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Jiang J, Hong J, Tringale K, Reyngold M, Crane C, Tyagi N, Veeraraghavan H. Progressively refined deep joint registration segmentation (ProRSeg) of gastrointestinal organs at risk: Application to MRI and cone-beam CT. Med Phys 2023; 50:4758-4774. [PMID: 37265185 PMCID: PMC11009869 DOI: 10.1002/mp.16527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/27/2023] [Accepted: 05/08/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Adaptive radiation treatment (ART) for locally advanced pancreatic cancer (LAPC) requires consistently accurate segmentation of the extremely mobile gastrointestinal (GI) organs at risk (OAR) including the stomach, duodenum, large and small bowel. Also, due to lack of sufficiently accurate and fast deformable image registration (DIR), accumulated dose to the GI OARs is currently only approximated, further limiting the ability to more precisely adapt treatments. PURPOSE Develop a 3-D Progressively refined joint Registration-Segmentation (ProRSeg) deep network to deformably align and segment treatment fraction magnetic resonance images (MRI)s, then evaluate segmentation accuracy, registration consistency, and feasibility for OAR dose accumulation. METHOD ProRSeg was trained using five-fold cross-validation with 110 T2-weighted MRI acquired at five treatment fractions from 10 different patients, taking care that same patient scans were not placed in training and testing folds. Segmentation accuracy was measured using Dice similarity coefficient (DSC) and Hausdorff distance at 95th percentile (HD95). Registration consistency was measured using coefficient of variation (CV) in displacement of OARs. Statistical comparison to other deep learning and iterative registration methods were done using the Kruskal-Wallis test, followed by pair-wise comparisons with Bonferroni correction applied for multiple testing. Ablation tests and accuracy comparisons against multiple methods were done. Finally, applicability of ProRSeg to segment cone-beam CT (CBCT) scans was evaluated on a publicly available dataset of 80 scans using five-fold cross-validation. RESULTS ProRSeg processed 3D volumes (128 × 192 × 128) in 3 s on a NVIDIA Tesla V100 GPU. It's segmentations were significantly more accurate (p < 0.001 $p<0.001$ ) than compared methods, achieving a DSC of 0.94 ±0.02 for liver, 0.88±0.04 for large bowel, 0.78±0.03 for small bowel and 0.82±0.04 for stomach-duodenum from MRI. ProRSeg achieved a DSC of 0.72±0.01 for small bowel and 0.76±0.03 for stomach-duodenum from public CBCT dataset. ProRSeg registrations resulted in the lowest CV in displacement (stomach-duodenumC V x $CV_{x}$ : 0.75%,C V y $CV_{y}$ : 0.73%, andC V z $CV_{z}$ : 0.81%; small bowelC V x $CV_{x}$ : 0.80%,C V y $CV_{y}$ : 0.80%, andC V z $CV_{z}$ : 0.68%; large bowelC V x $CV_{x}$ : 0.71%,C V y $CV_{y}$ : 0.81%, andC V z $CV_{z}$ : 0.75%). ProRSeg based dose accumulation accounting for intra-fraction (pre-treatment to post-treatment MRI scan) and inter-fraction motion showed that the organ dose constraints were violated in four patients for stomach-duodenum and for three patients for small bowel. Study limitations include lack of independent testing and ground truth phantom datasets to measure dose accumulation accuracy. CONCLUSIONS ProRSeg produced more accurate and consistent GI OARs segmentation and DIR of MRI and CBCTs compared to multiple methods. Preliminary results indicates feasibility for OAR dose accumulation using ProRSeg.
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Affiliation(s)
- Jue Jiang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jun Hong
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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McDonald BA, Zachiu C, Christodouleas J, Naser MA, Ruschin M, Sonke JJ, Thorwarth D, Létourneau D, Tyagi N, Tadic T, Yang J, Li XA, Bernchou U, Hyer DE, Snyder JE, Bubula-Rehm E, Fuller CD, Brock KK. Dose accumulation for MR-guided adaptive radiotherapy: From practical considerations to state-of-the-art clinical implementation. Front Oncol 2023; 12:1086258. [PMID: 36776378 PMCID: PMC9909539 DOI: 10.3389/fonc.2022.1086258] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/27/2023] Open
Abstract
MRI-linear accelerator (MR-linac) devices have been introduced into clinical practice in recent years and have enabled MR-guided adaptive radiation therapy (MRgART). However, by accounting for anatomical changes throughout radiation therapy (RT) and delivering different treatment plans at each fraction, adaptive radiation therapy (ART) highlights several challenges in terms of calculating the total delivered dose. Dose accumulation strategies-which typically involve deformable image registration between planning images, deformable dose mapping, and voxel-wise dose summation-can be employed for ART to estimate the delivered dose. In MRgART, plan adaptation on MRI instead of CT necessitates additional considerations in the dose accumulation process because MRI pixel values do not contain the quantitative information used for dose calculation. In this review, we discuss considerations for dose accumulation specific to MRgART and in relation to current MR-linac clinical workflows. We present a general dose accumulation framework for MRgART and discuss relevant quality assurance criteria. Finally, we highlight the clinical importance of dose accumulation in the ART era as well as the possible ways in which dose accumulation can transform clinical practice and improve our ability to deliver personalized RT.
