1
|
Midroni J, Salunkhe R, Liu Z, Chow R, Boldt G, Palma D, Hoover D, Vinogradskiy Y, Raman S. Incorporation of Functional Lung Imaging Into Radiation Therapy Planning in Patients With Lung Cancer: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00481-4. [PMID: 38631538 DOI: 10.1016/j.ijrobp.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
Our purpose was to provide an understanding of current functional lung imaging (FLI) techniques and their potential to improve dosimetry and outcomes for patients with lung cancer receiving radiation therapy (RT). Excerpta Medica dataBASE (EMBASE), PubMed, and Cochrane Library were searched from 1990 until April 2023. Articles were included if they reported on FLI in one of: techniques, incorporation into RT planning for lung cancer, or quantification of RT-related outcomes for patients with lung cancer. Studies involving all RT modalities, including stereotactic body RT and particle therapy, were included. Meta-analyses were conducted to investigate differences in dose-function parameters between anatomic and functional RT planning techniques, as well as to investigate correlations of dose-function parameters with grade 2+ radiation pneumonitis (RP). One hundred seventy-eight studies were included in the narrative synthesis. We report on FLI modalities, dose-response quantification, functional lung (FL) definitions, FL avoidance techniques, and correlations between FL irradiation and toxicity. Meta-analysis results show that FL avoidance planning gives statistically significant absolute reductions of 3.22% to the fraction of well-ventilated lung receiving 20 Gy or more, 3.52% to the fraction of well-perfused lung receiving 20 Gy or more, 1.3 Gy to the mean dose to the well-ventilated lung, and 2.41 Gy to the mean dose to the well-perfused lung. Increases in the threshold value for defining FL are associated with decreases in functional parameters. For intensity modulated RT and volumetric modulated arc therapy, avoidance planning results in a 13% rate of grade 2+ RP, which is reduced compared with results from conventional planning cohorts. A trend of increased predictive ability for grade 2+ RP was seen in models using FL information but was not statistically significant. FLI shows promise as a method to spare FL during thoracic RT, but interventional trials related to FL avoidance planning are sparse. Such trials are critical to understanding the effect of FL avoidance planning on toxicity reduction and patient outcomes.
Collapse
Affiliation(s)
- Julie Midroni
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada
| | - Rohan Salunkhe
- Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zhihui Liu
- Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Gabriel Boldt
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - David Palma
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada; Ontario Institute for Cancer Research, Toronto, Canada
| | - Douglas Hoover
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, United States of America; Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, United States of America
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| |
Collapse
|
2
|
Flakus MJ, Wuschner AE, Wallat EM, Graham M, Shao W, Shanmuganayagam D, Christensen GE, Reinhardt JM, Bayouth JE. Validation of CT-based ventilation and perfusion biomarkers with histopathology confirms radiation-induced pulmonary changes in a porcine model. Sci Rep 2023; 13:9377. [PMID: 37296169 PMCID: PMC10256800 DOI: 10.1038/s41598-023-36292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Imaging biomarkers can assess disease progression or prognoses and are valuable tools to help guide interventions. Particularly in lung imaging, biomarkers present an opportunity to extract regional information that is more robust to the patient's condition prior to intervention than current gold standard pulmonary function tests (PFTs). This regional aspect has particular use in functional avoidance radiation therapy (RT) in which treatment planning is optimized to avoid regions of high function with the goal of sparing functional lung and improving patient quality of life post-RT. To execute functional avoidance, detailed dose-response models need to be developed to identify regions which should be protected. Previous studies have begun to do this, but for these models to be clinically translated, they need to be validated. This work validates two metrics that encompass the main components of lung function (ventilation and perfusion) through post-mortem histopathology performed in a novel porcine model. With these methods validated, we can use them to study the nuanced radiation-induced changes in lung function and develop more advanced models.
