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Meixner E, Glogauer B, Klüter S, Wagner F, Neugebauer D, Hoeltgen L, Dinges LA, Harrabi S, Liermann J, Vinsensia M, Weykamp F, Hoegen-Saßmannshausen P, Debus J, Hörner-Rieber J. Validation of different automated segmentation models for target volume contouring in postoperative radiotherapy for breast cancer and regional nodal irradiation. Clin Transl Radiat Oncol 2024; 49:100855. [PMID: 39308634 PMCID: PMC11415814 DOI: 10.1016/j.ctro.2024.100855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/26/2024] [Accepted: 09/10/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction Target volume delineation is routinely performed in postoperative radiotherapy (RT) for breast cancer patients, but it is a time-consuming process. The aim of the present study was to validate the quality, clinical usability and institutional-specific implementation of different auto-segmentation tools into clinical routine. Methods Three different commercially available, artificial intelligence-, ESTRO-guideline-based segmentation models (M1-3) were applied to fifty consecutive reference patients who received postoperative local RT including regional nodal irradiation for breast cancer for the delineation of clinical target volumes: the residual breast, implant or chestwall, axilla levels 1 and 2, the infra- and supraclavicular regions, the interpectoral and internal mammary nodes. Objective evaluation metrics of the created structures were conducted with the Dice similarity index (DICE) and the Hausdorff distance, and a manual evaluation of usability. Results The resulting geometries of the segmentation models were compared to the reference volumes for each patient and required no or only minor corrections in 72 % (M1), 64 % (M2) and 78 % (M3) of the cases. The median DICE and Hausdorff values for the resulting planning target volumes were 0.87-0.88 and 2.96-3.55, respectively. Clinical usability was significantly correlated with the DICE index, with calculated cut-off values used to define no or minor adjustments of 0.82-0.86. Right or left sided target and breathing method (deep inspiration breath hold vs. free breathing) did not impact the quality of the resulting structures. Conclusion Artificial intelligence-based auto-segmentation programs showed high-quality accuracy and provided standardization and efficient support for guideline-based target volume contouring as a precondition for fully automated workflows in radiotherapy treatment planning.
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Affiliation(s)
- Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Benjamin Glogauer
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Friedrich Wagner
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - David Neugebauer
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Lisa A Dinges
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Maria Vinsensia
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Research Center (DKFZ), Clinical Cooperation Unit Radiation Oncology, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Philipp Hoegen-Saßmannshausen
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Research Center (DKFZ), Clinical Cooperation Unit Radiation Oncology, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Research Center (DKFZ), Clinical Cooperation Unit Radiation Oncology, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
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Zaidi F, Calame P, Chevalier C, Henriques J, Vernerey D, Vuitton L, Heyd B, Borg C, Boustani J. A comparison of target volumes drawn on arterial and venous phase scans during radiation therapy planning for patients with pancreatic cancer: the PANCRINJ study. Radiat Oncol 2024; 19:90. [PMID: 39010133 PMCID: PMC11251351 DOI: 10.1186/s13014-024-02477-8] [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: 01/06/2024] [Accepted: 06/18/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND The planification of radiation therapy (RT) for pancreatic cancer (PC) requires a dosimetric computed tomography (CT) scan to define the gross tumor volume (GTV). The main objective of this study was to compare the inter-observer variability in RT planning between the arterial and the venous phases following intravenous contrast. METHODS PANCRINJ was a prospective monocentric study that included twenty patients with non-metastatic PC. Patients underwent a pre-therapeutic CT scan at the arterial and venous phases. The delineation of the GTV was performed by one radiologist (gold standard) and two senior radiation oncologists (operators). The primary objective was to compare the Jaccard conformity index (JCI) for the GTVs computed between the GS (gold standard) and the operators between the arterial and the venous phases with a Wilcoxon signed rank test for paired samples. The secondary endpoints were the geographical miss index (GMI), the kappa index, the intra-operator variability, and the dose-volume histograms between the arterial and venous phases. RESULTS The median JCI for the arterial and venous phases were 0.50 (range, 0.17-0.64) and 0.41 (range, 0.23-0.61) (p = 0.10) respectively. The median GS-GTV was statistically significantly smaller compared to the operators at the arterial (p < 0.0001) and venous phases (p < 0.001), respectively. The GMI were low with few tumors missed for all patients with a median GMI of 0.07 (range, 0-0.79) and 0.05 (range, 0-0.39) at the arterial and venous phases, respectively (p = 0.15). There was a moderate agreement between the radiation oncologists with a median kappa index of 0.52 (range 0.38-0.57) on the arterial phase, and 0.52 (range 0.36-0.57) on the venous phase (p = 0.08). The intra-observer variability for GTV delineation was lower at the venous phase than at the arterial phase for the two operators. There was no significant difference between the arterial and the venous phases regarding the dose-volume histogram for the operators. CONCLUSIONS Our results showed inter- and intra-observer variability in delineating GTV for PC without significant differences between the arterial and the venous phases. The use of both phases should be encouraged. Our findings suggest the need to provide training for radiation oncologists in pancreatic imaging and to collaborate within a multidisciplinary team.
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Affiliation(s)
- Fabien Zaidi
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France
| | - Paul Calame
- Department of Radiology, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Cédric Chevalier
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France
| | - Julie Henriques
- Methodology and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France
| | - Dewi Vernerey
- Methodology and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France
| | - Lucine Vuitton
- Department of Gastroenteroly, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Bruno Heyd
- Department of Digestive surgery, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Christophe Borg
- Department of Oncology, University of Bourgogne Franche-Comté, CHU Besançon, Besançon, 25030, France
| | - Jihane Boustani
- Department of Radiotherapy, University of Bourgogne Franche-Comté, CHU Besançon, CHRU Besançon, Service de Radiothérapie, Hôpital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, 25030, France.
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, F-25000, France.
