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Kuipers SC, Godart J, Corbeau A, Breedveld S, Mens JWM, de Boer SM, Nout RA, Hoogeman MS. Dosimetric impact of bone marrow sparing for robustly optimized IMPT for locally advanced cervical cancer. Radiother Oncol 2024; 195:110222. [PMID: 38471634 DOI: 10.1016/j.radonc.2024.110222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND PURPOSE To investigate the trade-off between bone marrow sparing (BMS) and dose to organs at risk (OARs) for intensity modulated proton therapy (IMPT) for women with locally advanced cervical cancer (LACC). MATERIALS AND METHODS Twenty LACC patients were retrospectively included. IMPT plans were created for each patient using automated treatment planning. These plans progressively reduced bone marrow mean doses by steps of 1 GyRBE, while constraining target coverage and conformality. The relation between bone marrow dose and bladder, small bowel, rectum, and sigmoid doses was evaluated. RESULTS A total of 140 IMPT plans were created. Plans without BMS had an average [range] bone marrow mean dose of 17.3 [14.7-21.6] GyRBE , which reduced to 12.0 [10.0-14.0] GyRBE with maximum BMS. The mean OAR dose [range] increased modestly for 1 GyRBE BMS: 0.2 [0.0 - 0.6] GyRBE for bladder, 0.3 [-0.2 - 0.7] GyRBE for rectum, 0.4 [0.1 - 0.8] GyRBE for small bowel, and 0.2 [-0.2 - 0.4] GyRBE for sigmoid. Moreover, for maximum BMS, mean OAR doses [range] escalated by 3.3 [0.1 - 6.7] GyRBE for bladder, 5.8 [1.8 - 12.4] GyRBE for rectum, 3.9 [1.6 - 5.9] GyRBE for small bowel, and 2.7 [0.6 - 5.9] GyRBE for sigmoid. CONCLUSION Achieving 1 GyRBE BMS for IMPT is feasible for LACC patients with limited dosimetric impact on other OARs. While further bone marrow dose reduction is possible for some patients, it may increase OAR doses substantially for others. Hence, we recommend a personalized approach when introducing BMS into clinical IMPT treatment planning to carefully assess individual patient benefits and risks.
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Affiliation(s)
- S C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands.
| | - J Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
| | - A Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J W M Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
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Corbeau A, Heemsbergen WD, Kuipers SC, Godart J, Creutzberg CL, Nout RA, de Boer SM. Predictive Factors for Toxicity After Primary Chemoradiation for Locally Advanced Cervical Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 119:127-142. [PMID: 37979708 DOI: 10.1016/j.ijrobp.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE Women with locally advanced cervical cancer (LACC) undergoing primary platinum-based chemoradiotherapy and brachytherapy often experience toxicities. Normal-tissue complication probability (NTCP) models quantify toxicity risk and aid in optimizing radiation therapy to minimize side effects. However, it is unclear which predictors to include in an NTCP model. The aim of this systematic review was to provide an overview of the identified predictors contributing to gastrointestinal (GI), genitourinary (GU), and vaginal toxicities and insufficiency fractures for LACC. METHODS AND MATERIALS A systematic search was performed and articles evaluating the relationship between predictors and toxicities in women with LACC treated with primary chemoradiation were included. The Quality In Prognosis Studies tool was used to assess risk of bias, with high-risk studies being excluded from further analysis. Relationships between dose-volume parameters, patient and treatment characteristics, and toxicity endpoints were analyzed. RESULTS Seventy-three studies were identified. Twenty-six had a low or moderate risk of bias and were therefore included. Brachytherapy-related dose-volume parameters of the GI tract, including rectum and bowel equivalent dose in 2 Gy fractions (EQD2) D2 cm3, were frequently related to toxicities, unlike GU dose-volume parameters. Furthermore, (recto)vaginal point doses predicted toxicities. Few studies evaluated external beam radiation therapy dose-volume parameters and identified rectum EQD2 V30 Gy, V40 Gy, and V55 Gy, bowel and bladder EQD2 V40 Gy as toxicity predictors. Also, total reference air kerma and vaginal reference length were associated with toxicities. Relationships between patient characteristics and GI toxicity were inconsistent. The extent of vaginal involvement at diagnosis, baseline symptoms, and obesity predicted GU or vaginal toxicities. Only 1 study evaluated insufficiency fractures and demonstrated lower pretreatment bone densities to be associated. CONCLUSIONS This review detected multiple candidate predictors of toxicity. Larger studies should consider insufficiency fractures, assess dose levels from external beam radiation therapy, and quantify the relationship between the predictors and treatment-related toxicities in women with LACC to further facilitate NTCP model development for clinical use.