Collapse
Affiliation(s)
- Mattison J Flakus
- Department of Medical Physics, University of Wisconsin - Madison, Madison, WI, USA.
| | - Antonia E Wuschner
- Department of Medical Physics, University of Wisconsin - Madison, Madison, WI, USA
| | - Eric M Wallat
- Department of Medical Physics, University of Wisconsin - Madison, Madison, WI, USA
| | - Melissa Graham
- Research Animal Resources and Compliance, University of Wisconsin - Madison, Madison, WI, USA
| | - Wei Shao
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Dhanansayan Shanmuganayagam
- Department of Surgery, University of Wisconsin - Madison, Madison, WI, USA
- Department of Animal and Dairy Sciences, University of Wisconsin - Madison, Madison, WI, USA
| | - Gary E Christensen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, USA
- Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - John E Bayouth
- Department of Radiation Medicine, Oregon Health Sciences University, Portland, OR, USA
| |
Collapse
|
3
|
Wuschner AE, Flakus MJ, Wallat EM, Reinhardt JM, Shanmuganayagam D, Christensen GE, Gerard SE, Bayouth JE. CT-derived vessel segmentation for analysis of post-radiation therapy changes in vasculature and perfusion. Front Physiol 2022; 13:1008526. [PMID: 36324304 PMCID: PMC9619090 DOI: 10.3389/fphys.2022.1008526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/05/2022] [Indexed: 11/22/2022] Open
Abstract
Vessel segmentation in the lung is an ongoing challenge. While many methods have been able to successfully identify vessels in normal, healthy, lungs, these methods struggle in the presence of abnormalities. Following radiotherapy, these methods tend to identify regions of radiographic change due to post-radiation therapytoxicities as vasculature falsely. By combining texture analysis and existing vasculature and masking techniques, we have developed a novel vasculature segmentation workflow that improves specificity in irradiated lung while preserving the sensitivity of detection in the rest of the lung. Furthermore, radiation dose has been shown to cause vascular injury as well as reduce pulmonary function post-RT. This work shows the improvements our novel vascular segmentation method provides relative to existing methods. Additionally, we use this workflow to show a dose dependent radiation-induced change in vasculature which is correlated with previously measured perfusion changes (R2 = 0.72) in both directly irradiated and indirectly damaged regions of perfusion. These results present an opportunity to extend non-contrast CT-derived models of functional change following radiation therapy.
Collapse
Affiliation(s)
- Antonia E. Wuschner
- Department of Medical Physics, University of Wisconsin, Madison, WI, United States
- *Correspondence: Antonia E. Wuschner,
| | - Mattison J. Flakus
- Department of Medical Physics, University of Wisconsin, Madison, WI, United States
| | - Eric M. Wallat
- Department of Medical Physics, University of Wisconsin, Madison, WI, United States
| | - Joseph M. Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa, IA, United States
| | | | - Gary E Christensen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa, IA, United States
- Department of Radiation Oncology, University of Iowa, Iowa, IA, United States
| | - Sarah E. Gerard
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa, IA, United States
| | - John E. Bayouth
- Department of Radiation Medicine, Oregon Health Sciences University, Portland, OR, United States
| |
Collapse
|
4
|
Wuschner AE, Flakus MJ, Wallat EM, Reinhardt JM, Shanmuganayagam D, Christensen GE, Bayouth JE. Measuring Indirect Radiation-Induced Perfusion Change in Fed Vasculature Using Dynamic Contrast CT. J Pers Med 2022; 12:jpm12081254. [PMID: 36013203 PMCID: PMC9410208 DOI: 10.3390/jpm12081254] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 12/13/2022] Open
Abstract
Recent functional lung imaging studies have presented evidence of an “indirect effect” on perfusion damage, where regions that are unirradiated or lowly irradiated but that are supplied by highly irradiated regions observe perfusion damage post-radiation therapy (RT). The purpose of this work was to investigate this effect using a contrast-enhanced dynamic CT protocol to measure perfusion change in five novel swine subjects. A cohort of five Wisconsin Miniature Swine (WMS) were given a research course of 60 Gy in five fractions delivered locally to a vessel in the lung using an Accuray Radixact tomotherapy system with Synchrony motion tracking to increase delivery accuracy. Imaging was performed prior to delivering RT and 3 months post-RT to yield a 28−36 frame image series showing contrast flowing in and out of the vasculature. Using MIM software, contours were placed in six vessels on each animal to yield a contrast flow curve for each vessel. The contours were placed as follows: one at the point of max dose, one low-irradiated (5−20 Gy) branching from the max dose vessel, one low-irradiated (5−20 Gy) not branching from the max dose vessel, one unirradiated (<5 Gy) branching from the max dose vessel, one unirradiated (<5 Gy) not branching from the max dose vessel, and one in the contralateral lung. Seven measurements (baseline-to-baseline time and difference, slope up and down, max rise and value, and area under the curve) were acquired for each vessel’s contrast flow curve in each subject. Paired Student t-tests showed statistically significant (p < 0.05) reductions in the area under the curve in the max dose, and both fed contours indicating an overall reduction in contrast in these regions. Additionally, there were statistically significant reductions observed when comparing pre- and post-RT in slope up and down in the max dose, low-dose fed, and no-dose fed contours but not the low-dose not-fed, no-dose not-fed, or contralateral contours. These findings suggest an indirect damage effect where irradiation of the vasculature causes a reduction in perfusion in irradiated regions as well as regions fed by the irradiated vasculature.
