P, Guipaud O, Viktorsson K, Ahire V, Baatout S, Boterberg T, Cizkova J, Dostál M, Fernandez-Palomo C, Filipova A, François A, Geiger M, Hunter A, Jassim H, Edin NFJ, Jordan K, Koniarová I, Selvaraj VK, Meade AD, Milliat F, Montoro A, Politis C, Savu D, Sémont A, Tichy A, Válek V, Vogin G. Clinical Radiobiology for Radiation Oncology. RADIOBIOLOGY TEXTBOOK 2023:237-309. [DOI: 10.1007/978-3-031-18810-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
AbstractThis chapter is focused on radiobiological aspects at the molecular, cellular, and tissue level which are relevant for the clinical use of ionizing radiation (IR) in cancer therapy. For radiation oncology, it is critical to find a balance, i.e., the therapeutic window, between the probability of tumor control and the probability of side effects caused by radiation injury to the healthy tissues and organs. An overview is given about modern precision radiotherapy (RT) techniques, which allow optimal sparing of healthy tissues. Biological factors determining the width of the therapeutic window are explained. The role of the six typical radiobiological phenomena determining the response of both malignant and normal tissues in the clinic, the 6R’s, which are Reoxygenation, Redistribution, Repopulation, Repair, Radiosensitivity, and Reactivation of the immune system, is discussed. Information is provided on tumor characteristics, for example, tumor type, growth kinetics, hypoxia, aberrant molecular signaling pathways, cancer stem cells and their impact on the response to RT. The role of the tumor microenvironment and microbiota is described and the effects of radiation on the immune system including the abscopal effect phenomenon are outlined. A summary is given on tumor diagnosis, response prediction via biomarkers, genetics, and radiomics, and ways to selectively enhance the RT response in tumors. Furthermore, we describe acute and late normal tissue reactions following exposure to radiation: cellular aspects, tissue kinetics, latency periods, permanent or transient injury, and histopathology. Details are also given on the differential effect on tumor and late responding healthy tissues following fractionated and low dose rate irradiation as well as the effect of whole-body exposure.
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The impact of organ motion and the appliance of mitigation strategies on the effectiveness of hypoxia-guided proton therapy for non-small cell lung cancer. Radiother Oncol 2022; 176:208-214. [PMID: 36228759 DOI: 10.1016/j.radonc.2022.09.021] [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: 04/25/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the impact of organ motion on hypoxia-guided proton therapy treatments for non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS Hypoxia PET and 4D imaging data of six NSCLC patients were used to simulate hypoxia-guided proton therapy with different motion mitigation strategies including rescanning, breath-hold, respiratory gating and tumour tracking. Motion-induced dose degradation was estimated for treatment plans with dose painting of hypoxic tumour sub-volumes at escalated dose levels. Tumour control probability (TCP) and dosimetry indices were assessed to weigh the clinical benefit of dose escalation and motion mitigation. In addition, the difference in normal tissue complication probability (NTCP) between escalated proton and photon VMAT treatments has been assessed. RESULTS Motion-induced dose degradation was found for target coverage (CTV V95% up to -4%) and quality of the dose-escalation-by-contour (QRMS up to 6%) as a function of motion amplitude and amount of dose escalation. The TCP benefit coming from dose escalation (+4-13%) outweighs the motion-induced losses (<2%). Significant average NTCP reductions of dose-escalated proton plans were found for lungs (-14%), oesophagus (-10%) and heart (-16%) compared to conventional VMAT plans. The best plan dosimetry was obtained with breath hold and respiratory gating with rescanning. CONCLUSION NSCLC affected by hypoxia appears to be a prime target for proton therapy which, by dose-escalation, allows to mitigate hypoxia-induced radio-resistance despite the sensitivity to organ motion. Furthermore, substantial reduction in normal tissue toxicity can be expected compared to conventional VMAT. Accessibility and standardization of hypoxia imaging and clinical trials are necessary to confirm these findings in a clinical setting.
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Jiang L, Lyu Q, Abdelhamid AMH, Hui S, Sheng K. An efficient rectangular optimization method for sparse orthogonal collimator based small animal irradiation. Phys Med Biol 2022; 67:10.1088/1361-6560/ac910b. [PMID: 36084625 PMCID: PMC9595432 DOI: 10.1088/1361-6560/ac910b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/09/2022] [Indexed: 11/11/2022]
Abstract
Objective.Intensity-modulated radiotherapy (IMRT) is widely used in clinical radiotherapy, treating varying malignancies with conformal doses. As the test field for clinical translation, preclinical small animal experiments need to mimic the human radiotherapy condition, including IMRT. However, small animal IMRT is a systematic challenge due to the lack of corresponding hardware and software for miniaturized targets.Approach.The sparse orthogonal collimators (SOC) based on the direct rectangular aperture optimization (RAO) substantially simplified the hardware for miniaturization. This study investigates and evaluates a significantly improved RAO algorithm for complex mouse irradiation using SOC. Because the Kronecker product representation of the rectangular aperture is the main limitation of the computational performance, we reformulated matrix multiplication in the data fidelity term using multiplication with small matrices instead of the Kronecker product of the dose loading matrices. Solving the optimization problem was further accelerated using the Fast Iterative Shrinkage-Thresholding Algorithm (FISTA).Main results.Four mouse cases, including a liver, a brain tumor, a concave U-target, and a complex total marrow irradiation (TMI) case, were included in this study with manually delineated targets and OARs. Seven coplanar-field SOC IMRT (sIMRT) plans were compared with idealistic fluence map based IMRT (iIMRT) plans. For the first three cases with simpler and smaller targets, the differences between sIMRT plans and iIMRT plans in the planning target volumes (PTV) statistics are within 1%. For the TMI case, the sIMRT plans are superior in reducing hot spots (also termedDmax) of PTV, kidneys, lungs, heart, and bowel by 20.5%, 31.5%, 24.67%, 20.13%, and 17.78%, respectively. On average, in four cases in this study, the sIMRT plan conformity is comparable to that of the iIMRT's with lightly increased R50 and Integral Dose by 2.23% and 2.78%.Significance.The significantly improved sIMRT optimization method allows fast plan creation in under 1 min for smaller targets and makes complex TMI planning feasible while achieving comparable dosimetry to idealistic IMRT with fluence map optimization.
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Affiliation(s)
- Lu Jiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Qihui Lyu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Amr M H Abdelhamid
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
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Krarup MMK, Fischer BM, Christensen TN. New PET Tracers: Current Knowledge and Perspectives in Lung Cancer. Semin Nucl Med 2022; 52:781-796. [PMID: 35752465 DOI: 10.1053/j.semnuclmed.2022.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 11/11/2022]
Abstract
PET/CT with the tracer 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) has improved diagnostic imaging in cancer and is routinely used for diagnosing, staging and treatment planning in lung cancer patients. However, pitfalls of [18F]FDG-PET/CT limit the use in specific settings. Additionally, lung cancer is still the leading cause of cancer associated death and has high risk of recurrence after curative treatment. These circumstances have led to the continuous search for more sensitive and specific PET tracers to optimize lung cancer diagnosis, staging, treatment planning and evaluation. The objective of this review is to present and discuss current knowledge and perspectives of new PET tracers for use in lung cancer. A literature search was performed on PubMed and clinicaltrials.gov, limited to the past decade, excluding case reports, preclinical studies and studies on established tracers such as [18F]FDG and DOTATE. The most relevant papers from the search were evaluated. Several tracers have been developed targeting specific tumor characteristics and hallmarks of cancer. A small number of tracers have been studied extensively and evaluated head-to-head with [18F]FDG-PET/CT, whereas others need further investigation and validation in larger clinical trials. At this moment, none of the tracers can replace [18F]FDG-PET/CT. However, they might serve as supplementary imaging methods to provide more knowledge about biological tumor characteristics and visualize intra- and inter-tumoral heterogeneity.
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Affiliation(s)
- Marie M K Krarup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark.
| | - Barbara M Fischer
- Department of Clinical Medicine, Faculty of Health, Univeristy of Copenhagen (UCPH), Copenhagen, Denmark; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Tine N Christensen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark
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Falahatpour Z, Geramifar P, Mahdavi SR, Abdollahi H, Salimi Y, Nikoofar A, Ay MR. Potential advantages of FDG-PET radiomic feature map for target volume delineation in lung cancer radiotherapy. J Appl Clin Med Phys 2022; 23:e13696. [PMID: 35699200 PMCID: PMC9512354 DOI: 10.1002/acm2.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/20/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To investigate the potential benefits of FDG PET radiomic feature maps (RFMs) for target delineation in non-small cell lung cancer (NSCLC) radiotherapy. METHODS Thirty-two NSCLC patients undergoing FDG PET/CT imaging were included. For each patient, nine grey-level co-occurrence matrix (GLCM) RFMs were generated. gross target volume (GTV) and clinical target volume (CTV) were contoured on CT (GTVCT , CTVCT ), PET (GTVPET40 , CTVPET40 ), and RFMs (GTVRFM , CTVRFM ,). Intratumoral heterogeneity areas were segmented as GTVPET50-Boost and radiomic boost target volume (RTVBoost ) on PET and RFMs, respectively. GTVCT in homogenous tumors and GTVPET40 in heterogeneous tumors were considered as GTVgold standard (GTVGS ). One-way analysis of variance was conducted to determine the threshold that finds the best conformity for GTVRFM with GTVGS . Dice similarity coefficient (DSC) and mean absolute percent error (MAPE) were calculated. Linear regression analysis was employed to report the correlations between the gold standard and RFM-derived target volumes. RESULTS Entropy, contrast, and Haralick correlation (H-correlation) were selected for tumor segmentation. The threshold values of 80%, 50%, and 10% have the best conformity of GTVRFM-entropy , GTVRFM-contrast , and GTVRFM-H-correlation with GTVGS , respectively. The linear regression results showed a positive correlation between GTVGS and GTVRFM-entropy (r = 0.98, p < 0.001), between GTVGS and GTVRFM-contrast (r = 0.93, p < 0.001), and between GTVGS and GTVRFM-H-correlation (r = 0.91, p < 0.001). The average threshold values of 45% and 15% were resulted in the best segmentation matching between CTVRFM-entropy and CTVRFM-contrast with CTVGS , respectively. Moreover, we used RFM to determine RTVBoost in the heterogeneous tumors. Comparison of RTVBoost with GTVPET50-Boost MAPE showed the volume error differences of 31.7%, 36%, and 34.7% in RTVBoost-entropy , RTVBoost-contrast , and RTVBoost-H-correlation , respectively. CONCLUSIONS FDG PET-based radiomics features in NSCLC demonstrated a promising potential for decision support in radiotherapy, helping radiation oncologists delineate tumors and generate accurate segmentation for heterogeneous region of tumors.
