1
|
Vander Veken L, Van Ooteghem G, Ghaye B, Razavi A, Dechambre D, Geets X. Lung and Liver Stereotactic Body Radiation Therapy During Mechanically Assisted Deep Inspiration Breath-Holds: A Prospective Feasibility Trial. Adv Radiat Oncol 2024; 9:101563. [PMID: 39155885 PMCID: PMC11327938 DOI: 10.1016/j.adro.2024.101563] [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: 01/14/2024] [Accepted: 06/08/2024] [Indexed: 08/20/2024] Open
Abstract
Purpose Radiation therapy for tumors subject to breathing-related motion during breath-holds (BHs) has the potential to substantially reduce the irradiated volume. Mechanically assisted and noninvasive ventilation (MANIV) could ensure the target repositioning accuracy during each BH while facilitating treatment feasibility through oxygen supplementation and a perfectly replicated mechanical support. However, there is currently no clinical evidence substantiating the use of MANIV-induced BH for moving tumors. The aim of this work was, therefore, to evaluate the technique's performance under real treatment conditions. Methods and Materials Patients eligible for lung or liver stereotactic body radiation therapy were prospectively included in a single-arm trial. The primary endpoint corresponded to the treatment feasibility with MANIV. Secondary outcomes comprised intrafraction geometric uncertainties extracted from real-time imaging, tolerance to BH, and treatment time. Results Treatment was successfully delivered in 92.9% (13/14) of patients: 1 patient with a liver tumor was excluded because of a mechanically induced gastric insufflation displacing the liver cranially by more than 1 cm. In the left-right/anteroposterior/craniocaudal directions, the recalculated safety margins based on intrafraction positional data were 4.6 mm/5.1 mm/5.6 mm and 4.7 mm/7.3 mm/5.9 mm for lung and liver lesions, respectively. Compared with the free-breathing internal target volume and midposition approaches, the average reduction in the planning target volume with MANIV reached -47.2% ± 15.3%, P < .001, and -29.4% ± 19.2%, P = .007, for intrathoracic tumors and -23.3% ± 12.4%, P < .001, and -9.3% ± 15.3%, P = .073, for upper abdominal tumors, respectively. For 1 liver lesion, large caudal drifts of occasionally more than 1 cm were measured. The total slot time was 53.1 ± 10.6 minutes with a BH comfort level of 80.1% ± 10.6%. Conclusions MANIV enables high treatment feasibility within a nonselected population. Accurate intrafraction tumor repositioning is achieved for lung tumors. Because of occasional intra-BH caudal drifts, pretreatment assessment of BH stability for liver lesions is, however, recommended.
Collapse
Affiliation(s)
- Loïc Vander Veken
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Geneviève Van Ooteghem
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Benoît Ghaye
- Radiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Ariane Razavi
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Dechambre
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Xavier Geets
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
2
|
Rabe M, Kurz C, Thummerer A, Landry G. Artificial intelligence for treatment delivery: image-guided radiotherapy. Strahlenther Onkol 2024:10.1007/s00066-024-02277-9. [PMID: 39138806 DOI: 10.1007/s00066-024-02277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/07/2024] [Indexed: 08/15/2024]
Abstract
Radiation therapy (RT) is a highly digitized field relying heavily on computational methods and, as such, has a high affinity for the automation potential afforded by modern artificial intelligence (AI). This is particularly relevant where imaging is concerned and is especially so during image-guided RT (IGRT). With the advent of online adaptive RT (ART) workflows at magnetic resonance (MR) linear accelerators (linacs) and at cone-beam computed tomography (CBCT) linacs, the need for automation is further increased. AI as applied to modern IGRT is thus one area of RT where we can expect important developments in the near future. In this review article, after outlining modern IGRT and online ART workflows, we cover the role of AI in CBCT and MRI correction for dose calculation, auto-segmentation on IGRT imaging, motion management, and response assessment based on in-room imaging.
Collapse
Affiliation(s)
- Moritz Rabe
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Bavaria, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Bavaria, Germany
| | - Adrian Thummerer
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Bavaria, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Bavaria, Germany.
- German Cancer Consortium (DKTK), partner site Munich, a partnership between the DKFZ and the LMU University Hospital Munich, Marchioninistraße 15, 81377, Munich, Bavaria, Germany.
- Bavarian Cancer Research Center (BZKF), Marchioninistraße 15, 81377, Munich, Bavaria, Germany.
| |
Collapse
|
3
|
Manabe Y, Shiinoki T, Fujimoto K, Ueda K, Karita M, Ono T, Kajima M, Tanaka H. Intra- and inter-fractional variations of tumors with fiducial markers measured using respiratory-correlated computed tomography images for respiratory gated lung stereotactic body radiation therapy. J Appl Clin Med Phys 2024; 25:e14280. [PMID: 38252745 PMCID: PMC11163493 DOI: 10.1002/acm2.14280] [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: 10/22/2023] [Revised: 10/22/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
PURPOSE This study evaluated the intra- and inter-fractional variation of tumors with fiducial markers (FMs), relative to the tumor-FM distance, to establish how close an FM should be inserted for respiratory-gated stereotactic body radiation therapy (RG-SBRT). METHODS Forty-five lung tumors treated with RG-SBRT were enrolled. End-expiratory computed tomography (CT) (CTplan) and four-dimensional-CT (4D-CT) scans were obtained for planning. End-expiratory CT (CTfr) scanning was performed before each fraction. The FMs were divided into two groups based on the median tumor-FM distance in the CTplan (Dp). For the intra-fractional variation, the correlations between the corresponding tumor and FM intra-fractional motions, defined as the centroid coordinates of those in each 0-90% phase, with the 50% phase of 4D-CT as the origin, were calculated in the left-right, anterior-posterior, and superior-inferior directions. Furthermore, the maximum difference in the tumor-FM distance in each phase of 4D-CT scan, based on those in the 50% phase of 4D-CT scan (Dmax), was obtained. Inter-fractional variation was defined as the maximum distance between the tumors in CTplan and CTfr, when the CT scans were fused based on each FM or vertebra. RESULTS The median Dp was 26.1 mm. While FM intra-fractional motions were significantly and strongly correlated with the tumor intra-fractional motions in only anterior-posterior and superior-inferior directions for the Dp > 26 mm group, they were significantly and strongly correlated in all directions for the Dp ≤ 26 mm group. In all directions, Dmax values of the Dp ≤ 26 mm group were lower than those of the Dp > 26 mm group. The inter-fractional variations based on the Dp ≤ 26 mm were smaller than those on the Dp > 26 mm and on the vertebra in all directions. CONCLUSIONS Regarding intra- and inter-fractional variation, FMs for Dp ≤ 26 mm can increase the accuracy for RG-SBRT.
Collapse
Affiliation(s)
- Yuki Manabe
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Takehiro Shiinoki
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Koya Fujimoto
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Kazushi Ueda
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Masako Karita
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Taiki Ono
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Miki Kajima
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| | - Hidekazu Tanaka
- Department of Radiation OncologyYamaguchi University Graduate School of MedicineUbeYamaguchiJapan
| |
Collapse
|
4
|
Claridge Mackonis E, Stensmyr R, Poldy R, White P, Moutrie Z, Gorjiara T, Seymour E, Erven T, Hardcastle N, Haworth A. Improving motion management in radiation therapy: findings from a workshop and survey in Australia and New Zealand. Phys Eng Sci Med 2024:10.1007/s13246-024-01405-0. [PMID: 38805104 DOI: 10.1007/s13246-024-01405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/09/2024] [Indexed: 05/29/2024]
Abstract
Motion management has become an integral part of radiation therapy. Multiple approaches to motion management have been reported in the literature. To allow the sharing of experiences on current practice and emerging technology, the University of Sydney and the New South Wales/Australian Capital Territory branch of the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) held a two-day motion management workshop. To inform the workshop program, participants were invited to complete a survey prior to the workshop on current use of motion management techniques and their opinion on the effectiveness of each approach. A post-workshop survey was also conducted, designed to capture changes in opinion as a result of workshop participation. The online workshop was the most well attended ever hosted by the ACPSEM, with over 300 participants and a response to the pre-workshop survey was received from at least 60% of the radiation therapy centres in Australia and New Zealand. Motion management is extensively used in the region with use of deep inspiration breath-hold (DIBH) reported by 98% of centres for left-sided breast treatments and 91% for at least some right-sided breast treatments. Surface guided radiation therapy (SGRT) was the most popular session at the workshop and survey results showed that the use of SGRT is likely to increase. The workshop provided an excellent opportunity for the exchange of knowledge and experience, with most survey respondents indicating that their participation would lead to improvements in the quality of delivery of treatments at their centres.
