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Cattell RF, Hsia AT, Kim J, Qian X, Lu S, Slade A, Mani K, Ryu S, Xu Z. Intrafractional motion and dosimetric analysis in prostate stereotactic body radiation therapy with auto beam hold technique. Biomed Phys Eng Express 2024; 10:045052. [PMID: 38923907 DOI: 10.1088/2057-1976/ad4b1d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/14/2024] [Indexed: 06/28/2024]
Abstract
Objective: To summarize our institutional prostate stereotactic body radiation therapy (SBRT) experience using auto beam hold (ABH) technique for intrafractional prostate motion and assess ABH tolerance of 10-millimeter (mm) diameter.Approach: Thirty-two patients (160 fractions) treated using ABH technique between 01/2018 and 03/2021 were analyzed. During treatment, kV images were acquired every 20-degree gantry rotation to visualize 3-4 gold fiducials within prostate to track target motion. If the fiducial center fell outside the tolerance circle (diameter = 10 mm), beam was automatically turned off for reimaging and repositioning. Number of beam holds and couch translational movement magnitudes were recorded. Dosimetric differences from intrafractional motion were calculated by shifting planned isocenter.Main Results: Couch movement magnitude (mean ± SD) in vertical, longitudinal and lateral directions were -0.7 ± 2.5, 1.4 ± 2.9 and -0.1 ± 0.9 mm, respectively. For most fractions (77.5%), no correction was necessary. Number of fractions requiring one, two, or three corrections were 15.6%, 5.6% and 1.3%, respectively. Of the 49 corrections, couch shifts greater than 3 mm were seen primarily in the vertical (31%) and longitudinal (39%) directions; corresponding couch shifts greater than 5 mm occurred in 2% and 6% of cases. Dosimetrically, 100% coverage decreased less than 2% for clinical target volume (CTV) (-1 ± 2%) and less than 10% for PTV (-10 ± 6%). Dose to bladder, bowel and urethra tended to increase (Bladder: ΔD10%:184 ± 466 cGy, ΔD40%:139 ± 241 cGy, Bowel: ΔD1 cm3:54 ± 129 cGy; ΔD5 cm3:44 ± 116 cGy, Urethra: ΔD0.03 cm3:1 ± 1%). Doses to the rectum tended to decrease (Rectum: ΔD1 cm3:-206 ± 564 cGy, ΔD10%:-97 ± 426 cGy; ΔD20%:-50 ± 251 cGy).Significance: With the transition from conventionally fractionated intensity modulated radiation therapy to SBRT for localized prostate cancer treatment, it is imperative to ensure that dose delivery is spatially accurate for appropriate coverage to target volumes and limiting dose to surrounding organs. Intrafractional motion monitoring can be achieved using triggered imaging to image fiducial markers and ABH to allow for reimaging and repositioning for excessive motion.
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Affiliation(s)
- Renee F Cattell
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - An Ting Hsia
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Jinkoo Kim
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Xin Qian
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Siming Lu
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Alexander Slade
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Kartik Mani
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Samuel Ryu
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
| | - Zhigang Xu
- Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States of America
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Winter JD, Reddy V, Li W, Craig T, Raman S. Impact of technological advances in treatment planning, image guidance, and treatment delivery on target margin design for prostate cancer radiotherapy: an updated review. Br J Radiol 2024; 97:31-40. [PMID: 38263844 PMCID: PMC11027310 DOI: 10.1093/bjr/tqad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/22/2023] [Accepted: 11/21/2023] [Indexed: 01/25/2024] Open
Abstract
Recent innovations in image guidance, treatment delivery, and adaptive radiotherapy (RT) have created a new paradigm for planning target volume (PTV) margin design for patients with prostate cancer. We performed a review of the recent literature on PTV margin selection and design for intact prostate RT, excluding post-operative RT, brachytherapy, and proton therapy. Our review describes the increased focus on prostate and seminal vesicles as heterogenous deforming structures with further emergence of intra-prostatic GTV boost and concurrent pelvic lymph node treatment. To capture recent innovations, we highlight the evolution in cone beam CT guidance, and increasing use of MRI for improved target delineation and image registration and supporting online adaptive RT. Moreover, we summarize new and evolving image-guidance treatment platforms as well as recent reports of novel immobilization strategies and motion tracking. Our report also captures recent implementations of artificial intelligence to support image guidance and adaptive RT. To characterize the clinical impact of PTV margin changes via model-based risk estimates and clinical trials, we highlight recent high impact reports. Our report focusses on topics in the context of PTV margins but also showcase studies attempting to move beyond the PTV margin recipes with robust optimization and probabilistic planning approaches. Although guidelines exist for target margins conventional using CT-based image guidance, further validation is required to understand the optimal margins for online adaptation either alone or combined with real-time motion compensation to minimize systematic and random uncertainties in the treatment of patients with prostate cancer.
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Affiliation(s)
- Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Varun Reddy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
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Mangesius J, Seppi T, Ibrahim R, Fleischmann K, Ginestet A, Vorbach S, Hart T, Pointner M, Mangesius S, Ganswindt U. Dynamic intrafractional position monitoring with implanted fiducial markers for enhanced accuracy in radiotherapy of prostate cancer. Phys Eng Sci Med 2023; 46:1365-1374. [PMID: 37523057 PMCID: PMC10703977 DOI: 10.1007/s13246-023-01304-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Recent advances in the radiation therapy of prostate cancer have brought a shift toward moderate- and ultra-hypofractionated treatment schedules. Reducing safety margins can broaden the therapeutic window in stereotactic treatments and alleviate concerns for toxicity in high dose-per-fraction treatment schedules. Management of intrafractional motion is a necessity for stereotactic body radiation therapy (SBRT). It can be achieved by performing intrafractional image guidance and position corrections. We evaluate the suitability of such a novel prostate motion management system and its potential benefit for treatment accuracy. METHODS Intrafractional IGRT was performed for 22 patients during 149 treatment sessions using repeated orthogonal kV-XR imaging of implanted fiducial markers with the ExacTrac Dynamic (EXTD) system. Position measurements were taken four times during each arc of the applied volumetric modulated arc therapy (VMAT). Position correction was performed if translational deviation exceeded 2 mm in any direction. RESULTS Of 677 single EXTD measurements, 20.6% exceeded the predefined threshold of 2 mm 3D deviation. Without intrafractional corrections, 39.4% of all individual measurements would exceed the threshold. The 3D accuracy could thus significantly be improved, reducing mean 3D shifts from 1.97 (± 1.44) mm to 1.39 (± 1.01) mm by performing intrafractional IGRT. In total, 34% of all treatment sessions required correction of intrafractional position shifts. CONCLUSION Monitoring of prostate motion using repeated intrafractional orthogonal kV-X-ray-based position measurements of implanted fiducial markers proved to be a reliable method to improve precision of stereotactic irradiations of the prostate. It can prevent unacceptable translation deviations in one third of all sessions.
