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Dashnamoorthy S, Jeyasingh E, Rajamanickam K. Validation of esophageal cancer treatment methods from 3D-CRT, IMRT, and Rapid Arc plans using custom Python software to compare radiobiological plans to normal tissue integral dosage. Rep Pract Oncol Radiother 2023; 28:54-65. [PMID: 37122909 PMCID: PMC10132189 DOI: 10.5603/rpor.a2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/12/2023] [Indexed: 05/02/2023] Open
Abstract
Background The aim was to develop in-house software that is able to calculate and generate the biological plan evaluation of the esophagus treatment plan using the Niemierko model for normal tissue complication probability and tumor control probability. The Niemierko model can be applied for esophagus cancer treatment plan to estimate the tumor control probability (TCP) and the normal tissue complication probability (NTCP) using different planning techniques. The equivalent uniform dose (EUD) and effective volume parameters were compared with organ at risk. Subsequently, EUD and TCP parameter were compared with tumor volume for all five different planning techniques. Materials and methods Ten cases for esophageal cancer were included in this study. For each patient, five treatment plans were generated. The Anisotropic analytical algorithms (AAA) were used for dose calculation for the three-dimensional conformal radiation therapy (3D-CRT), intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) techniques. The in-house developed radiobiological plan evaluation software using python programming is used for this study which takes a dose volume histogram (DVH) text file as an input file for biological plan evaluation. Results and Conclusion EUD, NTCP, TCP and effective volume were calculated from the Niemierko model using the in-house developed python based software and compared with treatment monitor units (MU) with all five different treatment plan. The best technique is quantified as benchmarked out of other different qualities of treatment. The four field 3D-CRT treatment plan is found to be the best suited from the perspective of biological plan index evaluation among the other planning techniques.
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Affiliation(s)
- Sougoumarane Dashnamoorthy
- Thangam Cancer Center, Namakkal, Tamil Nadu, India
- Department of Physics, Jamal Mohamed College (Autonomous), Affiliated to Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Ebenezar Jeyasingh
- Department of Physics, Jamal Mohamed College (Autonomous), Affiliated to Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
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The impact of organ motion and the appliance of mitigation strategies on the effectiveness of hypoxia-guided proton therapy for non-small cell lung cancer. Radiother Oncol 2022; 176:208-214. [PMID: 36228759 DOI: 10.1016/j.radonc.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the impact of organ motion on hypoxia-guided proton therapy treatments for non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS Hypoxia PET and 4D imaging data of six NSCLC patients were used to simulate hypoxia-guided proton therapy with different motion mitigation strategies including rescanning, breath-hold, respiratory gating and tumour tracking. Motion-induced dose degradation was estimated for treatment plans with dose painting of hypoxic tumour sub-volumes at escalated dose levels. Tumour control probability (TCP) and dosimetry indices were assessed to weigh the clinical benefit of dose escalation and motion mitigation. In addition, the difference in normal tissue complication probability (NTCP) between escalated proton and photon VMAT treatments has been assessed. RESULTS Motion-induced dose degradation was found for target coverage (CTV V95% up to -4%) and quality of the dose-escalation-by-contour (QRMS up to 6%) as a function of motion amplitude and amount of dose escalation. The TCP benefit coming from dose escalation (+4-13%) outweighs the motion-induced losses (<2%). Significant average NTCP reductions of dose-escalated proton plans were found for lungs (-14%), oesophagus (-10%) and heart (-16%) compared to conventional VMAT plans. The best plan dosimetry was obtained with breath hold and respiratory gating with rescanning. CONCLUSION NSCLC affected by hypoxia appears to be a prime target for proton therapy which, by dose-escalation, allows to mitigate hypoxia-induced radio-resistance despite the sensitivity to organ motion. Furthermore, substantial reduction in normal tissue toxicity can be expected compared to conventional VMAT. Accessibility and standardization of hypoxia imaging and clinical trials are necessary to confirm these findings in a clinical setting.