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Affiliation(s)
- Anouk Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sander C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Jeremy Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Chen CS, Wang YM, Huang EY. Comparative Analysis of Oncologic Outcomes in Patients with Squamous Cell Carcinoma of the Uterine Cervix with High-Risk Features for Para-Aortic Recurrence: Prophylactic Extended-Field versus Pelvic Chemoradiotherapy. Cancer Manag Res 2024; 16:269-279. [PMID: 38585434 PMCID: PMC10999217 DOI: 10.2147/cmar.s451137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/13/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose To compare the oncologic outcomes of prophylactic extended-field radiation therapy (EFRT) and whole pelvic radiation therapy (WPRT) in cervical patients at high risk of para-aortic lymph node (PALN) recurrence. Patients and Methods From July 1999 to May 2022, a total of 115 patients with cervical cancer and high-risk features of PALN recurrence based on tumor markers, positive LNs and extensive parametrial invasion were retrospectively analyzed. All patients had received EFRT or WPRT at a dose of 39.6-45 Gy and concurrent chemotherapy. In EFRT, coverage was extended to include the para-aortic region below the level of the left renal vein or T12. Results Twenty-eight and 87 patients underwent EFRT and WPRT, respectively. For patients who survived, the median follow-up time was 60.8 months (range 9.2-131.6 months) in the EFRT group and 115.9 months (range 16.9-212.1 months) in the WPRT group. The 5-year overall survival (OS) and pelvic, extrapelvic and PALN recurrence rates were 87.7% vs 60.8% (p=0.019), 10.9% vs 25.3% (p=0.119), 18.1% vs 45.8% (p=0.011), and 0% vs 30.4% (p=0.005), respectively, between the EFRT and WPRT groups. Multivariate analysis revealed that EFRT and 2018 FIGO stage IV disease status were significant predictors of OS and extrapelvic recurrence. Conclusion Compared to WPRT, EFRT significantly improved OS and reduced extrapelvic and PALN recurrence in patients with cervical cancer with high-risk recurrence features.
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Affiliation(s)
- Chung-Shih Chen
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, 833, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, 833, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung City, 804, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, 833, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung City, 804, Taiwan
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Kong W, Oud M, Habraken SJM, Huiskes M, Astreinidou E, Rasch CRN, Heijmen BJM, Breedveld S. SISS-MCO: large scale sparsity-induced spot selection for fast and fully-automated robust multi-criteria optimisation of proton plans. Phys Med Biol 2024; 69:055035. [PMID: 38224619 DOI: 10.1088/1361-6560/ad1e7a] [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: 07/24/2023] [Accepted: 01/15/2024] [Indexed: 01/17/2024]
Abstract
Objective.Intensity modulated proton therapy (IMPT) is an emerging treatment modality for cancer. However, treatment planning for IMPT is labour-intensive and time-consuming. We have developed a novel approach for multi-criteria optimisation (MCO) of robust IMPT plans (SISS-MCO) that is fully automated and fast, and we compare it for head and neck, cervix, and prostate tumours to a previously published method for automated robust MCO (IPBR-MCO, van de Water 2013).Approach.In both auto-planning approaches, the applied automated MCO of spot weights was performed with wish-list driven prioritised optimisation (Breedveld 2012). In SISS-MCO, spot weight MCO was applied once for every patient after sparsity-induced spot selection (SISS) for pre-selection of the most relevant spots from a large input set of candidate spots. IPBR-MCO had several iterations of spot re-sampling, each followed by MCO of the weights of the current spots.Main results.Compared to the published IPBR-MCO, the novel SISS-MCO resulted in similar or slightly superior plan quality. Optimisation times were reduced by a factor of 6 i.e. from 287 to 47 min. Numbers of spots and energy layers in the final plans were similar.Significance.The novel SISS-MCO automatically generated high-quality robust IMPT plans. Compared to a published algorithm for automated robust IMPT planning, optimisation times were reduced on average by a factor of 6. Moreover, SISS-MCO is a large scale approach; this enables optimisation of more complex wish-lists, and novel research opportunities in proton therapy.