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Affiliation(s)
- Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria.
| | - Thomas Seppi
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Ramine Ibrahim
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Katrin Fleischmann
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Angela Ginestet
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Samuel Vorbach
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Tilmann Hart
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Martin Pointner
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Stephanie Mangesius
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ute Ganswindt
- Department of Radiation Oncology, Medical University of Innsbruck, Univ.-Klinik für Strahlentherapie-Radioonkologie, Anichstrasse 35, Innsbruck, 6020, Austria
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Arumugam S, Wong K, Do V, Sidhom M. Reducing the margin in prostate radiotherapy: optimizing radiotherapy with a general-purpose linear accelerator using an in-house position monitoring system. Front Oncol 2023; 13:1116999. [PMID: 37519807 PMCID: PMC10373585 DOI: 10.3389/fonc.2023.1116999] [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: 12/06/2022] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Purpose To study the feasibility of optimizing the Clinical Target Volume to Planning Target Volume (CTV-PTV) margin in prostate radiotherapy(RT) with a general-purpose linear accelerator using an in-house developed position monitoring system, SeedTracker. Methods A cohort of 30 patients having definitive prostate radiotherapy treated within an ethics-approved prospective trial was considered for this study. The intrafraction prostate motion and the position deviations were measured using SeedTracker system during each treatment fraction. Using this data the CTV-PTV margin required to cover 90% of the patients with a minimum of 95% of the prescription dose to CTV was calculated using van Herk's formula. The margin calculations were performed for treatment scenarios both with and without applying the position corrections for observed position deviations. The feasibility of margin reduction with real-time monitoring was studied by assessing the delivered dose that incorporates the actual target position during treatment delivery and comparing it with the planned dose. This assessment was performed for plans generated with reduced CTV-PTV margin in the range of 7mm-3mm. Results With real-time monitoring and position corrections applied the margin of 2.0mm, 2.1mm and 2.1mm in LR, AP and SI directions were required to meet the criteria of 90% population to receive 95% of the dose prescription to CTV. Without position corrections applied for observed position deviations a margin of 3.1mm, 4.0mm and 3.0mm was required in LR, AP and SI directions to meet the same criteria. A mean ± SD reduction of 0.5 ± 1.8% and 3 ± 7% of V60 for the rectum and bladder can be achieved for every 1mm reduction of PTV margin. With position corrections applied, the CTV D99 can be delivered within -0.2 ± 0.3 Gy of the planned dose for plans with a 3mm margin. Without applying corrections for position deviations the CTV D99 was reduced by a maximum of 1.1 ± 1.1 Gy for the 3mm margin plan and there was a statistically significant difference between planned and delivered dose for 3mm and 4mm margin plans. Conclusion This study demonstrates the feasibility of reducing the margin in prostate radiotherapy with SeedTracker system without compromising the dose delivery accuracy to CTV while reducing dose to critical structures.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Karen Wong
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Viet Do
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
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O'Connor LM, Quinn A, Denley S, Leigh L, Martin J, Dowling JA, Skehan K, Warren-Forward H, Greer PB. Cone beam computed tomography image guidance within a magnetic resonance imaging-only planning workflow. Phys Imaging Radiat Oncol 2023; 27:100472. [PMID: 37720461 PMCID: PMC10500022 DOI: 10.1016/j.phro.2023.100472] [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: 05/15/2023] [Revised: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 09/19/2023] Open
Abstract
Background and purpose Magnetic Resonance Imaging (MRI)-only planning workflows offer many advantages but raises challenges regarding image guidance. The study aimed to assess the viability of MRI to Cone Beam Computed Tomography (CBCT) based image guidance for MRI-only planning treatment workflows. Materials and methods An MRI matching training package was developed. Ten radiation therapists, with a range of clinical image guidance experience and experience with MRI, completed the training package prior to matching assessment. The matching assessment was performed on four match regions: prostate gold seed, prostate soft tissue, rectum/anal canal and gynaecological. Each match region consisted of five patients, with three CBCTs per patient, resulting in fifteen CBCTs for each match region. The ten radiation therapists performed the CBCT image matching to CT and to MRI for all regions and recorded the match values. Results The median inter-observer variation for MRI-CBCT matching and CT-CBCT matching for all regions were within 2 mm and 1 degree. There was no statistically significant association in the inter-observer variation in mean match values and radiation therapist image guidance experience levels. There was no statistically significant association in inter-observer variation in mean match values for MRI experience levels for prostate soft tissue and gynaecological match regions, while there was a statistically significant difference for prostate gold seed and rectum match regions. Conclusion The results of this study support the concept that with focussed training, an MRI to CBCT image guidance approach can be successfully implemented in a clinical planning workflow.
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Affiliation(s)
- Laura M O'Connor
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
- School of Health Sciences, University of Newcastle, University Drive, Newcastle, NSW 2308, Australia
| | - Alesha Quinn
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
| | - Samuel Denley
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, Lot 1 Kookaburra Ct, New Lambton Heights, NSW 2305, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
| | - Jason A Dowling
- Australian E-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Bowen Bridge Rd, Herston, QLD 4029, Australia
| | - Kate Skehan
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
| | - Helen Warren-Forward
- School of Health Sciences, University of Newcastle, University Drive, Newcastle, NSW 2308, Australia
| | - Peter B Greer
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah, Newcastle, NSW 2298, Australia
- School of Information and Physical Sciences, University of Newcastle, University Drive, Newcastle, NSW 2308, Australia
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Kuo HC, Della-Biancia C, Damato AL, Happersett L, Lim SB, Cerviño LI, Shasha D, Berry S. Clinical Experience and Feasibility of Using 2D-kVimage Online Intervention in the Ultrafractionated Stereotactic Radiation Treatment of Prostate Cancer. Pract Radiat Oncol 2023; 13:e308-e318. [PMID: 36476984 PMCID: PMC11253237 DOI: 10.1016/j.prro.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This study reports clinical experience and feasibility of using a 2-dimensional (2D)-kV image system with online intervention in the ultrafractionated stereotactic body radiation treatment (UF-SBRT) of prostate cancer. METHODS AND MATERIALS Fifteen patients with prostate cancer who had a low- to intermediate-risk marker implanted received UF-SBRT with online 2D-kV image tracking and a manual beam interruption strategy with a 2-mm motion threshold. A total of 180 kV paired setup images and 1272 intrabeam 2D-kV images were analyzed to evaluate the setup deviation and intratreatment target deviation. Correlation of expected treatment interruptions with a set of parameters (eg, image and treatment time; direction of deviation) was performed (Spearman test). A subset of the data from 22 fractions was re-evaluated to check the differences in analysis results between using the planning position and using the pretreatment setup position as a reference. Margins based on the derived system and random errors were calculated to evaluate the feasibility of the workflow in ensuring prostate coverage during treatment. RESULTS Mean target motion in 3D propagated from 1.0 mm (setup at 0 minutes) to 2.0 mm (beam on at 7 minutes) to 2.4 mm (end at 13.5 minutes). Out of 75 fractions, 50 were found to require beam interruption. Interruption had a strong correlation with prostate motion along the longitudinal direction and had moderate correlation with prostate motion along the vertical direction and the prostate's treatment starting position along vertical and longitudinal directions. Using the pretreatment position as a reference for intrabeam monitoring, the magnitude of motion deviation from the reference position was reduced by 0.3 mm at a vertical direction and 0.4 mm at lateral and longitudinal directions. The calculated 3D margin to ensure target coverage was 3.7 mm, 4.6 mm, and 5.0 mm in lateral, vertical, and longitudinal directions, respectively. CONCLUSIONS Prostate motion propagated over time. It is feasible to use a 2D-kV online intrabeam monitoring system with a proper intervention scheme to perform UF-SBRT for prostate cancer.