Collapse
Affiliation(s)
| | | | - Rachel Poldy
- Canberra Region Cancer Centre, Canberra, Australia
| | - Paul White
- South Eastern Sydney LHD, Randwick, Australia
| | - Zoë Moutrie
- South Western Sydney Cancer Services, Sydney, NSW, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- South Western Sydney Clinical School, University of NSW, Liverpool, NSW, Australia
| | | | | | - Tania Erven
- South Western Sydney Cancer Services, Sydney, NSW, Australia
| | - Nicholas Hardcastle
- Peter MacCallum Cancer Centres, Melbourne, Australia
- Institute of Medical Physics, University of Sydney, Camperdown, Australia
| | - Annette Haworth
- Institute of Medical Physics, University of Sydney, Camperdown, Australia
| |
Collapse
|
5
|
Burton A, Gaudreault M, Hardcastle N, Lye J, Beveridge S, Kry SF, Franich R. Optimized scoring of end-to-end dosimetry audits for passive motion management - A simulation study using the IROC thorax phantom. Phys Med 2024; 121:103363. [PMID: 38653119 DOI: 10.1016/j.ejmp.2024.103363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/24/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
Dosimetry audits for passive motion management require dynamically-acquired measurements in a moving phantom to be compared to statically calculated planned doses. This study aimed to characterise the relationship between planning and delivery errors, and the measured dose in the Imaging and Radiation Oncology Core (IROC) thorax phantom, to assess different audit scoring approaches. Treatment plans were created using a 4DCT scan of the IROC phantom, equipped with film and thermoluminescent dosimeters (TLDs). Plans were created on the average intensity projection from all bins. Three levels of aperture complexity were explored: dynamic conformal arcs (DCAT), low-, and high-complexity volumetric modulated arcs (VMATLo, VMATHi). Simulated-measured doses were generated by modelling motion using isocenter shifts. Various errors were introduced including incorrect setup position and target delineation. Simulated-measured film doses were scored using gamma analysis and compared within specific regions of interest (ROIs) as well as the entire film plane. Positional offsets were estimated based on isodoses on the film planes, and point doses within TLD contours were compared. Motion-induced differences between planned and simulated-measured doses were evident even without introduced errors Gamma passing rates within target-centred ROIs correlated well with error-induced dose differences, while whole film passing rates did not. Isodose-based setup position measurements demonstrated high sensitivity to errors. Simulated point doses at TLD locations yielded erratic responses to introduced errors. ROI gamma analysis demonstrated enhanced sensitivity to simulated errors compared to whole film analysis. Gamma results may be further contextualized by other metrics such as setup position or maximum gamma.
Collapse
Affiliation(s)
- Alex Burton
- Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), Yallambie, Victoria 3085, Australia; Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, the University of Melbourne, Victoria 3000, Australia; School of Science, RMIT University, Melbourne, Victoria 3000, Australia.
| | - Mathieu Gaudreault
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, the University of Melbourne, Victoria 3000, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, the University of Melbourne, Victoria 3000, Australia; Centre for Medical Radiation Physics, University of Wollongong, New South Wales 2522, Australia
| | - Jessica Lye
- Olivia Newton John Cancer Research and Wellness Centre, Heidelberg 3084, Australia
| | - Sabeena Beveridge
- Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), Yallambie, Victoria 3085, Australia
| | - Stephen F Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Imaging and Radiation Oncology Core, Houston, TX 77054, USA
| | - Rick Franich
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; School of Science, RMIT University, Melbourne, Victoria 3000, Australia
| |
Collapse
|
6
|
Renner A, Gulyas I, Buschmann M, Heilemann G, Knäusl B, Heilmann M, Widder J, Georg D, Trnková P. Explicitly encoding the cyclic nature of breathing signal allows for accurate breathing motion prediction in radiotherapy with minimal training data. Phys Imaging Radiat Oncol 2024; 30:100594. [PMID: 38883146 PMCID: PMC11176922 DOI: 10.1016/j.phro.2024.100594] [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: 02/07/2024] [Revised: 05/17/2024] [Accepted: 05/25/2024] [Indexed: 06/18/2024] Open
Abstract
Background and purpose Active breathing motion management in radiotherapy consists of motion monitoring, quantification and mitigation. It is impacted by associated latencies of a few 100 ms. Artificial neural networks can successfully predict breathing motion and eliminate latencies. However, they require usually a large dataset for training. The objective of this work was to demonstrate that explicitly encoding the cyclic nature of the breathing signal into the training data enables significant reduction of training datasets which can be obtained from healthy volunteers. Material and methods Seventy surface scanner breathing signals from 25 healthy volunteers in anterior-posterior direction were used for training and validation (ratio 4:1) of long short-term memory models. The model performance was compared to a model using decomposition into phase, amplitude and a time-dependent baseline. Testing of the models was performed on 55 independent breathing signals in anterior-posterior direction from surface scanner (35 lung, 20 liver) of 30 patients with a mean breathing amplitude of (5.9 ± 6.7) mm. Results Using the decomposed breathing signal allowed for a reduction of the absolute root-mean square error (RMSE) from 0.34 mm to 0.12 mm during validation. Testing using patient data yielded an average absolute RMSE of the breathing signal of (0.16 ± 0.11) mm with a prediction horizon of 500 ms. Conclusion It was demonstrated that a motion prediction model can be trained with less than 100 datasets of healthy volunteers if breathing cycle parameters are considered. Applied to 55 patients, the model predicted breathing motion with a high accuracy.
Collapse
Affiliation(s)
- Andreas Renner
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Ingo Gulyas
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Martin Buschmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Gerd Heilemann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Martin Heilmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Joachim Widder
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Petra Trnková
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Forde E, Josipovic M, Kamphuis M, Lopez J, Remeijer P, Rivera S, Scherer P, Wiersema L, de Jong R. What does "Advanced" mean in 2023? reflecting on 10 years of the ESTRO advanced Skills in modern radiotherapy course. Tech Innov Patient Support Radiat Oncol 2024; 29:100227. [PMID: 38126041 PMCID: PMC10733086 DOI: 10.1016/j.tipsro.2023.100227] [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: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective. Teaching these "advanced skills" has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.
Collapse
Affiliation(s)
- E. Forde
- Applied Radiation Therapy Trinity (ARTT), Discipline of Radiation Therapy, School of Medicine, Trinity St. James's Cancer Institute, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - M. Josipovic
- Department of Clinical Medicine, Faculty of Health, University of Copenhagen, Copenhagen Denmark
| | - M. Kamphuis
- Medical Imaging and Radiation Therapy, Inholland University of applied sciences, Haarlem, the Netherlands
| | - J. Lopez
- Department of Radiation Oncology, Instituto de Biomedicina de Sevilla/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - P. Remeijer
- Department of Radiation Oncology, The Dutch Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - S. Rivera
- Institut Gustave-Roussy, Villejuif, France
| | - P. Scherer
- University Clinic for Radiotherapy and RadioOncology of the PMU at the County Hospital Salzburg, Austria
| | - L. Wiersema
- Department of Radiation Oncology, The Dutch Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - R. de Jong
- Department of Radiation Oncology, Amsterdam University Medical Centres - location AMC, Cancer Institute Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
8
|
Knäusl B, Belotti G, Bertholet J, Daartz J, Flampouri S, Hoogeman M, Knopf AC, Lin H, Moerman A, Paganelli C, Rucinski A, Schulte R, Shimizu S, Stützer K, Zhang X, Zhang Y, Czerska K. A review of the clinical introduction of 4D particle therapy research concepts. Phys Imaging Radiat Oncol 2024; 29:100535. [PMID: 38298885 PMCID: PMC10828898 DOI: 10.1016/j.phro.2024.100535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024] Open
Abstract
Background and purpose Many 4D particle therapy research concepts have been recently translated into clinics, however, remaining substantial differences depend on the indication and institute-related aspects. This work aims to summarise current state-of-the-art 4D particle therapy technology and outline a roadmap for future research and developments. Material and methods This review focused on the clinical implementation of 4D approaches for imaging, treatment planning, delivery and evaluation based on the 2021 and 2022 4D Treatment Workshops for Particle Therapy as well as a review of the most recent surveys, guidelines and scientific papers dedicated to this topic. Results Available technological capabilities for motion surveillance and compensation determined the course of each 4D particle treatment. 4D motion management, delivery techniques and strategies including imaging were diverse and depended on many factors. These included aspects of motion amplitude, tumour location, as well as accelerator technology driving the necessity of centre-specific dosimetric validation. Novel methodologies for X-ray based image processing and MRI for real-time tumour tracking and motion management were shown to have a large potential for online and offline adaptation schemes compensating for potential anatomical changes over the treatment course. The latest research developments were dominated by particle imaging, artificial intelligence methods and FLASH adding another level of complexity but also opportunities in the context of 4D treatments. Conclusion This review showed that the rapid technological advances in radiation oncology together with the available intrafractional motion management and adaptive strategies paved the way towards clinical implementation.
Collapse
Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Belotti
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Mischa Hoogeman
- Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, The Netherlands
| | - Antje C Knopf
- Institut für Medizintechnik und Medizininformatik Hochschule für Life Sciences FHNW, Muttenz, Switzerland
| | - Haibo Lin
- New York Proton Center, New York, NY, USA
| | - Astrid Moerman
- Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Chiara Paganelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Antoni Rucinski
- Institute of Nuclear Physics Polish Academy of Sciences, PL-31342 Krakow, Poland
| | - Reinhard Schulte
- Division of Biomedical Engineering Sciences, School of Medicine, Loma Linda University
| | - Shing Shimizu
- Department of Carbon Ion Radiotherapy, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kristin Stützer
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden – Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Xiaodong Zhang
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
| | - Katarzyna Czerska
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
| |
Collapse
|
9
|
Hardcastle N, Josipovic M, Clementel E, Hernandez V, Smyth G, Gober M, Wilke L, Eaton D, Josset S, Lazarakis S, Saez J, Vieillevigne L, Jornet N, Mancosu P. Recommendation on the technical and dosimetric data to be included in stereotactic body radiation therapy clinical trial publications based on a systematic review. Radiother Oncol 2024; 190:110042. [PMID: 38043902 DOI: 10.1016/j.radonc.2023.110042] [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: 05/12/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/05/2023]
Abstract
The results of phase II and III trials on Stereotactic Body Radiation Therapy (SBRT) increased adoption of SBRT worldwide. The ability to replicate clinical trial outcomes in routine practice depends on the capability to reproduce technical and dosimetric procedures used in the clinical trial. In this systematic review, we evaluated if peer-reviewed publications of clinical trials in SBRT reported sufficient technical data to ensure safe and robust implementation in real world clinics. Twenty papers were selected for inclusion, and data was extracted by a working group of medical physicists created following the ESTRO 2021 physics workshop. A large variability in technical and dosimetric data were observed, with frequent lack of required information for reproducing trial procedures. None of the evaluated studies were judged completely reproducible from a technical perspective. A list of recommendations has been provided by the group, based on the analysis and consensus process, to ensure an adequate reproducibility of technical parameters in primary SBRT clinical trials. Future publications should consider these recommendations to assist transferability of the clinical trial in real world practice.