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Affiliation(s)
- Brigid A. McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cornel Zachiu
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Mohamed A. Naser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tuebingen, Tuebingen, Germany
| | - Daniel Létourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Daniel E. Hyer
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Jeffrey E. Snyder
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | | | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kristy K. Brock
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Driever T, Hulshof MCCM, Bel A, Sonke JJ, van der Horst A. Quantifying intrafractional gastric motion using auto-segmentation on MRI: Deformation and respiratory-induced displacement compared. J Appl Clin Med Phys 2022; 24:e13864. [PMID: 36565168 PMCID: PMC10113698 DOI: 10.1002/acm2.13864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE For accurate pre-operative gastric radiotherapy, intrafractional changes must be taken into account. The aim of this study is to quantify local gastric deformations and compare these deformations with respiratory-induced displacement. MATERIALS AND METHODS Coronal 2D MRI scans (15-16 min; 120 repetitions of 25-27 interleaved slices) were obtained for 18 healthy volunteers. A deep-learning network was used to auto-segment the stomach. To separate out respiratory-induced displacements, auto-segmentations were rigidly shifted in superior-inferior (SI) direction to align the centre of mass (CoM) within every slice. From these shifted auto-segmentations, 3D iso-probability surfaces (isosurfaces) were established: a reference surface for POcc = 0.50 and 50 other isosurfaces (from POcc = 0.01 to 0.99), with POcc indicating the probability of occupation by the stomach. For each point on the reference surface, distances to all isosurfaces were determined and a cumulative Gaussian was fitted to this probability-distance dataset to obtain a standard deviation (SDdeform ) expressing local deformation. For each volunteer, we determined median and 98th percentile of SDdeform over the reference surface and compared these with the respiratory-induced displacement SDresp , that is, the SD of all CoM shifts (paired Wilcoxon signed-rank, α = 0.05). RESULTS Larger deformations were mostly seen in the antrum and pyloric region. Median SDdeform (range, 2.0-2.9 mm) was smaller than SDresp (2.7-8.8 mm) for each volunteer (p < 0.00001); 98th percentile of SDdeform (3.2-7.3 mm) did not significantly differ from SDresp (p = 0.13). CONCLUSION Locally, gastric deformations can be large. Overall, however, these deformations are limited compared to respiratory-induced displacement. Therefore, unless respiratory motion is considerably reduced, the need to separately include these deformation uncertainties in the treatment margins may be limited.
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Affiliation(s)
- Theo Driever
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Teuwen J, Gouw ZA, Sonke JJ. Artificial Intelligence for Image Registration in Radiation Oncology. Semin Radiat Oncol 2022; 32:330-342. [DOI: 10.1016/j.semradonc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Keijnemans K, Borman PTS, Uijtewaal P, Woodhead PL, Raaymakers BW, Fast MF. A hybrid 2D/4D-MRI methodology using simultaneous multislice imaging for radiotherapy guidance. Med Phys 2022; 49:6068-6081. [PMID: 35694905 PMCID: PMC9545880 DOI: 10.1002/mp.15802] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/18/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Respiratory motion management is important in abdominothoracic radiotherapy. Fast imaging of the tumor can facilitate multileaf collimator (MLC) tracking that allows for smaller treatment margins, while repeatedly imaging the full field‐of‐view is necessary for 4D dose accumulation. This study introduces a hybrid 2D/4D‐MRI methodology that can be used for simultaneous MLC tracking and dose accumulation on a 1.5 T Unity MR‐linac (Elekta AB, Stockholm, Sweden). Methods We developed a hybrid 2D/4D‐MRI methodology that uses a simultaneous multislice (SMS) accelerated MRI sequence, which acquires two coronal slices simultaneously and repeatedly cycles through slice positions over the image volume. As a result, the fast 2D imaging can be used prospectively for MLC tracking and the SMS slices can be sorted retrospectively into respiratory‐correlated 4D‐MRIs for dose accumulation. Data were acquired in five healthy volunteers with an SMS‐bTFE and SMS‐TSE MRI sequence. For each sequence, a prebeam dataset and a beam‐on dataset were acquired simulating the two phases of MR‐linac treatments. Prebeam data were used to generate a 4D‐based motion model and a reference mid‐position volume, while beam‐on data were used for real‐time motion extraction and reconstruction of beam‐on 4D‐MRIs. In addition, an in‐silico computational phantom was used for validation of the hybrid 2D/4D‐MRI methodology. MLC tracking experiments were performed with the developed methodology, for which real‐time SMS data reconstruction was enabled on the scanner. A 15‐beam 8× 7.5 Gy intensity‐modulated radiotherapy plan for lung stereotactic body radiotherapy with isotropic 3 mm GTV‐to‐PTV margins was created. Dosimetry experiments were performed using a 4D motion phantom. The latency between target motion and updating the radiation beam was determined and compensated. Local gamma analyses were performed to quantify dose differences compared to a static reference delivery, and dose area histograms (DAHs) were used to quantify the GTV and PTV coverage. Results In‐vivo data acquisition and MLC tracking experiments were successfully performed with the developed hybrid 2D/4D‐MRI methodology. Real‐time liver–lung interface motion estimation had a Pearson's correlation of 0.996 (in‐vivo) and 0.998 (in‐silico). A median (5th–95th percentile) error of 0.0 (−0.9 to 0.7) mm and 0.0 (−0.2 to 0.2) mm was found for real‐time motion estimation for in‐vivo and in‐silico, respectively. Target motion prediction beyond the liver–lung interface had a median root mean square error of 1.6 mm (in‐vivo) and 0.5 mm (in‐silico). Beam‐on 4D MRI reconstruction required a median amount of data equal to an acquisition time of 2:21–3:17 min, which was 20% less data compared to the prebeam‐derived 4D‐MRI. System latency was reduced from 501 ± 12 ms to −1 ± 3 ms (SMS‐TSE) and from 398 ± 10 ms to −10 ± 4 ms (SMS‐bTFE) by a linear regression prediction filter. The local gamma analysis agreed within −3.8% to 3.3% (SMS‐bTFE) and −5.3% to 10% (SMS‐TSE) with a reference MRI sequence. The DAHs revealed a relative D98% GTV coverage between 97% and 100% (SMS‐bTFE) and 100% and 101% (SMS‐TSE) compared to the static reference. Conclusions The presented 2D/4D‐MRI methodology demonstrated the potential for accurately extracting real‐time motion for MLC tracking in abdominothoracic radiotherapy, while simultaneously reconstructing contiguous respiratory‐correlated 4D‐MRIs for dose accumulation.