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Affiliation(s)
- W Kong
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - M Oud
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S J M Habraken
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - M Huiskes
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - B J M Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
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Arians N, Lindel K, Krisam J, Oelmann-Avendano JT, Meixner E, König L, Hoerner-Rieber J, Wark A, Forster T, Weykamp F, Lang K, Schneeweiss A, Ellerbrock M, Mielke T, Herfarth K, Debus J. Treatment Tolerability and Toxicity of Postoperative Proton Beam Therapy for Gynecologic Malignancies: Results of the Prospective Phase 2 APROVE-trial. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00012-3. [PMID: 36642110 DOI: 10.1016/j.ijrobp.2023.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
PURPOSE The APROVE study is a prospective one-arm phase-2 study investigating the safety and treatment tolerability of postoperative proton beam therapy in women with uterine cervical or endometrial cancer. In this analysis, we report the primary study endpoint of safety and treatment tolerability as well as toxicity rates and progression-free survival (PFS). METHODS AND MATERIALS 25 patients were treated with postoperative proton beam therapy with a total dose of 45 to 50.4 Gy (RBE) in 5 to 6 × 1.8 Gy (RBE) fractions weekly using active raster-scanning intensity modulated proton beam therapy (IMPT). Sequential or simultaneous platinum-based chemotherapy was administered if indicated. The primary endpoint was defined as the lack of any acute ≥grade 3 gastrointestinal (GI) or urogenital (GU) toxicity according to the Common Terminology Criteria for Adverse Events v 4.0 or premature treatment abortion. Secondary endpoints were clinical symptoms and toxicity, quality of life, and PFS. RESULTS All patients completed IMPT according to the protocol, with a median treatment duration of 43 days (range, 33 to 51 days). No patient developed gastrointestinal or genitourinary toxicity ≥grade 3, and the treatment tolerability rate was 100%. Therefore, the null hypothesis H0: Tolerability Rate ≤80% could be rejected in favor of the alternative hypothesis H1: Tolerability rate >80% using an exact binomial test with a one-sided significance level of α = 10% (one-sided P value P = .0059). The median follow-up time after the end of IMPT was 25.1 months (range, 20.2 to 50.3 months). 18 of 25 (75%) patients completed the study follow-up of 24 months. 7 patients had progressive disease. Kaplan-Meier-estimated mean PFS was 39.9 months (95% confidence interval: 33.37 to 46.5 months). CONCLUSIONS Postoperative IMPT is a safe treatment option for cervical and endometrial cancer patients, with only low-grade acute and late toxicities. Larger randomized trials are necessary to further assess the potential of IMPT and improve patient selection.
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Affiliation(s)
- Nathalie Arians
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany.
| | - Katja Lindel
- Municipal Hospital Karlsruhe, Department of Radiation Oncology, Karlsruhe, Germany
| | - Johannes Krisam
- Institute for Medical Biometry, Heidelberg University, Heidelberg, Germany
| | | | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Antje Wark
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Andreas Schneeweiss
- Division of Gynecologic Oncology, National Center for Tumor Diseases, Heidelberg, Germany
| | - Malte Ellerbrock
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Mielke
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Heidelberg, Germany
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Health-related quality of life and patient-reported symptoms after postoperative proton beam radiotherapy of cervical and endometrial cancer: 2-year results of the prospective phase II APROVE-trial. Radiat Oncol 2023; 18:5. [PMID: 36624483 PMCID: PMC9827629 DOI: 10.1186/s13014-023-02198-4] [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: 08/17/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The APROVE-trial investigated the tolerability of postoperative proton beam therapy in women with cervical or endometrial cancer. The present analysis evaluated the secondary endpoints of health-related quality of life (HRQOL) and patient-reported symptoms. METHODS 25 patients were included in this prospective phase-II-trial and treated with postoperative radiotherapy using protons alone or in combination with chemotherapy. To attain general and gynecologic-specific HRQOL measures, the EORTC-QLQ-C30 questionnaires combined with -QLQ-CX24 for cervical and -QLQ-EN24 for endometrial cancer were assessed at baseline, at the end of RT and up to 2 years after radiotherapy. The results were compared to an age-matched norm reference population. Symptoms were assessed using Common Terminology Criteria for Adverse Events (CTCAE) and institutional patient-reported symptoms grading. RESULTS Scores regarding global health status were markedly impaired at baseline (mean: 58.0 ± 20.1) compared to reference population data, but significantly (p = 0.036) improved and evened out to comparable norm values 2 years after proton therapy (mean: 69.9 ± 19.3). Treatment caused acute and long-term worsening of pain (p = 0.048) and gastrointestinal symptoms (p = 0.016) for women with endometrial cancer, but no higher-grade CTCAE ≥ 3° toxicity was observed. Dosimetric evaluation of rectum, sigmoid, large and small bowel showed no correlation with the reported gastrointestinal symptoms. After 2 years, fatigue had significantly improved (p = 0.030), whereas patients with cervical cancer experienced more often lymphedema (p = 0.017). Scores for endometrial cancer pertaining to sexual activity (p = 0.048) and body image (p = 0.022) had improved post treatment; in the latter this effect persisted after 2 years. CONCLUSION Proton beam therapy in the adjuvant setting was well tolerated with only low-grade side effects concerning gastrointestinal symptoms, lymphedema and pain. Overall quality of life was impaired at baseline, but patients were able to recover to values comparable to norm population 2 years after proton therapy. Larger studies are needed to confirm whether the benefit of proton therapy translates into a clinical effect. Sexual dysfunction remains an important issue. TRIAL REGISTRATION The trial was registered at https://clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT03184350, 09th June 2017).