Collapse
Affiliation(s)
- Nicholas Hardcastle
- Physical Sciences, Peter MacCallum Cancer Centre & Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia
| | - Mirjana Josipovic
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet (RH), Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Enrico Clementel
- European Organisation for the Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Victor Hernandez
- Department of Medical Physics, Hospital Sant Joan de Reus, IISPV, 43204 Tarragona, Spain
| | - Gregory Smyth
- The London Radiotherapy Centre, HCA Healthcare UK, London, UK
| | - Manuela Gober
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Lotte Wilke
- Department of Radiation Oncology, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Stéphanie Josset
- Department of Medical Physics, Institut de Cancerologie de l'Ouest, 44805 Saint-Herblain, France
| | - Smaro Lazarakis
- Physical Sciences, Peter MacCallum Cancer Centre & Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia
| | - Jordi Saez
- Department of Radiation Oncology, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Laure Vieillevigne
- Department of Medical Physics, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse, F-31059 Toulouse, France
| | - Núria Jornet
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Pietro Mancosu
- Medical Physics Unit, Radiotherapy Department, IRCCS Humanitas Research Hospital, Rozzano-Milano, Italy
| |
Collapse
|
10
|
Sengupta C, Nguyen DT, Moodie T, Mason D, Luo J, Causer T, Liu SF, Brown E, Inskip L, Hazem M, Chao M, Wang T, Lee YY, van Gysen K, Sullivan E, Cosgriff E, Ramachandran P, Poulsen P, Booth J, O'Brien R, Greer P, Keall P. The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients. Radiother Oncol 2024; 190:110031. [PMID: 38008417 DOI: 10.1016/j.radonc.2023.110031] [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: 09/11/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients. METHODS/MATERIALS The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone. RESULTS The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone. CONCLUSIONS This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.
Collapse
Affiliation(s)
| | | | | | - Daniel Mason
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Jianjie Luo
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Trent Causer
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Sau Fan Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | - Elizabeth Brown
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | - Maryam Hazem
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Menglei Chao
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Tim Wang
- Crown Princess Mary Cancer Centre, Australia
| | - Yoo Y Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | | | | | | | - Per Poulsen
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Australia; Institute of Medical Physics, The University of Sydney, Australia
| | - Ricky O'Brien
- Image X Institute, The University of Sydney, Australia; RMIT University, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Australia
| | - Paul Keall
- Image X Institute, The University of Sydney, Australia
| |
Collapse
|
11
|
Knäusl B. The role of 4D particle therapy in daily patient care and research. Phys Imaging Radiat Oncol 2024; 29:100560. [PMID: 38434207 PMCID: PMC10906392 DOI: 10.1016/j.phro.2024.100560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
12
|
Katano A, Nozawa Y, Minamitani M, Ohira S, Nakagawa K. Intrafractional Diaphragm Variations During Breath-Hold Stereotactic Body Radiotherapy for a Liver Tumor Based on Real-Time Registration Between Kilovoltage Projection Streaming and Digitally Reconstructed Radiograph Images: A Case Report. Cureus 2023; 15:e48188. [PMID: 38054156 PMCID: PMC10695080 DOI: 10.7759/cureus.48188] [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] [Accepted: 11/02/2023] [Indexed: 12/07/2023] Open
Abstract
In liver stereotactic body radiotherapy (SBRT), precise image guidance is paramount, serving as the foundation of this treatment approach. The accuracy of SBRT in liver cancer treatment heavily relies on meticulous imaging techniques. The diaphragm, situated adjacent to the liver, is a crucial anatomical structure susceptible to positional and motion variations, which can potentially impact the accuracy of liver tumor targeting. This study explores the application of real-time kilovoltage projection streaming images (KVPSI) in comparison to digitally reconstructed radiography (DRR) for assessing diaphragm position deviations during breath-hold liver tumor SBRT. A 76-year-old male diagnosed with cholangiocarcinoma underwent breath-hold SBRT using split arc volumetric modulated arc therapy (VMAT), where a full arc was split into six sub-arcs, each spanning 60 degrees. The diaphragm dome positions were continuously monitored through KVPSI during treatment. The intrafractional position deviations of the diaphragm were calculated and analyzed for each split arc. The case report revealed a mean diaphragm dome deviation of 0.47 mm (standard deviation: 4.47 mm) in the entire arc. This pioneering study showcases the feasibility of intrafractional diaphragm position variation assessment using real-time KVPSI during the breath-hold liver tumor VMAT-SBRT. Integrating real-time imaging techniques enhances our comprehension of the intra-breath-hold variations, thereby guiding adaptive treatment strategies and potentially improving treatment outcomes. Clinical validation through further research is essential.
Collapse
Affiliation(s)
- Atsuto Katano
- Radiology, The University of Tokyo Hospital, Tokyo, JPN
| | - Yuki Nozawa
- Radiology, The University of Tokyo Hospital, Tokyo, JPN
| | | | - Shingo Ohira
- Comprehensive Radiation Oncology, The University of Tokyo, Tokyo, JPN
| | - Keiichi Nakagawa
- Comprehensive Radiation Oncology, The University of Tokyo, Tokyo, JPN
| |
Collapse
|
13
|
Loebner HA, Frauchiger D, Mueller S, Guyer G, Mackeprang PH, Stampanoni MFM, Fix MK, Manser P, Bertholet J. Technical note: Feasibility of gating for dynamic trajectory radiotherapy - Mechanical accuracy and dosimetric performance. Med Phys 2023; 50:6535-6542. [PMID: 37338935 DOI: 10.1002/mp.16533] [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: 11/07/2022] [Revised: 04/01/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Dynamic trajectory radiotherapy (DTRT) extends state-of-the-art volumetric modulated arc therapy (VMAT) by dynamic table and collimator rotations during beam-on. The effects of intrafraction motion during DTRT delivery are unknown, especially regarding the possible interplay between patient and machine motion with additional dynamic axes. PURPOSE To experimentally assess the technical feasibility and quantify the mechanical and dosimetric accuracy of respiratory gating during DTRT delivery. METHODS A DTRT and VMAT plan are created for a clinically motivated lung cancer case and delivered to a dosimetric motion phantom (MP) placed on the table of a TrueBeam system using Developer Mode. The MP reproduces four different 3D motion traces. Gating is triggered using an external marker block, placed on the MP. Mechanical accuracy and delivery time of the VMAT and DTRT deliveries with and without gating are extracted from the logfiles. Dosimetric performance is assessed by means of gamma evaluation (3% global/2 mm, 10% threshold). RESULTS The DTRT and VMAT plans are successfully delivered with and without gating for all motion traces. Mechanical accuracy is similar for all experiments with deviations <0.14° (gantry angle), <0.15° (table angle), <0.09° (collimator angle) and <0.08 mm (MLC leaf positions). For DTRT (VMAT), delivery times are 1.6-2.3 (1.6- 2.5) times longer with than without gating for all motion traces except one, where DTRT (VMAT) delivery is 5.0 (3.6) times longer due to a substantial uncorrected baseline drift affecting only DTRT delivery. Gamma passing rates with (without) gating for DTRT/VMAT were ≥96.7%/98.5% (≤88.3%/84.8%). For one VMAT arc without gating it was 99.6%. CONCLUSION Gating is successfully applied during DTRT delivery on a TrueBeam system for the first time. Mechanical accuracy is similar for VMAT and DTRT deliveries with and without gating. Gating substantially improved dosimetric performance for DTRT and VMAT.
Collapse
Affiliation(s)
- Hannes A Loebner
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Daniel Frauchiger
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Silvan Mueller
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Paul-Henry Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Michael K Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| |
Collapse
|
14
|
Burghelea M, Bakkali Tahiri J, Dhont J, Kyndt M, Gulyban A, Szkitsak J, Bogaert E, van Gestel D, Reynaert N. Results of a multicenter 4D computed tomography quality assurance audit: Evaluating image accuracy and consistency. Phys Imaging Radiat Oncol 2023; 28:100479. [PMID: 37694265 PMCID: PMC10485145 DOI: 10.1016/j.phro.2023.100479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
Background and purpose 4D Computed Tomography (4DCT) technology captures the location and movement of tumors and nearby organs at risk over time. In this study, a multi-institutional multi-vendor 4DCT audit was initiated to assess the accuracy of current imaging protocols. Materials and methods Twelve centers, including thirteen scanners performed a 4DCT acquisition of a dynamic thorax phantom using the institution's own protocol with the in-house breathing monitoring system. Five regular and three irregular breathing patterns were used. Image acquisition and reconstruction were followed by automated image analysis with our in-house developed 4DCT QA program (QAMotion). CT number accuracy, volume deviation, amplitude deviation, and spatial integrity were assessed per pattern using both the segmented volumes and line profiles. Results Regular breathing curves showed relatively accurate results across all institutions, with mean volume and CT number deviations and median amplitude deviation below 2%, 5 HU and 2 mm, respectively. Results obtained for irregular patterns showed more variation across the institutions. Volume and CT number deviations co-occurred with a blurring of the sphere, interpolation, or double-structure artifacts that were confirmed through the line profiles. For some of the irregular patterns, amplitude deviations up to 6 mm were observed. Maximum Intensity Projection (MaxIP) correctly captured the applied motion amplitude with deviations across all institutions within 2 mm except for double amplitude pattern. Conclusions All centers invited to participate in the audit responded positively, highlighting the need for a comprehensive yet easy-to-execute 4DCT quality assurance program. The largest variances between the results from one institution to another confirmed that a standardized 4DCT audit is warranted.