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Rong Y, Chen Q, Fu Y, Yang X, Al-Hallaq HA, Wu QJ, Yuan L, Xiao Y, Cai B, Latifi K, Benedict SH, Buchsbaum JC, Qi XS. NRG Oncology Assessment of Artificial Intelligence Deep Learning-Based Auto-segmentation for Radiation Therapy: Current Developments, Clinical Considerations, and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:261-280. [PMID: 37972715 PMCID: PMC11023777 DOI: 10.1016/j.ijrobp.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 09/16/2023] [Accepted: 10/14/2023] [Indexed: 11/19/2023]
Abstract
Deep learning neural networks (DLNN) in Artificial intelligence (AI) have been extensively explored for automatic segmentation in radiotherapy (RT). In contrast to traditional model-based methods, data-driven AI-based models for auto-segmentation have shown high accuracy in early studies in research settings and controlled environment (single institution). Vendor-provided commercial AI models are made available as part of the integrated treatment planning system (TPS) or as a stand-alone tool that provides streamlined workflow interacting with the main TPS. These commercial tools have drawn clinics' attention thanks to their significant benefit in reducing the workload from manual contouring and shortening the duration of treatment planning. However, challenges occur when applying these commercial AI-based segmentation models to diverse clinical scenarios, particularly in uncontrolled environments. Contouring nomenclature and guideline standardization has been the main task undertaken by the NRG Oncology. AI auto-segmentation holds the potential clinical trial participants to reduce interobserver variations, nomenclature non-compliance, and contouring guideline deviations. Meanwhile, trial reviewers could use AI tools to verify contour accuracy and compliance of those submitted datasets. In recognizing the growing clinical utilization and potential of these commercial AI auto-segmentation tools, NRG Oncology has formed a working group to evaluate the clinical utilization and potential of commercial AI auto-segmentation tools. The group will assess in-house and commercially available AI models, evaluation metrics, clinical challenges, and limitations, as well as future developments in addressing these challenges. General recommendations are made in terms of the implementation of these commercial AI models, as well as precautions in recognizing the challenges and limitations.
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Affiliation(s)
- Yi Rong
- Mayo Clinic Arizona, Phoenix, AZ
| | - Quan Chen
- City of Hope Comprehensive Cancer Center Duarte, CA
| | - Yabo Fu
- Memorial Sloan Kettering Cancer Center, Commack, NY
| | | | | | | | - Lulin Yuan
- Virginia Commonwealth University, Richmond, VA
| | - Ying Xiao
- University of Pennsylvania/Abramson Cancer Center, Philadelphia, PA
| | - Bin Cai
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Stanley H Benedict
- University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | | | - X Sharon Qi
- University of California Los Angeles, Los Angeles, CA
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Variability of Target Volumes and Organs at Risk Delineation in Breast Cancer Radiation Therapy: Quality Assurance Results of the Pretrial Benchmark Case for the POTENTIAL Trial. Pract Radiat Oncol 2022; 12:397-408. [DOI: 10.1016/j.prro.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/23/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
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Nourzadeh H, Hui C, Ahmad M, Sadeghzadehyazdi N, Watkins WT, Dutta SW, Alonso CE, Trifiletti DM, Siebers JV. Knowledge-based quality control of organ delineations in radiation therapy. Med Phys 2022; 49:1368-1381. [PMID: 35028948 DOI: 10.1002/mp.15458] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 10/17/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To reduce the likelihood of errors in organ delineations used for radiotherapy treatment planning, a knowledge-based quality control (KBQC) system, which discriminates between valid and anomalous delineations is developed. METHOD AND MATERIALS The KBQC is comprised of a group-wise inference system and anomaly detection modules trained using historical priors from 296 locally advanced lung and prostate cancer patient computational tomographies (CTs). The inference system discriminates different organs based on shape, relational, and intensity features. For a given delineated image set, the inference system solves a combinatorial optimization problem that results in an organ group whose relational features follow those of the training set considering the posterior probabilities obtained from support vector machine (SVM), discriminant subspace ensemble (DSE), and artificial neural network (ANN) classifiers. These classifiers are trained on nonrelational features with a 10-fold cross-validation scheme. The anomaly detection module is a bank of ANN autoencoders, each corresponding with an organ, trained on nonrelational features. A heuristic rule detects anomalous organs that exceed predefined organ-specific tolerances for the feature reconstruction error and the classifier's posterior probabilities. Independent data sets with anomalous delineations were used to test the overall performance of the KBQC system. The anomalous delineations were manually manipulated, computer-generated, or propagated based on a transformation obtained by imperfect registrations. Both peer-review-based scoring system and shape similarity coefficient (DSC) were used to label regions of interest (ROIs) as normal or anomalous in two independent test cohorts. RESULTS The accuracy of the classifiers was ≥ $\ge$ 99.8%, and the minimum per-class F1-scores were 0.99, 0.99, and 0.98 for SVM, DSE, and ANN, respectively. The group-wise inference system reduced the miss-classification likelihood for the test data set with anomalous delineations compared to each individual classifier and a fused classifier that used the average posterior probability of all classifiers. For 15 independent locally advanced lung patients, the system detected > $>$ 79% of the anomalous ROIs. For 1320 auto-segmented abdominopelvic organs, the anomaly detection system identified anomalous delineations, which also had low Dice similarity coefficient values with respect to manually delineated organs in the training data set. CONCLUSION The KBQC system detected anomalous delineations with superior accuracy compared to classification methods that judge only based on posterior probabilities.