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Thummerer A, Seller Oria C, Zaffino P, Visser S, Meijers A, Guterres Marmitt G, Wijsman R, Seco J, Langendijk JA, Knopf AC, Spadea MF, Both S. Deep learning-based 4D-synthetic CTs from sparse-view CBCTs for dose calculations in adaptive proton therapy. Med Phys 2022; 49:6824-6839. [PMID: 35982630 PMCID: PMC10087352 DOI: 10.1002/mp.15930] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/20/2022] [Accepted: 08/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Time-resolved 4D cone beam-computed tomography (4D-CBCT) allows a daily assessment of patient anatomy and respiratory motion. However, 4D-CBCTs suffer from imaging artifacts that affect the CT number accuracy and prevent accurate proton dose calculations. Deep learning can be used to correct CT numbers and generate synthetic CTs (sCTs) that can enable CBCT-based proton dose calculations. PURPOSE In this work, sparse view 4D-CBCTs were converted into 4D-sCT utilizing a deep convolutional neural network (DCNN). 4D-sCTs were evaluated in terms of image quality and dosimetric accuracy to determine if accurate proton dose calculations for adaptive proton therapy workflows of lung cancer patients are feasible. METHODS A dataset of 45 thoracic cancer patients was utilized to train and evaluate a DCNN to generate 4D-sCTs, based on sparse view 4D-CBCTs reconstructed from projections acquired with a 3D acquisition protocol. Mean absolute error (MAE) and mean error were used as metrics to evaluate the image quality of single phases and average 4D-sCTs against 4D-CTs acquired on the same day. The dosimetric accuracy was checked globally (gamma analysis) and locally for target volumes and organs-at-risk (OARs) (lung, heart, and esophagus). Furthermore, 4D-sCTs were also compared to 3D-sCTs. To evaluate CT number accuracy, proton radiography simulations in 4D-sCT and 4D-CTs were compared in terms of range errors. The clinical suitability of 4D-sCTs was demonstrated by performing a 4D dose reconstruction using patient specific treatment delivery log files and breathing signals. RESULTS 4D-sCTs resulted in average MAEs of 48.1 ± 6.5 HU (single phase) and 37.7 ± 6.2 HU (average). The global dosimetric evaluation showed gamma pass ratios of 92.3% ± 3.2% (single phase) and 94.4% ± 2.1% (average). The clinical target volume showed high agreement in D98 between 4D-CT and 4D-sCT, with differences below 2.4% for all patients. Larger dose differences were observed in mean doses of OARs (up to 8.4%). The comparison with 3D-sCTs showed no substantial image quality and dosimetric differences for the 4D-sCT average. Individual 4D-sCT phases showed slightly lower dosimetric accuracy. The range error evaluation revealed that lung tissues cause range errors about three times higher than the other tissues. CONCLUSION In this study, we have investigated the accuracy of deep learning-based 4D-sCTs for daily dose calculations in adaptive proton therapy. Despite image quality differences between 4D-sCTs and 3D-sCTs, comparable dosimetric accuracy was observed globally and locally. Further improvement of 3D and 4D lung sCTs could be achieved by increasing CT number accuracy in lung tissues.