Collapse
Affiliation(s)
- Manuela Burghelea
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium
- Université Libre De Bruxelles, Radiophysics and MRI physics laboratory, Brussels, Belgium
| | - Jinane Bakkali Tahiri
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium
- Medical Physics Department, GasthuisZusters Antwerpen Ziekenhuizen, Antwerp, Belgium
| | - Jennifer Dhont
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium
- Université Libre De Bruxelles, Radiophysics and MRI physics laboratory, Brussels, Belgium
| | | | - Akos Gulyban
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium
- Université Libre De Bruxelles, Radiophysics and MRI physics laboratory, Brussels, Belgium
| | - Juliane Szkitsak
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Evelien Bogaert
- Department of Radiotherapy-Oncology, Ghent University Hospital, Gent, Belgium
| | - Dirk van Gestel
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Radiation Oncology Department, Brussels, Belgium
| | - Nick Reynaert
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Department of Medical Physics, Brussels, Belgium
- Université Libre De Bruxelles, Radiophysics and MRI physics laboratory, Brussels, Belgium
| |
Collapse
|
15
|
Wu C, Murray V, Siddiq SS, Tyagi N, Reyngold M, Crane C, Otazo R. Real-time 4D MRI using MR signature matching (MRSIGMA) on a 1.5T MR-Linac system. Phys Med Biol 2023; 68:10.1088/1361-6560/acf3cc. [PMID: 37619588 PMCID: PMC10513779 DOI: 10.1088/1361-6560/acf3cc] [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: 05/11/2023] [Accepted: 08/24/2023] [Indexed: 08/26/2023]
Abstract
Objective. To develop real-time 4D MRI using MR signature matching (MRSIGMA) for volumetric motion imaging in patients with pancreatic cancer on a 1.5T MR-Linac system.Approach. Two consecutive MRI scans with 3D golden-angle radial stack-of-stars acquisitions were performed on ten patients with inoperable pancreatic cancer. The complete first scan (905 angles) was used to compute a 4D motion dictionary including ten pairs of 3D motion images and signatures. The second scan was used for real-time imaging, where each angle (275 ms) was processed separately to match it to one of the dictionary entries. The complete second scan was also used to compute a 4D reference to assess motion tracking performance.Dicecoefficients of the gross tumor volume (GTV) and two organs-at-risk (duodenum-stomach and small bowel) were calculated between signature matching and reference. In addition, volume changes, displacements, center of mass shifts, andDicescores over time were calculated to characterize motion.Main results. Total imaging latency of MRSIGMA (acquisition + matching) was less than 300 ms. TheDicecoefficients were 0.87 ± 0.06 (GTV), 0.86 ± 0.05 (duodenum-stomach), and 0.85 ± 0.05 (small bowel), which indicate high accuracy (high mean value) and low uncertainty (low standard deviation) of MRSIGMA for real-time motion tracking. The center of mass shift was 3.1 ± 2.0 mm (GTV), 5.3 ± 3.0 mm (duodenum-stomach), and 3.4 ± 1.5 mm (small bowel). TheDicescores over time (0.97 ± [0.01-0.03]) were similarly high for MRSIGMA and reference scans in all the three contours.Significance. This work demonstrates the feasibility of real-time 4D MRI using MRSIGMA for volumetric motion tracking on a 1.5T MR-Linac system. The high accuracy and low uncertainty of real-time MRSIGMA is an essential step towards continuous treatment adaptation of tumors affected by real-time respiratory motion and could ultimately improve treatment safety by optimizing ablative dose delivery near gastrointestinal organs.
Collapse
Affiliation(s)
- Can Wu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Victor Murray
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Syed S. Siddiq
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ricardo Otazo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
16
|
Aznar MC, Carrasco de Fez P, Corradini S, Mast M, McNair H, Meattini I, Persson G, van Haaren P. ESTRO-ACROP guideline: Recommendations on implementation of breath-hold techniques in radiotherapy. Radiother Oncol 2023; 185:109734. [PMID: 37301263 DOI: 10.1016/j.radonc.2023.109734] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
The use of breath-hold techniques in radiotherapy, such as deep-inspiration breath hold, is increasing although guidelines for clinical implementation are lacking. In these recommendations, we aim to provide an overview of available technical solutions and guidance for best practice in the implementation phase. We will discuss specific challenges in different tumour sites including factors such as staff training and patient coaching, accuracy, and reproducibility. In addition, we aim to highlight the need for further research in specific patient groups. This report also reviews considerations for equipment, staff training and patient coaching, as well as image guidance for breath-hold treatments. Dedicated sections for specific indications, namely breast cancer, thoracic and abdominal tumours are also included.
Collapse
Affiliation(s)
- Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
| | - Pablo Carrasco de Fez
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Mirjam Mast
- Department of Radiotherapy, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - Helen McNair
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, UK
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Gitte Persson
- Department of Oncology, Herlev-Gentofte Hospital, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Denmark
| | - Paul van Haaren
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| |
Collapse
|
17
|
Hindley N, Shieh CC, Keall P. A patient-specific deep learning framework for 3D motion estimation and volumetric imaging during lung cancer radiotherapy. Phys Med Biol 2023; 68:14NT01. [PMID: 37364571 DOI: 10.1088/1361-6560/ace1d0] [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: 02/17/2023] [Accepted: 06/26/2023] [Indexed: 06/28/2023]
Abstract
Objective. Respiration introduces a constant source of irregular motion that poses a significant challenge for the precise irradiation of thoracic and abdominal cancers. Current real-time motion management strategies require dedicated systems that are not available in most radiotherapy centers. We sought to develop a system that estimates and visualises the impact of respiratory motion in 3D given the 2D images acquired on a standard linear accelerator.Approach. In this paper we introduceVoxelmap, a patient-specific deep learning framework that achieves 3D motion estimation and volumetric imaging using the data and resources available in standard clinical settings. Here we perform a simulation study of this framework using imaging data from two lung cancer patients.Main results. Using 2D images as input and 3D-3DElastixregistrations as ground-truth,Voxelmapwas able to continuously predict 3D tumor motion with mean errors of 0.1 ± 0.5, -0.6 ± 0.8, and 0.0 ± 0.2 mm along the left-right, superior-inferior, and anterior-posterior axes respectively.Voxelmapalso predicted 3D thoracoabdominal motion with mean errors of -0.1 ± 0.3, -0.1 ± 0.6, and -0.2 ± 0.2 mm respectively. Moreover, volumetric imaging was achieved with mean average error 0.0003, root-mean-squared error 0.0007, structural similarity 1.0 and peak-signal-to-noise ratio 65.8.Significance. The results of this study demonstrate the possibility of achieving 3D motion estimation and volumetric imaging during lung cancer treatments on a standard linear accelerator.
Collapse
Affiliation(s)
| | - Chun-Chien Shieh
- Image X Institute, University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, University of Sydney, Sydney, Australia
| | - Paul Keall
- Image X Institute, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
18
|
Knäusl B, Taasti VT, Poulsen P, Muren LP. Surveying the clinical practice of treatment adaptation and motion management in particle therapy. Phys Imaging Radiat Oncol 2023; 27:100457. [PMID: 37361612 PMCID: PMC10285555 DOI: 10.1016/j.phro.2023.100457] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Vicki T Taasti
- Department of Radiation Oncology (Maastro), GROW - School for Oncology and Reproduction, Maastricht, University Medical Centre+, Maastricht, The Netherlands
| | - Per Poulsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University, Aarhus, Denmark
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
19
|
Liang Z, Zhang M, Shi C, Huang ZR. Real-time respiratory motion prediction using photonic reservoir computing. Sci Rep 2023; 13:5718. [PMID: 37029184 PMCID: PMC10082218 DOI: 10.1038/s41598-023-31296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/09/2023] [Indexed: 04/09/2023] Open
Abstract
Respiration induced motion is a well-recognized challenge in many clinical practices including upper body imaging, lung tumor motion tracking and radiation therapy. In this work, we present a recurrent neural network algorithm that was implemented in a photonic delay-line reservoir computer (RC) for real-time respiratory motion prediction. The respiratory motion signals are quasi-periodic waveforms subject to a variety of non-linear distortions. In this work, we demonstrated for the first time that RC can be effective in predicting short to medium range of respiratory motions within practical timescales. A double-sliding window technology is explored to enable the real-time establishment of an individually trained model for each patient and the real-time processing of live-streamed respiratory motion data. A breathing dataset from a total of 76 patients with breathing speeds ranging from 3 to 20 breaths per minute (BPM) is studied. Motion prediction of look-ahead times of 66.6, 166.6, and 333 ms are investigated. With a 333 ms look-ahead time, the real-time RC model achieves an average normalized mean square error (NMSE) of 0.025, an average mean absolute error (MAE) of 0.34 mm, an average root mean square error (RMSE) of 0.45 mm, an average therapeutic beam efficiency (TBE) of 94.14% for an absolute error (AE) < 1 mm, and 99.89% for AE < 3 mm. This study demonstrates that real-time RC is an efficient computing framework for high precision respiratory motion prediction.
Collapse
Affiliation(s)
- Zhizhuo Liang
- Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Meng Zhang
- Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Chengyu Shi
- City of Hope Medical Center, Duarte, CA, 91010, USA
| | - Z Rena Huang
- Rensselaer Polytechnic Institute, Troy, NY, 12180, USA.
| |
Collapse
|
20
|
Zhang Y, Trnkova P, Toshito T, Heijmen B, Richter C, Aznar M, Albertini F, Bolsi A, Daartz J, Bertholet J, Knopf A. A survey of practice patterns for real-time intrafractional motion-management in particle therapy. Phys Imaging Radiat Oncol 2023; 26:100439. [PMID: 37124167 PMCID: PMC10133874 DOI: 10.1016/j.phro.2023.100439] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Background and purpose Organ motion compromises accurate particle therapy delivery. This study reports on the practice patterns for real-time intrafractional motion-management in particle therapy to evaluate current clinical practice and wishes and barriers to implementation. Materials and methods An institutional questionnaire was distributed to particle therapy centres worldwide (7/2020-6/2021) asking which type(s) of real-time respiratory motion management (RRMM) methods were used, for which treatment sites, and what were the wishes and barriers to implementation. This was followed by a three-round DELPHI consensus analysis (10/2022) to define recommendations on required actions and future vision. With 70 responses from 17 countries, response rate was 100% for Europe (23/23 centres), 96% for Japan (22/23) and 53% for USA (20/38). Results Of the 68 clinically operational centres, 85% used RRMM, with 41% using both rescanning and active methods. Sixty-four percent used active-RRMM for at least one treatment site, mostly with gating guided by an external marker. Forty-eight percent of active-RRMM users wished to expand or change their RRMM technique. The main barriers were technical limitations and limited resources. From the DELPHI analysis, optimisation of rescanning parameters, improvement of motion models, and pre-treatment 4D evaluation were unanimously considered clinically important future focus. 4D dose calculation was identified as the top requirement for future commercial treatment planning software. Conclusion A majority of particle therapy centres have implemented RRMM. Still, further development and clinical integration were desired by most centres. Joint industry, clinical and research efforts are needed to translate innovation into efficient workflows for broad-scale implementation.