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Affiliation(s)
- Hsiang-Chi Kuo
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Cesar Della-Biancia
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Antonio L Damato
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura Happersett
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seng Boh Lim
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura I Cerviño
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Shasha
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Berry
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Sengupta C, Skouboe S, Ravkilde T, Poulsen PR, Nguyen DT, Greer PB, Moodie T, Hardcastle N, Hayden AJ, Turner S, Siva S, Tai KH, Martin J, Booth JT, O'Brien R, Keall PJ. The dosimetric error due to uncorrected tumor rotation during real-time adaptive prostate stereotactic body radiation therapy. Med Phys 2023; 50:20-29. [PMID: 36354288 PMCID: PMC10099881 DOI: 10.1002/mp.16094] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/06/2022] [Accepted: 10/27/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During prostate stereotactic body radiation therapy (SBRT), prostate tumor translational motion may deteriorate the planned dose distribution. Most of the major advances in motion management to date have focused on correcting this one aspect of the tumor motion, translation. However, large prostate rotation up to 30° has been measured. As the technological innovation evolves toward delivering increasingly precise radiotherapy, it is important to quantify the clinical benefit of translational and rotational motion correction over translational motion correction alone. PURPOSE The purpose of this work was to quantify the dosimetric impact of intrafractional dynamic rotation of the prostate measured with a six degrees-of-freedom tumor motion monitoring technology. METHODS The delivered dose was reconstructed including (a) translational and rotational motion and (b) only translational motion of the tumor for 32 prostate cancer patients recruited on a 5-fraction prostate SBRT clinical trial. Patients on the trial received 7.25 Gy in a treatment fraction. A 5 mm clinical target volume (CTV) to planning target volume (PTV) margin was applied in all directions except the posterior direction where a 3 mm expansion was used. Prostate intrafractional translational motion was managed using a gating strategy, and any translation above the gating threshold was corrected by applying an equivalent couch shift. The residual translational motion is denoted as T r e s $T_{res}$ . Prostate intrafractional rotational motion R u n c o r r $R_{uncorr}$ was recorded but not corrected. The dose differences from the planned dose due to T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ , ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and due to T r e s $T_{res}$ alone, ΔD( T r e s $T_{res}$ ), were then determined for CTV D98, PTV D95, bladder V6Gy, and rectum V6Gy. The residual dose error due to uncorrected rotation, R u n c o r r $R_{uncorr}$ was then quantified: Δ D R e s i d u a l $\Delta D_{Residual}$ = ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) - ΔD( T res ${T}_{\textit{res}}$ ). RESULTS Fractional data analysis shows that the dose differences from the plan (both ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and ΔD( T r e s $T_{res}$ )) for CTV D98 was less than 5% in all treatment fractions. ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) was larger than 5% in one fraction for PTV D95, in one fraction for bladder V6Gy, and in five fractions for rectum V6Gy. Uncorrected rotation, R u n c o r r $R_{uncorr}$ induced residual dose error, Δ D R e s i d u a l $\Delta D_{Residual}$ , resulted in less dose to CTV and PTV in 43% and 59% treatment fractions, respectively, and more dose to bladder and rectum in 51% and 53% treatment fractions, respectively. The cumulative dose over five fractions, ∑D( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and ∑D( T r e s $T_{res}$ ), was always within 5% of the planned dose for all four structures for every patient. CONCLUSIONS The dosimetric impact of tumor rotation on a large prostate cancer patient cohort was quantified in this study. These results suggest that the standard 3-5 mm CTV-PTV margin was sufficient to account for the intrafraction prostate rotation observed for this cohort of patients, provided an appropriate gating threshold was applied to correct for translational motion. Residual dose errors due to uncorrected prostate rotation were small in magnitude, which may be corrected using different treatment adaptation strategies to further improve the dosimetric accuracy.
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Affiliation(s)
- Chandrima Sengupta
- ACRF Image X Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Simon Skouboe
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Ravkilde
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Doan Trang Nguyen
- ACRF Image X Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Peter B Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, New South Wales, Australia
| | - Trevor Moodie
- Crown Princess Mary Cancer Center, Sydney, New South Wales, Australia
| | | | - Amy J Hayden
- Crown Princess Mary Cancer Center, Sydney, New South Wales, Australia
| | - Sandra Turner
- Crown Princess Mary Cancer Center, Sydney, New South Wales, Australia
| | - Shankar Siva
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
| | - Keen-Hun Tai
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, New South Wales, Australia
| | - Jeremy T Booth
- Northern Sydney Cancer Center, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ricky O'Brien
- ACRF Image X Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Paul J Keall
- ACRF Image X Institute, University of Sydney, Sydney, New South Wales, Australia
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Goddard L, Jeong K, Tang J, Garg M, Tomé WA. Reducing PTV margins for prostate SBRT with motion compensation and gating techniques. J Appl Clin Med Phys 2022; 24:e13861. [PMID: 36478148 PMCID: PMC10113684 DOI: 10.1002/acm2.13861] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/10/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study is to investigate the dosimetric accuracy of prostate SBRT when motion is considered. To account for target movement, motion compensation and gating techniques were investigated with PTV margins reduced to 2 mm. To allow for dosimetric measurements a Delta4 phantom, Gafchromic film, and Hexamotion motion platform were utilized. Four motion files were utilized that represent a range of motions. Analysis of measured prostate motions for fifteen patients was performed to ensure detected motions were similar to those previously reported and motion files utilized were suitable. Five patient plans were utilized to allow for the effects of MLC and target motion interplay to be investigated. For both motion compensation and gating techniques, plans were delivered to the stationary phantom and for each of four motion types with/without compensation/gating enabled. Using a 3%, 2 mm and 80% threshold gamma criteria, film measurements had an average pass rate of 80.5% for uncorrected deliveries versus 96.0% for motion compensated deliveries. For gated techniques average pass rates increased from 89.9% for uncorrected to 94.8% with gating enabled. Measurements with the Delta4 arrays were analyzed with a 3%, 2 mm and 10% threshold dose. An average pass rate of 83.8% was measured for uncorrected motions versus 94.8% with motion compensation. For the gated technique an average pass rate of 87.2% was found for uncorrected motions versus 96.9% with gating enabled. These results show that very high gamma pass rates are achievable when motion compensation or gating techniques are applied. When target motion is not accounted for shifts up to 5 mm in planned versus delivered isodose distributions were found. However, when motion compensation, or gated techniques were applied, much smaller differences between planned and delivered isodose distributions were found. With these techniques dose delivery accuracy is greatly improved, allowing for PTV margins to be reduced.