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Affiliation(s)
- Katrinus Keijnemans
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Pim T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Prescilla Uijtewaal
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Peter L Woodhead
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.,Elekta AB, kungstensgatan 18, 113 57 Stockholm, Sweden
| | - Bas W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Janssen TM, Aitken K, Alongi F, Barry A, Bernchou U, Boeke S, Hall WA, Hosni A, Kroon P, Nachbar M, Saeed H, Jürgenliemk-Schulz IM, Schytte T, Verkooijen HM, Nowee M. First multicentre experience of SABR for lymph node and liver oligometastatic disease on the unity MR-Linac. Tech Innov Patient Support Radiat Oncol 2022; 22:50-54. [PMID: 35586786 PMCID: PMC9108982 DOI: 10.1016/j.tipsro.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/21/2022] [Indexed: 10/31/2022] Open
Abstract
Since August 2018 patients are treated on a 1.5 Tesla MR-Linac (MRL) for oligometastatic disease. We present current workflows and practice standards from seven institutions for the initial patients treated for lymph node and liver metastases. In this work a large variation in treatment strategies was found. Since currently there is little evidence preferring one strategy over the other, clinical registries and future research need to focus on the clinical relevance of the variations in institutional treatment strategies.
The treatment of oligometastatic disease using MR guidance is an evolving field. Since August 2018 patients are treated on a 1.5 Tesla MR-Linac (MRL). We present current workflows and practice standards from seven institutions for the initial patients treated for lymph node and liver metastases.
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Ligtenberg H, Hackett SL, Merckel LG, Snoeren L, Kontaxis C, Zachiu C, Bol GH, Verhoeff J, Fast MF. Towards mid-position based Stereotactic Body Radiation Therapy on the MR-linac for central lung tumours. Phys Imaging Radiat Oncol 2022; 23:24-31. [PMID: 35923896 PMCID: PMC9341269 DOI: 10.1016/j.phro.2022.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background and purpose: Central lung tumours can be treated by magnetic resonance (MR)-guided radiotherapy. Complications might be reduced by decreasing the Planning Target Volume (PTV) using mid-position (midP)-based planning instead of Internal Target Volume (ITV)-based planning. In this study, we aimed to verify a method to automatically derive patient-specific PTV margins for midP-based planning, and show dosimetric robustness of midP-based planning for a 1.5T MR-linac. Materials and methods: Central(n = 12) and peripheral(n = 4) central lung tumour cases who received 8x7.5 Gy were included. A midP-image was reconstructed from ten phases of the 4D-Computed Tomography using deformable image registration. The Gross Tumor Volume (GTV) was delineated on the midP-image and the PTV margin was automatically calculated based on van Herk’s margin recipe, treating the standard deviation of all Deformation Vector Fields, within the GTV, as random error component. Dosimetric robustness of midP-based planning for MR-linac using automatically derived margins was verified by 4D dose-accumulation. MidP-based plans were compared to ITV-based plans. Automatically derived margins were verified with manually derived margins. Results: The mean D95% target coverage in GTV + 2 mm was 59.9 Gy and 62.0 Gy for midP- and ITV-based central lung plans, respectively. The mean lung dose was significantly lower for midP-based treatment plans (difference:-0.3 Gy; p<0.042). Automatically derived margins agreed within one millimeter with manually derived margins. Conclusions: This retrospective study indicates that mid-position-based treatment plans for central lung Stereotactic Body Radiation Therapy yield lower OAR doses compared to ITV-based treatment plans on the MR-linac. Patient-specific GTV-to-PTV margins can be derived automatically and result in clinically acceptable target coverage.
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Technical feasibility and clinical evaluation of 4D-MRI guided liver SBRT on the MR-linac. Radiother Oncol 2022; 167:285-291. [PMID: 35033603 DOI: 10.1016/j.radonc.2022.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/15/2021] [Accepted: 01/04/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Image-guided stereotactic body radiation therapy (SBRT) is an important local treatment for liver metastases. MRI-guidance enables direct tumor visualization, eliminating fiducial marker implantation. The purpose of this study was to test technical feasibility of our 4D-MRI guided liver SBRT workflow. Additionally, intra-fraction target motion and consequent target-coverage were studied. MATERIALS&METHODS Patients with liver metastases were included in this sub-study of the prospective UMBRELLA clinical trial. Patients received mid-position (midP) SBRT. The daily adapt-to-position workflow included localization, verification and intra-fraction tumor midP monitoring using 4D-MRI. Technical feasibility was established based on persistence of the treatment protocol, treatment time ≤1 hour, no geographical miss and no unexpected acute toxicity grade >3. All 4D-MRIs were registered to the planning midP-CT and tumor midP and amplitude were calculated. Additionally, delivered target dose was accumulated incorporating the 4D-MRI intra-fraction tumor motion and evaluated with Monte-Carlo error simulations. RESULTS 20 patients with liver metastases were included and treated with 4D-MRI guided SBRT. Feasibility criteria were met in all-but-one patient. No grade ≥3 acute toxicity was observed. Group mean (M), systematic and random midP-drifts were 2.4mm, 2.6mm and 3.1mm in CC-direction. 4D-MRI tumor CC-amplitudes were reduced compared to the simulation 4D-CT (M=-1.9mm) and decreased during treatment (M=-1.4mm). Dose accumulation showed adquate target-coverage on a population level. CONCLUSION We successfully demonstrated technical feasibility of 4D-MRI guided SBRT in a cohort of 20 patients with liver metastases. However, substantial midposition drifts occurred which stress the need for intra-fraction motion management strategies to further increase the precision of treatment delivery.