Collapse
Affiliation(s)
- Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Petra Trnkova
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Toshiyuki Toshito
- Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Marianne Aznar
- Faculty of Biology, Medicine and Health, Division of Cancer Sciences, University of Manchester, United Kingdom
| | | | - Alexandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Juliane Daartz
- F. Burr Proton Therapy, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Antje Knopf
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Institute for Medical Engineering and Medical Informatics, School of Life Science FHNW, Muttenz, Switzerland
| |
Collapse
|
21
|
Trnkova P, Zhang Y, Toshito T, Heijmen B, Richter C, Aznar MC, Albertini F, Bolsi A, Daartz J, Knopf AC, Bertholet J. A survey of practice patterns for adaptive particle therapy for interfractional changes. Phys Imaging Radiat Oncol 2023; 26:100442. [PMID: 37197154 PMCID: PMC10183663 DOI: 10.1016/j.phro.2023.100442] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Background and purpose Anatomical changes may compromise the planned target coverage and organs-at-risk dose in particle therapy. This study reports on the practice patterns for adaptive particle therapy (APT) to evaluate current clinical practice and wishes and barriers to further implementation. Materials and methods An institutional questionnaire was distributed to PT centres worldwide (7/2020-6/2021) asking which type of APT was used, details of the workflow, and what the wishes and barriers to implementation were. Seventy centres from 17 countries participated. A three-round Delphi consensus analysis (10/2022) among the authors followed to define recommendations on required actions and future vision. Results Out of the 68 clinically operational centres, 84% were users of APT for at least one treatment site with head and neck being most common. APT was mostly performed offline with only two online APT users (plan-library). No centre used online daily re-planning. Daily 3D imaging was used for APT by 19% of users. Sixty-eight percent of users had plans to increase their use or change their technique for APT. The main barrier was "lack of integrated and efficient workflows". Automation and speed, reliable dose deformation for dose accumulation and higher quality of in-room volumetric imaging were identified as the most urgent task for clinical implementation of online daily APT. Conclusion Offline APT was implemented by the majority of PT centres. Joint efforts between industry research and clinics are needed to translate innovations into efficient and clinically feasible workflows for broad-scale implementation of online APT.
Collapse
Affiliation(s)
- Petra Trnkova
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Corresponding author.
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Toshiyuki Toshito
- Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Marianne C. Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| | - Antje C. Knopf
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Institute for Medical Engineering and Medical Informatics, School of Life Science FHNW, Muttenz, Switzerland
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| |
Collapse
|
22
|
Vander Veken L, Van Ooteghem G, Razavi A, Da Rita Quaresma S, Longton E, Kirkove C, Ledoux B, Vandermeulen A, Abdel Massih C, Henderickx P, Gabriels M, Delvaux C, Salah F, Vaandering A, Geets X. Voluntary versus mechanically-induced deep inspiration breath-hold for left breast cancer: A randomized controlled trial. Radiother Oncol 2023; 183:109598. [PMID: 36898583 DOI: 10.1016/j.radonc.2023.109598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND PURPOSE Deep inspiration breath-hold (DIBH) protects critical organs-at-risk (OARs) for adjuvant breast radiotherapy. Guidance systems e.g. surface guided radiation therapy (SGRT) improve the positional breast reproducibility and stability during DIBH. In parallel, OARs sparing with DIBH is enhanced through different techniques e.g. prone position, continuous positive airway pressure (CPAP). By inducing repeated DIBH with the same level of positive pressure, mechanically-assisted and non-invasive ventilation (MANIV) could potentially combine these DIBH optimizations. MATERIALS AND METHODS We conducted a randomized, open-label, multicenter and single-institution non-inferiority trial. Sixty-six patients eligible for adjuvant left whole-breast radiotherapy in supine position were equally assigned between mechanically-induced DIBH (MANIV-DIBH) and voluntary DIBH guided by SGRT (sDIBH). The co-primary endpoints were positional breast stability and reproducibility with a non-inferiority margin of 1 mm. Secondary endpoints were tolerance assessed daily via validated scales, treatment time, dose to OARs and their inter-fraction positional reproducibility. RESULTS Differences between both arms for positional breast reproducibility and stability occurred at a sub-millimetric level (p < 0.001 for non-inferiority). The left anterior descending artery near-max dose (14,6 ± 12,0 Gy vs. 7,7 ± 7,1 Gy, p = 0,018) and mean dose (5,0 ± 3,5 Gy vs. 3,0 ± 2,0 Gy, p = 0,009) were improved with MANIV-DIBH. The same applied for the V5Gy of the left ventricle (2,4 ± 4,1 % vs. 0,8 ± 1,6 %, p = 0,001) as well as for the left lung V20Gy (11,4 ± 2,8 % vs. 9,7 ± 2,7 %, p = 0,019) and V30Gy (8,0 ± 2,6 % vs. 6,5 ± 2,3 %, p = 0,0018). Better heart's inter-fraction positional reproducibility was observed with MANIV-DIBH. Tolerance and treatment time were similar. CONCLUSION Mechanical ventilation provides the same target irradiation accuracy as with SGRT while better protecting and repositioning OARs.
Collapse
Affiliation(s)
- Loïc Vander Veken
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium.
| | - Geneviève Van Ooteghem
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Ariane Razavi
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Eleonore Longton
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Carine Kirkove
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Benjamin Ledoux
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Ad Vandermeulen
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Christel Abdel Massih
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Pascale Henderickx
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Mortimer Gabriels
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Céline Delvaux
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Faycal Salah
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Aude Vaandering
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Xavier Geets
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| |
Collapse
|
23
|
Giżyńska MK, Seppenwoolde Y, Kilby W, Heijmen BJ. A novel external/internal tumor tracking approach to compensate for respiratory motion baseline drifts. Phys Med Biol 2023; 68. [PMID: 36753764 DOI: 10.1088/1361-6560/acba79] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/08/2023] [Indexed: 02/10/2023]
Abstract
Objective.Real-time respiratory tumor tracking as implemented in a robotic treatment unit is based on continuous optical measurement of the position of external markers and a correlation model between them and internal target positions, which are established with X-ray imaging of the tumor, or fiducials placed in or around the tumor. Correlation models are created with fifteen simultaneously measured external/internal marker position pairs divided over the respiratory cycle. Every 45-150 s, the correlation model is updated by replacing the three first acquired data pairs with three new pairs. Tracking simulations for >120.000 computer-generated respiratory tracks demonstrated that this tracking approach resulted in relevant inaccuracies in internal target position predictions, especially in case of presence of respiratory motion baseline drifts.Approach.To better cope with drifts, we introduced a novel correlation model with an explicit time dependence, and we proposed to replace the currently applied linear-motion tracking (LMT) by mixed-model tracking (MMT). In MMT, the linear correlation model is extended with an explicit time dependence in case of a detected baseline drift. MMT prediction accuracies were then established for the same >120.000 computer-generated patients as used for LMT.Main results.For 150 s update intervals, MMT outperformed LMT in internal target position prediction accuracy for 93.7 ∣ 97.2% of patients with 0.25 ∣ 0.5 mm min-1linear respiratory motion baseline drifts with similar numbers of X-ray images and similar treatment times. For the upper 25% of patients, mean 3D internal target position prediction errors reduced by 0.7 ∣ 1.8 mm, while near maximum reductions (upper 10% of patients) were 0.9 ∣ 2.0 mm.Significance.For equal numbers of acquired X-ray images, MMT greatly improved tracking accuracy compared to LMT, especially in the presence of baseline drifts. Even with almost 50% less acquired X-ray images, MMT still outperformed LMT in internal target position prediction accuracy.
Collapse
Affiliation(s)
- Marta K Giżyńska
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Yvette Seppenwoolde
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Warren Kilby
- Accuray Incorporated, Sunnyvale, CA, United States of America
| | - Ben Jm Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
24
|
Kamima T, Iino M, Sakai R, Ito Y, Sakae T, Moriya S, Tokumasu K, Yoshioka Y. Evaluation of the four-dimensional motion of lung tumors during end-exhalation breath-hold conditions using volumetric cine computed tomography images. Radiother Oncol 2023; 182:109573. [PMID: 36822360 DOI: 10.1016/j.radonc.2023.109573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND AND PURPOSE This study was performed to evaluate the four-dimensional motion of lung tumors during end-exhalation (EE) breath-holding (BH) using cine computed tomography (CT) and investigate the correlation between tumor and surrogate marker motions. MATERIALS AND METHODS This study included 28 patients who underwent stereotactic body radiation therapy at our institution and were capable of 15-20 s of EE BH within a ±1.5-mm gating window with external markers. During EE BH with cine CT, 21 s of continuous data were acquired using 320-row multislice CT. Displacements in the tumor position during EE BH were assessed in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions. Pearson's correlation coefficient (r) between tumor motions during EE BH and diaphragm/external marker motions was also determined. RESULTS The mean absolute maximum displacements of the tumor position during EE BH were 1.3 (range: 0.2-4.0), 1.9 (range: 0.3-12.0), and 1.3 (range: 0.1-7.2) mm in the LR, AP, and SI directions, respectively. The displacement of the tumor position in the AP direction was weakly correlated (|r| < 0.4) with the external marker and diaphragm displacements in many cases (proportions of 50% and 46%, respectively). CONCLUSION We found some cases showing substantial displacement in lung tumor positions during EE BH, especially in the AP direction. Because these tumor position displacements did not correlate with surrogate markers and were difficult to detect, we recommend pretreatment evaluation of the four-dimensional motions of tumors during BH using cine CT.