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Affiliation(s)
- Hamidreza Nourzadeh
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Radiation Oncology Department, University of Virginia, Charlottesville, Virginia, USA
| | | | - Mahmoud Ahmad
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Sunil W Dutta
- Radiation Oncology Department, Emory University, Georgia, USA
| | | | | | - Jeffrey V Siebers
- Radiation Oncology Department, University of Virginia, Charlottesville, Virginia, USA
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Role of the Neuroradiologist and Neurosurgeon in Contouring with the Clinical Oncologist for Stereotactic Radiosurgery. Clin Oncol (R Coll Radiol) 2022; 34:398-406. [DOI: 10.1016/j.clon.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
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7
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Sherer MV, Lin D, Elguindi S, Duke S, Tan LT, Cacicedo J, Dahele M, Gillespie EF. Metrics to evaluate the performance of auto-segmentation for radiation treatment planning: A critical review. Radiother Oncol 2021; 160:185-191. [PMID: 33984348 PMCID: PMC9444281 DOI: 10.1016/j.radonc.2021.05.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022]
Abstract
Advances in artificial intelligence-based methods have led to the development and publication of numerous systems for auto-segmentation in radiotherapy. These systems have the potential to decrease contour variability, which has been associated with poor clinical outcomes and increased efficiency in the treatment planning workflow. However, there are no uniform standards for evaluating auto-segmentation platforms to assess their efficacy at meeting these goals. Here, we review the most frequently used evaluation techniques which include geometric overlap, dosimetric parameters, time spent contouring, and clinical rating scales. These data suggest that many of the most commonly used geometric indices, such as the Dice Similarity Coefficient, are not well correlated with clinically meaningful endpoints. As such, a multi-domain evaluation, including composite geometric and/or dosimetric metrics with physician-reported assessment, is necessary to gauge the clinical readiness of auto-segmentation for radiation treatment planning.
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Affiliation(s)
- Michael V Sherer
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, United States
| | - Diana Lin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Sharif Elguindi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Simon Duke
- Department of Oncology, Cambridge University Hospitals, United Kingdom
| | - Li-Tee Tan
- Department of Oncology, Cambridge University Hospitals, United Kingdom
| | - Jon Cacicedo
- Department of Radiation Oncology, Cruces University Hospital/BioCruces Health Research Institute, Osakidetza, Barakaldo, Spain
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States.
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Brunner TB, Haustermans K, Huguet F, Morganti AG, Mukherjee S, Belka C, Krempien R, Hawkins MA, Valentini V, Roeder F. ESTRO ACROP guidelines for target volume definition in pancreatic cancer. Radiother Oncol 2021; 154:60-69. [DOI: 10.1016/j.radonc.2020.07.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/08/2023]
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Duke SL, Tan LT, Jensen NB, Rumpold T, De Leeuw AA, Kirisits C, Lindegaard JC, Tanderup K, Pötter RC, Nout RA, Jürgenliemk-Schulz IM. Implementing an online radiotherapy quality assurance programme with supporting continuous medical education – report from the EMBRACE-II evaluation of cervix cancer IMRT contouring. Radiother Oncol 2020; 147:22-29. [DOI: 10.1016/j.radonc.2020.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022]
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Holyoake DLP, Warren DR, Hurt C, Aznar M, Partridge M, Mukherjee S, Hawkins MA. Stomach Dose-Volume Predicts Acute Gastrointestinal Toxicity in Chemoradiotherapy for Locally Advanced Pancreatic Cancer. Clin Oncol (R Coll Radiol) 2018; 30:418-426. [PMID: 29602584 DOI: 10.1016/j.clon.2018.02.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/05/2018] [Accepted: 02/27/2018] [Indexed: 01/06/2023]
Abstract
AIMS Gastrointestinal toxicity impedes dose escalation in chemoradiotherapy for hepatobiliary malignancies. Toxicity risk depends on clinical and radiotherapy metrics. We aimed to identify predictive factors using data from two prospective phase II clinical trials of locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Ninety-one patients with available data from the ARCII (59.4 Gy in 33 fractions with gemcitabine, cisplatin and nelfinavir, n = 23) and SCALOP (50.4 Gy in 28 fractions with capecitabine or gemcitabine, n = 74) trials were studied. The independent variables analysed comprised age, sex, performance status, baseline symptoms, tumour size, weight loss, chemotherapy regimen and dose-volume histogram of stomach and duodenum in 5 Gy bins. The outcome measures used were Common Terminology Criteria of Adverse Events (CTCAE) grade and risk of CTCAE grade ≥2 acute upper gastrointestinal toxicity (anorexia, pain, nausea and/or vomiting). The risk of CTCAE grade ≥2 events was modelled using multivariable logistic regression and prediction of severity grade using ordinal regression. RESULTS CTCAE grade ≥2 symptoms occurred in 38 patients (42%). On univariate analysis, stomach V35-45Gy was predictive of risk (odds ratio 1.035, 95% confidence interval 1.007-1.063) and grade (1.023, 1.003-1.044) of toxicity. The area under the curve was 0.632 (0.516-0.747) with toxicity risk 33/66 (50%) above and 5/25 (20%) below the optimal discriminatory threshold (7.1 cm3). Using a threshold of 30 cm3, risk was 13/20 (65%) versus 25/71 (35%). The optimal multivariable logistic regression model incorporated patient sex, chemotherapy regimen and stomach V35-45Gy. Receiving gemcitabine rather than capecitabine (odds ratio 3.965, 95% confidence interval 1.274-12.342) and weight loss during induction chemotherapy (1.216, 1.043-1.419) were significant predictors for the SCALOP cohort, whereas age predicted toxicity risk in ARCII only (1.344, 1.015-1.780). Duodenum dose-volume did not predict toxicity risk or severity in any cohort. CONCLUSIONS In chemoradiotherapy for LAPC the volume of stomach irradiated to a moderately high dose (35-45 Gy) predicts the incidence and severity of acute toxicity. Other predictive factors can include age, sex, recent weight loss and concomitant chemotherapy agents.