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Chen Y, Gong G, Wang Y, Liu C, Su Y, Wang L, Yang B, Yin Y. Comparative Evaluation of 4-Dimensional Computed Tomography and 4-Dimensional Magnetic Resonance Imaging to Delineate the Target of Primary Liver Cancer. Technol Cancer Res Treat 2021; 20:15330338211045499. [PMID: 34617855 PMCID: PMC8504652 DOI: 10.1177/15330338211045499] [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] [Indexed: 12/24/2022] Open
Abstract
Purpose: To evaluate the feasibility of 4-dimensional magnetic resonance imaging (4DMRI) in establishing the target of primary liver cancer in comparison with 4-dimensional computed tomography (4DCT). Methods and Materials: A total of 23 patients with primary liver cancer who received radiotherapy were selected, and 4DCT and T2w-4DMRI simulations were conducted to obtain 4DCT and T2w-4DMRI simulation images. The 4DCT and T2w-4DMRI data were sorted into 10 and 8 respiratory phase bins, respectively. The liver and gross tumor volumes (GTVs) were delineated in all images using programmed clinical workflows under tumor delineation guidelines. The internal organs at risk volumes (IRVs) and internal target volumes (ITVs) were the unions of all the phase livers and GTVs, respectively. Then, the artifacts, liver volume, GTV, and motion range in 4DCT and T2w-4DMRI were compared. Results: The mean GTV volume based on 4DMRI was 136.42 ± 231.27 cm3, which was 25.04 cm3 (15.5%) less than that of 4DCT (161.46 ± 280.29 cm3). The average volume of ITV determined by 4DMRI was 166.12 ± 270.43 cm3, which was 22.44 cm3 (11.9%) less than that determined by 4DCT (188.56 ± 307.57 cm3). Liver volume and IRV in 4DMRI increased by 4.0% and 6.6%, respectively, compared with 4DCT. The difference in tumor motion by T2w-4DMRI based on the centroid was greater than that of 4DCT in the L/R, A/P, and S/I directions, and the average displacement differences were 2.6, 2.8, and 6.9 mm, respectively. The severe artifacts in 4DCT were 47.8% (11/23) greater than in 4DMRI 17.4% (4/23). Conclusions: Compared with 4DCT, T2-weighted and navigator-triggered 4DMRI produces fewer artifacts and larger motion differences in hepatic intrafraction tumors, which is a feasible technique for primary liver cancer treatment planning.
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Affiliation(s)
- Yukai Chen
- East China University of Technology, Nanchang, Jiangxi, China
| | - Guanzhong Gong
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - Yinxing Wang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - Chenlu Liu
- School of Nuclear Science and Technology, University of South China, Hengyang, China
| | - Ya Su
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - Lizhen Wang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - Bo Yang
- East China University of Technology, Nanchang, Jiangxi, China
| | - Yong Yin
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
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den Boer D, Veldman JK, van Tienhoven G, Bel A, van Kesteren Z. Evaluating differences in respiratory motion estimates during radiotherapy: a single planning 4DMRI versus daily 4DMRI. Radiat Oncol 2021; 16:188. [PMID: 34565384 PMCID: PMC8474826 DOI: 10.1186/s13014-021-01915-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background In radiotherapy, respiratory-induced tumor motion is typically measured using a single four-dimensional computed tomography acquisition (4DCT). Irregular breathing leads to inaccurate motion estimates, potentially resulting in undertreatment of the tumor and unnecessary dose to healthy tissue. The aim of the research was to determine if a daily pre-treatment 4DMRI-strategy led to a significantly improved motion estimate compared to single planning 4DMRI (with or without outlier rejection). Methods 4DMRI data sets from 10 healthy volunteers were acquired. The first acquisition simulated a planning MRI, the respiratory motion estimate (constructed from the respiratory signal, i.e. the 1D navigator) was compared to the respiratory signal in the subsequent scans (simulating 5–29 treatment fractions). The same procedure was performed using the first acquisition of each day as an estimate for the subsequent acquisitions that day (2 per day, 4–20 per volunteer), simulating a daily MRI strategy. This was done for three outlier strategies: no outlier rejection (NoOR); excluding 5% of the respiratory signal whilst minimizing the range (Min95) and excluding the datapoints outside the mean end-inhalation and end-exhalation positions (MeanIE). Results The planning MRI median motion estimates were 27 mm for NoOR, 18 mm for Min95, and 13 mm for MeanIE. The daily MRI median motion estimates were 29 mm for NoOR, 19 mm for Min95 and 15 mm for MeanIE. The percentage of time outside the motion estimate were for the planning MRI: 2%, 10% and 32% for NoOR, Min95 and MeanIE respectively. These values were reduced with the daily MRI strategy: 0%, 6% and 17%. Applying Min95 accounted for a 30% decrease in motion estimate compared to NoOR. Conclusion A daily MRI improved the estimation of respiratory motion as compared to a single 4D (planning) MRI significantly. Combining the Min95 technique with a daily 4DMRI resulted in a decrease of inclusion time of 6% with a 30% decrease of motion. Outlier rejection alone on a planning MRI often led to underestimation of the movement and could potentially lead to an underdosage. Trial registration: protocol W15_373#16.007 Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01915-1.
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Affiliation(s)
- Duncan den Boer
- Department of Radiotherapy, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Johannes K Veldman
- Department of Radiotherapy, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Geertjan van Tienhoven
- Department of Radiotherapy, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiotherapy, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Zdenko van Kesteren
- Department of Radiotherapy, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Cuccia F, Alongi F, Belka C, Boldrini L, Hörner-Rieber J, McNair H, Rigo M, Schoenmakers M, Niyazi M, Slagter J, Votta C, Corradini S. Patient positioning and immobilization procedures for hybrid MR-Linac systems. Radiat Oncol 2021; 16:183. [PMID: 34544481 PMCID: PMC8454038 DOI: 10.1186/s13014-021-01910-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/09/2021] [Indexed: 02/08/2023] Open
Abstract
Hybrid magnetic resonance (MR)-guided linear accelerators represent a new horizon in the field of radiation oncology. By harnessing the favorable combination of on-board MR-imaging with the possibility to daily recalculate the treatment plan based on real-time anatomy, the accuracy in target and organs-at-risk identification is expected to be improved, with the aim to provide the best tailored treatment. To date, two main MR-linac hybrid machines are available, Elekta Unity and Viewray MRIdian. Of note, compared to conventional linacs, these devices raise practical issues due to the positioning phase for the need to include the coil in the immobilization procedure and in order to perform the best reproducible positioning, also in light of the potentially longer treatment time. Given the relative novelty of this technology, there are few literature data regarding the procedures and the workflows for patient positioning and immobilization for MR-guided daily adaptive radiotherapy. In the present narrative review, we resume the currently available literature and provide an overview of the positioning and setup procedures for all the anatomical districts for hybrid MR-linac systems.