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Gits HC, Dozois EJ, Houdek MT, Ho TP, Okuno SH, Guenzel RM, McGrath LA, Kraling AJ, Johnson JE, Lester SC. New school technology meets old school technique: Intensity modulated proton therapy and laparoscopic pelvic sling facilitate safe and efficacious treatment of pelvic sarcoma. Adv Radiat Oncol 2022; 7:101008. [PMID: 36034194 PMCID: PMC9404264 DOI: 10.1016/j.adro.2022.101008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Small bowel tolerance may be dose-limiting in the management of some pelvic and abdominal malignancies with curative-intent radiation therapy. Multiple techniques previously have been attempted to exclude the small bowel from the radiation field, including the surgical insertion of an absorbable mesh to serve as a temporary pelvic sling. This case highlights a clinically meaningful application of this technique with modern radiation therapy. Methods and Materials A patient with locally invasive, unresectable high-grade sarcoma of the right pelvic vasculature was evaluated for definitive radiation therapy. The tumor immediately abutted the small bowel. The patient underwent laparoscopic placement of a mesh sling to retract the abutting small bowel and subsequently completed intensity modulated proton therapy. Results The patient tolerated the mesh insertion procedure and radiation therapy well with no significant toxic effects. The combination approach achieved excellent dose metrics, and the patient has no evidence of progression 14 months out from treatment. Conclusions The combination of mesh as a pelvic sling and proton radiation therapy enabled the application of a curative dose of radiation therapy and should be considered for patients in need of curative-intent radiation when the bowel is in close proximity to the target.
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Affiliation(s)
- Hunter C. Gits
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Eric J. Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Thanh P. Ho
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott H. Okuno
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Laura A. McGrath
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Alan J. Kraling
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
- Corresponding author: Scott C. Lester, MD
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Taunk N. The role of proton therapy in gynecological radiation oncology. Int J Gynecol Cancer 2022; 32:414-420. [DOI: 10.1136/ijgc-2021-002459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/06/2022] [Indexed: 11/04/2022] Open
Abstract
Proton beam therapy is an external beam radiotherapy modality that offers potentially similar efficacy and reduced toxicity compared with photon radiotherapy due to little to no exit dose of radiation beyond the intended target. Improvements in radiotherapy from two-dimensional, to three-dimensional, to intensity-modulated radiation therapy have offered comparable to improved efficacy of radiation therapy with progressive reductions in toxicity. Proton beam therapy may offer further improvements, with multiple dosimetric studies demonstrating potential reductions in exposure of normal tissue to radiation, particularly bowel and bone marrow. Proton beam therapy offers avenues for dose escalation or re-irradiation, which were previously not feasible with photon radiotherapy. Although early clinical data generally demonstrate safety, feasibility, and efficacy in a few series, prospective clinical trials are limited and needed to better define who might benefit from proton therapy. In this review, we discuss the history, dosimetry, available clinical data, and technical needs to deliver high-quality proton therapy.
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Zientara N, Giles E, Le H, Short M. A scoping review of patient selection methods for proton therapy. J Med Radiat Sci 2022; 69:108-121. [PMID: 34476905 PMCID: PMC8892419 DOI: 10.1002/jmrs.540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/08/2021] [Accepted: 08/07/2021] [Indexed: 01/14/2023] Open
Abstract
The aim was to explore various national and international clinical decision-making tools and dose comparison methods used for selecting cancer patients for proton versus X-ray radiation therapy. To address this aim, a literature search using defined scoping review methods was performed in Medline and Embase databases as well as grey literature. Articles published between 1 January 2015 and 4 August 2020 and those that clearly stated methods of proton versus X-ray therapy patient selection and those published in English were eligible for inclusion. In total, 321 studies were identified of which 49 articles met the study's inclusion criteria representing 13 countries. Six different clinical decision-making tools and 14 dose comparison methods were identified, demonstrating variability within countries and internationally. Proton therapy was indicated for all paediatric patients except those with lymphoma and re-irradiation where individualised model-based selection was required. The most commonly reported patient selection tools included the Normal Tissue Complication Probability model, followed by cost-effectiveness modelling and dosimetry comparison. Model-based selection methods were most commonly applied for head and neck clinical indications in adult cohorts (48% of studies). While no 'Gold Standard' currently exists for proton therapy patient selection with variations evidenced globally, some of the patient selection methods identified in this review can be used to inform future practice in Australia. As literature was not identified from all countries where proton therapy centres are available, further research is needed to evaluate patient selection methods in these jurisdictions for a comprehensive overview.