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Affiliation(s)
- Zahra Falahatpour
- Department of Medical Physics, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Geramifar
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Rabie Mahdavi
- Department of Medical Physics, Faculty of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Abdollahi
- Department of Radiology Technology, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Yazdan Salimi
- Department of Biomedical Engineering and Medical Physics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Nikoofar
- Department of Radiation Oncology, Faculty of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ay
- Department of Medical Physics, Tehran University of Medical Sciences, Tehran, Iran
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Vaz SC, Adam JA, Delgado Bolton RC, Vera P, van Elmpt W, Herrmann K, Hicks RJ, Lievens Y, Santos A, Schöder H, Dubray B, Visvikis D, Troost EGC, de Geus-Oei LF. Joint EANM/SNMMI/ESTRO practice recommendations for the use of 2-[ 18F]FDG PET/CT external beam radiation treatment planning in lung cancer V1.0. Eur J Nucl Med Mol Imaging 2022; 49:1386-1406. [PMID: 35022844 PMCID: PMC8921015 DOI: 10.1007/s00259-021-05624-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/15/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE 2-[18F]FDG PET/CT is of utmost importance for radiation treatment (RT) planning and response monitoring in lung cancer patients, in both non-small and small cell lung cancer (NSCLC and SCLC). This topic has been addressed in guidelines composed by experts within the field of radiation oncology. However, up to present, there is no procedural guideline on this subject, with involvement of the nuclear medicine societies. METHODS A literature review was performed, followed by a discussion between a multidisciplinary team of experts in the different fields involved in the RT planning of lung cancer, in order to guide clinical management. The project was led by experts of the two nuclear medicine societies (EANM and SNMMI) and radiation oncology (ESTRO). RESULTS AND CONCLUSION This guideline results from a joint and dynamic collaboration between the relevant disciplines for this topic. It provides a worldwide, state of the art, and multidisciplinary guide to 2-[18F]FDG PET/CT RT planning in NSCLC and SCLC. These practical recommendations describe applicable updates for existing clinical practices, highlight potential flaws, and provide solutions to overcome these as well. Finally, the recent developments considered for future application are also reviewed.
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Affiliation(s)
- Sofia C. Vaz
- Nuclear Medicine Radiopharmacology, Champalimaud Centre for the Unkown, Champalimaud Foundation, Lisbon, Portugal
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judit A. Adam
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Roberto C. Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño (La Rioja), Spain
| | - Pierre Vera
- Henri Becquerel Cancer Center, QuantIF-LITIS EA 4108, Université de Rouen, Rouen, France
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Rodney J. Hicks
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Andrea Santos
- Nuclear Medicine Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Heiko Schöder
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Bernard Dubray
- Department of Radiotherapy and Medical Physics, Centre Henri Becquerel, Rouen, France
- QuantIF-LITIS EA4108, University of Rouen, Rouen, France
| | | | - Esther G. C. Troost
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden – Rossendorf (HZDR), Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Köthe A, Bizzocchi N, Safai S, Lomax AJ, Weber DC, Fattori G. Investigating the potential of proton therapy for hypoxia-targeted dose escalation in non-small cell lung cancer. Radiat Oncol 2021; 16:199. [PMID: 34635135 PMCID: PMC8507157 DOI: 10.1186/s13014-021-01914-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/13/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypoxia is known to be prevalent in solid tumors such as non-small cell lung cancer (NSCLC) and reportedly correlates with poor prognostic clinical outcome. PET imaging can provide in-vivo hypoxia measurements to support targeted radiotherapy treatment planning. We explore the potential of proton therapy in performing patient-specific dose escalation and compare it with photon volumetric modulated arc therapy (VMAT). METHODS Dose escalation has been calibrated to the patient specific tumor response of ten stage IIb-IIIb NSCLC patients by combining HX4-PET imaging and radiobiological modelling of oxygen enhancement ratio (OER) to target variable tumor hypoxia. In a dose-escalation-by-contour approach, escalated dose levels were simulated to the most hypoxic region of the primary target and its effectiveness in improving loco-regional tumor control was assessed. Furthermore, the impact on normal tissue of proton treatments including dose escalation was evaluated in comparison to the normal tissue complication probability (NTCP) of conventional VMAT plans. RESULTS Ignoring regions of tumor hypoxia can cause overestimation of TCP values by up to 10%, which can effectively be recovered on average to within 0.9% of the nominal TCP, using patient-specific dose escalations of up to 22% of the prescribed dose to PET defined hypoxic regions. Despite such dose escalations, the use of protons could also simultaneously reduce mean doses to the heart (- 14.3 GyRBE), lung (- 8.3 GyRBE), esophagus (- 6.9 GyRBE) and spinal cord (- 3.8 Gy) compared to non-escalated VMAT plans. These reductions are predicted to lead to clinically relevant decreases in NTCP for radiation-induced pneumonitis (- 11.3%), high grade heart toxicity (- 7.4%) and esophagitis (- 7.5%). CONCLUSIONS This study suggests that the administration of proton therapy for dose escalation to patient specific regions of tumor hypoxia in the treatment of NSCLC can mitigate TCP reduction due to hypoxia-induced radio resistance, while simultaneously reducing NTCP levels even when compared to non-escalated treatments delivered with state-of-the-art photon techniques.
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Affiliation(s)
- Andreas Köthe
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland. .,Department of Physics, ETH-Hönggerberg, Zurich, Switzerland.
| | - Nicola Bizzocchi
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland
| | - Sairos Safai
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland
| | - Antony John Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland.,Department of Physics, ETH-Hönggerberg, Zurich, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland.,Radiation Oncology Department, Inselspital Universitätsspital Bern, Bern, Switzerland.,Radiation Oncology Department, University Hospital of Zurich, Zurich, Switzerland
| | - Giovanni Fattori
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen, Switzerland
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12
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Elamir AM, Stanescu T, Shessel A, Tadic T, Yeung I, Letourneau D, Kim J, Lukovic J, Dawson LA, Wong R, Barry A, Brierley J, Gallinger S, Knox J, O'Kane G, Dhani N, Hosni A, Taylor E. Simulated dose painting of hypoxic sub-volumes in pancreatic cancer stereotactic body radiotherapy. Phys Med Biol 2021; 66. [PMID: 34438383 DOI: 10.1088/1361-6560/ac215c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/26/2021] [Indexed: 12/26/2022]
Abstract
Dose painting of hypoxic tumour sub-volumes using positron-emission tomography (PET) has been shown to improve tumour controlin silicoin several sites, predominantly head and neck and lung cancers. Pancreatic cancer presents a more stringent challenge, given its proximity to critical gastro-intestinal organs-at-risk (OARs), anatomic motion, and impediments to reliable PET hypoxia quantification. A radiobiological model was developed to estimate clonogen survival fraction (SF), using18F-fluoroazomycin arabinoside PET (FAZA PET) images from ten patients with unresectable pancreatic ductal adenocarcinoma to quantify oxygen enhancement effects. For each patient, four simulated five-fraction stereotactic body radiotherapy (SBRT) plans were generated: (1) a standard SBRT plan aiming to cover the planning target volume with 40 Gy, (2) dose painting plans delivering escalated doses to a maximum of three FAZA-avid hypoxic sub-volumes, (3) dose painting plans with simulated spacer separating the duodenum and pancreatic head, and (4), plans with integrated boosts to geometric contractions of the gross tumour volume (GTV). All plans saturated at least one OAR dose limit. SF was calculated for each plan and sensitivity of SF to simulated hypoxia quantification errors was evaluated. Dose painting resulted in a 55% reduction in SF as compared to standard SBRT; 78% with spacer. Integrated boosts to hypoxia-blind geometric contractions resulted in a 41% reduction in SF. The reduction in SF for dose-painting plans persisted for all hypoxia quantification parameters studied, including registration and rigid motion errors that resulted in shifts and rotations of the GTV and hypoxic sub-volumes by as much as 1 cm and 10 degrees. Although proximity to OARs ultimately limited dose escalation, with estimated SFs (∼10-5) well above levels required to completely ablate a ∼10 cm3tumour, dose painting robustly reduced clonogen survival when accounting for expected treatment and imaging uncertainties and thus, may improve local response and associated morbidity.
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Affiliation(s)
- Ahmed M Elamir
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Teodor Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrea Shessel
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ivan Yeung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Canada
| | - Daniel Letourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jelena Lukovic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Steven Gallinger
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Jennifer Knox
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Grainne O'Kane
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Neesha Dhani
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Edward Taylor
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
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13
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Carles M, Fechter T, Radicioni G, Schimek-Jasch T, Adebahr S, Zamboglou C, Nicolay NH, Martí-Bonmatí L, Nestle U, Grosu AL, Baltas D, Mix M, Gkika E. FDG-PET Radiomics for Response Monitoring in Non-Small-Cell Lung Cancer Treated with Radiation Therapy. Cancers (Basel) 2021; 13:cancers13040814. [PMID: 33672052 PMCID: PMC7919471 DOI: 10.3390/cancers13040814] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In this study, we strive to identify clinically relevant image feature (IF) changes during chemoradiation in patients with non-small-cell lung cancer (NSCLC) to be able to predict tumor responses in an early stage of treatment. All patients underwent static (3D) and respiratory-gated 4D PET/CT scans before treatment and a 3D scan during or after treatment. Our proposed method rejects IF changes due to intrinsic variability such as noise, resolution and movement through breathing. The IF variability observed across 4D PET is employed as a patient individualized normalization factor to emphasize statistically relevant IF changes during treatment. Abstract The aim of this study is to identify clinically relevant image feature (IF) changes during chemoradiation and evaluate their efficacy in predicting treatment response. Patients with non-small-cell lung cancer (NSCLC) were enrolled in two prospective trials (STRIPE, PET-Plan). We evaluated 48 patients who underwent static (3D) and retrospectively-respiratory-gated 4D PET/CT scans before treatment and a 3D scan during or after treatment. Our proposed method rejects IF changes due to intrinsic variability. The IF variability observed across 4D PET is employed as a patient individualized normalization factor to emphasize statistically relevant IF changes during treatment. Predictions of overall survival (OS), local recurrence (LR) and distant metastasis (DM) were evaluated. From 135 IFs, only 17 satisfied the required criteria of being normally distributed across 4D PET and robust between 3D and 4D images. Changes during treatment in the area-under-the-curve of the cumulative standard-uptake-value histogram (δAUCCSH) within primary tumor discriminated (AUC = 0.87, Specificity = 0.78) patients with and without LR. The resulted prognostic model was validated with a different segmentation method (AUC = 0.83) and in a different patient cohort (AUC = 0.63). The quantification of tumor FDG heterogeneity by δAUCCSH during chemoradiation correlated with the incidence of local recurrence and might be recommended for monitoring treatment response in patients with NSCLC.