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Affiliation(s)
- Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy.
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy
- University of Brescia, Brescia, Italy
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Luca Boldrini
- Radiology, Radiation Oncology and Hematology Department, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Helen McNair
- The Royal Marsden NHS Foundation Trust, and Institute of Cancer Research Sutton, Surrey, UK
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, VR, Italy
| | - Maartje Schoenmakers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Judith Slagter
- Department of Radiation Oncology - Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio Votta
- Radiology, Radiation Oncology and Hematology Department, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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12
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Hama Y, Tate E. Superparamagnetic iron oxide-enhanced MRI-guided stereotactic ablative radiation therapy for liver metastasis. Rep Pract Oncol Radiother 2021; 26:470-474. [PMID: 34277103 PMCID: PMC8281898 DOI: 10.5603/rpor.a2021.0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/23/2021] [Indexed: 11/25/2022] Open
Abstract
Background MRI-guided radiation therapy can image a target and irradiate it at the same time. Superparamagnetic iron oxide (SPIO) is a liver-specific contrast agent that can selectively visualize liver tumors, even if plain MRI does not depict them. The purpose of this study was to present a proof of concept of SPIO-enhanced MRI-guided radiation therapy for liver tumor. Case presentation MRI-guided stereotactic ablative radiation therapy (SABR) was planned for a patient with impaired renal function who developed liver metastases after nephroureterectomy for ureteral cancer. Because liver metastasis was not visualized on plain MRI, SPIO-enhanced MRI was performed at 0.35 T using true fast imaging with steady-state free precession (true FISP) pulse sequence and SABR was performed. Liver metastasis was clearly visualized by SPIO-enhanced MRI, and MRI-guided SABR was performed without adverse events. Conclusion Even if liver metastasis is not visualized by plain MRI, liver metastasis can be clearly depicted by administering SPIO, and MRI-guided radiation therapy can be performed.
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Affiliation(s)
- Yukihiro Hama
- Department of Radiation Oncology, Tokyo-Edogawa Cancer Centre, Edogawa Hospital, Tokyo, Japan
| | - Etsuko Tate
- Department of Radiation Oncology, Tokyo-Edogawa Cancer Centre, Edogawa Hospital, Tokyo, Japan
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13
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Chandra RA, Keane FK, Voncken FEM, Thomas CR. Contemporary radiotherapy: present and future. Lancet 2021; 398:171-184. [PMID: 34166607 DOI: 10.1016/s0140-6736(21)00233-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023]
Abstract
Oncology care is increasingly a multidisciplinary endeavour, and radiation therapy continues to have a key role across the disease spectrum in nearly every cancer. However, the field of radiation oncology is still one of the most poorly understood of the cancer disciplines. In this Review, we attempt to summarise and contextualise developments within the field of radiation oncology for the non-radiation oncologist. We discuss advancements in treatment technologies and imaging, followed by an overview of the interplay with advancements in systemic therapy and surgical techniques. Finally, we review new frontiers in radiation oncology, including advances within the metastatic disease continuum, reirradiation, and emerging types of radiation therapy.
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Affiliation(s)
- Ravi A Chandra
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Francine E M Voncken
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA
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14
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van de Lindt TN, Fast MF, van den Wollenberg W, Kaas J, Betgen A, Nowee ME, Jansen EP, Schneider C, van der Heide UA, Sonke JJ. Validation of a 4D-MRI guided liver stereotactic body radiation therapy strategy for implementation on the MR-linac. Phys Med Biol 2021; 66. [PMID: 33887708 DOI: 10.1088/1361-6560/abfada] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Purpose. Accurate tumor localization for image-guided liver stereotactic body radiation therapy (SBRT) is challenging due to respiratory motion and poor tumor visibility on conventional x-ray based images. Novel integrated MRI and radiotherapy systems enable direct in-room tumor visualization, potentially increasing treatment accuracy. As these systems currently do not provide a 4D image-guided radiotherapy strategy, we developed a 4D-MRI guided liver SBRT workflow and validated all steps for implementation on the Unity MR-linac.Materials and Methods. The proposed workflow consists of five steps: (1) acquisition of a daily 4D-MRI scan, (2) 4D-MRI to mid-position planning-CT rigid tumor registration, (3) calculation of daily tumor midP misalignment, (4) plan adaptation using adapt-to-position (ATP) with segment-weights optimization and (5) adapted plan delivery. The workflow was first validated in a motion phantom, performing regular motion at different baselines (±5 to ±10 mm) and patient-derived respiratory signals with varying degrees of irregularity. 4D-MRI derived respiratory signals and 4D-MRI to planning CT registrations were compared to the phantom input, and gamma and dose-area-histogram analyses were performed on the delivered dose distributions on film. Additionally, 4D-MRI to CT registration performance was evaluated in patient images using the full-circle method (transitivity analysis). Plan adaption was further analyzedin-silicoby creating adapted treatment plans for 15 patients with oligometastatic liver disease.Results. Phantom trajectories could be reliably extracted from 4D-MRI scans and 4D-MRI to CT registration showed submillimeter accuracy. The DAH-analysis demonstrated excellent coverage of the dose evaluation structures GTV and GTVTD. The median daily rigid 4D-MRI to midP-CT registration precision in patient images was <2 mm. The ATP strategy restored the target dose without increased exposure to the OARs and plan quality was independent from 3D shift distance in the range of 1-26 mm.Conclusions. The proposed 4D-MRI guided strategy showed excellent performance in all workflow tests in preparation of the clinical introduction on the Unity MR-linac.