Collapse
Affiliation(s)
- Tatsuya Kamima
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan; Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Misae Iino
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Ryohei Sakai
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Yasushi Ito
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Takeji Sakae
- Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Shunsuke Moriya
- Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kenji Tokumasu
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Yasuo Yoshioka
- Radiation Oncology Department, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| |
Collapse
|
25
|
Ball HJ, Santanam L, Senan S, Tanyi JA, van Herk M, Keall PJ. Results from the AAPM Task Group 324 respiratory motion management in radiation oncology survey. J Appl Clin Med Phys 2022; 23:e13810. [PMID: 36316761 PMCID: PMC9680579 DOI: 10.1002/acm2.13810] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/12/2022] [Accepted: 09/19/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To quantify the clinical practice of respiratory motion management in radiation oncology. METHODS A respiratory motion management survey was designed and conducted based on clinician survey guidelines. The survey was administered to American Association of Physicists in Medicine (AAPM) members on 17 August 2020 and closed on 13 September 2020. RESULTS A total of 527 respondents completed the entire survey and 651 respondents completed part of the survey, with the partially completed surveys included in the analysis. Overall, 84% of survey respondents used deep inspiration breath hold for left-sided breast cancer. Overall, 83% of respondents perceived respiratory motion management for thoracic and abdominal cancer radiotherapy patients to be either very important or required. Overall, 95% of respondents used respiratory motion management for thoracic and abdominal sites, with 36% of respondents using respiratory motion management for at least 90% of thoracic and abdominal patients. The majority (60%) of respondents used the internal target volume method to treat thoracic and abdominal cancer patients, with 25% using breath hold or abdominal compression and 13% using gating or tracking. CONCLUSIONS A respiratory motion management survey has been completed by AAPM members. Respiratory motion management is generally considered very important or required and is widely used for breast, thoracic, and abdominal cancer treatments.
Collapse
Affiliation(s)
- Helen J. Ball
- ACRF Image X InstituteFaculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Lakshmi Santanam
- Medical Physics DepartmentMemorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
| | - Suresh Senan
- Amsterdam University Medical Centers – VUmc LocationAmsterdamThe Netherlands
| | - James A. Tanyi
- Department of Radiation OncologyGeisinger Cancer InstituteDanvillePennsylvaniaUSA
| | - Marcel van Herk
- Department of Radiotherapy Related Research, Division of Cancer Sciences, Faculty of MedicineBiology and HealthSchool of Medical SciencesThe University of ManchesterManchesterUK
| | - Paul J. Keall
- ACRF Image X InstituteFaculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| |
Collapse
|
26
|
Elhamiasl M, Salvo K, Poels K, Defraene G, Lambrecht M, Geets X, Sterpin E, Nuyts J. Low-dose CT allows for accurate proton therapy dose calculation and plan optimization. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8dde] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. Protons offer a more conformal dose delivery compared to photons, yet they are sensitive to anatomical changes over the course of treatment. To minimize range uncertainties due to anatomical variations, a new CT acquisition at every treatment session would be paramount to enable daily dose calculation and subsequent plan adaptation. However, the series of CT scans results in an additional accumulated patient dose. Reducing CT radiation dose and thereby decreasing the potential risk of radiation exposure to patients is desirable, however, lowering the CT dose results in a lower signal-to-noise ratio and therefore in a reduced quality image. We hypothesized that the signal-to-noise ratio provided by conventional CT protocols is higher than needed for proton dose distribution estimation. In this study, we aim to investigate the effect of CT imaging dose reduction on proton therapy dose calculations and plan optimization. Approach. To verify our hypothesis, a CT dose reduction simulation tool has been developed and validated to simulate lower-dose CT scans from an existing standard-dose scan. The simulated lower-dose CTs were then used for proton dose calculation and plan optimization and the results were compared with those of the standard-dose scan. The same strategy was adopted to investigate the effect of CT dose reduction on water equivalent thickness (WET) calculation to quantify CT noise accumulation during integration along the beam. Main results. The similarity between the dose distributions acquired from the low-dose and standard-dose CTs was evaluated by the dose-volume histogram and the 3D Gamma analysis. The results on an anthropomorphic head phantom and three patient cases indicate that CT imaging dose reduction up to 90% does not have a significant effect on proton dose calculation and plan optimization. The relative error was employed to evaluate the similarity between WET maps and was found to be less than 1% after reducing the CT imaging dose by 90%. Significance. The results suggest the possibility of using low-dose CT for proton therapy dose estimation, since the dose distributions acquired from the standard-dose and low-dose CTs are clinically equivalent.
Collapse
|
27
|
Burton A, Beveridge S, Hardcastle N, Lye J, Sanagou M, Franich R. Adoption of respiratory motion management in radiation therapy. Phys Imaging Radiat Oncol 2022; 24:21-29. [PMID: 36148153 PMCID: PMC9485913 DOI: 10.1016/j.phro.2022.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose A survey on the patterns of practice of respiratory motion management (MM) was distributed to 111 radiation therapy facilities to inform the development of an end-to-end dosimetry audit including respiratory motion. Materials and methods The survey (distributed via REDCap) asked facilities to provide information specific to the combinations of MM techniques (breath-hold gating – BHG, internal target volume – ITV, free-breathing gating – FBG, mid-ventilation – MidV, tumour tracking – TT), sites treated (thorax, upper abdomen, lower abdomen), and fractionation regimes (conventional, stereotactic ablative body radiation therapy – SABR) used in their clinic. Results The survey was completed by 78% of facilities, with 98% of respondents indicating that they used at least one form of MM. The ITV approach was common to all MM-users, used for thoracic treatments by 89% of respondents, and upper and lower abdominal treatments by 38%. BHG was the next most prevalent (41% of MM users), with applications in upper abdominal and thoracic treatment sites (28% vs 25% respectively), but minimal use in the lower abdomen (9%). FBG and TT were utilised sparingly (17%, 7% respectively), and MidV was not selected at all. Conclusions Two distinct treatment workflows (including use of motion limitation, imaging used for motion assessment, dose calculation, and image guidance procedures) were identified for the ITV and BHG MM techniques, to form the basis of the initial audit. Thoracic SABR with the ITV approach was common to nearly all respondents, while upper abdominal SABR using BHG stood out as more technically challenging. Other MM techniques were sparsely used, but may be considered for future audit development.
Collapse
|
28
|
Fjellanger K, Rossi L, Heijmen BJM, Pettersen HES, Sandvik IM, Breedveld S, Sulen TH, Hysing LB. Patient selection, inter-fraction plan robustness and reduction of toxicity risk with deep inspiration breath hold in intensity-modulated radiotherapy of locally advanced non-small cell lung cancer. Front Oncol 2022; 12:966134. [PMID: 36110942 PMCID: PMC9469652 DOI: 10.3389/fonc.2022.966134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background State-of-the-art radiotherapy of locally advanced non-small cell lung cancer (LA-NSCLC) is performed with intensity-modulation during free breathing (FB). Previous studies have found encouraging geometric reproducibility and patient compliance of deep inspiration breath hold (DIBH) radiotherapy for LA-NSCLC patients. However, dosimetric comparisons of DIBH with FB are sparse, and DIBH is not routinely used for this patient group. The objective of this simulation study was therefore to compare DIBH and FB in a prospective cohort of LA-NSCLC patients treated with intensity-modulated radiotherapy (IMRT). Methods For 38 LA-NSCLC patients, 4DCTs and DIBH CTs were acquired for treatment planning and during the first and third week of radiotherapy treatment. Using automated planning, one FB and one DIBH IMRT plan were generated for each patient. FB and DIBH was compared in terms of dosimetric parameters and NTCP. The treatment plans were recalculated on the repeat CTs to evaluate robustness. Correlations between ΔNTCPs and patient characteristics that could potentially predict the benefit of DIBH were explored. Results DIBH reduced the median Dmean to the lungs and heart by 1.4 Gy and 1.1 Gy, respectively. This translated into reductions in NTCP for radiation pneumonitis grade ≥2 from 20.3% to 18.3%, and for 2-year mortality from 51.4% to 50.3%. The organ at risk sparing with DIBH remained significant in week 1 and week 3 of treatment, and the robustness of the target coverage was similar for FB and DIBH. While the risk of radiation pneumonitis was consistently reduced with DIBH regardless of patient characteristics, the ability to reduce the risk of 2-year mortality was evident among patients with upper and left lower lobe tumors but not right lower lobe tumors. Conclusion Compared to FB, DIBH allowed for smaller target volumes and similar target coverage. DIBH reduced the lung and heart dose, as well as the risk of radiation pneumonitis and 2-year mortality, for 92% and 74% of LA-NSCLC patients, respectively. However, the advantages varied considerably between patients, and the ability to reduce the risk of 2-year mortality was dependent on tumor location. Evaluation of repeat CTs showed similar robustness of the dose distributions with each technique.