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Affiliation(s)
- Montserrat Carles
- Department of Radiation Oncology, Division of Medical Physics, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (T.F.); (D.B.)
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- La Fe Health Research Institute, Biomedical Imaging Research Group (GIBI230-PREBI) and Imaging La Fe Node at Distributed Network for Biomedical Imaging (ReDIB) Unique Scientific and Technical Infrastructures (ICTS), 46026 Valencia, Spain;
- Correspondence:
| | - Tobias Fechter
- Department of Radiation Oncology, Division of Medical Physics, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (T.F.); (D.B.)
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
| | - Gianluca Radicioni
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Sonja Adebahr
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Constantinos Zamboglou
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Nils H. Nicolay
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Luis Martí-Bonmatí
- La Fe Health Research Institute, Biomedical Imaging Research Group (GIBI230-PREBI) and Imaging La Fe Node at Distributed Network for Biomedical Imaging (ReDIB) Unique Scientific and Technical Infrastructures (ICTS), 46026 Valencia, Spain;
| | - Ursula Nestle
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
- Department of Radiation Oncology, Kliniken Maria Hilf, GmbH Moenchengladbach, 41063 Moechengladbach, Germany
| | - Anca L. Grosu
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
| | - Dimos Baltas
- Department of Radiation Oncology, Division of Medical Physics, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (T.F.); (D.B.)
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
| | - Michael Mix
- Department of Nuclear Medicine, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany;
| | - Eleni Gkika
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg of the German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (S.A.); (C.Z.); (N.H.N.); (U.N.); (A.L.G.); (E.G.)
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, 79106 Freiburg, Germany; (G.R.); (T.S.-J.)
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14
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Schick U, Lucia F, Bourbonne V, Dissaux G, Pradier O, Jaouen V, Tixier F, Visvikis D, Hatt M. Use of radiomics in the radiation oncology setting: Where do we stand and what do we need? Cancer Radiother 2020; 24:755-761. [DOI: 10.1016/j.canrad.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022]
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15
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Mikhaylova E, Brooks J, Zuro D, Nouizi F, Kujawski M, Madabushi SS, Qi J, Zhang M, Chea J, Poku EK, Bowles N, Wong JYC, Shively JE, Yazaki PJ, Gulsen G, Cherry SR, Hui S. Prototype Small-Animal PET-CT Imaging System for Image-guided Radiation Therapy. IEEE ACCESS : PRACTICAL INNOVATIONS, OPEN SOLUTIONS 2019; 7:143207-143216. [PMID: 32435548 PMCID: PMC7239319 DOI: 10.1109/access.2019.2944683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Molecular imaging is becoming essential for precision targeted radiation therapy, yet progress is hindered from a lack of integrated imaging and treatment systems. We report the development of a prototype positron emission tomography (PET) scanner integrated into a commercial cone beam computed tomography (CBCT) based small animal irradiation system for molecular-image-guided, targeted external beam radiation therapy. The PET component consists of two rotating Hamamatsu time-of-flight PET modules positioned with a bore diameter of 101.6 mm and a radial field-of-view of 53.1 mm. The measured energy resolution after linearity correction at 511 KeV was 12.9% and the timing resolution was 283.6 ps. The measured spatial resolutions at the field-of-view center and 5 mm off the radial center were 2.6 mm × 2.6 mm × 1.6 mm and 2.6 mm × 2.6 mm × 2.7 mm respectively. 18F-Fluorodeoxyglucose-based PET imaging of a NEMA NU 4-2008 phantom resolved cylindrical volumes with diameters as small as 3 mm. To validate the system in-vivo, we performed 64Cu-DOTA-M5A PET and computed tomography (CT) imaging of carcinoembryonic antigen (CEA)-positive colorectal cancer in athymic nude mice and compared the results with a commercially available Siemens Inveon PET/CT system. The prototype PET system performed comparably to the Siemens system for identifying the location, size, and shape of tumors. Regions of heterogeneous 64Cu-DOTA-M5A uptake were observed. Using 64Cu-DOTA-M5A PET and CT images, a Monte Carlo-based radiation treatment plan was created to escalate the dose to the 64Cu-DOTA-M5A-based, highly active, biological target volume while largely sparing the normal tissue. Results demonstrate the feasibility of molecular-image-guided treatment plans using the prototype theranostic system.
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Affiliation(s)
- Ekaterina Mikhaylova
- Department of Biomedical Engineering, University of California Davis, Davis, CA 95616 USA
| | - Jamison Brooks
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
- Department of Radiation Oncology, University of Minnesota, Minneapolis 55455, MN
| | - Darren Zuro
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
- Department of Radiation Oncology, University of Minnesota, Minneapolis 55455, MN
| | - Farouk Nouizi
- Department of Radiological Sciences, University of California Irvine, Irvine, CA 92697, USA
| | - Maciej Kujawski
- Molecular Imaging and Therapy, City of Hope, Duarte, CA 91010, USA
| | | | - Jinyi Qi
- Department of Biomedical Engineering, University of California Davis, Davis, CA 95616 USA
| | - Mengxi Zhang
- Department of Biomedical Engineering, University of California Davis, Davis, CA 95616 USA
| | - Junie Chea
- Radiopharmacy, City of Hope, Duarte, CA 91010, USA
| | | | | | | | - John E. Shively
- Molecular Imaging and Therapy, City of Hope, Duarte, CA 91010, USA
| | - Paul J Yazaki
- Molecular Imaging and Therapy, City of Hope, Duarte, CA 91010, USA
| | - Gultekin Gulsen
- Department of Radiological Sciences, University of California Irvine, Irvine, CA 92697, USA
| | - Simon R. Cherry
- Department of Biomedical Engineering, University of California Davis, Davis, CA 95616 USA
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
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16
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Abstract
The progressive integration of positron emission tomography/computed tomography (PET/CT) imaging in radiation therapy has its rationale in the biological intertumoral and intratumoral heterogeneity of malignant lesions that require the individual adjustment of radiation dose to obtain an effective local tumor control in cancer patients. PET/CT provides information on the biological features of tumor lesions such as metabolism, hypoxia, and proliferation that can identify radioresistant regions and be exploited to optimize treatment plans. Here, we provide an overview of the basic principles of PET-based target volume selection and definition using 18F-fluorodeoxyglucose (18F-FDG) and then we focus on the emerging strategies of dose painting and adaptive radiotherapy using different tracers. Previous studies provided consistent evidence that integration of 18F-FDG PET/CT in radiotherapy planning improves delineation of target volumes and reduces the uncertainties and variabilities of anatomical delineation of tumor sites. PET-based dose painting and adaptive radiotherapy are feasible strategies although their clinical implementation is highly demanding and requires strong technical, computational, and logistic efforts. Further prospective clinical trials evaluating local tumor control, survival, and toxicity of these emerging strategies will promote the full integration of PET/CT in radiation oncology.
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Affiliation(s)
- Rosa Fonti
- Institute of Biostructures and Bioimages, National Research Council, Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Silvana Del Vecchio
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy.
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17
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Matuszak MM, Kashani R, Green M, Lee C, Cao Y, Owen D, Jolly S, Mierzwa M. Functional Adaptation in Radiation Therapy. Semin Radiat Oncol 2019; 29:236-244. [PMID: 31027641 DOI: 10.1016/j.semradonc.2019.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The promise of adaptive therapy to improve outcomes in radiation oncology has been an area of interest and research in the community for many years. One of the sources of data that can be used to drive adaptive therapy is functional information about the tumor or normal tissues. This avenue of adaptation includes many potential sources of data including global markers and functional imaging. Global markers can be assessments derived from blood measurements, patient functional testing, and circulating tumor material and functional imaging data comprises spatial physiological information from various imaging studies such as positron emission tomography, magnetic resonance imaging, and single photon emission computed tomography. The goal of functional adaptation is to use these functional data to adapt radiation therapy to improve patient outcomes. While functional adaptation holds a lot of promise, there are challenges such as quantifying and minimizing uncertainties, streamlining clinical implementation, determining the ideal way to incorporate information within treatment plan optimization, and proving the clinical benefit through trials. This paper will discuss the types of functional information currently being used for adaptation, highlight several areas where functional adaptation has been studied, and introduce some of the barriers to more widespread clinical implementation.
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Affiliation(s)
- Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI.
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Michael Green
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Michelle Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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18
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Kjellsson Lindblom E, Ureba A, Dasu A, Wersäll P, Even AJG, van Elmpt W, Lambin P, Toma-Dasu I. Impact of SBRT fractionation in hypoxia dose painting - Accounting for heterogeneous and dynamic tumor oxygenation. Med Phys 2019; 46:2512-2521. [PMID: 30924937 DOI: 10.1002/mp.13514] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 02/18/2019] [Accepted: 03/13/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Tumor hypoxia, often found in nonsmall cell lung cancer (NSCLC), implies an increased resistance to radiotherapy. Pretreatment assessment of tumor oxygenation is, therefore, warranted in these patients, as functional imaging of hypoxia could be used as a basis for dose painting. This study aimed at investigating the feasibility of using a method for calculating the dose required in hypoxic subvolumes segmented on 18 F-HX4 positron emission tomography (PET) imaging of NSCLC. METHODS Positron emission tomography imaging data based on the hypoxia tracer 18 F-HX4 of 19 NSCLC patients were included in the study. Normalized tracer uptake was converted to oxygen partial pressure (pO2 ) and hypoxic target volumes (HTVs) were segmented using a threshold of 10 mmHg. Uniform doses required to overcome the hypoxic resistance in the target volumes were calculated based on a previously proposed method taking into account the effect of interfraction reoxygenation, for fractionation schedules ranging from extremely hypofractionated stereotactic body radiotherapy (SBRT) to conventionally fractionated radiotherapy. RESULTS Gross target volumes ranged between 6.2 and 859.6 cm3 , and the hypoxic fraction < 10 mmHg between 1.2% and 72.4%. The calculated doses for overcoming the resistance of cells in the HTVs were comparable to those currently prescribed in clinical practice as well as those previously tested in feasibility studies on dose escalation in NSCLC. Depending on the size of the HTV and the distribution of pO2 , HTV doses were calculated as 43.6-48.4 Gy for a three-fraction schedule, 51.7-57.6 Gy for five fractions, and 59.5-66.4 Gy for eight fractions. For patients in whom the HTV pO2 distribution was more favorable, a lower dose was required despite a bigger volume. Tumor control probability was lower for single-fraction schedules, while higher levels of tumor control probability were found for schedules employing several fractions. CONCLUSIONS The method to account for heterogeneous and dynamic hypoxia in target volume segmentation and dose prescription based on 18 F-HX4-PET imaging appears feasible in NSCLC patients. The distribution of oxygen partial pressure within HTV could impact the required prescribed dose more than the size of the volume.