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Affiliation(s)
- Tessa N van de Lindt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin F Fast
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jochem Kaas
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anja Betgen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marlies E Nowee
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Edwin Pm Jansen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Christoph Schneider
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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15
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Keijnemans K, Borman PTS, van Lier ALHMW, Verhoeff JJC, Raaymakers BW, Fast MF. Simultaneous multi-slice accelerated 4D-MRI for radiotherapy guidance. Phys Med Biol 2021; 66. [PMID: 33827065 DOI: 10.1088/1361-6560/abf591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022]
Abstract
4D-MRI is becoming increasingly important for daily guidance of thoracic and abdominal radiotherapy. This study exploits the simultaneous multi-slice (SMS) technique to accelerate the acquisition of a balanced turbo field echo (bTFE) and a turbo spin echo (TSE) coronal 4D-MRI sequence performed on 1.5 T MRI scanners. SMS single-shot bTFE and TSE sequences were developed to acquire a stack of 52 coronal 2D images over 30 dynamics. Simultaneously excited slices were separated by half the field of view. Slices intersecting with the liver-lung interface were used as navigator slices. For each navigator slice location, an end-exhale dynamic was automatically identified, and used to derive the self-sorting signal by rigidly registering the remaining dynamics. Navigator slices were sorted into 10 amplitude bins, and the temporal relationship of simultaneously excited slices was used to generate sorted 4D-MRIs for 12 healthy volunteers. The self-sorting signal was validated using anin vivopeak-to-peak motion analysis. The smoothness of the liver-lung interface was quantified by comparing to sagittal cine images acquired directly after the SMS-4D-MRI sequence. To ensure compatibility with the MR-linac radiotherapy workflow, the 4D-MRIs were transformed into 3D mid-position (MidP) images using deformable image registration. Consistency of the deformable vector fields was quantified in terms of the distance discordance metric (DDM) in the body. The SMS-4D-TSE sequence was additionally acquired for 3 lung cancer patients to investigate tumor visibility. SMS-4D-MRI acquisition and processing took approximately 7 min. 4D-MRI reconstruction was possible for 26 out of 27 acquired datasets. Missing data in the sorted 4D-MRIs varied from 4%-26% for the volunteers and varied from 8%-24% for the patients. Peak-to-peak (SD) amplitudes analysis agreed within 1.8 (1.1) mm and 0.9 (0.4) mm between the sorted 4D-MRIs and the self-sorting signals of the volunteers and patients, respectively. Liver-lung interface smoothness was found to be in the range of 0.6-3.1 mm for volunteers. The percentage of DDM values smaller than 2 mm was in the range of 85%-89% and 86%-92% for the volunteers and patients, respectively. Lung tumors were clearly visibility in the SMS-4D-TSE images and MidP images. Two fast SMS-accelerated 4D-MRI sequences were developed resulting in T2/T1or T2weighted contrast. The SMS-4D-MRIs and derived 3D MidP-MRIs yielded anatomically plausible images and good tumor visibility. SMS-4D-MRI is therefore a strong candidate to be used for treatment simulation and daily guidance of thoracic and abdominal MR-guided radiotherapy.
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Affiliation(s)
- K Keijnemans
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - P T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - A L H M W van Lier
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - J J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - B W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - M F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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16
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Boldrini L, Corradini S, Gani C, Henke L, Hosni A, Romano A, Dawson L. MR-Guided Radiotherapy for Liver Malignancies. Front Oncol 2021; 11:616027. [PMID: 33869001 PMCID: PMC8047407 DOI: 10.3389/fonc.2021.616027] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
MR guided radiotherapy represents one of the most promising recent technological innovations in the field. The possibility to better visualize therapy volumes, coupled with the innovative online adaptive radiotherapy and motion management approaches, paves the way to more efficient treatment delivery and may be translated in better clinical outcomes both in terms of response and reduced toxicity. The aim of this review is to present the existing evidence about MRgRT applications for liver malignancies, discussing the potential clinical advantages and the current pitfalls of this new technology.
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Affiliation(s)
- Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University, Tübingen, Germany
| | - Lauren Henke
- Department of Radiation Oncology, Washington University in St Louis, St Louis, MO, United States
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
| | - Laura Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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17
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Juan-Cruz C, Fast MF, Sonke JJ. A multivariable study of deformable image registration evaluation metrics in 4DCT of thoracic cancer patients. Phys Med Biol 2021; 66:035019. [PMID: 33227717 DOI: 10.1088/1361-6560/abcd18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Deformable image registration (DIR) accuracy is often validated using manually identified landmarks or known deformations generated using digital or physical phantoms. In daily practice, the application of these approaches is limited since they are time-consuming or require additional equipment. An alternative is the use of metrics automatically derived from the registrations, but their interpretation is not straightforward. In this work we aim to determine the suitability of DIR-derived metrics to validate the accuracy of 4 commonly used DIR algorithms. First, we investigated the DIR accuracy using a landmark-based metric (target registration error (TRE)) and a digital phantom-based metric (known deformation recovery error (KDE)). 4DCT scans of 16 thoracic cancer patients along with corresponding pairwise anatomical landmarks (AL) locations were collected from two public databases. Digital phantoms with known deformations were generated by each DIR algorithm to test all other algorithms and compute KDE. TRE and KDE were evaluated at AL. KDE was additionally quantified in coordinates randomly sampled (RS) inside the lungs. Second, we investigated the associations of 5 DIR-derived metrics (distance discordance metric (DDM), inverse consistency error (ICE), transitivity (TE), spatial (SS) and temporal smoothness (TS)) with DIR accuracy through uni- and multivariable linear regression models. TRE values were found higher compared to KDE values and these varied depending on the phantom used. The algorithm with the best accuracy achieved average values of TRE = 1.1 mm and KDE ranging from 0.3 to 0.8 mm. DDM was the best predictor of DIR accuracy, with moderate correlations (R 2 < 0.61). Poor correlations were obtained at AL for algorithms with better accuracy, which improved when evaluated at RS. Only slight correlation improvement was obtained with a multivariable analysis (R 2 < 0.64). DDM can be a useful metric to identify inaccuracies for different DIR algorithms without employing landmarks or digital phantoms.