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Affiliation(s)
- Lee Goddard
- Department of Radiation Oncology Montefiore Medical Center Bronx New York USA
- Albert Einstein College of Medicine Bronx New York USA
| | - Kyoungkeun Jeong
- Department of Radiation Oncology Montefiore Medical Center Bronx New York USA
- Albert Einstein College of Medicine Bronx New York USA
| | - Justin Tang
- Department of Radiation Oncology Montefiore Medical Center Bronx New York USA
- Albert Einstein College of Medicine Bronx New York USA
| | - Madhur Garg
- Department of Radiation Oncology Montefiore Medical Center Bronx New York USA
- Albert Einstein College of Medicine Bronx New York USA
| | - Wolfgang A. Tomé
- Department of Radiation Oncology Montefiore Medical Center Bronx New York USA
- Albert Einstein College of Medicine Bronx New York USA
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Panizza D, Faccenda V, Lucchini R, Daniotti MC, Trivellato S, Caricato P, Pisoni V, De Ponti E, Arcangeli S. Intrafraction Prostate Motion Management During Dose-Escalated Linac-Based Stereotactic Body Radiation Therapy. Front Oncol 2022; 12:883725. [PMID: 35463373 PMCID: PMC9021501 DOI: 10.3389/fonc.2022.883725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Extreme hypofractionation requires tight planning margins, high dose gradients, and strict adherence to planning criteria in terms of patient positioning and organ motion mitigation. This study reports the first clinical experience worldwide using a novel electromagnetic (EM) tracking device for intrafraction prostate motion management during dose-escalated linac-based stereotactic body radiation therapy (SBRT). Methods Thirteen patients with organ-confined prostate cancer underwent dose-escalated SBRT using flattening filter-free (FFF) volumetric modulated arc therapy (VMAT). The EM tracking device consisted of an integrated Foley catheter with a transmitter. Patients were simulated and treated with a filled bladder and an empty rectum. Setup accuracy was achieved by ConeBeam-CT (CBCT) matching, and motion was tracked during all the procedure. Treatment was interrupted when the signals exceeded a 2 mm threshold in any of the three spatial directions and, unless the offset was transient, target position was re-defined by repeating CBCT. Moreover, the displacements that would have occurred without any intrafraction organ motion management (i.e. no interruptions and repositionings) were simulated. Results In 31 out of 56 monitored fractions (55%), no intervention was required to correct the target position. In 25 (45%) a correction was mandated, but only in 10 (18%), the beam delivery was interrupted. Total treatment time lasted on average 10.2 minutes, 6.7 minutes for setup, and 3.5 minutes for beam delivery. Without any intrafraction motion management, the overall mean treatment time and the mean delivery time would have been 6.9 minutes and 3.2 minutes, respectively. The prostate would have been found outside the tolerance in 8% of the total session time, in 4% of the time during the setup, and in 14% during the beam-on phase. Predominant motion pattern was posterior and its probability increased with time, with a mean motion ≤ 2 mm occurring within 10 minutes. Conclusions EM real-time tracking was successfully implemented for intrafraction motion management during dose-escalated prostate SBRT. Results showed that most of the observed displacements were < 2 mm in any direction; however, there were a non-insignificant number of fractions with motion exceeding the predefined threshold, which would have otherwise gone undetected without intrafraction motion management.
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Affiliation(s)
- Denis Panizza
- Medical Physics Department, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | - Raffaella Lucchini
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,Radiation Oncology Department, ASST Monza, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | | | - Paolo Caricato
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | | | - Elena De Ponti
- Medical Physics Department, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,Radiation Oncology Department, ASST Monza, Monza, Italy
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10
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Muurholm CG, Ravkilde T, De Roover R, Skouboe S, Hansen R, Crijns W, Depuydt T, Poulsen PR. Experimental investigation of dynamic real-time rotation-including dose reconstruction during prostate tracking radiotherapy. Med Phys 2022; 49:3574-3584. [PMID: 35395104 PMCID: PMC9322296 DOI: 10.1002/mp.15660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/12/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hypofractionation in prostate radiotherapy is of increasing interest. Steep dose gradients and a large weight on each individual fraction emphasize the need for motion management. Real-time motion management techniques such as multi-leaf collimator (MLC) tracking or couch tracking typically adjust for translational motion while rotations remain uncompensated with unknown dosimetric impact. PURPOSE The purpose of this study is to demonstrate and validate dynamic real-time rotation-including dose reconstruction during radiotherapy experiments with and without MLC and couch tracking. METHODS Real-time dose reconstruction was performed using the in-house developed software DoseTracker. DoseTracker receives streamed target positions and accelerator parameters during treatment delivery and uses a pencil beam algorithm with water density assumption to reconstruct the dose in a moving target. DoseTracker's ability to reconstruct motion-induced dose errors in a dynamically rotating and translating target was investigated during three different scenarios: (1) no motion compensation and translational motion correction with (2) MLC tracking and (3) couch tracking. In each scenario, dose reconstruction was performed online and in real-time during delivery of two dual-arc volumetric modulated arc therapy (VMAT) prostate plans with a prescribed fraction dose of 7 Gy to the prostate and simultaneous intraprostatic lesion boosts with doses of at least 8 Gy, but up to 10 Gy as long as the organs-at-risk dose constraints were fulfilled. The plans were delivered to a pelvis phantom that replicated three patient-measured motion traces using a rotational insert with 21 layers of EBT3 film spaced 2.5 mm apart. DoseTracker repeatedly calculated the actual motion-including dose increment and the planned static dose increment since the last calculation in 84500 points in the film stack. The experiments were performed with a TrueBeam accelerator with MLC and couch tracking based on electromagnetic transponders embedded in the film stack. The motion-induced dose error was quantified as the difference between the final cumulative dose with motion and without motion using the 2D 2%/2mm γ-failure rate and the difference in dose to 95% of the clinical target volume (CTV ΔD95% ) and the gross target volume (GTV ΔD95% ) as well as the difference in dose to 0.1 cm3 of the urethra, bladder, and rectum (ΔD0.1CC ). The motion-induced errors were compared between dose reconstructions and film measurements. RESULTS The dose was reconstructed in all calculation points at a mean frequency of 4.7 Hz. The root-mean-square difference between real-time reconstructed and film measured motion-induced errors was 3.1%-points (γ-failure rate), 0.13 Gy (CTV ΔD95% ), 0.23 Gy (GTV ΔD95% ), 0.19 Gy (urethra ΔD0.1CC ), 0.09 Gy (bladder ΔD0.1CC ), and 0.07 Gy (rectum ΔD0.1CC ). CONCLUSIONS In a series of phantom experiments, online real-time rotation-including dose reconstruction was performed for the first time. The calculated motion-induced errors agreed well with film measurements. The dose reconstruction provides a valuable tool for monitoring dose delivery and investigating the efficacy of advanced motion-compensation techniques in the presence of translational and rotational motion. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Thomas Ravkilde