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Affiliation(s)
- Emely Kjellsson Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | - Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | | | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, S-17176, Sweden
| | - Aniek J G Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden.,Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, S-17176, Sweden
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19
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O'Connor JPB, Robinson SP, Waterton JC. Imaging tumour hypoxia with oxygen-enhanced MRI and BOLD MRI. Br J Radiol 2019; 92:20180642. [PMID: 30272998 PMCID: PMC6540855 DOI: 10.1259/bjr.20180642] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 01/06/2023] Open
Abstract
Hypoxia is known to be a poor prognostic indicator for nearly all solid tumours and also is predictive of treatment failure for radiotherapy, chemotherapy, surgery and targeted therapies. Imaging has potential to identify, spatially map and quantify tumour hypoxia prior to therapy, as well as track changes in hypoxia on treatment. At present no hypoxia imaging methods are available for routine clinical use. Research has largely focused on positron emission tomography (PET)-based techniques, but there is gathering evidence that MRI techniques may provide a practical and more readily translational alternative. In this review we focus on the potential for imaging hypoxia by measuring changes in longitudinal relaxation [R1; termed oxygen-enhanced MRI or tumour oxygenation level dependent (TOLD) MRI] and effective transverse relaxation [R2*; termed blood oxygenation level dependent (BOLD) MRI], induced by inhalation of either 100% oxygen or the radiosensitising hyperoxic gas carbogen. We explain the scientific principles behind oxygen-enhanced MRI and BOLD and discuss significant studies and their limitations. All imaging biomarkers require rigorous validation in order to translate into clinical use and the steps required to further develop oxygen-enhanced MRI and BOLD MRI into decision-making tools are discussed.
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Affiliation(s)
| | - Simon P Robinson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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20
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Ghita M, Dunne V, Hanna GG, Prise KM, Williams JP, Butterworth KT. Preclinical models of radiation-induced lung damage: challenges and opportunities for small animal radiotherapy. Br J Radiol 2019; 92:20180473. [PMID: 30653332 DOI: 10.1259/bjr.20180473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Despite a major paradigm shift in radiotherapy planning and delivery over the past three decades with continuing refinements, radiation-induced lung damage (RILD) remains a major dose limiting toxicity in patients receiving thoracic irradiations. Our current understanding of the biological processes involved in RILD which includes DNA damage, inflammation, senescence and fibrosis, is based on clinical observations and experimental studies in mouse models using conventional radiation exposures. Whilst these studies have provided vital information on the pulmonary radiation response, the current implementation of small animal irradiators is enabling refinements in the precision and accuracy of dose delivery to mice which can be applied to studies of RILD. This review presents the current landscape of preclinical studies in RILD using small animal irradiators and highlights the challenges and opportunities for the further development of this emerging technology in the study of normal tissue damage in the lung.
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Affiliation(s)
- Mihaela Ghita
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Northern Ireland, UK
| | - Victoria Dunne
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Northern Ireland, UK
| | - Gerard G Hanna
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Northern Ireland, UK.,2 Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Northern Ireland, UK
| | - Kevin M Prise
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Northern Ireland, UK
| | - Jaqueline P Williams
- 3 University of Rochester Medical Centre, University of Rochester , Rochester , USA
| | - Karl T Butterworth
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Northern Ireland, UK
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Sabbagh A, Jacobs C, Cooke R, Chu KY, Ng SM, Strauss VY, Virdee PS, Hawkins MA, Aznar MC, Muirhead R. Is There a Role for an 18F-fluorodeoxyglucose-derived Biological Boost in Squamous Cell Anal Cancer? Clin Oncol (R Coll Radiol) 2019; 31:72-80. [PMID: 30583927 DOI: 10.1016/j.clon.2018.11.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/01/2018] [Accepted: 11/07/2018] [Indexed: 02/04/2023]
Abstract
AIMS To investigate the potential role for a biological boost in anal cancer by assessing whether subvolumes of high 18F-fluorodeoxyglucose (FDG) avidity, identified at outset, are spatially consistent during a course of chemoradiotherapy (CRT). MATERIALS AND METHODS FDG-positron emission tomography (FDG-PET) scans from 21 patients enrolled into the ART study (NCT02145416) were retrospectively analysed. In total, 29 volumes including both primary tumours and involved nodes >2 cm were identified. FDG-PET scans were carried out before treatment and on day 8 or 9 of CRT. FDG subvolumes were created using a percentage of maximum FDG avidity at thresholds of 34%, 40%, 50%, on the pre-treatment scans, and 70% and 80% on the subsequent scans. Both FDG-PET scans were deformably registered to the planning computed tomography scan. The overlap fraction and the vector distance were calculated to assess spatial consistency. FDG subvolumes for further investigation had an overlap fraction >0.7, as this has been defined in previous publications as a 'good' correlation. RESULTS The median overlap fractions between the diagnostic FDG-PET subvolumes 34%, 40% and 50% of maximum standardised uptake value (SUVmax) and subsequent FDG-PET subvolumes of 70% of SUVmax were 0.97, 0.92 and 0.81. The median overlap fraction between the diagnostic FDG-PET subvolumes 34%, 40% and 50% and subsequent FDG-PET subvolumes of 80% were 1.00, 1.00 and 0.92. The median (range) vector distance values between diagnostic FDG-PET subvolumes 34%, 40% and 50% and subsequent FDG-PET subvolumes of 80% were 0.74 mm (0.19-2.94) 0.74 mm (0.19-3.39) and 0.71 mm (0.2-3.29), respectively. Twenty of 29 volumes (69.0%) achieved a threshold > 0.7 between the FDG 50% subvolume on the diagnostic scan and the FDG 80% subvolume on the subsequent scan. CONCLUSION FDG-avid subvolumes identified at baseline were spatially consistent during a course of CRT treatment. The subvolume of 50% of SUVmax on the pre-treatment scan could be considered as a potential target for dose escalation.
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Affiliation(s)
- A Sabbagh
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK
| | - C Jacobs
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK
| | - R Cooke
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK; CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - K-Y Chu
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK; CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - S M Ng
- Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Oxford, UK
| | - V Y Strauss
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - P S Virdee
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - M C Aznar
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - R Muirhead
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK.
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22
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Fakir H, Chen J, Sachs RK. Hypo-fractionated boost in locally advanced non-small cell lung cancer: temporal distribution of boost fractions. Phys Med Biol 2018; 63:235018. [PMID: 30484435 DOI: 10.1088/1361-6560/aaee24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
To propose new schemas for radiation boosting of primary tumors, in locally advanced non-small cell lung cancers (NSCLC), in conjunction with standard chemoradiotherapy. To investigate the effect of temporal distributions of the boost fractions on tumor control. NSCLC cases, previously treated with 60 Gy in 30 fractions, were retrospectively planned by adding a radiation boost (25 Gy in 5 fractions) to the primary tumor. Several integrated and sequential boosting schedules were considered. Biological doses were calculated for targets and organs at risk (OAR). Tumor control probabilities (TCP) were calculated using an empirical model and a stochastic model that accounts more systematically for tumor growth kinetics and cell kill. For heterogeneous patient populations, the TCPs for different boost schedules ranged from 82% to 84% and from 73% to 74% for integrated and sequential boosting respectively. For individual tumors with specific growth parameters, the TCP varied by up to 19% between the different schedules. The TCP for sequential boosting was expected to be up to 67% lower than front integrated boosting. The gap in TCP between schedules was higher for tumors with higher clonogenic cell numbers, lower radio-sensitivity, shorter doubling times and lower cell loss. The proposed boosting schemas are dosimetrically feasible and biologically effective. We suggest that the boosts are most effective when given during the first week of treatment and least effective when given sequentially after the end of treatment. The effect of boost scheduling and the effectiveness of front boosting are expected to be most significant for tumors with high clonogenic cell numbers, fast growing rates, low cell loss and low radio-sensitivity. Ultimately, animal studies and clinical trials, guided by biology modeling as presented in the present work, will be needed to verify the effectiveness of fine tuning temporal distributions of radiotherapy fractions.
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Affiliation(s)
- H Fakir
- Department of Physics and Engineering, London Health Sciences Centre, London, Ontario, Canada. Department of Medical Biophysics, Western University, London, Ontario, Canada. Author to whom any correspondence should be addressed
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Li C, Zhang X, Pang L, Huang Y, Gao Y, Sun X, Yu J, Meng X. Spatial Concordance of Tumor Proliferation and Accelerated Repopulation from Pathologic Images to 3′-[18F]Fluoro-3′-Deoxythymidine PET Images: a Basic Study Guided for PET-Based Radiotherapy Dose Painting. Mol Imaging Biol 2018; 21:713-721. [DOI: 10.1007/s11307-018-1292-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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24
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External validation of an NTCP model for acute esophageal toxicity in locally advanced NSCLC patients treated with intensity-modulated (chemo-)radiotherapy. Radiother Oncol 2018; 129:249-256. [DOI: 10.1016/j.radonc.2018.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/23/2018] [Accepted: 07/23/2018] [Indexed: 01/06/2023]
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25
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Wang X, Cui H, Gong G, Fu Z, Zhou J, Gu J, Yin Y, Feng D. Computational delineation and quantitative heterogeneity analysis of lung tumor on 18F-FDG PET for radiation dose-escalation. Sci Rep 2018; 8:10649. [PMID: 30006600 PMCID: PMC6045640 DOI: 10.1038/s41598-018-28818-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/18/2018] [Indexed: 12/13/2022] Open
Abstract
Quantitative measurement and analysis of tumor metabolic activities could provide a more optimal solution to personalized accurate dose painting. We collected PET images of 58 lung cancer patients, in which the tumor exhibits heterogeneous FDG uptake. We design an automated delineation and quantitative heterogeneity measurement of the lung tumor for dose-escalation. For tumor delineation, our algorithm firstly separates the tumor from its adjacent high-uptake tissues using 3D projection masks; then the tumor boundary is delineated with our stopping criterion of joint gradient and intensity affinities. For dose-escalation, tumor sub-volumes with low, moderate and high metabolic activities are extracted and measured. Based on our quantitative heterogeneity measurement, a sub-volume oriented dose-escalation plan is implemented in intensity modulated radiation therapy (IMRT) planning system. With respect to manual tumor delineations by two radiation oncologists, the paired t-test demonstrated our model outperformed the other computational methods in comparison (p < 0.05) and reduced the variability between inter-observers. Compared to standard uniform dose prescription, the dosimetry results demonstrated that the dose-escalation plan statistically boosted the dose delivered to high metabolic tumor sub-volumes (p < 0.05). Meanwhile, the doses received by organs-at-risk (OAR) including the heart, ipsilateral lung and contralateral lung were not statistically different (p > 0.05).