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Affiliation(s)
- Adrian Thummerer
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carmen Seller Oria
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paolo Zaffino
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Sabine Visser
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arturs Meijers
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Gabriel Guterres Marmitt
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robin Wijsman
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joao Seco
- Department of Biomedical Physics in Radiation Oncology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany.,Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany
| | - Johannes Albertus Langendijk
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antje Christin Knopf
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department I of Internal Medicine, Center for Integrated Oncology Cologne, University Hospital of Cologne, Cologne, Germany
| | - Maria Francesca Spadea
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Stefan Both
- Department, of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Thummerer A, Seller Oria C, Zaffino P, Meijers A, Guterres Marmitt G, Wijsman R, Seco J, Langendijk JA, Knopf AC, Spadea MF, Both S. Clinical suitability of deep learning based synthetic CTs for adaptive proton therapy of lung cancer. Med Phys 2021; 48:7673-7684. [PMID: 34725829 PMCID: PMC9299115 DOI: 10.1002/mp.15333] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/22/2021] [Accepted: 10/27/2021] [Indexed: 01/14/2023] Open
Abstract
Purpose Adaptive proton therapy (APT) of lung cancer patients requires frequent volumetric imaging of diagnostic quality. Cone‐beam CT (CBCT) can provide these daily images, but x‐ray scattering limits CBCT‐image quality and hampers dose calculation accuracy. The purpose of this study was to generate CBCT‐based synthetic CTs using a deep convolutional neural network (DCNN) and investigate image quality and clinical suitability for proton dose calculations in lung cancer patients. Methods A dataset of 33 thoracic cancer patients, containing CBCTs, same‐day repeat CTs (rCT), planning‐CTs (pCTs), and clinical proton treatment plans, was used to train and evaluate a DCNN with and without a pCT‐based correction method. Mean absolute error (MAE), mean error (ME), peak signal‐to‐noise ratio, and structural similarity were used to quantify image quality. The evaluation of clinical suitability was based on recalculation of clinical proton treatment plans. Gamma pass ratios, mean dose to target volumes and organs at risk, and normal tissue complication probabilities (NTCP) were calculated. Furthermore, proton radiography simulations were performed to assess the HU‐accuracy of sCTs in terms of range errors. Results On average, sCTs without correction resulted in a MAE of 34 ± 6 HU and ME of 4 ± 8 HU. The correction reduced the MAE to 31 ± 4HU (ME to 2 ± 4HU). Average 3%/3 mm gamma pass ratios increased from 93.7% to 96.8%, when the correction was applied. The patient specific correction reduced mean proton range errors from 1.5 to 1.1 mm. Relative mean target dose differences between sCTs and rCT were below ± 0.5% for all patients and both synthetic CTs (with/without correction). NTCP values showed high agreement between sCTs and rCT (<2%). Conclusion CBCT‐based sCTs can enable accurate proton dose calculations for APT of lung cancer patients. The patient specific correction method increased the image quality and dosimetric accuracy but had only a limited influence on clinically relevant parameters.
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Affiliation(s)
- Adrian Thummerer
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carmen Seller Oria
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paolo Zaffino
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Arturs Meijers
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gabriel Guterres Marmitt
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robin Wijsman
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joao Seco
- Department of Biomedical Physics in Radiation Oncology, Deutsches Krebsfoschungszentrum (DKFZ), Heidelberg, Germany.,Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany
| | - Johannes Albertus Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antje-Christin Knopf
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department I of Internal Medicine, Center for Integrated Oncology Cologne, University Hospital of Cologne, Cologne, Germany
| | - Maria Francesca Spadea
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Stefan Both
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Toma-Dasu I, Moiseenko V, Purdie TG, Carlson DJ. Recent Developments in the Prediction of Clinical Outcomes Data in Radiation Oncology. Int J Radiat Oncol Biol Phys 2020; 108:513-517. [PMID: 32976778 DOI: 10.1016/j.ijrobp.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Iuliana Toma-Dasu
- Department of Physics, Medical Radiation Physics, Stockholm University, Stockholm, Sweden; Department of Oncology and Pathology, Medical Radiation Physics, Karolinska Institutet, Stockholm, Sweden
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Thomas G Purdie
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
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Generalizability assessment of head and neck cancer NTCP models based on the TRIPOD criteria. Radiother Oncol 2020; 146:143-150. [DOI: 10.1016/j.radonc.2020.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