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Affiliation(s)
- Nicole Zientara
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Liverpool Cancer Therapy CentreLiverpool HospitalSydneyNew South WalesAustralia
| | - Eileen Giles
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Hien Le
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Michala Short
- UniSA Cancer Research InstituteUniSA Allied Health and Human PerformanceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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PROTECT: Prospective Phase-II-Trial Evaluating Adaptive Proton Therapy for Cervical Cancer to Reduce the Impact on Morbidity and the Immune System. Cancers (Basel) 2021; 13:cancers13205179. [PMID: 34680328 PMCID: PMC8533850 DOI: 10.3390/cancers13205179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/01/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Chemoradiation with photon radiotherapy is very effective as a locally advanced cervical cancer (LACC) treatment. However, the majority of women with LACC experience treatment-related toxicity involving the gastrointestinal and urogenital tracts and the immune system. Compared to that of photon therapy, proton therapy substantially reduces undesired dose to the organs around the tumor, leading to a decrease in radiotherapy-related side-effects. At present, few studies on proton therapy in patients with LACC will be conducted. The PROTECT trial aims to evaluate the differences in side effects between photon therapy and proton therapy, both combined with chemotherapy, for LACC. Fifteen patients will be enrolled per treatment group. Information will be collected on the differences in dose to the organs around the tumor, treatment-related side effects, and the impact on the immune system. This information will be used to assess the potential of proton therapy as an innovative treatment for LACC. Abstract External beam radiation therapy (EBRT) with concurrent chemotherapy followed by brachytherapy is a very effective treatment for locally advanced cervical cancer (LACC). However, treatment-related toxicity is common and reduces the patient’s quality of life (QoL) and ability to complete treatment or undergo adjuvant therapies. Intensity modulated proton therapy (IMPT) enables a significant dose reduction in organs at risk (OAR), when compared to that of standard intensity-modulated radiation therapy (IMRT) or volumetric-modulated arc therapy (VMAT). However, clinical studies evaluating whether IMPT consequently reduces side effects for LACC are lacking. The PROTECT trial is a nonrandomized prospective multicenter phase-II-trial comparing clinical outcomes after IMPT or IMRT/VMAT in LACC. Thirty women aged >18 years with a histological diagnosis of LACC will be included in either the IMPT or IMRT/VMAT group. Treatment includes EBRT (45 Gy in 25 fractions of 1.8 Gy), concurrent five weekly cisplatin (40 mg/m2), and 3D image (MRI)-guided adaptive brachytherapy. The primary endpoint is pelvic bones Dmean and mean bowel V15Gy. Secondary endpoints include dosimetric parameters, oncological outcomes, health-related QoL, immune response, safety, and tolerability. This study provides the first data on the potential of IMPT to reduce OAR dose in clinical practice and improve toxicity and QoL for patients with LACC.
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Wortman BG, Post CCB, Powell ME, Khaw P, Fyles A, D'Amico R, Haie-Meder C, Jürgenliemk-Schulz IM, McCormack M, Do V, Katsaros D, Bessette P, Baron MH, Nout RA, Whitmarsh K, Mileshkin L, Lutgens LCHW, Kitchener HC, Brooks S, Nijman HW, Astreinidou E, Putter H, Creutzberg CL, de Boer SM. Radiation Therapy Techniques and Treatment-Related Toxicity in the PORTEC-3 Trial: Comparison of 3-Dimensional Conformal Radiation Therapy Versus Intensity-Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2021; 112:390-399. [PMID: 34610387 DOI: 10.1016/j.ijrobp.2021.09.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Radiation therapy techniques have developed from 3-dimensional conformal radiation therapy (3DCRT) to intensity modulated radiation therapy (IMRT), with better sparing of the surrounding normal tissues. The current analysis aimed to investigate whether IMRT, compared to 3DCRT, resulted in fewer adverse events (AEs) and patient-reported symptoms in the randomized PORTEC-3 trial for high-risk endometrial cancer. METHODS AND MATERIALS Data on AEs and patient-reported quality of life (QoL) of the PORTEC-3 trial were available for analysis. Physician-reported AEs were graded using Common Terminology Criteria for Adverse Events v3.0. QoL was assessed by the European Organisation for Research and Treatment of Cancer QLQC30, CX24, and OV28 questionnaires. Data were compared between 3DCRT and IMRT. A P value of ≤ .01 was considered statistically significant due to the risk of multiple testing. For QoL, combined scores 1 to 2 ("not at all" and "a little") versus 3 to 4 ("quite a bit" and "very much") were compared between the techniques. RESULTS Of 658 evaluable patients, 559 received 3DCRT and 99 IMRT. Median follow-up was 74.6 months. During treatment no significant differences were observed, with a trend for more grade ≥3 AEs, mostly hematologic and gastrointestinal, after 3DCRT (37.7% vs 26.3%, P = .03). During follow-up, 15.4% (vs 4%) had grade ≥2 diarrhea, and 26.1% (vs 13.1%) had grade ≥2 hematologic AEs after 3DCRT (vs IMRT) (both P < .01). Among 574 (87%) patients evaluable for QoL, 494 received 3DCRT and 80 IMRT. During treatment, 37.5% (vs 28.6%) reported diarrhea after 3DCRT (vs IMRT) (P = .125); 22.1% (versus 10.0%) bowel urgency (P = 0039), and 18.2% and 8.6% abdominal cramps (P = .058). Other QoL scores showed no differences. CONCLUSIONS IMRT resulted in fewer grade ≥3 AEs during treatment and significantly lower rates of grade ≥2 diarrhea and hematologic AEs during follow-up. Trends toward fewer patient-reported bowel urgency and abdominal cramps were observed after IMRT compared to 3DCRT.