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Affiliation(s)
- Xiuying Wang
- BMIT research group, School of Information Technologies, The University of Sydney, Sydney, Australia.
| | - Hui Cui
- BMIT research group, School of Information Technologies, The University of Sydney, Sydney, Australia
| | - Guanzhong Gong
- The Radiation Oncology Department of Shandong Cancer Hospital, Affiliated to Shandong University, Jinan, China
| | - Zheng Fu
- PET/CT center, Shandong Tumor Hospital and Institute, Shandong Academy of Medical Sciences, Jinan, China
| | | | - Jiabing Gu
- The Radiation Oncology Department of Shandong Cancer Hospital, Affiliated to Shandong University, Jinan, China
| | - Yong Yin
- The Radiation Oncology Department of Shandong Cancer Hospital, Affiliated to Shandong University, Jinan, China.
| | - Dagan Feng
- BMIT research group, School of Information Technologies, The University of Sydney, Sydney, Australia.,Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
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Barrett S, Hanna GG, Marignol L. An overview on personalisation of radiotherapy prescriptions in locally advanced non-small cell lung cancer: Are we there yet? Radiother Oncol 2018; 128:520-533. [PMID: 29908871 DOI: 10.1016/j.radonc.2018.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/21/2018] [Accepted: 05/28/2018] [Indexed: 12/25/2022]
Abstract
Standard of care radiotherapy in LA-NSCLC is 60-66 Gy in 30-33 fractions. However outcomes for these patients are poor with 5-year survival in the range of 10-20%. Randomised controlled trials have shown that dose escalation in a linear fashion does not improve outcomes for all patients, thus there is a need to tailor the prescription to the individual patient. This review assesses the strategies published to personalise the radiation therapy dose prescription in LA-NSCLC. A systematic and scoping search of the literature was performed to identify studies that met the inclusion criteria. 19 relevant studies were identified ranging from prospective clinical trials to mathematically modelled concept studies. Heterogeneity existed between all clinical studies. Nine heterogeneous publications proposed methodology to adapt the dose prescription to the individual patient. A number of encouraging strategies have been identified but fall short of the evidence level required to influence clinical practice.
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Affiliation(s)
- Sarah Barrett
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Dublin, Ireland.
| | - Gerard G Hanna
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, United Kingdom.
| | - Laure Marignol
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Dublin, Ireland.
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27
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Grootjans W, de Geus-Oei LF, Bussink J. Image-guided adaptive radiotherapy in patients with locally advanced non-small cell lung cancer: the art of PET. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2018; 62:369-384. [PMID: 29869486 DOI: 10.23736/s1824-4785.18.03084-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
With a worldwide annual incidence of 1.8 million cases, lung cancer is the most diagnosed form of cancer in men and the third most diagnosed form of cancer in women. Histologically, 80-85% of all lung cancers can be categorized as non-small cell lung cancer (NSCLC). For patients with locally advanced NSCLC, standard of care is fractionated radiotherapy combined with chemotherapy. With the aim of improving clinical outcome of patients with locally advanced NSCLC, combined and intensified treatment approaches are increasingly being used. However, given the heterogeneity of this patient group with respect to tumor biology and subsequent treatment response, a personalized treatment approach is required to optimize therapeutic effect and minimize treatment induced toxicity. Medical imaging, in particular positron emission tomography (PET), before and during the course radiotherapy is increasingly being used to personalize radiotherapy. In this setting, PET imaging can be used to improve delineation of target volumes, employ molecularly-guided dose painting strategies, early response monitoring, prediction and monitoring of treatment-related toxicity. The concept of PET image-guided adaptive radiotherapy (IGART) is an interesting approach to personalize radiotherapy for patients with locally advanced NSCLC, which might ultimately contribute to improved clinical outcomes and reductions in frequency of treatment-related adverse events in this patient group. In this review, we provide a comprehensive overview of available clinical data supporting the use of PET imaging for IGART in patients with locally advanced NSCLC.
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Affiliation(s)
- Willem Grootjans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands -
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
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Radiomics in Nuclear Medicine Applied to Radiation Therapy: Methods, Pitfalls, and Challenges. Int J Radiat Oncol Biol Phys 2018; 102:1117-1142. [PMID: 30064704 DOI: 10.1016/j.ijrobp.2018.05.022] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 02/06/2023]
Abstract
Radiomics is a recent area of research in precision medicine and is based on the extraction of a large variety of features from medical images. In the field of radiation oncology, comprehensive image analysis is crucial to personalization of treatments. A better characterization of local heterogeneity and the shape of the tumor, depicting individual cancer aggressiveness, could guide dose planning and suggest volumes in which a higher dose is needed for better tumor control. In addition, noninvasive imaging features that could predict treatment outcome from baseline scans could help the radiation oncologist to determine the best treatment strategies and to stratify patients as at low risk or high risk of recurrence. Nuclear medicine molecular imaging reflects information regarding biological processes in the tumor thanks to a wide range of radiotracers. Many studies involving 18F-fluorodeoxyglucose positron emission tomography suggest an added value of radiomics compared with the use of conventional PET metrics such as standardized uptake value for both tumor diagnosis and prediction of recurrence or treatment outcome. However, these promising results should not hide technical difficulties that still currently prevent the approach from being widely studied or clinically used. These difficulties mostly pertain to the variability of the imaging features as a function of the acquisition device and protocol, the robustness of the models with respect to that variability, and the interpretation of the radiomic models. Addressing the impact of the variability in acquisition and reconstruction protocols is needed, as is harmonizing the radiomic feature calculation methods, to ensure the reproducibility of studies in a multicenter context and their implementation in a clinical workflow. In this review, we explain the potential impact of positron emission tomography radiomics for radiation therapy and underline the various aspects that need to be carefully addressed to make the most of this promising approach.
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Ureba A, Lindblom E, Dasu A, Uhrdin J, Even AJG, van Elmpt W, Lambin P, Wersäll P, Toma-Dasu I. Non-linear conversion of HX4 uptake for automatic segmentation of hypoxic volumes and dose prescription. Acta Oncol 2018; 57:485-490. [PMID: 29141489 DOI: 10.1080/0284186x.2017.1400177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tumour hypoxia is associated with increased radioresistance and poor response to radiotherapy. Pre-treatment assessment of tumour oxygenation could therefore give the possibility to tailor the treatment by calculating the required boost dose needed to overcome the increased radioresistance in hypoxic tumours. This study concerned the derivation of a non-linear conversion function between the uptake of the hypoxia-PET tracer 18F-HX4 and oxygen partial pressure (pO2). MATERIAL AND METHODS Building on previous experience with FMISO including experimental data on tracer uptake and pO2, tracer-specific model parameters were derived for converting the normalised HX4-uptake at the optimal imaging time point to pO2. The conversion function was implemented in a Python-based computational platform utilising the scripting and the registration modules of the treatment planning system RayStation. Subsequently, the conversion function was applied to determine the pO2 in eight non-small-cell lung cancer (NSCLC) patients imaged with HX4-PET before the start of radiotherapy. Automatic segmentation of hypoxic target volumes (HTVs) was then performed using thresholds around 10 mmHg. The HTVs were compared to sub-volumes segmented based on a tumour-to-blood ratio (TBR) of 1.4 using the aortic arch as the reference oxygenated region. The boost dose required to achieve 95% local control was then calculated based on the calibrated levels of hypoxia, assuming inter-fraction reoxygenation due to changes in acute hypoxia but no overall improvement of the oxygenation status. RESULTS Using the developed conversion tool, HTVs could be obtained using pO2 a threshold of 10 mmHg which were in agreement with the TBR segmentation. The dose levels required to the HTVs to achieve local control were feasible, being around 70-80 Gy in 24 fractions. CONCLUSIONS Non-linear conversion of tracer uptake to pO2 in NSCLC imaged with HX4-PET allows a quantitative determination of the dose-boost needed to achieve a high probability of local control.
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Affiliation(s)
- Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | - Emely Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | | | | | - Aniek J. G. Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
- Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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30
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Positron emission tomography and computed tomographic (PET/CT) imaging for radiation therapy planning in anal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2018; 126:6-12. [PMID: 29759568 DOI: 10.1016/j.critrevonc.2018.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/22/2018] [Accepted: 03/21/2018] [Indexed: 12/19/2022] Open
Abstract
To improve the accuracy of chemoradiation therapy in anal cancer patients PET/CT is frequently used in the planning of radiation therapy. A systematic review was performed to assess impact on survival, quality of life, symptom score, change in target definition and treatment intention. Systematic literature searches were conducted in Medline, EMBASE, the Cochrane Library, and Centre for Reviews and Dissemination. Ten cross-sectional studies were identified. No data were available on survival or quality of life. The summary estimate of the proportion of patients in which PET/CT had an impact on the target definition, was 23% (95% CI 16;33). The corresponding summary estimate of a change in treatment intent from curative to palliative was 3% (95% CI 2;6). Almost one in four patients had a change in target definition, which supports the use of PET/CT in radiation therapy planning, but the consequence regarding survival and quality of life is still uncertain.
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31
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Frood R, McDermott G, Scarsbrook A. Respiratory-gated PET/CT for pulmonary lesion characterisation-promises and problems. Br J Radiol 2018; 91:20170640. [PMID: 29338327 DOI: 10.1259/bjr.20170640] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
2-deoxy-2-(18Fluorine)-fluoro-D-glucose (FDG) PET/CT is an integral part of lung carcinoma staging and frequently used in the assessment of solitary pulmonary nodules. However, a limitation of conventional three-dimensional PET/CT when imaging the thorax is its susceptibility to motion artefact, which blurs the signal from the lesion resulting in inaccurate representation of size and metabolic activity. Respiratory gated (four-dimensional) PET/CT aims to negate the effects of motion artefact and provide a more accurate interpretation of pulmonary nodules and lymphadenopathy. There have been recent advances in technology and a shift from traditional hardware to more streamlined software methods for respiratory gating which should allow more widespread use of respiratory-gating in the future. The purpose of this article is to review the evidence surrounding four-dimensional PET/CT in pulmonary lesion characterisation.