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Nieder C, Imingen KS, Mannsåker B, Yobuta R, Haukland E. Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer. Radiat Oncol 2020; 15:91. [PMID: 32357936 PMCID: PMC7195792 DOI: 10.1186/s13014-020-01550-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/24/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Esophagitis influences quality of life and might cause treatment interruption and hospitalization. Previous studies of risk factors focused on curative treatment for non-small cell lung cancer (NSCLC), which often involves concomitant chemoradiation (CRT). Given the uncertainty around extrapolation of dose constraints, we analyzed risk factors in patients treated with hypofractionated palliative regimens. Patients and methods A retrospective review of 106 patients treated with palliative radiotherapy or CRT between 2009 and 2017 was performed. Inclusion criteria: prescribed total dose 30–54 Gy, dose per fraction 2.5–4 Gy, esophageal dose > 1 Gy. Uni- and multivariate analyses were performed in 97 eligible patients to identify predictive factors for acute esophagitis grade ≥ 1 (CTCAE 5.0). Results Forty percent of patients were treated with 15 fractions of 2.8 Gy (42 Gy) and 28% also received chemotherapy according to the CONRAD study regimen (induction and concomitant Carboplatin/Vinorelbine) published by the Norwegian Lung Cancer Group. Thirty-four percent were treated with 10 fractions of 3 Gy. Stage IV NSCLC was present in 47%. Esophagus Dmax was 39 Gy (population median) and Dmean 15 Gy. Overall 31% of patients developed esophagitis (26% grade 2–3, no grade 4–5). Several dosimetric parameters correlated with the risk of esophagitis (Dmax, Dmean, D5cc, V20, V30, V35, V40). Dmax outperformed other dosimetric variables in multivariate analysis. Furthermore, concomitant chemotherapy significantly increased the risk of esophagitis, while oral steroid medication reduced it. In patients with Dmax ≥40 Gy a reduced Dmean (≤20 Gy) was beneficial. Conclusion In order to reduce esophagitis after hypofractionated palliative treatment lower doses than those recommended in curative NSCLC settings are preferable. Besides esophageal dose, CRT is the main risk factor for esophagitis. Additional work is needed to confirm that steroids are able to modify the risk (or to rule out confounding effects of baseline variables not included in our database).
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway.
| | - Kristian S Imingen
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway
| | - Rosalba Yobuta
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway
| | - Ellinor Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway
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Perspectives on the model-based approach to proton therapy trials: A retrospective study of a lung cancer randomized trial. Radiother Oncol 2020; 147:8-14. [PMID: 32224318 DOI: 10.1016/j.radonc.2020.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of this study was to assess whether a model-based approach applied retrospectively to a completed randomized controlled trial (RCT) would have significantly altered the selection of patients of the original trial, using the same selection criteria and endpoint for testing the potential clinical benefit of protons compared to photons. METHODS AND MATERIALS A model-based approach, based on three widely used normal tissue complication probability (NTCP) models for radiation pneumonitis (RP), was applied retrospectively to a completed non-small cell lung cancer RCT (NCT00915005). It was assumed that patients were selected by the model-based approach if their expected ΔNTCP value was above a threshold of 5%. The endpoint chosen matched that of the original trial, the first occurrence of severe (grade ≥3) RP. RESULTS Our analysis demonstrates that NTCP differences between proton and photon therapy treatments may be too small to support a model-based trial approach for lung cancer using RP as the normal tissue endpoint. The analyzed lung trial showed that less than 19% (32/165) of patients enrolled in the completed trial would have been enrolled in a model-based trial, prescribing photon therapy to all other patients. The number of patients enrolled was also found to be dependent on the type of NTCP model used for evaluating RP, with the three models enrolling 3%, 13% or 19% of patients. This result does show limitations in NTCP models which would affect the success of a model-based trial approach. No conclusion regarding the development of RP in patients randomized by the model-based approach could statistically be made. CONCLUSIONS Uncertainties in the outcome models to predict NTCP are the inherent drawback of a model-based approach to clinical trials. The impact of these uncertainties on enrollment in model-based trials depends on the predicted difference between the two treatment arms and on the set threshold for patient stratification. Our analysis demonstrates that NTCP differences between proton and photon therapy treatments may be too small to support a model-based trial approach for specific treatment sites, such as lung cancer, depending on the chosen normal tissue endpoint.
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EGCG, a green tea polyphenol, as one more weapon in the arsenal to fight radiation esophagitis? Radiother Oncol 2019; 137:192-193. [PMID: 31133342 DOI: 10.1016/j.radonc.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 12/25/2022]
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