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Affiliation(s)
- Celia Juan-Cruz
- The Netherlands Cancer Institute, Radiotherapy Department, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Martin F Fast
- The Netherlands Cancer Institute, Radiotherapy Department, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- The Netherlands Cancer Institute, Radiotherapy Department, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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18
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Gani C, Boeke S, McNair H, Ehlers J, Nachbar M, Mönnich D, Stolte A, Boldt J, Marks C, Winter J, Künzel LA, Gatidis S, Bitzer M, Thorwarth D, Zips D. Marker-less online MR-guided stereotactic body radiotherapy of liver metastases at a 1.5 T MR-Linac - Feasibility, workflow data and patient acceptance. Clin Transl Radiat Oncol 2021; 26:55-61. [PMID: 33319073 PMCID: PMC7723999 DOI: 10.1016/j.ctro.2020.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Stereotactic body radiotherapy (SBRT) is an established ablative treatment for liver tumors with excellent local control rates. Magnetic resonance imaging guided radiotherapy (MRgRT) provides superior soft tissue contrast and may therefore facilitate a marker-less liver SBRT workflow. The goal of the present study was to investigate feasibility, workflow parameters, toxicity and patient acceptance of MRgSBRT on a 1.5 T MR-Linac. METHODS Ten consecutive patients with liver metastases treated on a 1.5 T MR-Linac were included in this prospective trial. Tumor delineation was performed on four-dimensional computed tomography scans and both exhale triggered and free-breathing T2 MRI scans from the MR-Linac. An internal target volume based approach was applied. Organ at risk constraints were based on the UKSABR guidelines (Version 6.1). Patient acceptance regarding device specific aspects was assessed and toxicity was scored according to the common toxicity criteria of adverse events, version 5. RESULTS Nine of ten tumors were clearly visible on the 1.5 T MR-Linac. No patient had fiducial markers placed for treatment. All patients were treated with three or five fractions. Median dose to 98% of the gross tumor volume was 38.5 Gy. The median time from "patient identity check" until "beam-off" was 31 min. Median beam on time was 9.6 min. Online MRgRT was well accepted in general and no treatment had to be interrupted on patient request. No event of symptomatic radiation induced liver disease was observed after a median follow-up of ten month (range 3-17 months). CONCLUSION Our early experience suggests that online 1.5 T MRgSBRT of liver metastases represents a promising new non-invasive marker-free treatment modality based on high image quality, clinically reasonable in-room times and high patient acceptance. Further studies are necessary to assess clinical outcome, to validate advanced motion management and to explore the benefit of online response adaptive liver SBRT.
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Affiliation(s)
- Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - S. Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - H. McNair
- Department of Radiotherapy, The Royal Marsden Hospital NHS Foundation Trust, United Kingdom
| | - J. Ehlers
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - M. Nachbar
- Section for Biomedical Physics. Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - D. Mönnich
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Section for Biomedical Physics. Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - A. Stolte
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - J. Boldt
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - C. Marks
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - J. Winter
- Section for Biomedical Physics. Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Luise A. Künzel
- Section for Biomedical Physics. Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - S. Gatidis
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital, Eberhard Karls University, Tübingen, Germany
| | - M. Bitzer
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology and Infectious Diseases, Eberhard Karls University, Tübingen, Germany
| | - D. Thorwarth
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Section for Biomedical Physics. Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - D. Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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19
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Russell E, McMahon SJ, Russell B, Mohamud H, McGarry CK, Schettino G, Prise KM. Effects of Gadolinium MRI Contrast Agents on DNA Damage and Cell Survival when Used in Combination with Radiation. Radiat Res 2020; 194:298-309. [PMID: 32942305 DOI: 10.1667/rade-20-00008.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/23/2020] [Indexed: 11/03/2022]
Abstract
Gadolinium is a commonly used contrast agent for magnetic resonance imaging (MRI). The goal of this work was to determine how MRI contrast agents affect radiosensitivity for tumour cells. Using a 225kVp X-ray cabinet source, immunofluorescence and clonogenic assays were performed on six cancer cell lines: lung (H460), pancreas (MiaPaCa2), prostate (DU145), breast (MCF7), brain (U87) and liver (HEPG2). Dotarem® contrast agent, at concentrations of 0.2, 2 and 20 mM, was used to determine its effect on DNA damage and cell survival. Measurements were performed using inductively coupled plasma mass spectrometry (ICP-MS) to determine the amount of gadolinium taken up by each cell line for each concentration. A statistically significant increase in DNA damage was seen for all cell lines at a dose of 1 Gy for concentrations of 2 and 20 mM, at 1 h postirradiation. At 24 h postirradiation, most of the DNA damage had been repaired, with approximately 90% repair for almost all doses of radiation and concentrations of Dotarem. Clonogenic results showed no statistically significant decrease in cell survival for any cell line or concentration. Uptake measurements showed cell line-specific variations in uptake, with MCF7 and HEPG2 cells having a high percentage uptake compared to other cell lines, with 151.4 ± 0.3 × 10-15 g and 194.8 ± 0.4 × 10-15 g per cell, respectively, at 2 mM Dotarem concentration. In this work, a variability in gadolinium uptake was observed between cell lines. A significant increase was seen in initial levels of DNA damage after 1 Gy irradiation for all six cancer cell lines; however, no significant decrease in cell survival was seen with the clonogenic assay. The observation of high levels of repair suggest that while initial levels of DNA damage are increased, this damage is almost entirely repaired within 24 h, and does not affect the ability of cells to survive and produce colonies.