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Affiliation(s)
- Bastiaan G Wortman
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Cathalijne C B Post
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Melanie E Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, United Kingdom
| | - Pearly Khaw
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Romerai D'Amico
- Department of Radiotherapy, Azienda Socio Sanitaria Territoriale, Lecco, Italy
| | | | | | - Mary McCormack
- Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Viet Do
- Radiation Oncology, Liverpool & Macarthur Cancer Therapy Center, NSW, Australia
| | - Dionyssios Katsaros
- Department of Surgical Sciences, Gynecologic Oncology, Città della Salute and Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Paul Bessette
- Gynecologic Oncology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie Hélène Baron
- Department of Radiotherapy, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Henry C Kitchener
- Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Susan Brooks
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Hans W Nijman
- Department of Gynecologic Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Eleftheria Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Musunuru HB, Pifer PM, Mohindra P, Albuquerque K, Beriwal S. Advances in management of locally advanced cervical cancer. Indian J Med Res 2021; 154:248-261. [PMID: 35142642 PMCID: PMC9131769 DOI: 10.4103/ijmr.ijmr_1047_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Globally, cervical cancer has the fourth highest cancer incidence and mortality in women. Cervical cancer is unique because it has effective prevention, screening, and treatment options. This review discusses the current cervical cancer advances with a focus on locally advanced cervical cancer. Topics discussed include diagnostic imaging principles, surgical management with adjuvant therapy and definitive concurrent chemoradiotherapy. Emphasis is given on current advances and future research directions in radiation therapy (RT) with an emphasis on three-dimensional brachytherapy, intensity-modulated RT, image-guided RT, proton RT and hyperthermia.
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Affiliation(s)
- Hima Bindu Musunuru
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Phillip M Pifer
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | - Kevin Albuquerque
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
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Berger T, Godart J, Jagt T, Vittrup AS, Fokdal LU, Lindegaard JC, Kibsgaard Jensen NB, Zolnay A, Reijtenbagh D, Trnkova P, Tanderup K, Hoogeman M. Dosimetric Impact of Intrafraction Motion in Online-Adaptive Intensity Modulated Proton Therapy for Cervical Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1580-1587. [PMID: 33227442 DOI: 10.1016/j.ijrobp.2020.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/23/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE A method was recently developed for online-adaptive intensity modulated proton therapy (IMPT) in patients with cervical cancer. The advantage of this approach, relying on the use of tight margins, is challenged by the intrafraction target motion. The purpose of this study was to evaluate the dosimetric effect of intrafraction motion on the target owing to changes in bladder filling in patients with cervical cancer treated with online-adaptive IMPT. METHODS AND MATERIALS In 10 patients selected to have large uterus motion induced by bladder filling, the intrafraction anatomic changes were simulated for several prefraction durations for online (automated) contouring and planning. For each scenario, the coverage of the primary target was evaluated with margins of 2.5 and 5 mm. RESULTS Using a 5- mm planning target volume margin, median accumulated D98% was greater than 42.75 GyRBE1.1 (95% of the prescribed dose) in the case of a prefraction duration of 5 and 10 minutes. For a prefraction duration of 15 minutes, this parameter deteriorated to 42.6 GyRBE1.1. When margins were reduced to 2.5 mm, only a 5-minute duration resulted in median target D98% above 42.75 GyRBE1.1. In addition, smaller bladders were found to be associated with larger dose degradations compared with larger bladders. CONCLUSIONS This study indicates that intrafraction anatomic changes can have a substantial dosimetric effect on target coverage in an online-adaptive IMPT scenario for patients subject to large uterus motion. A margin of 5 mm was sufficient to compensate for the intrafraction motion due to bladder filling for up to 10 minutes of prefraction time. However, compensation for the uncertainties that were disregarded in this study, by using margins or robust optimization, is also required. Furthermore, a large bladder volume restrains intrafraction target motion and is recommended for treating patients in this scenario. Assuming that online-adaptive IMPT remains beneficial as long as narrow margins are used (5 mm or below), this study demonstrates its feasibility with regard to intrafraction motion.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Jérémy Godart
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Thyrza Jagt
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | | | | | | | | | - Andras Zolnay
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Dominique Reijtenbagh
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Petra Trnkova