Collapse
Affiliation(s)
- Antonia E. Wuschner
- University of Wisconsin, Madison, WI 53706, USA; (M.J.F.); (E.M.W.); (D.S.); (J.E.B.)
- Correspondence:
| | - Mattison J. Flakus
- University of Wisconsin, Madison, WI 53706, USA; (M.J.F.); (E.M.W.); (D.S.); (J.E.B.)
| | - Eric M. Wallat
- University of Wisconsin, Madison, WI 53706, USA; (M.J.F.); (E.M.W.); (D.S.); (J.E.B.)
| | | | | | | | - John E. Bayouth
- University of Wisconsin, Madison, WI 53706, USA; (M.J.F.); (E.M.W.); (D.S.); (J.E.B.)
| |
Collapse
|
5
|
Wang X, Dai Y, Zhang H, Xia H, Kan Q. Expression Level and Clinical Significance of AK021443 in Non-Small-Cell Lung Carcinoma. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7957121. [PMID: 35320997 PMCID: PMC8938069 DOI: 10.1155/2022/7957121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022]
Abstract
To explore the prognostic potential of AK021443 in non-small-cell lung carcinoma (NSCLC), AK021443 levels in NSCLC specimens were determined by quantitative real-time polymerase chain reaction (qRT-PCR). The correlation between the AK021443 level and pathological factors in NSCLC patients was analyzed. Kaplan-Meier curves were plotted for assessing the prognostic value of AK021443 in NSCLC patients. Potential factors influencing NSCLC prognosis were analyzed by multivariable Cox regression test. AK021443 was upregulated in NSCLC specimens than normal ones. Its level was correlated to histological type, tumor differentiation, TNM staging, and lymphatic metastasis in NSCLC patients. AK021443 was the independent risk factor for the overall survival of NSCLC. AK021443 is highly expressed in NSCLC specimens, which is correlated to histological type, tumor differentiation, TNM staging, and lymphatic metastasis in NSCLC patients. It is the independent prognostic factor for NSCLC.
Collapse
Affiliation(s)
- Xiyong Wang
- Department of Oncology, Suzhou Hospital Affiliated to Anhui Medical University (Suzhou Municipal Hospital), Suzhou, China
| | - Yu Dai
- Department of Oncology, Suzhou Hospital Affiliated to Anhui Medical University (Suzhou Municipal Hospital), Suzhou, China
| | - Hongming Zhang
- Department of Respiratory Medicine, Yancheng Third People's Hospital, The Affiliated Yancheng Hospital of Southeast University, Yancheng, China
| | - Honglin Xia
- Clinical Laboratory, Suzhou Hospital Affiliated to Anhui Medical University (Suzhou Municipal Hospital), Suzhou, China
| | - Qingsheng Kan
- Department of Oncology, Suzhou Hospital Affiliated to Anhui Medical University (Suzhou Municipal Hospital), Suzhou, China
| |
Collapse
|
6
|
Liu X, Shao C, Fu J. Promising Biomarkers of Radiation-Induced Lung Injury: A Review. Biomedicines 2021; 9:1181. [PMID: 34572367 PMCID: PMC8470495 DOI: 10.3390/biomedicines9091181] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022] Open
Abstract
Radiation-induced lung injury (RILI) is one of the main dose-limiting side effects in patients with thoracic cancer during radiotherapy. No reliable predictors or accurate risk models are currently available in clinical practice. Severe radiation pneumonitis (RP) or pulmonary fibrosis (PF) will reduce the quality of life, even when the anti-tumor treatment is effective for patients. Thus, precise prediction and early diagnosis of lung toxicity are critical to overcome this longstanding problem. This review summarizes the primary mechanisms and preclinical animal models of RILI reported in recent decades, and analyzes the most promising biomarkers for the early detection of lung complications. In general, ideal integrated models considering individual genetic susceptibility, clinical background parameters, and biological variations are encouraged to be built up, and more prospective investigations are still required to disclose the molecular mechanisms of RILI as well as to discover valuable intervention strategies.