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Affiliation(s)
- D L P Holyoake
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D R Warren
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - C Hurt
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - M Aznar
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Usefulness of a new online patient-specific quality assurance system for respiratory-gated radiotherapy. Phys Med 2017; 43:63-72. [PMID: 29195565 DOI: 10.1016/j.ejmp.2017.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/27/2017] [Accepted: 10/14/2017] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The accuracy of gated irradiation may decrease when treatment is performed with short "beam-on" times. Also, the dose is subject to variation between treatment sessions if the respiratory rate is irregular. We therefore evaluated the impact of the differences between gated and non-gated treatment on doses using a new online quality assurance (QA) system for respiratory-gated radiotherapy. METHODS We generated dose estimation models to associate dose and pulse information using a 0.6 cc Farmer chamber and our QA system. During gated irradiation with each of seven regular and irregular respiratory patterns, with the Farmer chamber readings as references, we evaluated our QA system's accuracy. We then used the QA system to assess the impact of respiratory patterns on dose distribution for three lung and three liver radiotherapy plans. Gated and non-gated plans were generated and compared. RESULTS There was agreement within 1.7% between the ionization chamber and our system for several regular and irregular motion patterns. For dose distributions with measured errors, there were larger differences between gated and non-gated treatment for high-dose regions within the planned treatment volume (PTV). Compared with a non-gated plan, PTV D95% for a gated plan decreased by -1.5% to -2.6%. Doses to organs at risk were similar with both plans. CONCLUSIONS Our simple system estimated the radiation dose to the patient using only pulse information from the linac, even during irregular respiration. The quality of gated irradiation for each patient can be verified fraction by fraction.
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Gurney-Champion OJ, Versteijne E, van der Horst A, Lens E, Rütten H, Heerkens HD, Paardekooper GMRM, Berbee M, Rasch CRN, Stoker J, Engelbrecht MRW, van Herk M, Nederveen AJ, Klaassen R, van Laarhoven HWM, van Tienhoven G, Bel A. Addition of MRI for CT-based pancreatic tumor delineation: a feasibility study. Acta Oncol 2017; 56:923-930. [PMID: 28375667 DOI: 10.1080/0284186x.2017.1304654] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE To assess the effect of additional magnetic resonance imaging (MRI) alongside the planning computed tomography (CT) scan on target volume delineation in pancreatic cancer patients. MATERIAL AND METHODS Eight observers (radiation oncologists) from six institutions delineated the gross tumor volume (GTV) on 3DCT, and internal GTV (iGTV) on 4DCT of four pancreatic cancer patients, while MRI was available in a second window (CT + MRI). Variations in volume, generalized conformity index (CIgen), and overall observer variation, expressed as standard deviation (SD) of the distances between delineated surfaces, were analyzed. CIgen is a measure of overlap of the delineated iGTVs (1 = full overlap, 0 = no overlap). Results were compared with those from an earlier study that assessed the interobserver variation by the same observers on the same patients on CT without MRI (CT-only). RESULTS The maximum ratios between delineated volumes within a patient were 6.1 and 22.4 for the GTV (3DCT) and iGTV (4DCT), respectively. The average (root-mean-square) overall observer variations were SD = 0.41 cm (GTV) and SD = 0.73 cm (iGTV). The mean CIgen was 0.36 for GTV and 0.37 for iGTV. When compared to the iGTV delineated on CT-only, the mean volumes of the iGTV on CT + MRI were significantly smaller (32%, Wilcoxon signed-rank, p < .0005). The median volumes of the iGTV on CT + MRI were included for 97% and 92% in the median volumes of the iGTV on CT. Furthermore, CT + MRI showed smaller overall observer variations (root-mean-square SD = 0.59 cm) in six out of eight delineated structures compared to CT-only (root-mean-square SD = 0.72 cm). However, large local observer variations remained close to biliary stents and pathological lymph nodes, indicating issues with instructions and instruction compliance. CONCLUSIONS The availability of MRI images during target delineation of pancreatic cancer on 3DCT and 4DCT resulted in smaller target volumes and reduced the interobserver variation in six out of eight delineated structures.
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Affiliation(s)
- Oliver J. Gurney-Champion
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Eva Versteijne
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Eelco Lens
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Heidi Rütten
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Maaike Berbee
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Coen R. N. Rasch
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc R. W. Engelbrecht
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel van Herk
- Faculty of Biology, Medicine & Health, Division of Cancer Sciences, University of Manchester and Christie NHS Trust, Manchester, UK
| | - Aart J. Nederveen
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Remy Klaassen
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Versteijne E, Lens E, van der Horst A, Bel A, Visser J, Punt CJA, Suker M, van Eijck CHJ, van Tienhoven G. Quality assurance of the PREOPANC trial (2012-003181-40) for preoperative radiochemotherapy in pancreatic cancer : The dummy run. Strahlenther Onkol 2017; 193:630-638. [PMID: 28608305 PMCID: PMC5519646 DOI: 10.1007/s00066-017-1153-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/11/2017] [Indexed: 01/09/2023]
Abstract
Background The Dutch Pancreatic Cancer Group initiated the national, multicentre, controlled PREOPANC trial, randomising between preoperative radiochemotherapy and direct explorative laparotomy for patients with (borderline) resectable pancreatic cancer. The aim of this dummy run is to evaluate compliance with the radiotherapy protocol of this trial, and the quality of delineation and radiation plans. Methods Eleven radiation oncology departments open for accrual of patients in the PREOPANC trial were provided with all necessary information of a selected ‘dummy’ patient. Each institute was asked to delineate the target volumes, including gross tumour volume, internal gross tumour volume (iGTV), internal clinical target volume, and planning target volume. The institutions were also asked to provide a radiation treatment plan in accordance with the PREOPANC trial protocol. Results The range of the iGTV was 19.3–77.2 cm3 with a mean iGTV of 41.5 cm3 (standard deviation 14.8 cm3). Nine institutions made a treatment plan using an arc technique for treatment delivery, one an intensity modulated technique and one a 3-field conformal technique. All institutions reached the prescribed target coverage, without exceeding the organs at risk constraints. The institution with the 3‑field conformal technique was advised to use a more sophisticated technique (e. g. volumetric modulated arc therapy) to reduce the dose to the spinal cord. Conclusion All institutions showed acceptable deviations from the PREOPANC trial protocol and achieved an acceptable quality of delineation and radiation technique. All institutions were allowed to continue participation in the PREOPANC trial. Electronic supplementary material The online version of this article (doi:10.1007/s00066-017-1153-6) contains supplementary material, which is available to authorized users. Supplementary material: PREOPANC Protocol, version 11, radiotherapy part
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Eelco Lens
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus Medical Center, Erasmus University, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Erasmus University, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Modelling duodenum radiotherapy toxicity using cohort dose-volume-histogram data. Radiother Oncol 2017; 123:431-437. [PMID: 28600084 PMCID: PMC5486774 DOI: 10.1016/j.radonc.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 12/25/2022]
Abstract
Background and purpose Gastro-intestinal toxicity is dose-limiting in abdominal radiotherapy and correlated with duodenum dose-volume parameters. We aimed to derive updated NTCP model parameters using published data and prospective radiotherapy quality-assured cohort data. Material and methods A systematic search identified publications providing duodenum dose-volume histogram (DVH) statistics for clinical studies of conventionally-fractionated radiotherapy. Values for the Lyman-Kutcher-Burman (LKB) NTCP model were derived through sum-squared-error minimisation and using leave-one-out cross-validation. Data were corrected for fraction size and weighted according to patient numbers, and the model refined using individual patient DVH data for two further cohorts from prospective clinical trials. Results Six studies with published DVH data were utilised, and with individual patient data included outcomes for 531 patients in total (median follow-up 16 months). Observed gastro-intestinal toxicity rates ranged from 0% to 14% (median 8%). LKB parameter values for unconstrained fit to published data were: n = 0.070, m = 0.46, TD50(1) [Gy] = 183.8, while the values for the model incorporating the individual patient data were n = 0.193, m = 0.51, TD50(1) [Gy] = 299.1. Conclusions LKB parameters derived using published data are shown to be consistent to those previously obtained using individual patient data, supporting a small volume-effect and dependence on exposure to high threshold dose.