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Affiliation(s)
- Russell Frood
- 1 Department of Nuclear Medicine, Leeds Teaching Hospitals NHS Trust , Leeds , United Kingdom
| | - Garry McDermott
- 2 Department of Medical Physics & Engineering, Leeds Teaching Hospitals NHS Trust , Leeds , United Kingdom
| | - Andrew Scarsbrook
- 1 Department of Nuclear Medicine, Leeds Teaching Hospitals NHS Trust , Leeds , United Kingdom.,3 Leeds Institute of Cancer and Pathology, University of Leeds , Leeds , United Kingdom
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33
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Salem A, Asselin MC, Reymen B, Jackson A, Lambin P, West CML, O'Connor JPB, Faivre-Finn C. Targeting Hypoxia to Improve Non-Small Cell Lung Cancer Outcome. J Natl Cancer Inst 2018; 110:4096546. [PMID: 28922791 DOI: 10.1093/jnci/djx160] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022] Open
Abstract
Oxygen deprivation (hypoxia) in non-small cell lung cancer (NSCLC) is an important factor in treatment resistance and poor survival. Hypoxia is an attractive therapeutic target, particularly in the context of radiotherapy, which is delivered to more than half of NSCLC patients. However, NSCLC hypoxia-targeted therapy trials have not yet translated into patient benefit. Recently, early termination of promising evofosfamide and tarloxotinib bromide studies due to futility highlighted the need for a paradigm shift in our approach to avoid disappointments in future trials. Radiotherapy dose painting strategies based on hypoxia imaging require careful refinement prior to clinical investigation. This review will summarize the role of hypoxia, highlight the potential of hypoxia as a therapeutic target, and outline past and ongoing hypoxia-targeted therapy trials in NSCLC. Evidence supporting radiotherapy dose painting based on hypoxia imaging will be critically appraised. Carefully selected hypoxia biomarkers suitable for integration within future NSCLC hypoxia-targeted therapy trials will be examined. Research gaps will be identified to guide future investigation. Although this review will focus on NSCLC hypoxia, more general discussions (eg, obstacles of hypoxia biomarker research and developing a framework for future hypoxia trials) are applicable to other tumor sites.
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Affiliation(s)
- Ahmed Salem
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marie-Claude Asselin
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bart Reymen
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Alan Jackson
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Philippe Lambin
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Catharine M L West
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - James P B O'Connor
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Corinne Faivre-Finn
- Division of Cancer Sciences and Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK; Department of Radiation Oncology (MAASTRO Lab), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
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MacManus M, Everitt S, Schimek-Jasch T, Li XA, Nestle U, Kong FMS. Anatomic, functional and molecular imaging in lung cancer precision radiation therapy: treatment response assessment and radiation therapy personalization. Transl Lung Cancer Res 2017; 6:670-688. [PMID: 29218270 DOI: 10.21037/tlcr.2017.09.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article reviews key imaging modalities for lung cancer patients treated with radiation therapy (RT) and considers their actual or potential contributions to critical decision-making. An international group of researchers with expertise in imaging in lung cancer patients treated with RT considered the relevant literature on modalities, including computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). These perspectives were coordinated to summarize the current status of imaging in lung cancer and flag developments with future implications. Although there are no useful randomized trials of different imaging modalities in lung cancer, multiple prospective studies indicate that management decisions are frequently impacted by the use of complementary imaging modalities, leading both to more appropriate treatments and better outcomes. This is especially true of 18F-fluoro-deoxyglucose (FDG)-PET/CT which is widely accepted to be the standard imaging modality for staging of lung cancer patients, for selection for potentially curative RT and for treatment planning. PET is also more accurate than CT for predicting survival after RT. PET imaging during RT is also correlated with survival and makes response-adapted therapies possible. PET tracers other than FDG have potential for imaging important biological process in tumors, including hypoxia and proliferation. MRI has superior accuracy in soft tissue imaging and the MRI Linac is a rapidly developing technology with great potential for online monitoring and modification of treatment. The role of imaging in RT-treated lung cancer patients is evolving rapidly and will allow increasing personalization of therapy according to the biology of both the tumor and dose limiting normal tissues.
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Affiliation(s)
- Michael MacManus
- Department of Radiation Oncology, Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Sarah Everitt
- Department of Radiation Oncology, Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI, USA
| | - Ursula Nestle
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Feng-Ming Spring Kong
- Indiana University Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
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Thomas HM, Kinahan PE, Samuel JJE, Bowen SR. Impact of tumour motion compensation and delineation methods on FDG PET-based dose painting plan quality for NSCLC radiation therapy. J Med Imaging Radiat Oncol 2017; 62:81-90. [PMID: 29193781 DOI: 10.1111/1754-9485.12693] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/18/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To quantitatively estimate the impact of different methods for both boost volume delineation and respiratory motion compensation of [18F] FDG PET/CT images on the fidelity of planned non-uniform 'dose painting' plans to the prescribed boost dose distribution. METHODS Six locally advanced non-small cell lung cancer (NSCLC) patients were retrospectively reviewed. To assess the impact of respiratory motion, time-averaged (3D AVG), respiratory phase-gated (4D GATED) and motion-encompassing (4D MIP) PET images were used. The boost volumes were defined using manual contour (MANUAL), fixed threshold (FIXED) and gradient search algorithm (GRADIENT). The dose painting prescription of 60 Gy base dose to the planning target volume and an integral dose of 14 Gy (total 74 Gy) was discretized into seven treatment planning substructures and linearly redistributed according to the relative SUV at every voxel in the boost volume. Fifty-four dose painting plan combinations were generated and conformity was evaluated using quality index VQ0.95-1.05, which represents the sum of planned dose voxels within 5% deviation from the prescribed dose. Trends in plan quality and magnitude of achievable dose escalation were recorded. RESULTS Different segmentation techniques produced statistically significant variations in maximum planned dose (P < 0.02), as well as plan quality between segmentation methods for 4D GATED and 4D MIP PET images (P < 0.05). No statistically significant differences in plan quality and maximum dose were observed between motion-compensated PET-based plans (P > 0.75). Low variability in plan quality was observed for FIXED threshold plans, while MANUAL and GRADIENT plans achieved higher dose with lower plan quality indices. CONCLUSIONS The dose painting plans were more sensitive to segmentation of boost volumes than PET motion compensation in this study sample. Careful consideration of boost target delineation and motion compensation strategies should guide the design of NSCLC dose painting trials.
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Affiliation(s)
- Hannah Mary Thomas
- Department of Radiation Oncology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Physics, School of Advanced Sciences, VIT University, Vellore, India
| | - Paul E Kinahan
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Stephen R Bowen
- Department of Radiation Oncology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
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Even AJG, Reymen B, La Fontaine MD, Das M, Mottaghy FM, Belderbos JSA, De Ruysscher D, Lambin P, van Elmpt W. Clustering of multi-parametric functional imaging to identify high-risk subvolumes in non-small cell lung cancer. Radiother Oncol 2017; 125:379-384. [PMID: 29122363 DOI: 10.1016/j.radonc.2017.09.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to identify tumour subregions with characteristic phenotypes based on pre-treatment multi-parametric functional imaging and correlate these subregions to treatment outcome. The subregions were created using imaging of metabolic activity (FDG-PET/CT), hypoxia (HX4-PET/CT) and tumour vasculature (DCE-CT). MATERIALS AND METHODS 36 non-small cell lung cancer (NSCLC) patients underwent functional imaging prior to radical radiotherapy. Kinetic analysis was performed on DCE-CT scans to acquire blood flow (BF) and volume (BV) maps. HX4-PET/CT and DCE-CT scans were non-rigidly co-registered to the planning FDG-PET/CT. Two clustering steps were performed on multi-parametric images: first to segment each tumour into homogeneous subregions (i.e. supervoxels) and second to group the supervoxels of all tumours into phenotypic clusters. Patients were split based on the absolute or relative volume of supervoxels in each cluster; overall survival was compared using a log-rank test. RESULTS Unsupervised clustering of supervoxels yielded four independent clusters. One cluster (high hypoxia, high FDG, intermediate BF/BV) related to a high-risk tumour type: patients assigned to this cluster had significantly worse survival compared to patients not in this cluster (p = 0.035). CONCLUSIONS We designed a subregional analysis for multi-parametric imaging in NSCLC, and showed the potential of subregion classification as a biomarker for prognosis. This methodology allows for a comprehensive data-driven analysis of multi-parametric functional images.
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Affiliation(s)
- Aniek J G Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands; The D-Lab: Decision Support for Precision Medicine, GROW - School for Oncology & MCCC, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Bart Reymen
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands
| | - Matthew D La Fontaine
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marco Das
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, The Netherlands
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, The Netherlands; Department of Nuclear Medicine, University Hospital Aachen, Germany
| | - José S A Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands; The D-Lab: Decision Support for Precision Medicine, GROW - School for Oncology & MCCC, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands
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Zhu T, Das S, Wong TZ. Integration of PET/MR Hybrid Imaging into Radiation Therapy Treatment. Magn Reson Imaging Clin N Am 2017; 25:377-430. [PMID: 28390536 DOI: 10.1016/j.mric.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hybrid PET/MR imaging is in early development for treatment planning. This article briefly reviews research and clinical applications of PET/MR imaging in radiation oncology. With improvements in workflow, more specific tracers, and fast and robust acquisition protocols, PET/MR imaging will play an increasingly important role in better target delineation for treatment planning and have clear advantages in the evaluation of tumor response and in a better understanding of tumor heterogeneity. With advances in treatment delivery and the potential of integrating PET/MR imaging with research on radiomics for radiation oncology, quantitative and physiologic information could lead to more precise and personalized RT.
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Affiliation(s)
- Tong Zhu
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Shiva Das
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Terence Z Wong
- Department of Radiology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA.
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Mönnich D, Thorwarth D, Leibfarth S, Pfannenberg C, Reischl G, Mauz PS, Nikolaou K, la Fougère C, Zips D, Welz S. Overlap of highly FDG-avid and FMISO hypoxic tumor subvolumes in patients with head and neck cancer. Acta Oncol 2017; 56:1577-1582. [PMID: 28849721 DOI: 10.1080/0284186x.2017.1363910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND PET imaging may be used to personalize radiotherapy (RT) by identifying radioresistant tumor subvolumes for RT dose escalation. Using the tracers [18F]-fluorodeoxyglucose (FDG) and [18F]-fluoromisonidazole (FMISO), different aspects of tumor biology can be visualized. FDG depicts various biological aspects, e.g., proliferation, glycolysis and hypoxia, while FMISO is more hypoxia specific. In this study, we analyzed size and overlap of volumes based on the two markers for head-and-neck cancer patients (HNSCC). MATERIAL AND METHODS Twenty five HNSCC patients underwent a CT scan, as well as FDG and dynamic FMISO PET/CT prior to definitive radio-chemotherapy in a prospective FMISO dose escalation study. Three PET-based subvolumes of the primary tumor (GTVprim) were segmented: a highly FDG-avid volume VFDG, a hypoxic volume on the static FMISO image acquired four hours post tracer injection (VH) and a retention/perfusion volume (VM) using pharmacokinetic modeling of dynamic FMISO data. Absolute volumes, overlaps and distances to agreement (DTA) were evaluated. RESULTS Sizes of PET-based volumes and the GTVprim are significantly different (GTVprim>VFDG>VH >VM; p < .05). VH is covered by VFDG or DTAs are small (mean coverage 74.4%, mean DTA 1.4 mm). Coverage of VM is less pronounced. With respect to VFDG and VH, the mean coverage is 48.7% and 43.1% and the mean DTA is 5.3 mm and 6.3 mm, respectively. For two patients, DTAs were larger than 2 cm. CONCLUSIONS Hypoxic subvolumes from static PET imaging are typically covered by or in close proximity to highly FDG-avid subvolumes. Therefore, dose escalation to FDG positive subvolumes should cover the static hypoxic subvolumes in most patients, with the disadvantage of larger volumes, resulting in a higher risk of dose-limiting toxicity. Coverage of subvolumes from dynamic FMISO PET is less pronounced. Further studies are needed to explore the relevance of mismatches in functional imaging.