Collapse
Affiliation(s)
- Xinglong Liu
- Institute of Radiation Medicine, Shanghai Medical College, Fudan University, Shanghai 200032, China;
| | - Chunlin Shao
- Institute of Radiation Medicine, Shanghai Medical College, Fudan University, Shanghai 200032, China;
| | - Jiamei Fu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200433, China
| |
Collapse
|
7
|
Porter EM, Myziuk NK, Quinn TJ, Lozano D, Peterson AB, Quach DM, Siddiqui ZA, Guerrero TM. Synthetic pulmonary perfusion images from 4DCT for functional avoidance using deep learning. Phys Med Biol 2021; 66. [PMID: 34293726 DOI: 10.1088/1361-6560/ac16ec] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/22/2021] [Indexed: 01/14/2023]
Abstract
Purpose.To develop and evaluate the performance of a deep learning model to generate synthetic pulmonary perfusion images from clinical 4DCT images for patients undergoing radiotherapy for lung cancer.Methods. A clinical data set of 58 pre- and post-radiotherapy99mTc-labeled MAA-SPECT perfusion studies (32 patients) each with contemporaneous 4DCT studies was collected. Using the inhale and exhale phases of the 4DCT, a 3D-residual network was trained to create synthetic perfusion images utilizing the MAA-SPECT as ground truth. The training process was repeated for a 50-imaging study, five-fold validation with twenty model instances trained per fold. The highest performing model instance from each fold was selected for inference upon the eight-study test set. A manual lung segmentation was used to compute correlation metrics constrained to the voxels within the lungs. From the pre-treatment test cases (N = 5), 50th percentile contours of well-perfused lung were generated from both the clinical and synthetic perfusion images and the agreement was quantified.Results. Across the hold-out test set, our deep learning model predicted perfusion with a Spearman correlation coefficient of 0.70 (IQR: 0.61-0.76) and a Pearson correlation coefficient of 0.66 (IQR: 0.49-0.73). The agreement of the functional avoidance contour pairs was Dice of 0.803 (IQR: 0.750-0.810) and average surface distance of 5.92 mm (IQR: 5.68-7.55).Conclusion. We demonstrate that from 4DCT alone, a deep learning model can generate synthetic perfusion images with potential application in functional avoidance treatment planning.