Collapse
Affiliation(s)
- Kristine Fjellanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
| | - Linda Rossi
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ben J. M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Inger Marie Sandvik
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Turid Husevåg Sulen
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv Bolstad Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
- *Correspondence: Liv Bolstad Hysing,
| |
Collapse
|
29
|
Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
Collapse
Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
30
|
Gulyas I, Trnkova P, Knäusl B, Widder J, Georg D, Renner A. A novel bone suppression algorithm in intensity‐based 2D/3D image registration for real‐time tumour motion monitoring: development and phantom‐based validation. Med Phys 2022; 49:5182-5194. [PMID: 35598307 PMCID: PMC9540269 DOI: 10.1002/mp.15716] [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: 10/21/2021] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background Real‐time tumor motion monitoring (TMM) is a crucial process for intra‐fractional respiration management in lung cancer radiotherapy. Since the tumor can be partly or fully located behind the ribs, the TMM is challenging. Purpose The aim of this work was to develop a bone suppression (BS) algorithm designed for real‐time 2D/3D marker‐less TMM to increase the visibility of the tumor when overlapping with bony structures and consequently to improve the accuracy of TMM. Method A BS method was implemented in the in‐house developed software for ultrafast intensity‐based 2D/3D tumor registration (Fast Image‐based Registration [FIRE]). The method operates on both, digitally reconstructed radiograph (DRR) and intra‐fractional X‐ray images. The bony structures are derived from computed tomography data by thresholding during ray‐casting, and the resulting bone DRR is subtracted from intra‐fractional X‐ray images to obtain a soft‐tissue‐only image for subsequent tumor registration. The accuracy of TMM utilizing BS was evaluated within a retrospective phantom study with nine different 3D‐printed tumor phantoms placed in the in‐house developed Advanced Radiation DOSimetry (ARDOS) breathing phantom. A 24 mm craniocaudal tumor motion, including rib eclipses, was simulated, and X‐ray images were acquired on the Elekta Versa HD Linac in the lateral and posterior–anterior directions. An error assessment for BS images was evaluated with respect to the ground truth tumor position. Results A total error (root mean square error) of 0.87 ± 0.23 mm and 1.03 ± 0.26 mm was found for posterior–anterior and lateral imaging; the mean time for BS was 8.03 ± 1.54 ms. Without utilizing BS, TMM failed in all X‐ray images since the registration algorithm focused on the rib position due to the predominant intensity of this tissue within DRR and X‐ray images. Conclusion The BS algorithm developed and implemented improved the accuracy, robustness, and stability of real‐time TMM in lung cancer in a phantom study, even in the case of rib interlude where normal tumor registration fails.
Collapse
Affiliation(s)
- Ingo Gulyas
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
| | - Petra Trnkova
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
| | - Barbara Knäusl
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
- MedAustron Ion Therapy Center Wiener Neustadt Austria
| | - Joachim Widder
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
| | - Dietmar Georg
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
- MedAustron Ion Therapy Center Wiener Neustadt Austria
| | - Andreas Renner
- Division of Medical Radiation Physics Department of Radiation Oncology Medical University of Vienna
| |
Collapse
|
31
|
Willmann J, Sidiqi B, Wang C, Czmielewski C, Li HJ, Dick-Godfrey R, Chawla M, Lee RP, Gelb E, Wu AJ, Lovelock M, Zhang Z, Yorke ED, Rimner A. Four-Dimensional Computed Tomography-Based Correlation of Respiratory Motion of Lung Tumors With Implanted Fiducials and an External Surrogate. Adv Radiat Oncol 2022; 7:100885. [PMID: 35198837 PMCID: PMC8792087 DOI: 10.1016/j.adro.2021.100885] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Our purpose was to assess the suitability of airway-implanted internal fiducial markers and an external surrogate of respiratory motion for motion management during radiation therapy of lung tumors. Methods and Materials We analyzed 4-dimensional computed tomography scans acquired during radiation therapy simulation for 28 patients with lung tumors who had anchored fiducial markers bronchoscopically implanted inside small airways in or near the tumor in a prospective trial. We used a linear mixed model to build population-based correlative models of tumor and surrogate motion. The first 24 of the 28 patients were used to build correlative models, and 4 of the 28 consecutive patients were excluded and used as an internal validation cohort. Of the 24 patients from the model building cohort, all were used for the models based on the internal fiducial. The external surrogate was completely visualized in 11 patients from the model building cohort, so only those were used for the models based on the external surrogate. Furthermore, we determined the predicted residual error sum of squares for our correlative models, which may serve as benchmarks for future research. Results The motion of the internal fiducials was significantly associated with the tumor motion in the anterior-posterior (P < .0001) and superior-inferior (SI) directions (P < .0001). We also observed a strong correlation of the external surrogate anterior-posterior motion to the tumor dominant SI motion (P < .0001). In the validation cohort, the internal fiducial SI motion was the only reliable predictor of lung tumor motion. Conclusions The internal fiducials appear to be more reliable predictors of lung tumor motion than the external surrogate. The suitability of such airway-implanted internal fiducial markers for advanced motion management techniques should be further investigated. Although the external surrogate seems to be less reliable, its wide availability and noninvasive application support its clinical utility, albeit the greater uncertainty will need to be compensated for.
Collapse
|
32
|
Webster A, McNair HA, Hansen VN, Lewis R, Patel E, Miles E, Hall E, Hafeez S, Huddart R. Recognising the challenges of implementing multi-centre adaptive plan of the day radiotherapy. Tech Innov Patient Support Radiat Oncol 2022; 21:31-35. [PMID: 35198744 PMCID: PMC8841376 DOI: 10.1016/j.tipsro.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/28/2022] Open
Abstract
Two multicentre adaptive radiotherapy trials utilising Plan of the Day (PoD) with a library of plans were introduced in 35 centres. The common issues that arose from all centres when introducing PoD were collated retrospectively, through reviewing the data pertaining to the pre-trial and on-trial quality assurance programme. It was found that 1,295 issues arose when introducing PoD in outlining, planning, treatment delivery i.e., PoD selection, and in the overall process of delivering PoD. There was no difference in the number of issues that arose from pre-trial to on-trial. Thus, it is recommended that the implementation of PoD is supported by guidance, reviews, and continuous monitoring.
Collapse
Affiliation(s)
- Amanda Webster
- National Radiotherapy Trials Quality Assurance Group (RTTQA), University College Hospital (UCLH), London, United Kingdom
| | - Helen A. McNair
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, Radiotherapy Department, London, United Kingdom
| | - Vibeke N. Hansen
- Copenhagen University Hospital -Rigshospitalet, Department of Oncology, Copenhagen, Denmark
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Emma Patel
- National Radiotherapy Trials Quality Assurance Group (RTTQA), University College Hospital (UCLH), London, United Kingdom
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Shaista Hafeez
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, Radiotherapy Department, London, United Kingdom
| | - Robert Huddart
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, Radiotherapy Department, London, United Kingdom
| | - RAIDER, HYBRID Trial Management Groups
- National Radiotherapy Trials Quality Assurance Group (RTTQA), University College Hospital (UCLH), London, United Kingdom
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, Radiotherapy Department, London, United Kingdom
- Copenhagen University Hospital -Rigshospitalet, Department of Oncology, Copenhagen, Denmark
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, United Kingdom
| |
Collapse
|
33
|
Ma M, Liu C, Wei R, Liang B, Dai J. Predicting machine's performance record using the stacked long short-term memory (LSTM) neural networks. J Appl Clin Med Phys 2022; 23:e13558. [PMID: 35170838 PMCID: PMC8906230 DOI: 10.1002/acm2.13558] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/23/2021] [Accepted: 01/21/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose The record of daily quality control (QC) items shows machine performance patterns and potentially provides warning messages for preventive actions. This study developed a neural network model that could predict the record and trend of data variations quantitively. Methods and materials The record of 24 QC items for a radiotherapy machine was investigated in our institute. The QC records were collected daily for 3 years. The stacked long short‐term memory (LSTM) model was used to develop the neural network model. A total of 867 records were collected to predict the record for the next 5 days. To compare the stacked LSTM, the autoregressive integrated moving average model (ARIMA) was developed on the same data set. The accuracy of the model was quantified by the mean absolute error (MAE), root‐mean‐square error (RMSE), and coefficient of determination (R2). To validate the robustness of the model, the record of four QC items was collected for another radiotherapy machine, which was input into the stacked LSTM model without changing any hyperparameters and ARIMA model. Results The mean MAE, RMSE, andR2 with 24 QC items were 0.013, 0.020, and 0.853 in LSTM, while 0.021, 0.030, and 0.618 in ARIMA, respectively. The results showed that the stacked LSTM outperforms the ARIMA. Moreover, the mean MAE, RMSE, andR2 with four QC items were 0.102, 0.151, and 0.770 in LSTM, while 0.162, 0.375, and 0.550 in ARIMA, respectively. Conclusions In this study, the stacked LSTM model can accurately predict the record and trend of QC items. Moreover, the stacked LSTM model is robust when applied to another radiotherapy machine. Predicting future performance record will foresee possible machine failure, allowing early machine maintenance and reducing unscheduled machine downtime.
Collapse
Affiliation(s)
- Min Ma
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenbin Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Ran Wei
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Liang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
34
|
Aznar M, Ntentas G, Enmark M, Flampouri S, Meidhal Petersen P, Ricardi U, Levis M. The role of motion management and position verification in lymphoma radiotherapy. Br J Radiol 2021; 94:20210618. [PMID: 34677090 PMCID: PMC8553184 DOI: 10.1259/bjr.20210618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022] Open
Abstract
In the last decades, the substantial technical progress in radiation oncology offered the opportunity for more accurate planning and delivery of treatment. At the same time, the evolution of systemic treatment and the advent of modern diagnostic tools allowed for more accurate staging and consequently a safe reduction of radiotherapy (RT) target volumes and RT doses in the treatment of lymphomas. As a result, incidental irradiation of organs at risk was reduced, with a consequent reduction of severe late toxicity in long-term lymphoma survivors. Nevertheless, these innovations warrant that professionals pay attention to concurrently ensure precise planning and dose delivery to the target volume and safe sparing of the organs at risk. In particular, target and organ motion should be carefully managed in order to prevent any compromise of treatment efficacy. Several aspects should be taken into account during the treatment pathway to minimise uncertainties and to apply a valuable motion management strategy, when needed. These include: reliable image registration between diagnostic and planning radiologic exams to facilitate the contouring process, image guidance to limit positioning uncertainties and to ensure the accuracy of dose delivery and management of lung motion through procedures of respiratory gating and breath control. In this review, we will cover the current clinical approaches to minimise these uncertainties in patients treated with modern RT techniques, with a particular focus on mediastinal lymphoma. In addition, since uncertainties have a different impact on the dose deposition of protons compared to conventional x-rays, the role of motion management and position verification in proton beam therapy (PBT) will be discussed in a separate section.