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands; Holland PTC, Delft, The Netherlands
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Mischa Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands; Holland PTC, Delft, The Netherlands
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Gort EM, Beukema JC, Matysiak W, Sijtsema NM, Aluwini S, Langendijk JA, Both S, Brouwer CL. Inter-fraction motion robustness and organ sparing potential of proton therapy for cervical cancer. Radiother Oncol 2020; 154:194-200. [PMID: 32956707 DOI: 10.1016/j.radonc.2020.09.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 09/02/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Large-field photon radiotherapy is current standard in the treatment of cervical cancer patients. However, with the increasing availability of Pencil Beam Scanning Proton Therapy (PBS-PT) and robust treatment planning techniques, protons may have significant advantages for cervical cancer patients in the reduction of toxicity. In this study, PBS-PT and photon Volumetric Modulated Arc Therapy (VMAT) were compared, examining target coverage and organ at risk (OAR) dose, taking inter- and intra-fraction motion into account. MATERIALS AND METHODS Twelve cervical cancer patients were included in this in-silico planning study. In all cases, a planning CT scan, five weekly repeat CT scans (reCTs) and an additional reCT 10 min after the first reCT were available. Two-arc VMAT and robustly optimised two- and four-field (2F and 4F) PBS-PT plans were robustly evaluated on planCTs and reCTs using set-up and range uncertainty. Nominal OAR doses and voxel-wise minimum target coverage robustness were compared. RESULTS Average voxel-wise minimum accumulated doses for pelvic target structures over all patients were adequate for both photon and proton treatment techniques (D98 > 95%, [91.7-99.3%]). Average accumulated dose of the para-aortic region was lower than the required 95%, D98 > 94.4% [91.1-98.2%]. With PBS-PT 4F, dose to all OARs was significantly lower than with VMAT. Major differences were observed for mean bowel bag V15Gy: 60% [39-70%] for VMAT vs 30% [10-52%] and 32% [9-54%] for PBS-PT 2F and 4F and for mean bone marrow V10Gy: 88% [82-97%] for VMAT vs 66% [60-73%] and 67% [60-75%] for PBS-PT 2F and 4F. CONCLUSION Robustly optimised PBS-PT for cervical cancer patients shows equivalent target robustness against inter- and intra-fraction variability compared to VMAT, and offers significantly better OAR sparing.
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Affiliation(s)
- Elske M Gort
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Jannet C Beukema
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Witold Matysiak
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Nanna M Sijtsema
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Shafak Aluwini
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Stefan Both
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands
| | - Charlotte L Brouwer
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, The Netherlands.
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Jagt TZ, Breedveld S, van Haveren R, Nout RA, Astreinidou E, Heijmen BJM, Hoogeman MS. Plan-library supported automated replanning for online-adaptive intensity-modulated proton therapy of cervical cancer. Acta Oncol 2019; 58:1440-1445. [PMID: 31271076 DOI: 10.1080/0284186x.2019.1627414] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Intensity-modulated proton therapy is sensitive to inter-fraction variations, including density changes along the pencil-beam paths and variations in organ-shape and location. Large day-to-day variations are seen for cervical cancer patients. The purpose of this study was to develop and evaluate a novel method for online selection of a plan from a patient-specific library of prior plans for different anatomies, and adapt it for the daily anatomy. Material and methods: The patient-specific library of prior plans accounting for altered target geometries was generated using a pretreatment established target motion model. Each fraction, the best fitting prior plan was selected. This prior plan was adapted using (1) a restoration of spot-positions (Bragg peaks) by adapting the energies to the new water equivalent path lengths; and (2) a spot addition to fully cover the target of the day, followed by a fast optimization of the spot-weights with the reference point method (RPM) to obtain a Pareto-optimal plan for the daily anatomy. Spot addition and spot-weight optimization could be repeated iteratively. The patient cohort consisted of six patients with in total 23 repeat-CT scans, with a prescribed dose of 45 Gy(RBE) to the primary tumor and the nodal CTV. Using a 1-plan-library (one prior plan based on all motion in the motion model) was compared to choosing from a 2-plan-library (two prior plans based on part of the motion). Results: Applying the prior-plan adaptation method with one iteration of adding spots resulted in clinically acceptable target coverage ( V95%≥95% and V107%≤2% ) for 37/46 plans using the 1-plan-library and 41/46 plans for the 2-plan-library. When adding spots twice, the 2-plan-library approach could obtain acceptable coverage for all scans, while the 1-plan-library approach showed V107%>2% for 3/46 plans. Similar OAR results were obtained. Conclusion: The automated prior-plan adaptation method can successfully adapt for the large day-to-day variations observed in cervical cancer patients.