Collapse
Affiliation(s)
- Evan M Porter
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Nicholas K Myziuk
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Thomas J Quinn
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Daniela Lozano
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Avery B Peterson
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America
| | - Duyen M Quach
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Zaid A Siddiqui
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas M Guerrero
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| |
Collapse
|
8
|
Collie D, Wright SH, Del-Pozo J, Kay E, Schwarz T, Parys M, Lawrence J. Regional and organ-level responses to local lung irradiation in sheep. Sci Rep 2021; 11:9553. [PMID: 33953285 PMCID: PMC8099861 DOI: 10.1038/s41598-021-88863-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 04/14/2021] [Indexed: 11/30/2022] Open
Abstract
Lung is a dose-limiting organ in radiotherapy. This may limit tumour control when effort is made in planning to limit the likelihood of radiation-induced lung injury (RILI). Understanding the factors that dictate susceptibility to radiation-induced pulmonary fibrosis will aid in the prevention and management of RILI, and may lead to more effective personalized radiotherapy treatment. As the interaction of regional and organ-level responses may shape the chronic consequences of RILI, we sought to characterise both aspects of the response in an ovine model. A defined volume of left pulmonary parenchyma was prescribed 5 fractions of 6 Gy within 14 days while the contralateral lung dose was constrained. Radiographic changes via computed tomography (CT) were documented to define differences in radio-exposed lung relative to non-exposed lung at d21, d63 and d171 (n = 2), and at d21, d147 and d227 (n = 2). Gross and histologic lung changes were evaluated in samples derived at necropsy examination to define the chronic pulmonary response to radiation. Irradiated lung demonstrated reduced radio-density and increased homogeneity as evidenced from texture based radiomic feature analysis, relative to the control lung. At necropsy, the radiation field was readily defined by pallor on the pleural surface, which was also evident on the cut surface of fixed lung specimens. The degree and homogeneity of pallor reflected the sparse presence of erythrocytes in alveolar septal capillaries of radiation-exposed lung. These changes contrasted with dilated and congested microvasculature in the contralateral control lung. Referencing data to measurements made in control lung volumes of sheep experiencing acute RILI indicated that interstitial collagen continues to deposit in the radio-exposed lung field. Overall lung vascularity increased during the chronic response, as evidenced by increased expression of endothelial cell marker (CD31); however, vascularity was consistently decreased in irradiated lung and was negatively correlated with lung collagen. Other organ-level responses included increased expression of alpha smooth muscle actin (ASMA), increased numbers of proliferating cells (Ki67 positive), and cells expressing the dendritic cell-lysosomal associated membrane protein (DC-LAMP) antigen. The chronic response to RILI in this model is effected at both the whole organ and local lung level. Whilst the long-term consequences of exposure to radiation involved the continued deposition of collagen in the radiation field, organ-level responses also included increased vascularization and increased expression of ASMA, Ki67 and DC-LAMP. Interrupting the interplay between these aspects may influence susceptibility to pulmonary fibrosis after radiotherapy. We advocate for the importance of large animal model systems in pursuing these opportunities to target local, organ-level and systemic mechanisms in parallel within the same subject over time.
Collapse
Affiliation(s)
- David Collie
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK.
| | - Steven H Wright
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
| | - Jorge Del-Pozo
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
| | - Elaine Kay
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
- Small Animal Clinical Sciences, School of Veterinary Medicine, University of Glasgow, Glasgow, UK
| | - Tobias Schwarz
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
| | - Magdalena Parys
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
| | - Jessica Lawrence
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Edinburgh, EH25 9RG, UK
- Department of Veterinary Clinical Sciences, University of Minnesota, St Paul, MN, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
9
|
Hoegen P, Lang C, Akbaba S, Häring P, Splinter M, Miltner A, Bachmann M, Stahl-Arnsberger C, Brechter T, El Shafie RA, Weykamp F, König L, Debus J, Hörner-Rieber J. Cone-Beam-CT Guided Adaptive Radiotherapy for Locally Advanced Non-small Cell Lung Cancer Enables Quality Assurance and Superior Sparing of Healthy Lung. Front Oncol 2020; 10:564857. [PMID: 33363005 PMCID: PMC7756078 DOI: 10.3389/fonc.2020.564857] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/04/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate the potential of cone-beam-CT (CB-CT) guided adaptive radiotherapy (ART) for locally advanced non-small cell lung cancer (NSCLC) for sparing of surrounding organs-at-risk (OAR). Materials and Methods In 10 patients with locally advanced NSCLC, daily CB-CT imaging was acquired during radio- (n = 4) or radiochemotherapy (n = 6) for simulation of ART. Patients were treated with conventionally fractionated intensity-modulated radiotherapy (IMRT) with total doses of 60–66 Gy (pPlan) (311 fraction CB-CTs). OAR were segmented