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Affiliation(s)
- Emily Russell
- Patrick G. Johnson Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, United Kingdom.,National Physical Laboratory, Teddington, TW11 0LW, United Kingdom
| | - Stephen J McMahon
- Patrick G. Johnson Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, United Kingdom
| | - Ben Russell
- National Physical Laboratory, Teddington, TW11 0LW, United Kingdom
| | - Hibaaq Mohamud
- National Physical Laboratory, Teddington, TW11 0LW, United Kingdom
| | - Conor K McGarry
- Patrick G. Johnson Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, United Kingdom.,Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Giuseppe Schettino
- National Physical Laboratory, Teddington, TW11 0LW, United Kingdom.,University of Surrey, Department of Physics, Guilford, GU2 7XH, United Kingdom
| | - Kevin M Prise
- Patrick G. Johnson Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, United Kingdom
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20
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Image-guided Radiotherapy to Manage Respiratory Motion: Lung and Liver. Clin Oncol (R Coll Radiol) 2020; 32:792-804. [PMID: 33036840 DOI: 10.1016/j.clon.2020.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/26/2020] [Accepted: 09/18/2020] [Indexed: 12/25/2022]
Abstract
Organ motion as a result of respiratory and cardiac motion poses significant challenges for the accurate delivery of radiotherapy to both the thorax and the upper abdomen. Modern imaging techniques during radiotherapy simulation and delivery now permit better quantification of organ motion, which in turn reduces tumour and organ at risk position uncertainty. These imaging advances, coupled with respiratory correlated radiotherapy delivery techniques, have led to the development of a range of approaches to manage respiratory motion. This review summarises the key strategies of image-guided respiratory motion management with a focus on lung and liver radiotherapy.
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21
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Eiben B, Bertholet J, Menten MJ, Nill S, Oelfke U, McClelland JR. Consistent and invertible deformation vector fields for a breathing anthropomorphic phantom: a post-processing framework for the XCAT phantom. Phys Med Biol 2020; 65:165005. [PMID: 32235043 DOI: 10.1088/1361-6560/ab8533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Breathing motion is challenging for radiotherapy planning and delivery. This requires advanced four-dimensional (4D) imaging and motion mitigation strategies and associated validation tools with known deformations. Numerical phantoms such as the XCAT provide reproducible and realistic data for simulation-based validation. However, the XCAT generates partially inconsistent and non-invertible deformations where tumours remain rigid and structures can move through each other. We address these limitations by post-processing the XCAT deformation vector fields (DVF) to generate a breathing phantom with realistic motion and quantifiable deformation. An open-source post-processing framework was developed that corrects and inverts the XCAT-DVFs while preserving sliding motion between organs. Those post-processed DVFs are used to warp the first XCAT-generated image to consecutive time points providing a 4D phantom with a tumour that moves consistently with the anatomy, the ability to scale lung density as well as consistent and invertible DVFs. For a regularly breathing case, the inverse consistency of the DVFs was verified and the tumour motion was compared to the original XCAT. The generated phantom and DVFs were used to validate a motion-including dose reconstruction (MIDR) method using isocenter shifts to emulate rigid motion. Differences between the reconstructed doses with and without lung density scaling were evaluated. The post-processing framework produced DVFs with a maximum [Formula: see text]-percentile inverse-consistency error of 0.02 mm. The generated phantom preserved the dominant sliding motion between the chest wall and inner organs. The tumour of the original XCAT phantom preserved its trajectory while deforming consistently with the underlying tissue. The MIDR was compared to the ground truth dose reconstruction illustrating its limitations. MIDR with and without lung density scaling resulted in small dose differences up to 1 Gy (prescription 54 Gy). The proposed open-source post-processing framework overcomes important limitations of the original XCAT phantom and makes it applicable to a wider range of validation applications within radiotherapy.
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Affiliation(s)
- Björn Eiben
- Centre for Medical Image Computing, Radiotherapy Image Computing Group, Department of Medical Physics and Biomedical Engineering University College London, London, United Kingdom of Great Britain and Northern Ireland
- Authors contributed equally
| | - Jenny Bertholet
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Authors contributed equally
| | - Martin J Menten
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Simeon Nill
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Uwe Oelfke
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Jamie R McClelland
- Centre for Medical Image Computing, Radiotherapy Image Computing Group, Department of Medical Physics and Biomedical Engineering University College London, London, United Kingdom of Great Britain and Northern Ireland
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22
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Morita R, Abo D, Sakuhara Y, Soyama T, Katoh N, Miyamoto N, Uchinami Y, Shimizu S, Shirato H, Kudo K. Percutaneous insertion of hepatic fiducial true-spherical markers for real-time adaptive radiotherapy. MINIM INVASIV THER 2019; 29:334-343. [DOI: 10.1080/13645706.2019.1663217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Ryo Morita
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Yusuke Sakuhara
- Department of Diagnostic Radiology, Tonan Hospital, Sapporo, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
| | - Naoki Miyamoto
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Yuusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Shinichi Shimizu
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Hiroki Shirato
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
- Proton Beam Therapy Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kohsuke Kudo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
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23
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Clark CH, Gagliardi G, Heijmen B, Malicki J, Thorwarth D, Verellen D, Muren LP. Adapting training for medical physicists to match future trends in radiation oncology. Phys Imaging Radiat Oncol 2019; 11:71-75. [PMID: 33458282 PMCID: PMC7807663 DOI: 10.1016/j.phro.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Catharine H. Clark
- Medical Physics, St Lukes Cancer Centre, Royal Surrey County Hospital, Guildford, UK
- Dept Medical Physics, National Physical Laboratory, Teddington, UK
| | - Giovanna Gagliardi
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Ben Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Julian Malicki
- Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Dirk Verellen
- Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Belgium
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
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