Collapse
Affiliation(s)
| | | | | | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | | | | | - Mario Levis
- Department of Oncology, University of Torino, Turin, Italy
| |
Collapse
|
35
|
An international survey of imaging practices in radiotherapy. Phys Med 2021; 90:53-65. [PMID: 34562809 DOI: 10.1016/j.ejmp.2021.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 12/25/2022] Open
Abstract
Improvements in delivery of radiation dose to target tissues in radiotherapy have increased the need for better image quality and led to a higher frequency of imaging patients. Imaging for treatment planning extends to function and motion assessment and devices are incorporated into medical linear accelerators (linacs) so that regions of tissue can be imaged at time of treatment delivery to ensure dose distributions are delivered as accurately as possible. A survey of imaging in 97 radiotherapy centres in nine countries on six continents has been undertaken with an on-line questionnaire administered through the International Commission on Radiological Protection mentorship programme to provide a snapshot of imaging practices. Responses show that all centres use CT for planning treatments and many utilise additional information from magnetic resonance imaging and positron emission tomography scans. Most centres have kV cone beam CT attached to at least some linacs and use this for the majority of treatment fractions. The imaging options available declined with the human development index (HDI) of the country, and the frequency of imaging during treatment depended more on country than treatment site with countries having lower HDIs imaging less frequently. The country with the lowest HDI had few kV imaging facilities and relied on MV planar imaging intermittently during treatment. Imaging protocols supplied by vendors are used in most centres and under half adapt exposure conditions to individual patients. Recording of patient doses, a knowledge of which is important in optimisation of imaging protocols, was limited primarily to European countries.
Collapse
|
36
|
Czerska K, Emert F, Kopec R, Langen K, McClelland JR, Meijers A, Miyamoto N, Riboldi M, Shimizu S, Terunuma T, Zou W, Knopf A, Rucinski A. Clinical practice vs. state-of-the-art research and future visions: Report on the 4D treatment planning workshop for particle therapy - Edition 2018 and 2019. Phys Med 2021; 82:54-63. [PMID: 33588228 DOI: 10.1016/j.ejmp.2020.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/18/2022] Open
Abstract
The 4D Treatment Planning Workshop for Particle Therapy, a workshop dedicated to the treatment of moving targets with scanned particle beams, started in 2009 and since then has been organized annually. The mission of the workshop is to create an informal ground for clinical medical physicists, medical physics researchers and medical doctors interested in the development of the 4D technology, protocols and their translation into clinical practice. The 10th and 11th editions of the workshop took place in Sapporo, Japan in 2018 and Krakow, Poland in 2019, respectively. This review report from the Sapporo and Krakow workshops is structured in two parts, according to the workshop programs. The first part comprises clinicians and physicists review of the status of 4D clinical implementations. Corresponding talks were given by speakers from five centers around the world: Maastro Clinic (The Netherlands), University Medical Center Groningen (The Netherlands), MD Anderson Cancer Center (United States), University of Pennsylvania (United States) and The Proton Beam Therapy Center of Hokkaido University Hospital (Japan). The second part is dedicated to novelties in 4D research, i.e. motion modelling, artificial intelligence and new technologies which are currently being investigated in the radiotherapy field.
Collapse
Affiliation(s)
- Katarzyna Czerska
- Institute of Nuclear Physics Polish Academy of Sciences, PL-31342 Krakow, Poland.
| | - Frank Emert
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | - Renata Kopec
- Institute of Nuclear Physics Polish Academy of Sciences, PL-31342 Krakow, Poland
| | - Katja Langen
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jamie R McClelland
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Arturs Meijers
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan; Faculty of Engineering, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Marco Riboldi
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Germany
| | - Shinichi Shimizu
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan; Department of Radiation Medical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Toshiyuki Terunuma
- Faculty of Medicine, University of Tsukuba, Japan; Proton Medical Research Center, University of Tsukuba Hospital, Japan
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Antje Knopf
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antoni Rucinski
- Institute of Nuclear Physics Polish Academy of Sciences, PL-31342 Krakow, Poland
| |
Collapse
|
37
|
McNair H, Wiseman T, Joyce E, Peet B, Huddart R. International survey; current practice in On-line adaptive radiotherapy (ART) delivered using Magnetic Resonance Image (MRI) guidance. Tech Innov Patient Support Radiat Oncol 2020; 16:1-9. [PMID: 32995576 PMCID: PMC7501460 DOI: 10.1016/j.tipsro.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 08/19/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The uptake of new technologies has varied internationally and there have often been barriers to implementation. On-line adaptive radiotherapy (ART) promises to improve patient outcome. This survey focuses on the implementation phase of delivering ART and professional roles and responsibilities currently involved in the workflow and changes which may be expected in the future. MATERIALS AND METHODS A 38 question survey included aspects on current practice; professional responsibilities; benefits and barriers; and decision making and responsibilities. For the purposes of the questionnaire and paper, ART was considered where tumour and /or organs at risk were contoured and re-planning was performed on-line. The questionnaire was electronically distributed via radiotherapy networks. RESULTS Nineteen international responses were received. Europe (n = 11), United States of America (n = 4); Canada (n = 2), Australia (n = 1) and Hong Kong (n = 1). The majority of centres started using ART in either 2018 (n = 7) or 2019 (n = 6). Four centres started treating with ART between 2015 and 2017, and the first was in 2014. Centres initially treated prostate and oligometastases patients, expanding to treat prostate, oligometastases, pancreas and rectum. The majority of centres were working in conventional roles, however moving towards radiographers taking more responsibility in contouring organs at risk (OAR), target and dosimetry. The three most important criteria chosen by medical doctors to determine if ART should be used were overall gross anatomy changes of target and OAR, target not covered by planning target volume (PTV) and OAR close to the high dose area. There was no clear consensus on the minimum improvement in dose to target or reduction in dose to OAR to warrant adaption. CONCLUSION On-line ART has been implemented successfully internationally. Initial practice maintains conventional professional roles and responsibilities, however there is trend to changing roles for the future. There is little consensus regarding the triggers of adaption.
Collapse
Affiliation(s)
- H.A. McNair
- Institute of Cancer Research, United Kingdom
| | - T Wiseman
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - E Joyce
- Royal Marsden NHS Foundation Trust, United Kingdom
| | - B Peet
- Royal Marsden NHS Foundation Trust, United Kingdom
| | | |
Collapse
|
38
|
Bertholet J, Anastasi G, Noble D, Bel A, van Leeuwen R, Roggen T, Duchateau M, Pilskog S, Garibaldi C, Tilly N, García-Mollá R, Bonaque J, Oelfke U, Aznar MC, Heijmen B. Patterns of practice for adaptive and real-time radiation therapy (POP-ART RT) part II: Offline and online plan adaption for interfractional changes. Radiother Oncol 2020; 153:88-96. [PMID: 32579998 PMCID: PMC7758781 DOI: 10.1016/j.radonc.2020.06.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/08/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The POP-ART RT study aims to determine to what extent and how intrafractional real-time respiratory motion management (RRMM), and plan adaptation for interfractional anatomical changes (ART) are used in clinical practice and to understand barriers to implementation. Here we report on part II: ART using more than one plan per target per treatment course. MATERIALS AND METHODS A questionnaire on the current practice of ART, wishes for expansion or implementation, and barriers to implementation was distributed worldwide. Four types of ART were discriminated: daily online replanning, online plan library, protocolled offline replanning (all three based on a protocol), and ad-hoc offline replanning. RESULTS The questionnaire was completed by 177 centres from 40 countries. ART was used by 61% of respondents (31% with protocol) for a median (range) of 3 (1-8) tumour sites. CBCT/MVCT was the main imaging modality except for online daily replanning (11 users) where 10 users used MR. Two thirds of respondents wished to implement ART for a new tumour site; 40% of these had plans to do it in the next 2 years. Human/material resources and technical limitations were the main barriers to further use and implementation. CONCLUSIONS ART was used for a broad range of tumour sites, mainly with ad-hoc offline replanning and for a median of 3 tumour sites. There was a large interest in implementing ART for more tumour sites, mainly limited by human/material resources and technical limitations. Daily online replanning was primarily performed on MR-linacs.
Collapse
Affiliation(s)
- Jenny Bertholet
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, United Kingdom; Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Gail Anastasi
- Department of Medical Physics, Royal Surrey County Hospital, St. Luke's Cancer Centre, Guildford, United Kingdom
| | - David Noble
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, United Kingdom
| | - Arjan Bel
- Amsterdam UMC, Department of Radiation Oncology, The Netherlands
| | - Ruud van Leeuwen
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Toon Roggen
- Applied Research, Varian Medical Systems Imaging Laboratory GmbH, Dättwil, Switzerland
| | | | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway; Department of Physics and Technology, University of Bergen, Norway
| | - Cristina Garibaldi
- IEO, European Institute of Oncology IRCCS, Unit of Radiation Research, Milan, Italy
| | - Nina Tilly
- Elekta Instruments AB, Stockholm, Sweden; Medical Radiation Physics, Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Rafael García-Mollá
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospital General Universitario de Valencia, Spain
| | - Jorge Bonaque
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castelló de la Plana, Spain
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, United Kingdom
| | - Marianne C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, United Kingdom; Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Ben Heijmen
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
| |
Collapse
|
39
|
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.
Collapse
|