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15
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Rivin Del Campo E, Rivera S, Martínez-Paredes M, Hupé P, Slocker Escarpa A, Borget I, Mazeron R, Scholl S, Palacios Eito A, Haie-Meder C, Chargari C, Deutsch E. Assessment of the novel online delineation workshop dummy run approach using FALCON within a European multicentre trial in cervical cancer (RAIDs). Radiother Oncol 2017; 124:130-138. [PMID: 28532608 DOI: 10.1016/j.radonc.2017.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/10/2017] [Accepted: 05/04/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Online delineation workshops (ODW) permit training of geographically dispersed participants. The purpose is to evaluate the methodology of an ODW using FALCON to harmonize delineation within a European multicentre trial on locally advanced cervical cancer (LACC). MATERIAL AND METHODS Two ODW included 46 clinicians (14 centres). Clinicians completed baseline (C1), guideline (C2) and final contours (C3) for external beam radiotherapy (EBRT) and brachytherapy (BT) for LACC. Interobserver and intraobserver variability was evaluated quantitatively (using the DICE index) and qualitatively compared to expert contours. RESULTS Nine clinicians submitted for EBRT and BT for C1-C3. Thirty-two sent any contour. Interobserver quantitative comparisons for EBRT showed significant improvement for C2 vs. C1 for bowel, CTV node, CTV-p and GTV node with significant detriment for GTV node (C3 vs. C1; C2), CTV-p (C3 vs. C2) and bowel (C3 vs. C2), showing in general an improvement in C2 vs. C1, with a detriment in C3 vs. C2 for two target volumes and an organ at risk. For BT there was significant improvement for C2 vs. C1 for bladder, GTV, HR-CTV and IR-CTV, with significant detriment for bladder (C3 vs. C2), thus overall improvement in C2 vs. C1, with only a detriment in C3 vs. C2 for bladder. Centres using MRI imaging for BT contouring did significantly better in the BT case for HR-CTV than those which used other techniques (C2 vs. C1: p<0.005; C3 vs. C1: p=0.02). Intraobserver quantitative comparisons showed significant improvement contouring a region of interest between C2 vs. C1, C3 vs. C1 and C3 vs. C2 for EBRT and between C2 and C1 for BT. CONCLUSIONS ODW offer training, initial contouring harmonization and allow assessment of centres.
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Affiliation(s)
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - María Martínez-Paredes
- Department of Radiology and Medical Physics, Medical School, University of Cordoba, Spain
| | - Philippe Hupé
- Institut Curie, Paris, France; PSL Research University, Paris, France; Inserm, U900, Paris, France; Mines Paris Tech, Fontainebleau, France; CNRS, UMR144, Paris, France
| | | | - Isabelle Borget
- Service de Biostatistique et d'Epidemiologie, Gustave Roussy, Villejuif, France; INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Renaud Mazeron
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Suzy Scholl
- Department of Medical Oncology, Institut Curie, Paris, France
| | - Amalia Palacios Eito
- Department of Radiation Oncology, Reina Sofia University Hospital, Cordoba, Spain
| | - Christine Haie-Meder
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
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Hurt CN, Falk S, Crosby T, McDonald A, Ray R, Joseph G, Staffurth J, Abrams RA, Griffiths G, Maughan T, Mukherjee S. Long-term results and recurrence patterns from SCALOP: a phase II randomised trial of gemcitabine- or capecitabine-based chemoradiation for locally advanced pancreatic cancer. Br J Cancer 2017; 116:1264-1270. [PMID: 28376080 PMCID: PMC5482737 DOI: 10.1038/bjc.2017.95] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/07/2017] [Accepted: 03/17/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND SCALOP, a randomised, phase II trial, tested the activity and safety of gemcitabine (GEM)-based and capecitabine (CAP)-based chemoradiation (CRT) for locally advanced pancreatic cancer (LAPC). Here we present the long-term outcomes. METHODS Eligibility: histologically proven LAPC ⩽7 cm. Following 12 weeks of induction GEMCAP chemotherapy (three cycles: GEM 1000 mg m-2 days 1, 8, 15; CAP 830 mg m-2 days 1-21 q28 days) patients with stable/responding disease, tumour ⩽6 cm, and WHO Performance Status 0-1 were randomised to receive one cycle GEMCAP followed by CAP (830 mg m-2 b.d. on weekdays only) or GEM (300 mg m-2 weekly) with radiation (50.4 Gy per 28 fractions). RESULTS One-hundred fourteen patients (28 UK centres) were registered between 24 December 2009 and 25 October 2011, and 74 were randomised (CAP-RT=36; GEM-RT=38). At the time of this analysis, 105 of the 114 patients had died and the surviving 9 patients had been followed up for a median of 10.9 months (IQR: 2.9-18.7). Updated median OS was 17.6 months (95% CI: 14.6-22.7) in the CAP-CRT arm and 14.6 months (95% CI: 11.1-16.0) in the GEM-CRT arm (intention-to-treat adjusted hazard ratio (HR): 0.68 (95% CI: 0.38-1.21, P=0.185)); median progression-free survival (PFS) was 12.0 months (95% CI: 10.0-15.2) in the CAP-CRT arm and 10.4 months (95% CI: 8.8-12.7) in the GEM-CRT arm (intention-to-treat adjusted HR: 0.60 (95% CI: 0.32-1.14, P=0.120)). In baseline multivariable model, age ⩾65 years, better performance status, CA19.9<613 IU l-1, and shorter tumour diameter predicted improved OS. CAP-CRT, age ⩾65 years, better performance status, CA19.9 <46 IU ml-1 predicted improved OS and PFS in the pre-radiotherapy model. Nine-month PFS was highly predictive of OS. CONCLUSIONS CAP-CRT remains the superior regimen. SCALOP showed that patients with CA19.9 <46 IU ml-1 after induction chemotherapy are more likely to benefit from CRT.