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Affiliation(s)
- Thyrza Z. Jagt
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sebastiaan Breedveld
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Rens van Haveren
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleftheria Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mischa S. Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- HollandPTC, Delft, The Netherlands
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Hussein M, Heijmen BJM, Verellen D, Nisbet A. Automation in intensity modulated radiotherapy treatment planning-a review of recent innovations. Br J Radiol 2018; 91:20180270. [PMID: 30074813 DOI: 10.1259/bjr.20180270] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Radiotherapy treatment planning of complex radiotherapy techniques, such as intensity modulated radiotherapy and volumetric modulated arc therapy, is a resource-intensive process requiring a high level of treatment planner intervention to ensure high plan quality. This can lead to variability in the quality of treatment plans and the efficiency in which plans are produced, depending on the skills and experience of the operator and available planning time. Within the last few years, there has been significant progress in the research and development of intensity modulated radiotherapy treatment planning approaches with automation support, with most commercial manufacturers now offering some form of solution. There is a rapidly growing number of research articles published in the scientific literature on the topic. This paper critically reviews the body of publications up to April 2018. The review describes the different types of automation algorithms, including the advantages and current limitations. Also included is a discussion on the potential issues with routine clinical implementation of such software, and highlights areas for future research.
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Affiliation(s)
- Mohammad Hussein
- 1 Metrology for Medical Physics Centre, National Physical Laboratory , Teddington , UK
| | - Ben J M Heijmen
- 2 Division of Medical Physics, Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Dirk Verellen
- 3 Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB) , Brussels , Belgium.,4 Radiotherapy Department, Iridium Kankernetwerk , Antwerp , Belgium
| | - Andrew Nisbet
- 5 Department of Medical Physics, Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,6 Department of Physics, University of Surrey , Guildford , UK
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Medical physics in radiation Oncology: New challenges, needs and roles. Radiother Oncol 2017; 125:375-378. [PMID: 29150160 DOI: 10.1016/j.radonc.2017.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 12/21/2022]
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Berger T, Petersen JBB, Lindegaard JC, Fokdal LU, Tanderup K. Impact of bowel gas and body outline variations on total accumulated dose with intensity-modulated proton therapy in locally advanced cervical cancer patients. Acta Oncol 2017; 56:1472-1478. [PMID: 28931343 DOI: 10.1080/0284186x.2017.1376753] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Density changes occurring during fractionated radiotherapy in the pelvic region may degrade proton dose distributions. The aim of the study was to quantify the dosimetric impact of gas cavities and body outline variations. MATERIAL AND METHODS Seven patients with locally advanced cervical cancer (LACC) were analyzed through a total of 175 daily cone beam computed tomography (CBCT) scans. Four-beams intensity-modulated proton therapy (IMPT) dose plans were generated targeting the internal target volume (ITV) composed of: primary tumor, elective and pathological nodes. The planned dose was 45 Gy [Relative-Biological-Effectiveness-weighted (RBE)] in 25 fractions and simultaneously integrated boosts of pathologic lymph nodes were 55-57.5 Gy (RBE). In total, 475 modified CTs were generated to evaluate the effect of: 1/gas cavities, 2/outline variations and 3/the two combined. The anatomy of each fraction was simulated by propagating gas cavities contours and body outlines from each daily CBCT to the pCT. Hounsfield units corresponding to gas and fat were assigned to the propagated contours. D98 (least dose received by the hottest 98% of the volume) and D99.9 for targets and V43Gy(RBE) (volume receiving ≥43 Gy(RBE)) for organs at risk (OARs) were recalculated on each modified CT, and total dose was evaluated through dose volume histogram (DVH) addition across all fractions. RESULTS Weight changes during radiotherapy were between -3.1% and 1.2%. Gas cavities and outline variations induced a median [range] dose degradation for ITV45 of 1.0% [0.5-3.5%] for D98 and 2.1% [0.8-6.4%] for D99.9. Outline variations had larger dosimetric impact than gas cavities. Worst nodal dose degradation was 2.0% for D98 and 2.3% for D99.9. The impact on bladder, bowel and rectum was limited with V43Gy(RBE) variations ≤3.5 cm3. CONCLUSION Bowel gas cavities and outline variations had minor impact on accumulated dose in targets and OAR of four-field IMPT in a LACC population of moderate weight changes.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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