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Robin De Roover
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Simon Skouboe
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Rune Hansen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Wouter Crijns
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Depuydt
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Per R Poulsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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11
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Taillez A, Bimbai AM, Lacornerie T, Le Deley MC, Lartigau EF, Pasquier D. Studies of Intra-Fraction Prostate Motion During Stereotactic Irradiation in First Irradiation and Re-Irradiation. Front Oncol 2021; 11:690422. [PMID: 34336678 PMCID: PMC8316636 DOI: 10.3389/fonc.2021.690422] [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: 04/02/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022] Open
Abstract
Background Understanding intra-fractional prostate motions is crucial for stereotactic body radiation therapy (SBRT). No studies have focused on the intra-fractional prostate motions during re-irradiation with SBRT. The objective was to evaluate these translational and rotational motions in primary treated patients and in the context of re-irradiation. Methods From January 2011 to March 2020, 162 patients with histologically proven prostate cancer underwent prostate SBRT, including 58 as part of a re-irradiation treatment. We used the continuous coordinates of the fiducial markers collected by an orthogonal X-ray dual-image monitoring system. The translations and rotations of the prostate were calculated. Prostate deviations representing overall movement was defined as the length of the 3D-vectors. Results A total of 858 data files were analyzed. The deviations over time in the group of primary treated patients were significantly larger than that of the group of re-irradiation, leading to a mean deviation of 2.73 mm (SD =1.00) versus 1.90 mm (SD =0.79), P<0.001. In the re-irradiation group, we identified displacements of -0.05 mm (SD =1.53), 0.20 mm (SD =1.46); and 0.42 mm (SD =1.24) in the left-right, superior-inferior and anterior-posterior planes. Overall, we observed increasing deviations over the first 30 min followed by a stabilization related to movements in the three translational axes. Conclusion This is the first study to focus on intrafraction prostate motions in the context of re-irradiation. We observed that intra-fraction prostate motions persisted in the setting of re-irradiation, although they showed a significant reduction when compared with the first irradiation. These results will help to better estimate random errors during SBRT treatment of intra-prostatic recurrence after irradiation.
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Affiliation(s)
- Alexandre Taillez
- Academic Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center, Lille, France.,University of Lille, Lille, France
| | - Andre-Michel Bimbai
- Department of Biostatistics, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Thomas Lacornerie
- Department of Medical Physics, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Marie-Cecile Le Deley
- Department of Biostatistics, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Eric F Lartigau
- Academic Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center, Lille, France.,University of Lille, Lille, France.,CRISTAL UMR CNRS 9189, University of Lille, Lille, France
| | - David Pasquier
- Academic Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center, Lille, France.,University of Lille, Lille, France.,CRISTAL UMR CNRS 9189, University of Lille, Lille, France
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12
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Skouboe S, De Roover R, Gammelmark Muurholm C, Ravkilde T, Crijns W, Hansen R, Depuydt T, Poulsen PR. Six degrees of freedom dynamic motion-including dose reconstruction in a commercial treatment planning system. Med Phys 2021; 48:1427-1435. [PMID: 33415778 DOI: 10.1002/mp.14707] [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: 08/21/2020] [Revised: 11/19/2020] [Accepted: 12/23/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Intrafractional motion during radiotherapy delivery can deteriorate the delivered dose. Dynamic rotational motion of up to 38 degrees has been reported during prostate cancer radiotherapy, but methods to determine the dosimetric consequences of such rotations are lacking. Here, we create and experimentally validate a dose reconstruction method that accounts for dynamic rotations and translations in a commercial treatment planning system (TPS). Interplay effects are quantified by comparing dose reconstructions with dynamic and constant rotations. METHODS The dose reconstruction accumulates the dose in points of interest while the points are moved in six degrees of freedom (6DoF) in a precalculated time-resolved four-dimensional (4D) dose matrix to emulate dynamic motion in a patient. The required 4D dose matrix was generated by splitting the original treatment plan into multiple sub-beams, each representing 0.4 s dose delivery, and recalculating the dose of the split plan in the TPS (Eclipse). The dose accumulation was performed via TPS scripting by querying the dose of each sub-beam in dynamically moving points, allowing dose reconstruction with any dynamic motion. The dose reconstruction was validated with film dosimetry for two prostate dual arc VMAT plans with intra-prostatic lesion boosts. The plans were delivered to a pelvis phantom with internal dynamic rotational motion of a film stack (21 films with 2.5 mm separation). Each plan was delivered without motion and with three prostate motion traces. Motion-including dose reconstruction was performed for each motion experiment using the actual dynamic rotation as well as a constant rotation equal to the mean rotation during the experiment. For each experiment, the 3%/2 mm γ failure rate of the TPS dose reconstruction was calculated with the film measurement being the reference. For each motion experiment, the motion-induced 3%/2 mm γ failure rate was calculated using the static delivery as the reference and compared between film measurements and TPS dose reconstruction. DVH metrics for RT structures fully contained in the film volume were also compared between film and TPS. RESULTS The mean γ failure rate of the TPS dose reconstructions when compared to film doses was 0.8% (two static experiments) and 1.7% (six dynamic experiments). The mean (range) of the motion-induced γ failure rate in film measurements was 35.4% (21.3-59.2%). The TPS dose reconstruction agreed with these experimental γ failure rates with root-mean-square errors of 2.1% (dynamic rotation dose reconstruction) and 17.1% (dose reconstruction assuming constant rotation). By DVH metrics, the mean (range) difference between dose reconstructions with dynamic and constant rotation was 4.3% (-0.3-10.6%) (urethra D 2 % ), -0.6% (-5.6%-2.5%) (urethra D 99 % ), 1.1% (-7.1-7.7%) (GTV D 2 % ), -1.4% (-17.4-7.1%) (GTV D 95 % ), -1.2% (-17.1-5.7%) (GTV D 99 % ), and -0.1% (-3.2-7.6%) (GTV mean dose). Dose reconstructions with dynamic motion revealed large interplay effects (cold and hot spots). CONCLUSIONS A method to perform dose reconstructions for dynamic 6DoF motion in a TPS was developed and experimentally validated. It revealed large differences in dose distribution between dynamic and constant rotations not identifiable through dose reconstructions with constant rotation.