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Affiliation(s)
- David Mönnich
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sara Leibfarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gerald Reischl
- Department of Diagnostic and Interventional Radiology, Preclinical Imaging and Radiopharmacy, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christian la Fougère
- Department of Radiology, Nuclear Medicine, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
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Even AJG, Reymen B, La Fontaine MD, Das M, Jochems A, Mottaghy FM, Belderbos JSA, De Ruysscher D, Lambin P, van Elmpt W. Predicting tumor hypoxia in non-small cell lung cancer by combining CT, FDG PET and dynamic contrast-enhanced CT. Acta Oncol 2017; 56:1591-1596. [PMID: 28840770 DOI: 10.1080/0284186x.2017.1349332] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Most solid tumors contain inadequately oxygenated (i.e., hypoxic) regions, which tend to be more aggressive and treatment resistant. Hypoxia PET allows visualization of hypoxia and may enable treatment adaptation. However, hypoxia PET imaging is expensive, time-consuming and not widely available. We aimed to predict hypoxia levels in non-small cell lung cancer (NSCLC) using more easily available imaging modalities: FDG-PET/CT and dynamic contrast-enhanced CT (DCE-CT). MATERIAL AND METHODS For 34 NSCLC patients, included in two clinical trials, hypoxia HX4-PET/CT, planning FDG-PET/CT and DCE-CT scans were acquired before radiotherapy. Scans were non-rigidly registered to the planning CT. Tumor blood flow (BF) and blood volume (BV) were calculated by kinetic analysis of DCE-CT images. Within the gross tumor volume, independent clusters, i.e., supervoxels, were created based on FDG-PET/CT. For each supervoxel, tumor-to-background ratios (TBR) were calculated (median SUV/aorta SUVmean) for HX4-PET/CT and supervoxel features (median, SD, entropy) for the other modalities. Two random forest models (cross-validated: 10 folds, five repeats) were trained to predict the hypoxia TBR; one based on CT, FDG, BF and BV, and one with only CT and FDG features. Patients were split in a training (trial NCT01024829) and independent test set (trial NCT01210378). For each patient, predicted, and observed hypoxic volumes (HV) (TBR > 1.2) were compared. RESULTS Fifteen patients (3291 supervoxels) were used for training and 19 patients (1502 supervoxels) for testing. The model with all features (RMSE training: 0.19 ± 0.01, test: 0.27) outperformed the model with only CT and FDG-PET features (RMSE training: 0.20 ± 0.01, test: 0.29). All tumors of the test set were correctly classified as normoxic or hypoxic (HV > 1 cm3) by the best performing model. CONCLUSIONS We created a data-driven methodology to predict hypoxia levels and hypoxia spatial patterns using CT, FDG-PET and DCE-CT features in NSCLC. The model correctly classifies all tumors, and could therefore, aid tumor hypoxia classification and patient stratification.
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Affiliation(s)
- Aniek J. G. Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart Reymen
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Matthew D. La Fontaine
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marco Das
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arthur Jochems
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Felix M. Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Nuclear Medicine, University Hospital Aachen, Aachen, Germany
| | - José S. A. Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Cancer Metabolism and Tumor Heterogeneity: Imaging Perspectives Using MR Imaging and Spectroscopy. CONTRAST MEDIA & MOLECULAR IMAGING 2017; 2017:6053879. [PMID: 29114178 PMCID: PMC5654284 DOI: 10.1155/2017/6053879] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/31/2017] [Accepted: 08/27/2017] [Indexed: 12/26/2022]
Abstract
Cancer cells reprogram their metabolism to maintain viability via genetic mutations and epigenetic alterations, expressing overall dynamic heterogeneity. The complex relaxation mechanisms of nuclear spins provide unique and convertible tissue contrasts, making magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) pertinent imaging tools in both clinics and research. In this review, we summarized MR methods that visualize tumor characteristics and its metabolic phenotypes on an anatomical, microvascular, microstructural, microenvironmental, and metabolomics scale. The review will progress from the utilities of basic spin-relaxation contrasts in cancer imaging to more advanced imaging methods that measure tumor-distinctive parameters such as perfusion, water diffusion, magnetic susceptibility, oxygenation, acidosis, redox state, and cell death. Analytical methods to assess tumor heterogeneity are also reviewed in brief. Although the clinical utility of tumor heterogeneity from imaging is debatable, the quantification of tumor heterogeneity using functional and metabolic MR images with development of robust analytical methods and improved MR methods may offer more critical roles of tumor heterogeneity data in clinics. MRI/MRS can also provide insightful information on pharmacometabolomics, biomarker discovery, disease diagnosis and prognosis, and treatment response. With these future directions in mind, we anticipate the widespread utilization of these MR-based techniques in studying in vivo cancer biology to better address significant clinical needs.
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Thorwarth D, Wack LJ, Mönnich D. Hypoxia PET imaging techniques: data acquisition and analysis. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0250-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A novel concept for tumour targeting with radiation: Inverse dose-painting or targeting the “Low Drug Uptake Volume”. Radiother Oncol 2017; 124:513-520. [DOI: 10.1016/j.radonc.2017.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/17/2017] [Accepted: 04/21/2017] [Indexed: 01/21/2023]
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Incerti E, Mapelli P, Vuozzo M, Fallanca F, Monterisi C, Bettinardi V, Moresco RM, Gianolli L, Picchio M. Clinical PET imaging of tumour hypoxia in lung cancer. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hypoxia 18F-FAZA PET/CT imaging in lung cancer and high-grade glioma: open issues in clinical application. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0240-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Peerlings J, Van De Voorde L, Mitea C, Larue R, Yaromina A, Sandeleanu S, Spiegelberg L, Dubois L, Lambin P, Mottaghy FM. Hypoxia and hypoxia response-associated molecular markers in esophageal cancer: A systematic review. Methods 2017; 130:51-62. [PMID: 28705470 DOI: 10.1016/j.ymeth.2017.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/08/2017] [Accepted: 07/04/2017] [Indexed: 12/22/2022] Open
Abstract
PURPOSE In this systematic review, the existing evidence of available hypoxia-associated molecular response biomarkers in esophageal cancer (EC) patients is summarized and set into the context of the role of hypoxia in the prediction of esophageal cancer, treatment response and treatment outcome. METHODS A systematic literature search was performed in Web of Science, MEDLINE, and PubMed databases using the keywords: hypoxia, esophagus, cancer, treatment outcome and treatment response. Eligible publications were independently evaluated by two reviewers. In total, 22 out of 419 records were included for systematic review. The described search strategy was applied weekly, with the last update being performed on April 3rd, 2017. RESULTS In esophageal cancer, several (non-)invasive biomarkers for hypoxia could be identified. Independent prognostic factors for treatment response include HIF-1α, CA IX, GLUT-1 overexpression and elevated uptake of the PET-tracer 18F-fluoroerythronitroimidazole (18F-FETNIM). Hypoxia-associated molecular responses represents a clinically relevant phenomenon in esophageal cancer and detection of elevated levels of hypoxia-associated biomarkers and tends to be associated with poor treatment outcome (i.e., overall survival, disease-free survival, complete response and local control). CONCLUSION Evaluation of tumor micro-environmental conditions, such as intratumoral hypoxia, is important to predict treatment outcome and efficacy. Promising non-invasive imaging-techniques have been suggested to assess tumor hypoxia and hypoxia-associated molecular responses. However, extensive validation in EC is lacking. Hypoxia-associated markers that are independent prognostic factors could potentially provide targets for novel treatment strategies to improve treatment outcome. For personalized hypoxia-guided treatment, safe and reliable makers for tumor hypoxia are needed to select suitable patients.
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Affiliation(s)
- Jurgen Peerlings
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Lien Van De Voorde
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Cristina Mitea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ruben Larue
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ala Yaromina
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sebastian Sandeleanu
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Linda Spiegelberg
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ludwig Dubois
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Philippe Lambin
- MAASTRO Clinic, Department of Radiation Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands; Department of Nuclear Medicine, University Hospital RWTH Aachen University, Aachen, Germany
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Lindblom E, Dasu A, Uhrdin J, Even A, van Elmpt W, Lambin P, Wersäll P, Toma-Dasu I. Defining the hypoxic target volume based on positron emission tomography for image guided radiotherapy - the influence of the choice of the reference region and conversion function. Acta Oncol 2017; 56:819-825. [PMID: 28464740 DOI: 10.1080/0284186x.2017.1293289] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hypoxia imaged by positron emission tomography (PET) is a potential target for optimization in radiotherapy. However, the implementation of this approach with respect to the conversion of intensities in the images into oxygenation and radiosensitivity maps is not straightforward. This study investigated the feasibility of applying two conversion approaches previously derived for 18F-labeled fluoromisonidazole (18F-FMISO)-PET images for the hypoxia tracer 18F-flortanidazole (18F-HX4). MATERIAL AND METHODS Ten non-small-cell lung cancer patients imaged with 18F-HX4 before the start of radiotherapy were considered in this study. PET image uptake was normalized to a well-oxygenated reference region and subsequently linear and non-linear conversions were used to determine tissue oxygenations maps. These were subsequently used to delineate hypoxic volumes based partial oxygen pressure (pO2) thresholds. The results were compared to hypoxic volumes segmented using a tissue-to-background ratio of 1.4 for 18F-HX4 uptake. RESULTS While the linear conversion function was not found to result in realistic oxygenation maps, the non-linear function resulted in reasonably sized sub-volumes in good agreement with uptake-based segmented volumes for a limited range of pO2 thresholds. However, the pO2 values corresponding to this range were significantly higher than what is normally considered as hypoxia. The similarity in size, shape, and relative location between uptake-based sub-volumes and volumes based on the conversion to pO2 suggests that the relationship between uptake and pO2 is similar for 18F-FMISO and 18F-HX4, but that the model parameters need to be adjusted for the latter. CONCLUSIONS A non-linear conversion function between uptake and oxygen partial pressure for 18F-FMISO-PET could be applied to 18F-HX4 images to delineate hypoxic sub-volumes of similar size, shape, and relative location as based directly on the uptake. In order to apply the model for e.g., dose-painting, new parameters need to be derived for the accurate calculation of dose-modifying factors for this tracer.