on every daily CB-CT and the tumor volumes were modified weekly depending on tumor changes. Doses actually delivered were recalculated on daily images (dPlan), and voxel-wise dose accumulation was performed using a deformable registration algorithm. For simulation of ART, treatment plans were adapted using the new contours and re-optimized weekly (aPlan). Results CB-CT showed continuous tumor regression of 1.1 ± 0.4% per day, leading to a residual gross tumor volume (GTV) of 65.3 ± 13.4% after 6 weeks of radiotherapy (p = 0.005). Corresponding PTVs decreased to 83.7 ± 7.8% (p = 0.005). In the actually delivered plans (dPlan), both conformity (p = 0.005) and homogeneity (p = 0.059) indices were impaired compared to the initial plans (pPlan). This resulted in higher actual lung doses than planned: V20Gy was 34.6 ± 6.8% instead of 32.8 ± 4.9% (p = 0.066), mean lung dose was 19.0 ± 3.1 Gy instead of 17.9 ± 2.5 Gy (p = 0.013). The generalized equivalent uniform dose (gEUD) of the lung was 18.9 ± 3.1 Gy instead of 17.8 ± 2.5 Gy (p = 0.013), leading to an increased lung normal tissue complication probability (NTCP) of 15.2 ± 13.9% instead of 9.6 ± 7.3% (p = 0.017). Weekly plan adaptation enabled decreased lung V20Gy of 31.6 ± 6.2% (−3.0%, p = 0.007), decreased mean lung dose of 17.7 ± 2.9 Gy (−1.3 Gy, p = 0.005), and decreased lung gEUD of 17.6 ± 2.9 Gy (−1.3 Gy, p = 0.005). Thus, resulting lung NTCP was reduced to 10.0 ± 9.5% (−5.2%, p = 0.005). Target volume coverage represented by conformity and homogeneity indices could be improved by weekly plan adaptation (CI: p = 0.007, HI: p = 0.114) and reached levels of the initial plan (CI: p = 0.721, HI: p = 0.333). Conclusion IGRT with CB-CT detects continuous GTV and PTV changes. CB-CT-guided ART for locally advanced NSCLC is feasible and enables superior sparing of healthy lung at high levels of plan conformity.
Collapse
Affiliation(s)
- Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Clemens Lang
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Mainz University Hospital, Mainz, Germany
| | - Peter Häring
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mona Splinter
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annette Miltner
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marion Bachmann
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Thomas Brechter
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
10
|
Thomas HMT, Zeng J, Lee, Jr HJ, Sasidharan BK, Kinahan PE, Miyaoka RS, Vesselle HJ, Rengan R, Bowen SR. Comparison of regional lung perfusion response on longitudinal MAA SPECT/CT in lung cancer patients treated with and without functional tissue-avoidance radiation therapy. Br J Radiol 2019; 92:20190174. [PMID: 31364397 PMCID: PMC6849661 DOI: 10.1259/bjr.20190174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/28/2019] [Accepted: 07/23/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The effect of functional lung avoidance planning on radiation dose-dependent changes in regional lung perfusion is unknown. We characterized dose-perfusion response on longitudinal perfusion single photon emission computed tomography (SPECT)/CT in two cohorts of lung cancer patients treated with and without functional lung avoidance techniques. METHODS The study included 28 primary lung cancer patients: 20 from interventional (NCT02773238) (FLARE-RT) and eight from observational (NCT01982123) (LUNG-RT) clinical trials. FLARE-RT treatment plans included perfused lung dose constraints while LUNG-RT plans adhered to clinical standards. Pre- and 3 month post-treatment macro-aggregated albumin (MAA) SPECT/CT scans were rigidly co-registered to planning four-dimensional CT scans. Tumour-subtracted lung dose was converted to EQD2 and sorted into 5 Gy bins. Mean dose and percent change between pre/post-RT MAA-SPECT uptake (%ΔPERF), normalized to total tumour-subtracted lung uptake, were calculated in each binned dose region. Perfusion frequency histograms of pre/post-RT MAA-SPECT were analyzed. Dose-response data were parameterized by sigmoid logistic functions to estimate maximum perfusion increase (%ΔPERFmaxincrease), maximum perfusion decrease (%ΔPERFmaxdecrease), dose midpoint (Dmid), and dose-response slope (k). RESULTS Differences in MAA perfusion frequency distribution shape between time points were observed in 11/20 (55%) FLARE-RT and 2/8 (25%) LUNG-RT patients (p < 0.05). FLARE-RT dose response was characterized by >10% perfusion increase in the 0-5 Gy dose bin for 8/20 patients (%ΔPERFmaxincrease = 10-40%), which was not observed in any LUNG-RT patients (p = 0.03). The dose midpoint Dmid at which relative perfusion declined by 50% trended higher in FLARE-RT compared to LUNG-RT cohorts (35 GyEQD2 vs 21 GyEQD2, p = 0.09), while the dose-response slope k was similar between FLARE-RT and LUNG-RT cohorts (3.1-3.2, p = 0.86). CONCLUSION Functional lung avoidance planning may promote increased post-treatment perfusion in low dose regions for select patients, though inter-patient variability remains high in unbalanced cohorts. These preliminary findings form testable hypotheses that warrant subsequent validation in larger cohorts within randomized or case-matched control investigations. ADVANCES IN KNOWLEDGE This novel preliminary study reports differences in dose-response relationships between patients receiving functional lung avoidance radiation therapy (FLARE-RT) and those receiving conventionally planned radiation therapy (LUNG-RT). Following further validation and testing of these effects in larger patient populations, individualized estimation of regional lung perfusion dose-response may help refine future risk-adaptive strategies to minimize lung function deficits and toxicity incidence.