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Affiliation(s)
- Simon Skouboe
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Robin De Roover
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | | | - Thomas Ravkilde
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Wouter Crijns
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Rune Hansen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Tom Depuydt
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Per Rugaard Poulsen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark.,Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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13
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De Roover R, Hansen R, Crijns W, Muurholm CG, Poels K, Skouboe S, Haustermans K, Poulsen PR, Depuydt T. Dosimetric impact of intrafraction prostate rotation and accuracy of gating, multi-leaf collimator tracking and couch tracking to manage rotation: An end-to-end validation using volumetric film measurements. Radiother Oncol 2020; 156:10-18. [PMID: 33264640 DOI: 10.1016/j.radonc.2020.11.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/30/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Both gating and tracking can mitigate the deteriorating dosimetric impact of intrafraction translation during prostate stereotactic body radiotherapy (SBRT). However, their ability to manage intrafraction rotation has not yet been thoroughly investigated. The dosimetric accuracy of gating, MLC tracking and couch tracking to manage intrafraction prostate rotation was investigated. MATERIALS AND METHODS Treatment plans for end-to-end tests of prostate SBRT with focal boosting were generated for a dynamic anthropomorphic pelvis phantom. The phantom applied internal lateral rotation (up to 25°) and coupled vertical and longitudinal translation of a radiochromic film stack that was used for dose measurements. Dose was delivered for each plan while the phantom applied motion according to three typical prostate motion traces without compensation (i), with gating (ii), with MLC tracking (iii) or with couch tracking (iv). Measured doses for the four motion compensation strategies were compared with the planned dose in terms of γ-index analysis, target coverage and organs at risk (OAR) sparing. RESULTS Intrafraction rotation reduced the 3%(global)/2mm γ-index passing rate (γPR) for the prostate target volume by median (range) -33.2% (-68.6%, -4.1%) when no motion compensation was applied. The use of motion compensation improved the γPR by 13.2% (-0.4%, 32.9%) for gating, by 6.0% (-0.8%, 27.7%) for MLC tracking and by 11.1% (1.2%, 22.9%) for couch tracking. The three compensation techniques improved the target coverage in most cases. Gating showed better OAR sparing than MLC tracking or couch tracking. CONCLUSIONS Compensation of intrafraction prostate rotation with gating, MLC tracking and couch tracking was investigated experimentally for the first time. All three techniques improved the dosimetric accuracy, but residual motion-related dose errors remained due to the lack of rotation correction.
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Affiliation(s)
- Robin De Roover
- Department of Oncology, KU Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Belgium.
| | - Rune Hansen
- Department of Medical Physics, Aarhus University Hospital, Denmark.
| | - Wouter Crijns
- Department of Oncology, KU Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Belgium.
| | | | - Kenneth Poels
- Department of Oncology, KU Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Belgium.
| | - Simon Skouboe
- Department of Oncology, Aarhus University Hospital, Denmark.
| | - Karin Haustermans
- Department of Oncology, KU Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Belgium.
| | - Per Rugaard Poulsen
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus University Hospital, Denmark.
| | - Tom Depuydt
- Department of Oncology, KU Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Belgium.
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14
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Shi K, Dipuglia A, Booth J, Alnaghy S, Kyme A, Keall P, Nguyen DT. Experimental evaluation of the dosimetric impact of intrafraction prostate rotation using film measurement with a 6DoF robotic arm. Med Phys 2020; 47:6068-6076. [PMID: 32997820 DOI: 10.1002/mp.14502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/02/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Tumor motion during radiotherapy can cause a reduction in target dose coverage and an increase in healthy tissue exposure. Tumor motion is not strictly translational and often exhibits complex six degree-of-freedom (6DoF) translational and rotational motion. Although the dosimetric impact of prostate tumor translational motion is well investigated, the dosimetric impact of 6DoF motion has only been studied with simulations or dose reconstruction. This study aims to experimentally quantify the dose error caused by 6DoF motion. The experiment was designed to test the hypothesis that 6DoF motion would cause larger dose errors than translational motion alone through gamma analyses of two-dimensional film measurements. METHODS Four patient-measured intrafraction prostate motion traces and four VMAT 7.25 Gy/Fx SBRT treatment plans were selected for the experiment. The traces represented typical motion patterns, including small-angle rotations (<4°), transient movement, persistent excursion, and erratic rotations (>6°). Gafchromic film was placed inside a custom-designed phantom, held by a high-precision 6DoF robotic arm for dose measurements in the coronal plane during treatment delivery. For each combination of the motion trace and treatment plan, two film measurements were made, one with 6DoF motion and the other with the three-dimensional (3D) translation components of the same trace. A gamma pass rate criteria of 2% relative dose/2 mm distance-to-agreement was used in this study and evaluated for each measurement with respect to the static reference film. Two test thresholds, 90% and 50% of the reference dose, were applied to investigate the difference in dose coverage for the PTV region and surrounding areas, respectively. The hypothesis was tested using a Wilcoxon signed-rank test. RESULTS For each of the 16 plan and motion trace pairs, a reduction in the gamma pass rate was observed for 6DoF motion compared with 3D translational motion. With 90% gamma-test threshold, the reduction was 5.8% ± 7.1% (P < 0.01). With 50% gamma-test threshold, the reduction was 4.1% ± 4.8% (P < 0.01). CONCLUSION For the first time, the dosimetric impact of intrafraction prostate rotation during SBRT treatment was measured experimentally. The experimental results support the hypothesis that 6DoF tumor motion causes higher dose error than translation motion alone.
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Affiliation(s)
- Kehuan Shi
- ACRF Image-X Institute, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew Dipuglia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia.,School of Physics, The University of Sydney, Sydney, NSW, Australia
| | - Saree Alnaghy
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Andre Kyme
- School of Biomedical Engineering, University of Sydney, Sydney, NSW, Australia
| | - Paul Keall
- ACRF Image-X Institute, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Doan Trang Nguyen
- ACRF Image-X Institute, Central Clinical School, University of Sydney, Sydney, NSW, Australia.,School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
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15
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Hewson EA, Nguyen DT, O'Brien R, Poulsen PR, Booth JT, Greer P, Eade T, Kneebone A, Hruby G, Moodie T, Hayden AJ, Turner SL, Hardcastle N, Siva S, Tai KH, Martin J, Keall PJ. Is multileaf collimator tracking or gating a better intrafraction motion adaptation strategy? An analysis of the TROG 15.01 stereotactic prostate ablative radiotherapy with KIM (SPARK) trial. Radiother Oncol 2020; 151:234-241. [DOI: 10.1016/j.radonc.2020.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/17/2020] [Accepted: 08/16/2020] [Indexed: 12/30/2022]