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Affiliation(s)
- C N Hurt
- Centre for Trials Research, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - S Falk
- Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - T Crosby
- Velindre Cancer Centre, Velindre Hospital, Velindre Road, Cardiff CF14 2TL, UK
| | - A McDonald
- Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow G12 0YN, UK
| | - R Ray
- Centre for Trials Research, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - G Joseph
- Velindre Cancer Centre, Velindre Hospital, Velindre Road, Cardiff CF14 2TL, UK
| | - J Staffurth
- Velindre Cancer Centre, Velindre Hospital, Velindre Road, Cardiff CF14 2TL, UK
| | - R A Abrams
- Department of Radiation Oncology, Rush University Medical Center, 500 S. Paulina, 013 Atrium Building, Chicago, IL 60612, USA
| | - G Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - T Maughan
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, Oxford University, Oxford OX3 7DQ, UK
| | - S Mukherjee
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, Oxford University, Oxford OX3 7DQ, UK
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17
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Versteijne E, Gurney-Champion OJ, van der Horst A, Lens E, Kolff MW, Buijsen J, Ebrahimi G, Neelis KJ, Rasch CRN, Stoker J, van Herk M, Bel A, van Tienhoven G. Considerable interobserver variation in delineation of pancreatic cancer on 3DCT and 4DCT: a multi-institutional study. Radiat Oncol 2017; 12:58. [PMID: 28335780 PMCID: PMC5364627 DOI: 10.1186/s13014-017-0777-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/06/2017] [Indexed: 12/13/2022] Open
Abstract
Background The delineation of pancreatic tumors on CT is challenging. In this study, we quantified the interobserver variation for pancreatic tumor delineation on 3DCT as well as on 4DCT. Methods Eight observers (radiation oncologists) from six institutions delineated pancreatic tumors of four patients with (borderline) resectable pancreatic cancer. The study consisted of two stages. In the 3DCT-stage, the gross tumor volume (GTV) was delineated on a contrast-enhanced scan. In the 4DCT-stage, the internal GTV (iGTV) was delineated, accounting for the respiratory motion. We calculated the volumes of the (i)GTV, the overlap of the delineated volumes (expressed as generalized conformity index: CIgen), the local observer variation (local standard deviation: SD) and the overall observer variation (overall SD). We compared these results between GTVs and iGTVs. Additionally, observers were asked to fill out a questionnaire concerning the difficulty of the delineation and their experience in delineating pancreatic tumors. Results The ratios of the largest to the smallest delineated GTV and iGTV within the same patient were 6.8 and 16.5, respectively. As the iGTV incorporates the GTV during all respiratory phases, the mean volumes of the iGTV (40.07 cm3) were larger than those of the GTV (29.91 cm3). For all patients, CIgen was larger for the iGTV than for the GTV. The mean overall observer variation (root-mean-square of all local SDs over four patients) was 0.63 cm and 0.80 cm for GTV and iGTV, respectively. The largest local observer variations were seen close to biliary stents and suspicious pathological enlarged lymph nodes, as some observers included them and some did not. This variation was more pronounced for the iGTV than for the GTV. The observers rated the 3DCT-stage and 4DCT-stage equally difficult and treated on average three to four pancreatic cancer patients per year. Conclusions A considerable interobserver variation in delineation of pancreatic tumors was observed. This variation was larger for 4D than for 3D delineation. The largest local observer variation was found around biliary stents and suspicious pathological enlarged lymph nodes. Electronic supplementary material The online version of this article (doi:10.1186/s13014-017-0777-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Oliver J Gurney-Champion
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Eelco Lens
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M Willemijn Kolff
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology, MAASTRO clinic, Doctor Tanslaan 12, 6229 ET, Maastricht, The Netherlands
| | - Gati Ebrahimi
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Leiden University, Postbus 9600, 2300 RC, Leiden, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marcel van Herk
- Faculty of Biology, Medicine & Health, Division of Molecular & Clinical Cancer Sciences, University of Manchester and Christie NHS trust, Oxford Road Manchester, M13 9PL, Manchester, United Kingdom
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Choi W, Xue M, Lane BF, Kang MK, Patel K, Regine WF, Klahr P, Wang J, Chen S, D'Souza W, Lu W. Individually optimized contrast-enhanced 4D-CT for radiotherapy simulation in pancreatic ductal adenocarcinoma. Med Phys 2017; 43:5659. [PMID: 27782710 DOI: 10.1118/1.4963213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop an individually optimized contrast-enhanced (CE) 4D-computed tomography (CT) for radiotherapy simulation in pancreatic ductal adenocarcinomas (PDA). METHODS Ten PDA patients were enrolled. Each underwent three CT scans: a 4D-CT immediately following a CE 3D-CT and an individually optimized CE 4D-CT using test injection. Three physicians contoured the tumor and pancreatic tissues. Image quality scores, tumor volume, motion, tumor-to-pancreas contrast, and contrast-to-noise ratio (CNR) were compared in the three CTs. Interobserver variations were also evaluated in contouring the tumor using simultaneous truth and performance level estimation. RESULTS Average image quality scores for CE 3D-CT and CE 4D-CT were comparable (4.0 and 3.8, respectively; P = 0.082), and both were significantly better than that for 4D-CT (2.6, P < 0.001). Tumor-to-pancreas contrast results were comparable in CE 3D-CT and CE 4D-CT (15.5 and 16.7 Hounsfield units (HU), respectively; P = 0.21), and the latter was significantly higher than in 4D-CT (9.2 HU, P = 0.001). Image noise in CE 3D-CT (12.5 HU) was significantly lower than in CE 4D-CT (22.1 HU, P = 0.013) and 4D-CT (19.4 HU, P = 0.009). CNRs were comparable in CE 3D-CT and CE 4D-CT (1.4 and 0.8, respectively; P = 0.42), and both were significantly better in 4D-CT (0.6, P = 0.008 and 0.014). Mean tumor volumes were significantly smaller in CE 3D-CT (29.8 cm3, P = 0.03) and CE 4D-CT (22.8 cm3, P = 0.01) than in 4D-CT (42.0 cm3). Mean tumor motion was comparable in 4D-CT and CE 4D-CT (7.2 and 6.2 mm, P = 0.17). Interobserver variations were comparable in CE 3D-CT and CE 4D-CT (Jaccard index 66.0% and 61.9%, respectively) and were worse for 4D-CT (55.6%) than CE 3D-CT. CONCLUSIONS CE 4D-CT demonstrated characteristics comparable to CE 3D-CT, with high potential for simultaneously delineating the tumor and quantifying tumor motion with a single scan.