Collapse
Affiliation(s)
- Hannah Mary T Thomas
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Howard J Lee, Jr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | | | - Paul E Kinahan
- Department of Radiology, University of Washington School of Medicine, Seattle, USA
| | - Robert S Miyaoka
- Department of Radiology, University of Washington School of Medicine, Seattle, USA
| | - Hubert J. Vesselle
- Department of Radiology, University of Washington School of Medicine, Seattle, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | | |
Collapse
|
11
|
Stieb S, Kiser K, van Dijk L, Livingstone NR, Elhalawani H, Elgohari B, McDonald B, Ventura J, Mohamed ASR, Fuller CD. Imaging for Response Assessment in Radiation Oncology: Current and Emerging Techniques. Hematol Oncol Clin North Am 2019; 34:293-306. [PMID: 31739950 DOI: 10.1016/j.hoc.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Imaging in radiation oncology is essential for the evaluation of treatment response in tumors and organs at risk. This influences further treatment decisions and could possibly be used to adapt therapy. This review article focuses on the currently used imaging modalities for response assessment in radiation oncology and gives an overview of new and promising techniques within this field.
Collapse
Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Kendall Kiser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Lisanne van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Nadia Roxanne Livingstone
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Baher Elgohari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Brigid McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Juan Ventura
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Abdallah Sherif Radwan Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| |
Collapse
|
12
|
Farr KP, Khalil AA, Grau C. Patient-reported lung symptoms and quality of life before and after radiation therapy for non-small cell lung cancer: correlation with radiation pneumonitis and functional imaging. Acta Oncol 2019; 58:1523-1527. [PMID: 31315492 DOI: 10.1080/0284186x.2019.1634835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Katherina P. Farr
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - Azza A. Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| |
Collapse
|
13
|
Abstract
Curative-intent lung cancer radiation therapy either alone (RT) or combined with immuno-chemotherapy is associated with potential risk of serious radiation-induced lung injury. This review provides a summary of the role of SPECT ventilation perfusion (V/Q) imaging as an emerging adjunct to lung cancer RT planning and treatment dosimetry. Denoted "functional lung avoidance RT" it is hypothesized that preferential dosimetric avoidance of physiologically functional lung may reduce the frequency of radiation-induced lung injury. SPECT V/Q imaging datasets available during the planning process allows the prioritization (or "personalization') of RT dose to minimize the volume of functional lung probabilistically exposed to injurious radiation dose. Selective escalation of target dose and adaptive planning and replanning is also enabled. The emergent importance of the tumor-lung microenvironment and its biologic relationship to local immune effectors in lung cancer provides further incentive to individualize RT planning and delivery. This review examines important normal tissue dosimetric constraints that are part of current standards-of-care and the new dosimetric parameters associated with functional lung avoidance RT. SPECT V/Q has been a valuable tool in investigating the feasibility and efficacy of functional lung avoidance RT but is yet to become main stream due to the lack of large clinical trials. It is encouraging however that functional lung avoidance is feasible in RT dose-target delineation and some of the more promising studies are discussed.
Collapse
Affiliation(s)
- Enid M Eslick
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Mark J Stevens
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Dale L Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|