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Gao Y, Zhao B, Gao X, Qi X, Liu S, Li Y, Jia C. Quantifying intra-fractional prostate motion trajectory for establishing a new gating strategy: a preliminary study. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2020. [DOI: 10.1080/16878507.2020.1785113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Yan Gao
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
| | - Bo Zhao
- Department of Engineering Physics, Tsinghua University, Beijing, China
- Key Laboratory of Particle & Radiation Imaging, Ministry of Education (Tsinghua University), Beijing, China
| | - Xianshu Gao
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
| | - Xin Qi
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
| | - Siwei Liu
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
| | - Yue Li
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
| | - Chenghao Jia
- Department of Radiation Oncology, Peking University First Hospital, Peking University, Beijing, China
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17
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Shiinoki T, Fujii F, Yuasa Y, Nonomura T, Fujimoto K, Sera T, Tanaka H. Analysis of dosimetric impact of intrafraction translation and rotation during respiratory‐gated stereotactic body radiotherapy with real‐time tumor monitoring of the lung using a novel six degrees‐of‐freedom robotic moving phantom. Med Phys 2020; 47:3870-3881. [DOI: 10.1002/mp.14369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/02/2020] [Accepted: 06/23/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Takehiro Shiinoki
- Department of Radiation Oncology Graduate School of Medicine Yamaguchi University 1‐1‐1 Minamikogushi Ube Yamaguchi755‐8505Japan
| | - Fumitake Fujii
- Department of Mechanical Engineering Graduate School of Science and Technology for Innovation Yamaguchi University 2‐16‐1 Tokiwadai Ube Yamaguchi755‐8611Japan
| | - Yuki Yuasa
- Department of Radiation Oncology Graduate School of Medicine Yamaguchi University 1‐1‐1 Minamikogushi Ube Yamaguchi755‐8505Japan
| | - Tatsuki Nonomura
- Department of Mechanical Engineering Graduate School of Science and Technology for Innovation Yamaguchi University 2‐16‐1 Tokiwadai Ube Yamaguchi755‐8611Japan
| | - Koya Fujimoto
- Department of Radiation Oncology Graduate School of Medicine Yamaguchi University 1‐1‐1 Minamikogushi Ube Yamaguchi755‐8505Japan
| | - Tatsuhiro Sera
- Department of Radiological Technology Yamaguchi University Hospital 1‐1‐1 Minamikogushi Ube Yamaguchi755‐8505Japan
| | - Hidekazu Tanaka
- Department of Radiation Oncology Graduate School of Medicine Yamaguchi University 1‐1‐1 Minamikogushi Ube Yamaguchi755‐8505Japan
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18
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Vanhanen A, Poulsen P, Kapanen M. Dosimetric effect of intrafraction motion and different localization strategies in prostate SBRT. Phys Med 2020; 75:58-68. [PMID: 32540647 DOI: 10.1016/j.ejmp.2020.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/04/2020] [Accepted: 06/06/2020] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to evaluate the dosimetric effect of continuous motion monitoring based localization (Calypso, Varian Medical Systems), gating and intrafraction motion correction in prostate SBRT. Delivered doses were modelled by reconstructing motion inclusive dose distributions for different localization strategies. Actually delivered dose (strategy A) utilized initial Calypso localization, CBCT and additional pre-treatment motion correction by kV-imaging and Calypso, and gating during the irradiation. The effect of gating was investigated by simulating non-gated treatments (strategy B). Additionally, non-gated and single image-guided (CBCT) localization was simulated (strategy C). A total of 308 fractions from 22 patients were reconstructed. The dosimetric effect was evaluated by comparing motion inclusive target and risk organ dose-volume parameters to planned values. Motion induced dose deficits were seen mainly in PTV and CTV to PTV margin regions, whereas CTV dose deficits were small in all strategies: mean ± SD difference in CTVD99% was -0.3 ± 0.4%, -0.4 ± 0.6% and -0.7 ± 1.2% in strategies A, B and C, respectively. Largest dose deficits were seen in individual fractions for strategy C (maximum dose reductions were -29.0% and -7.1% for PTVD95% and CTVD99%, respectively). The benefit of gating was minor, if additional motion correction was applied immediately prior to irradiation. Continuous motion monitoring based localization and motion correction ensured the target coverage and minimized the OAR exposure for every fraction and is recommended to use in prostate SBRT. The study is part of clinical trial NCT02319239.
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Affiliation(s)
- A Vanhanen
- Department of Oncology, Unit of Radiotherapy, Tampere University Hospital, POB-2000, 33521 Tampere, Finland; Department of Medical Physics, Medical Imaging Center, Tampere University Hospital, POB-2000, 33521 Tampere, Finland.
| | - P Poulsen
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 25, Entrance B3, 8200 Aarhus N, Denmark
| | - M Kapanen
- Department of Oncology, Unit of Radiotherapy, Tampere University Hospital, POB-2000, 33521 Tampere, Finland; Department of Medical Physics, Medical Imaging Center, Tampere University Hospital, POB-2000, 33521 Tampere, Finland
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Levin-Epstein R, Qiao-Guan G, Juarez JE, Shen Z, Steinberg ML, Ruan D, Valle L, Nickols NG, Kupelian PA, King CR, Cao M, Kishan AU. Clinical Assessment of Prostate Displacement and Planning Target Volume Margins for Stereotactic Body Radiotherapy of Prostate Cancer. Front Oncol 2020; 10:539. [PMID: 32373529 PMCID: PMC7177009 DOI: 10.3389/fonc.2020.00539] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/25/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose: To assess the optimal planning target volume (PTV) margins for stereotactic body radiotherapy (SBRT) of prostate cancer based on inter- and intra-fractional prostate motion determined from daily image guidance. Methods and Materials: Two hundred and five patients who were enrolled on two prospective studies of SBRT (8 Gy × 5 fractions) for localized prostate cancer treated at a single institution between 2012 and 2017 had complete inter- and intra-fractional shift data available. All patients had scheduled kilovoltage planar imaging during SBRT with rigid registration to intraprostatic fiducials prior to each of four half-arcs delivered per fraction, as well as cone beam CT verification of anatomy prior to each fraction. Inter- and intra- fractional shift data were obtained to estimate the required PTV margins based on the classic van Herk formula. Inter- and intra-fractional motion were compared between patients with and without severe toxicities using the independent two-sample Wilcoxon test. Results: The margins required to account for inter-fractional motion were estimated to be 0.99, 1.52, and 1.45 cm in lateral (LR), longitudinal (SI), and vertical (AP) directions, respectively. The margins required to account for intra-fractional motion were estimated to be 0.19, 0.27, and 0.31 cm in LR, SI and AP directions, respectively. Large intra-fractional shifts were mostly observed in the SI and AP directions, with 2.0 and 5.4% of patients experiencing average intra-fractional motion >3 mm in the SI and AP directions, respectively, compared with none experiencing mean shifts >3 mm in the LR direction. Six patients experienced grade 3 gastrointestinal or genitourinary toxicity. There were no significant differences in mean inter- or intra-fractional motion in any of the cardinal directions compared to patients without severe toxicity (inter-fractional p = 0.46-0.99, intra-fractional p = 0.10-0.84). Conclusion: The inter- and intra-fractional margins estimated from this study are in line with prior reported values. Intra-fractional prostate motion was generally small with larger margins required for the SI and AP directions, notably just slightly exceeding the commonly used 3 mm posterior PTV margin even with realignment between half-arcs. Development of severe toxicity was not significantly associated with the degree of inter- or intra-fractional motion.