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Affiliation(s)
- Wookjin Choi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York 10065 and Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Ming Xue
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Barton F Lane
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University School of Medicine, Daegu 41944, South Korea
| | - Kruti Patel
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Paul Klahr
- Philips Healthcare, Highland Heights, Ohio 44143
| | - Jiahui Wang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Warren D'Souza
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Wei Lu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York 10065 and Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
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Holyoake DLP, Robinson M, Grose D, McIntosh D, Sebag-Montefiore D, Radhakrishna G, Patel N, Partridge M, Mukherjee S, Hawkins MA. Conformity analysis to demonstrate reproducibility of target volumes for Margin-Intense Stereotactic Radiotherapy for borderline-resectable pancreatic cancer. Radiother Oncol 2016; 121:86-91. [PMID: 27519585 PMCID: PMC5100802 DOI: 10.1016/j.radonc.2016.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/22/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Margin-directed neoadjuvant radiotherapy for borderline-resectable pancreatic cancer (BRPC) aims to facilitate clear surgical margins. A systematic method was developed for definition of a boost target volume prior to a formal phase-I study. MATERIAL AND METHODS Reference structures were defined by two oncologists and one radiologist, target structures were submitted by eight oncologist investigators and compared using conformity indices. Resultant risk of duodenal bleed (NTCP) was modelled. RESULTS For GTV, reference volume was 2.1cm3 and investigator mean was 6.03cm3 (95% CI 3.92-8.13cm3), for boost volume 1.1cm3 and 1.25cm3 (1.02-1.48cm3). Mean Dice conformity coefficient for GTV was 0.47 (0.38-0.56), and for boost volume was significantly higher at 0.61 (0.52-0.70, p=0.01). Discordance index (DI) for GTV was 0.65 (0.56-0.75) and for boost volume was significantly lower at 0.39 (0.28-0.49, p=0.001). NTCP using reference contours was 2.95%, with mean for investigator contour plans 3.93% (3.63-4.22%). Correlations were seen between NTCP and GTV volume (p=0.02) and NTCP and DI (correlation coefficient 0.83 (0.29-0.97), p=0.01). CONCLUSIONS Better conformity with reference was shown for boost volume compared with GTV. Investigator GTV volumes were larger than reference, had higher DI scores and modelled toxicity risk. A consistent method of target structure definition for margin-directed pancreatic radiotherapy is demonstrated.
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Affiliation(s)
- Daniel L P Holyoake
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK; The Churchill Hospital, Oxford, UK
| | - Maxwell Robinson
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK; The Churchill Hospital, Oxford, UK
| | - Derek Grose
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - David Sebag-Montefiore
- University of Leeds, CRUK Leeds Centre, UK; Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | | | | | - Mike Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Somnath Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK; The Churchill Hospital, Oxford, UK
| | - Maria A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK; The Churchill Hospital, Oxford, UK.
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Fokas E, Spezi E, Patel N, Hurt C, Nixon L, Chu KY, Staffurth J, Abrams R, Mukherjee S. Comparison of investigator-delineated gross tumour volumes and quality assurance in pancreatic cancer: Analysis of the on-trial cases for the SCALOP trial. Radiother Oncol 2016; 120:212-6. [PMID: 27497804 PMCID: PMC5013754 DOI: 10.1016/j.radonc.2016.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/01/2016] [Accepted: 07/03/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE We performed a retrospective central review of tumour outlines in patients undergoing radiotherapy in the SCALOP trial. MATERIALS AND METHODS The planning CT scans were reviewed retrospectively by a central review team, and the accuracy of investigators' GTV (iGTV) and PTV (iPTV) was compared to the trials team-defined gold standard (gsGTV and gsPTV) using the Jaccard Conformity Index (JCI) and Geographical Miss Index (GMI). The prognostic value of JCI and GMI was also assessed. The RT plans were also reviewed against protocol-defined constraints. RESULTS 60 patients with diagnostic-quality planning scans were included. The median whole volume JCI for GTV was 0.64 (IQR: 0.43-0.82), and the median GMI was 0.11 (IQR: 0.05-0.22). For PTVs, the median JCI and GMI were 0.80 (IQR: 0.71-0.88) and 0.04 (IQR: 0.02-0.12) respectively. Tumour was completely missed in 1 patient, and⩾50% of the tumour was missed in 3. Patients with JCI for GTV⩾0.7 had 7.12 (95% CIs: 1.83-27.67, p=0.005) higher odds of progressing by 9months in multivariate analysis. Major deviations in RT planning were noted in 4.5% of cases. CONCLUSIONS Radiotherapy workshops and real-time central review of contours are required in RT trials of pancreatic cancer.