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Affiliation(s)
- Emely Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | - Alexandru Dasu
- The Skandion Clinic, Uppsala, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Aniek Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
- Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D, Thorwarth D. Prognostic value of dynamic hypoxia PET in head and neck cancer: Results from a planned interim analysis of a randomized phase II hypoxia-image guided dose escalation trial. Radiother Oncol 2017; 124:526-532. [PMID: 28434798 DOI: 10.1016/j.radonc.2017.04.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/27/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively assess the prognostic value of tumour hypoxia determined by dynamic [18F]Fluoromisonidazole (dynFMISO) PET/CT, and to evaluate both feasibility and toxicity in patients with locally advanced squamous cell carcinomas of the head and neck (LASCCHN) treated with dynFMISO image-guided dose escalation (DE) using dose-painting by contours. PATIENTS AND METHODS We present a planned interim analysis of a randomized phase II trial. N=25 patients with LASCCHN received baseline dynFMISO PET/CT to derive hypoxic volumes (HV). Patients with tumour hypoxia were randomized into standard radiochemotherapy (stdRT) (70Gy/35 fractions) or DE (77Gy/35 fractions) to the HV. Patients with non-hypoxic tumours were treated with stdRT. Loco-regional control (LRC) in hypoxic patients randomized to stdRT was compared to non-hypoxic patients. Feasibility and toxicity were analysed for patients in the DE arm and compared to stdRT. RESULTS With a mean follow-up of 27months, LRC in hypoxic patients receiving stdRT (n=10) was significantly worse compared to the non-hypoxic group (n=5) (2y-LRC 44.4% versus 100%, p=0.048). The respective LRC for the DE group (n=10) was 70.0%. Treatment compliance as well as acute and late toxicity did not show significant differences between the DE and the standard dose arms. CONCLUSION Tumour hypoxia determined by baseline dynFMISO PET/CT is associated with a high risk of local failure in patients with LASCCHN. First data suggest that DE to HV is feasible without excess toxicity.
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Affiliation(s)
- Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Christina Pfannenberg
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Mathias Reimold
- Department of Nuclear Medicine, University of Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, University of Heidelberg, Germany
| | - Claus Belka
- Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, LMU Munich, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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48
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Abstract
There is interest in identifying and quantifying tumor heterogeneity at the genomic, tissue pathology and clinical imaging scales, as this may help better understand tumor biology and may yield useful biomarkers for guiding therapy-based decision making. This review focuses on the role and value of using x-ray, CT, MRI and PET based imaging methods that identify, measure and map tumor heterogeneity. In particular we highlight the potential value of these techniques and the key challenges required to validate and qualify these biomarkers for clinical use.
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Affiliation(s)
- James P B O'Connor
- Institute of Cancer Sciences, University of Manchester, Manchester, UK; Department of Radiology, The Christie Hospital NHS Trust, Manchester, UK.
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49
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Positron emission tomography and computed tomographic imaging (PET/CT) for dose planning purposes of thoracic radiation with curative intent in lung cancer patients: A systematic review and meta-analysis. Radiother Oncol 2017; 123:71-77. [DOI: 10.1016/j.radonc.2017.02.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/07/2017] [Accepted: 02/20/2017] [Indexed: 12/25/2022]
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50
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Vera P, Thureau S, Chaumet-Riffaud P, Modzelewski R, Bohn P, Vermandel M, Hapdey S, Pallardy A, Mahé MA, Lacombe M, Boisselier P, Guillemard S, Olivier P, Beckendorf V, Salem N, Charrier N, Chajon E, Devillers A, Aide N, Danhier S, Denis F, Muratet JP, Martin E, Riedinger AB, Kolesnikov-Gauthier H, Dansin E, Massabeau C, Courbon F, Farcy Jacquet MP, Kotzki PO, Houzard C, Mornex F, Vervueren L, Paumier A, Fernandez P, Salaun M, Dubray B. Phase II Study of a Radiotherapy Total Dose Increase in Hypoxic Lesions Identified by 18F-Misonidazole PET/CT in Patients with Non-Small Cell Lung Carcinoma (RTEP5 Study). J Nucl Med 2017; 58:1045-1053. [PMID: 28254869 DOI: 10.2967/jnumed.116.188367] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/07/2017] [Indexed: 01/09/2023] Open
Abstract
See an invited perspective on this article on page 1043.This multicenter phase II study investigated a selective radiotherapy dose increase to tumor areas with significant 18F-misonidazole (18F-FMISO) uptake in patients with non-small cell lung carcinoma (NSCLC). Methods: Eligible patients had locally advanced NSCLC and no contraindication to concomitant chemoradiotherapy. The 18F-FMISO uptake on PET/CT was assessed by trained experts. If there was no uptake, 66 Gy were delivered. In 18F-FMISO-positive patients, the contours of the hypoxic area were transferred to the radiation oncologist. It was necessary for the radiotherapy dose to be as high as possible while fulfilling dose-limiting constraints for the spinal cord and lungs. The primary endpoint was tumor response (complete response plus partial response) at 3 mo. The secondary endpoints were toxicity, disease-free survival (DFS), and overall survival at 1 y. The target sample size was set to demonstrate a response rate of 40% or more (bilateral α = 0.05, power 1-β = 0.95). Results: Seventy-nine patients were preincluded, 54 were included, and 34 were 18F-FMISO-positive, 24 of whom received escalated doses of up to 86 Gy. The response rate at 3 mo was 31 of 54 (57%; 95% confidence interval [CI], 43%-71%) using RECIST 1.1 (17/34 responders in the 18F-FMISO-positive group). DFS and overall survival at 1 y were 0.86 (95% CI, 0.77-0.96) and 0.63 (95% CI, 0.49-0.74), respectively. DFS was longer in the 18F-FMISO-negative patients (P = 0.004). The radiotherapy dose was not associated with DFS when adjusting for the 18F-FMISO status. One toxic death (66 Gy) and 1 case of grade 4 pneumonitis (>66 Gy) were reported. Conclusion: Our approach results in a response rate of 40% or more, with acceptable toxicity. 18F-FMISO uptake in NSCLC patients is strongly associated with poor prognosis features that could not be reversed by radiotherapy doses up to 86 Gy.
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Affiliation(s)
- Pierre Vera
- Department of Nuclear Medicine, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, University of Rouen, Rouen, France
| | - Sébastien Thureau
- Department of Radiation Oncology and Medical Physics, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, Rouen, France
| | - Philippe Chaumet-Riffaud
- Department of Nuclear Medicine, Hôpitaux universitaires Paris Sud Bicêtre AP-HP and University Paris Sud, Paris, France
| | - Romain Modzelewski
- Department of Nuclear Medicine, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, University of Rouen, Rouen, France
| | - Pierre Bohn
- Department of Nuclear Medicine, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, University of Rouen, Rouen, France
| | - Maximilien Vermandel
- University Lille, Inserm, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, France
| | - Sébastien Hapdey
- Department of Nuclear Medicine, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, University of Rouen, Rouen, France
| | - Amandine Pallardy
- Department of Nuclear Medicine, Nantes University Hospital, Nantes, France
| | - Marc-André Mahé
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest (ICO)-René Gauducheau, Nantes, France
| | - Marie Lacombe
- Department of Nuclear Medicine, Institut de Cancérologie de l'Ouest (ICO), Nantes, France
| | - Pierre Boisselier
- Department of Radiation Oncology, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Sophie Guillemard
- Department of Nuclear Medicine, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Pierre Olivier
- Department of Nuclear Medicine, Brabois University Hospital, Nancy, France
| | - Veronique Beckendorf
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, Nancy, France
| | - Naji Salem
- Department of Radiation Oncology, Institut Paoli Calmette, Marseille, France
| | - Nathalie Charrier
- Department of Nuclear Medicine, Institut Paoli Calmette, Marseille, France
| | - Enrique Chajon
- Department of Radiation Oncology, Centre regional de lutte contre le cancer de Bretagne Eugène Marquis, Rennes, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre regional de lutte contre le cancer de Bretagne Eugène Marquis, Rennes, France
| | - Nicolas Aide
- Nicolas Aide, Nuclear Medicine and TEP Centre, Caen University Hospital and Inserm U1086 ANTICIPE, Caen, France
| | - Serge Danhier
- Department of Radiation Oncology, François Baclesse Cancer Center, Caen, France
| | - Fabrice Denis
- Department of Radiation Oncology, Institut Inter-Régional de Cancérologie (ILC), Centre Jean Bernard/Clinique Victor Hugo, Le Mans, France
| | - Jean-Pierre Muratet
- Department of Nuclear Medicine, Institut Inter-Régional de Cancérologie (ILC), Centre Jean Bernard/Clinique Victor Hugo, Le Mans, France
| | - Etienne Martin
- Radiation Oncology, Centre Georges-Francois Leclerc, Dijon, France
| | | | | | - Eric Dansin
- Department of Radiation Oncology, Oscar Lambret Center, Lille cedex, France
| | - Carole Massabeau
- Département de Radiothérapie. Institut Universitaire du Cancer, Toulouse cedex 9, France
| | - Fredéric Courbon
- Department of Nuclear Medicine, Institut Claudius Regaud, IUCT, Toulouse cedex 9, France
| | - Marie-Pierre Farcy Jacquet
- Department of Radiation Oncology, CHU de Nîmes, Institut de cancérologie du Gard, Rue Henri Pujol, Nîmes, France
| | - Pierre-Olivier Kotzki
- Department of Nuclear Medicine, Institut régional du Cancer Montpellier (ICM), Montpellier, France.,Department of Nuclear Medicine, CHU de Nîmes, Institut de cancérologie du Gard, Nîmes, France
| | - Claire Houzard
- Department of Nuclear Medicine, Hospices Civils de Lyon, Lyon, France
| | - Francoise Mornex
- Department of Radiation Oncology, Hospices Civils de Lyon, Lyon, France
| | | | - Amaury Paumier
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, site Paul Papin, France
| | - Philippe Fernandez
- Department of Nuclear Medicine, Hôpital Pellegrin, CHU de Bordeaux, France; and
| | - Mathieu Salaun
- Normandy University, UNIROUEN, QuantIF-LITIS EA 4108, Rouen University Hospital, Department of Pulmonology-Thoracic Oncology-Respiratory Intensive Care, Rouen, France
| | - Bernard Dubray
- Department of Radiation Oncology and Medical Physics, Henri Becquerel Cancer Center and Rouen University Hospital & QuantIF-LITIS, Rouen, France
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