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Affiliation(s)
- Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - George Qiao-Guan
- Case Western Reserve School of Medicine, Cleveland, OH, United States
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Zhouhuizi Shen
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dan Ruan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Radiation Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Patrick A. Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Christopher R. King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
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Keall P, Nguyen DT, O'Brien R, Hewson E, Ball H, Poulsen P, Booth J, Greer P, Hunter P, Wilton L, Bromley R, Kipritidis J, Eade T, Kneebone A, Hruby G, Moodie T, Hayden A, Turner S, Arumugam S, Sidhom M, Hardcastle N, Siva S, Tai KH, Gebski V, Martin J. Real-Time Image Guided Ablative Prostate Cancer Radiation Therapy: Results From the TROG 15.01 SPARK Trial. Int J Radiat Oncol Biol Phys 2020; 107:530-538. [PMID: 32234553 DOI: 10.1016/j.ijrobp.2020.03.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE Kilovoltage intrafraction monitoring (KIM) is a novel software platform implemented on standard radiation therapy systems and enabling real-time image guided radiation therapy (IGRT). In a multi-institutional prospective trial, we investigated whether real-time IGRT improved the accuracy of the dose patients with prostate cancer received during radiation therapy. METHODS AND MATERIALS Forty-eight patients with prostate cancer were treated with KIM-guided SABR with 36.25 Gy in 5 fractions. During KIM-guided treatment, the prostate motion was corrected for by either beam gating with couch shifts or multileaf collimator tracking. A dose reconstruction method was used to evaluate the dose delivered to the target and organs at risk with and without real-time IGRT. Primary outcome was the effect of real-time IGRT on dose distributions. Secondary outcomes included patient-reported outcomes and toxicity. RESULTS Motion correction occurred in ≥1 treatment for 88% of patients (42 of 48) and 51% of treatments (121 of 235). With real-time IGRT, no treatments had prostate clinical target volume (CTV) D98% dose 5% less than planned. Without real-time IGRT, 13 treatments (5.5%) had prostate CTV D98% doses 5% less than planned. The prostate CTV D98% dose with real-time IGRT was closer to the plan by an average of 1.0% (range, -2.8% to 20.3%). Patient outcomes showed no change in the 12-month patient-reported outcomes compared with baseline and no grade ≥3 genitourinary or gastrointestinal toxicities. CONCLUSIONS Real-time IGRT is clinically effective for prostate cancer SABR.
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Affiliation(s)
- Paul Keall
- ACRF Image X Institute, University of Sydney, Sydney, Australia.
| | - Doan Trang Nguyen
- ACRF Image X Institute, University of Sydney, Sydney, Australia; School of Biomedical Engineering, University of Technology, Sydney, Sydney, Australia
| | - Ricky O'Brien
- ACRF Image X Institute, University of Sydney, Sydney, Australia
| | - Emily Hewson
- ACRF Image X Institute, University of Sydney, Sydney, Australia
| | - Helen Ball
- ACRF Image X Institute, University of Sydney, Sydney, Australia
| | - Per Poulsen
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; School of Physics, University of Sydney, Sydney, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia; University of Newcastle, Newcastle, Australia
| | - Perry Hunter
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Lee Wilton
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Regina Bromley
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia
| | - John Kipritidis
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia
| | - Thomas Eade
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, University of Sydney, Sydney, Australia
| | - Andrew Kneebone
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, University of Sydney, Sydney, Australia
| | - George Hruby
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, University of Sydney, Sydney, Australia
| | - Trevor Moodie
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Amy Hayden
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Sandra Turner
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Liverpool Hospital, Sydney, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centres, Liverpool Hospital, Sydney, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia; Institute of Medical Physics, University of Sydney, Sydney, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Australia
| | - Keen-Hun Tai
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Australia
| | - Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia; University of Newcastle, Newcastle, Australia
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21
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The accuracy and precision of the KIM motion monitoring system used in the multi‐institutional TROG 15.01 Stereotactic Prostate Ablative Radiotherapy with KIM (SPARK) trial. Med Phys 2019; 46:4725-4737. [DOI: 10.1002/mp.13784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/07/2019] [Accepted: 08/16/2019] [Indexed: 01/19/2023] Open
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Martin J, Keall P, Siva S, Greer P, Christie D, Moore K, Dowling J, Pryor D, Chong P, McLeod N, Raman A, Lynam J, Smart J, Oldmeadow C, Tang CI, Murphy DG, Millar J, Tai KH, Holloway L, Reeves P, Hayden A, Lim T, Holt T, Sidhom M. TROG 18.01 phase III randomised clinical trial of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation: NINJA study protocol. BMJ Open 2019; 9:e030731. [PMID: 31434782 PMCID: PMC6707760 DOI: 10.1136/bmjopen-2019-030731] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Stereotactic body radiotherapy (SBRT) is a non-invasive alternative to surgery for the treatment of non-metastatic prostate cancer (PC). The objectives of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation (NINJA) clinical trial are to compare two emerging SBRT regimens for efficacy with technical substudies focussing on MRI only planning and the use of knowledge-based planning (KBP) to assess radiotherapy plan quality. METHODS AND ANALYSIS Eligible patients must have biopsy-proven unfavourable intermediate or favourable high-risk PC, have an Eastern Collaborative Oncology Group (ECOG) performance status 0-1 and provide written informed consent. All patients will receive 6 months in total of androgen deprivation therapy. Patients will be randomised to one of two SBRT regimens. The first will be 40 Gy in five fractions given on alternating days (SBRT monotherapy). The second will be 20 Gy in two fractions given 1 week apart followed 2 weeks later by 36 Gy in 12 fractions given five times per week (virtual high-dose rate boost (HDRB)). The primary efficacy outcome will be biochemical clinical control at 5 years. Secondary endpoints for the initial portion of NINJA look at the transition of centres towards MRI only planning and the impact of KBP on real-time (RT) plan assessment. The first 150 men will demonstrate accrual feasibility as well as addressing the KBP and MRI planning aims, prior to proceeding with total accrual to 472 patients as a phase III randomised controlled trial. ETHICS AND DISSEMINATION NINJA is a multicentre cooperative clinical trial comparing two SBRT regimens for men with PC. It builds on promising results from several single-armed studies, and explores radiation dose escalation in the Virtual HDRB arm. The initial component includes novel technical elements, and will form an important platform set for a definitive phase III study. TRIAL REGISTRATION NUMBER ANZCTN 12615000223538.
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Affiliation(s)
- Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Paul Keall
- Radiation Physics Laboratory, University of Sydney, Sydney, New South Wales, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Kevin Moore
- Department of Medical Physics, University of California San Diego, La Jolla, California, USA
| | - Jason Dowling
- The Australian e-Health Research Centre, CSIRO, Canberra, Australian Capital Territory, Australia
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital Health Service District, Woolloongabba, Queensland, Australia
| | - Peter Chong
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Nicholas McLeod
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Avi Raman
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - James Lynam
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Joanne Smart
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Colin I Tang
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Declan G Murphy
- Urological Service Team, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Department of Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Keen Hun Tai
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Lois Holloway
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Penny Reeves
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Health Research Economics, University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Amy Hayden
- Department of Radiation Oncology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tee Lim
- Genesis Care, Perth, Western Australia, Australia
| | - Tanya Holt
- Radiation Oncology Princess Alexandra Raymond Terrace, Brisbane, Queensland, Australia
| | - Mark Sidhom
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
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