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Affiliation(s)
- Emmanouil Fokas
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | | | - Neel Patel
- Oxford University Hospital NHS Foundation Trust, UK
| | - Chris Hurt
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, UK
| | - Lisette Nixon
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, UK
| | - Kwun-Ye Chu
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK; Oxford University Hospital NHS Foundation Trust, UK
| | - John Staffurth
- Institute of Cancer and Genetics, Cardiff University, UK; Cardiff NCRI RTTQA Centre, Velindre NHS Trust, UK
| | - Ross Abrams
- Department of Radiation Oncology, Rush University Medical Center, Chicago, USA
| | - Somnath Mukherjee
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK; Oxford University Hospital NHS Foundation Trust, UK.
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21
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Chan E, Arlinghaus LR, Cardin DB, Goff L, Berlin JD, Parikh A, Abramson RG, Yankeelov TE, Hiebert S, Merchant N, Bhaskara S, Chakravarthy AB. Phase I trial of vorinostat added to chemoradiation with capecitabine in pancreatic cancer. Radiother Oncol 2016; 119:312-8. [PMID: 27106554 DOI: 10.1016/j.radonc.2016.04.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/03/2016] [Accepted: 04/08/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE This single institution phase I trial determined the maximum tolerated dose (MTD) of concurrent vorinostat and capecitabine with radiation in non-metastatic pancreatic cancer. MATERIAL AND METHODS Twenty-one patients received escalating doses of vorinostat (100-400mg daily) during radiation. Capecitabine was given 1000mg q12 on the days of radiation. Radiation consisted of 30Gy in 10 fractions. Vorinostat dose escalation followed the standard 3+3 design. No dose escalation beyond 400mg vorinostat was planned. Diffusion-weighted (DW)-MRI pre- and post-treatment was used to evaluate in vivo tumor cellularity. RESULTS The MTD of vorinostat was 400mg. Dose limiting toxicities occurred in one patient each at dose levels 100mg, 300mg, and 400mg: 2 gastrointestinal toxicities and one thrombocytopenia. The most common adverse events were lymphopenia (76%) and nausea (14%). The apparent diffusion coefficient (ADC) increased in most tumors. Nineteen (90%) patients had stable disease, and two (10%) had progressive disease at time of surgery. Eleven patients underwent surgical exploration with four R0 resections and one R1 resection. Median overall survival was 1.1years (95% confidence interval 0.78-1.35). CONCLUSIONS The combination of vorinostat 400mg daily M-F and capecitabine 1000mg q12 M-F with radiation (30Gy in 10 fractions) was well tolerated with encouraging median overall survival.
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Affiliation(s)
- Emily Chan
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | | | - Dana B Cardin
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | - Laura Goff
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | - Jordan D Berlin
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | - Alexander Parikh
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | | | - Thomas E Yankeelov
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States; Vanderbilt University Institute of Imaging Science, United States; Departments of Radiology and Radiological Sciences, Biomedical Engineering, Physics, and Cancer Biology, Vanderbilt University, United States
| | - Scott Hiebert
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, United States
| | - Nipun Merchant
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, UHealth - University of Miami Health System, United States
| | - Srividya Bhaskara
- Department of Radiation Oncology and Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, United States
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Myrehaug S, Sahgal A, Russo SM, Lo SS, Rosati LM, Mayr NA, Lock M, Small W, Dorth JA, Ellis RJ, Teh BS, Herman JM. Stereotactic body radiotherapy for pancreatic cancer: recent progress and future directions. Expert Rev Anticancer Ther 2016; 16:523-30. [PMID: 26999329 DOI: 10.1586/14737140.2016.1168698] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Despite advances in surgical, medical, and radiation therapy for pancreatic cancer, the prognosis remains poor. At this time, the only chance for long-term survival is surgical resection. More challenging is the optimal management of unresectable locally advanced pancreatic cancer, which has historically been treated with concurrent chemoradiation or chemotherapy alone. However, the survival and local control benefit of conventional radiotherapy in addition to chemotherapy was unclear. More recently, stereotactic body radiotherapy (SBRT) is emerging as a viable approach to maximizing local tumor control with a tolerable side effect profile. SBRT achieves sharp dose fall-off facilitating safe delivery of highly focused radiation to the tumor over 1-5 days. Although the optimal regimen of pancreas SBRT has not yet been established, its short treatment course limits the delay of additional. Future directions involve prospective study of pancreas SBRT and exploration of biomarkers and imaging technology in order to adopt a personalized management paradigm.
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Affiliation(s)
- Sten Myrehaug
- a Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre , University of Toronto , Toronto , ON , Canada
| | - Arjun Sahgal
- a Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre , University of Toronto , Toronto , ON , Canada
| | - Suzanne M Russo
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Simon S Lo
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Lauren M Rosati
- c Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
| | - Nina A Mayr
- d Department of Radiation Oncology , University of Washington , Seattle , WA , USA
| | - Michael Lock
- e Department of Radiation Oncology, London Regional Cancer Program , University of Western Ontario , London , ON , Canada
| | - William Small
- f Department of Radiation Oncology , Loyola University Medical Center , Maywood , IL , USA
| | - Jennifer A Dorth
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Rodney J Ellis
- b Department of Radiation Oncology , University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center , Cleveland , OH , USA
| | - Bin S Teh
- g Department of Radiation Oncology , Houston Methodist Hospital, Weill Cornell Medical College , Houston , TX , USA
| | - Joseph M Herman
- c Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
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23
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Baumann M, Overgaard J. Bridging the valley of death: The new Radiotherapy & Oncology section “First in man – Translational innovations in radiation oncology”. Radiother Oncol 2016; 118:217-9. [DOI: 10.1016/j.radonc.2016.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 12/31/2022]
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