1
|
Iramina H, Tsuneda M, Okamoto H, Kadoya N, Mukumoto N, Toyota M, Fukunaga J, Fujita Y, Tohyama N, Onishi H, Nakamura M. Multi-institutional questionnaire-based survey on online adaptive radiotherapy performed using commercial systems in Japan in 2023. Radiol Phys Technol 2024:10.1007/s12194-024-00828-4. [PMID: 39028438 DOI: 10.1007/s12194-024-00828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
In this study, we aimed to conduct a survey on the current clinical practice of, staffing for, commissioning of, and staff training for online adaptive radiotherapy (oART) in the institutions that installed commercial oART systems in Japan, and to share the information with institutions that will implement oART systems in future. A web-based questionnaire, containing 107 questions, was distributed to nine institutions in Japan. Data were collected from November to December 2023. Three institutions each with the MRIdian (ViewRay, Oakwood Village, OH, USA), Unity (Elekta AB, Stockholm, Sweden), and Ethos (Varian Medical Systems, Palo Alto, CA, USA) systems completed the questionnaire. One institution (MRIdian) had not performed oART by the response deadline. Each institution had installed only one oART system. Hypofractionation, and moderate hypofractionation or conventional fractionation were employed in the MRIdian/Unity and Ethos systems, respectively. The elapsed time for the oART process was faster with the Ethos than with the other systems. All institutions added additional staff for oART. Commissioning periods differed among the oART systems owing to provision of beam data from the vendors. Chambers used during commissioning measurements differed among the institutions. Institutional training was provided by all nine institutions. To the best of our knowledge, this was the first survey about oART performed using commercial systems in Japan. We believe that this study will provide useful information to institutions that installed, are installing, or are planning to install oART systems.
Collapse
Affiliation(s)
- Hiraku Iramina
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan
| | - Masato Tsuneda
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Hiroyuki Okamoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Noriyuki Kadoya
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai-Shi, Miyagi, 980-8574, Japan
| | - Nobutaka Mukumoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka-Shi, Osaka, 545-8585, Japan
| | - Masahiko Toyota
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Clinical Technology, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Junichi Fukunaga
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka-Shi, Fukuoka, 812-8582, Japan
| | - Yukio Fujita
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Naoki Tohyama
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-Shi, Yamanashi, 409-3898, Japan
| | - Mitsuhiro Nakamura
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan.
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan.
| |
Collapse
|
2
|
Lund JÅ, Lydersen S, Aksnessæther B, Solberg A, Wanderås A, Lervåg C, Kaasa S, Tøndel H. Image guided radiotherapy in curative treatment for prostate cancer. 5-year results from a randomized controlled trial (RIC-trial). Radiother Oncol 2024; 196:110309. [PMID: 38670265 DOI: 10.1016/j.radonc.2024.110309] [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: 12/20/2023] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Between 2012 and 2015 we conducted a randomized controlled trial in prostate cancer patients comparing weekly 2-D portal imaging versus daily 3-D verification. AIM To evaluate the clinical outcomes of image guided radiotherapy by presenting rectal and urinary side effects, health related quality of life and progression free survival after 5-years follow up of a randomized controlled trial. METHODS We randomized 260 men with intermediate or high-risk prostate cancer to weekly 2-D portal imaging with 15 mm margin from CTV to PTV (Arm A) or daily 3-D cone-beam computer tomography with 7 mm margins (Arm B). Prescribed doses were 78 Gy/39 fractions. All patients received hormonal therapy. Primary end point was patient reported bowel symptoms and secondary outcomes were patient reported urinary symptoms, health- related quality of life and progression free survival. RESULTS Of the 216 patients available for analyses at 5 years more than 90 % completed patient reported outcome measures. There were no significant differences between study arms for any single items nor scales evaluating bowel symptoms. There were also no differences in self-reported urinary symptoms nor in health-related quality of life. Symptom scores were low in both study arms. Progression free survival was similar in Arm B as compared to arm A (Hazard ratio 1.01; 95 % CI 0.57 to 1.97). CONCLUSIONS Our results support that both 2-D weekly and 3-D daily image guided radiotherapy are safe and efficient treatments for PC and emphasize the need to evaluate technological progress in clinical trials with long follow-up.
Collapse
Affiliation(s)
- Jo-Åsmund Lund
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørg Aksnessæther
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Arne Solberg
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Wanderås
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway
| | - Christoffer Lervåg
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Hanne Tøndel
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
3
|
Borderías-Villarroel E, Barragán-Montero A, Sterpin E. Time is NTCP: Should we maximize patient throughput or perform online adaptation on proton therapy systems? Radiother Oncol 2024; 198:110389. [PMID: 38885906 DOI: 10.1016/j.radonc.2024.110389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Compared to conventional radiotherapy (XT), proton therapy (PT) may improve normal tissue complication probabilities (NTCP). However, PT typically requires higher adaptation rates due to an increased sensitivity to anatomical changes. Systematic online adaptation may address this issue, but it requires additional replanning time, decreasing patient throughput. Therefore, less patients would benefit in such case from PT for a given machine capacity, with results in worse NTCP. AIM To investigate the trade-off between PT patient throughput and NTCP gain as a function of the time needed for adaptation. METHODS A retrospective database of 14 lung patients with two repeated 4DCTs was used to compare NTCP values between XT and PT for NTCP2ym (2-year mortality), NTCPdysphagia and NTCPpneumonitis. Four scenarios were considered for PT: no adaptation using clinical robustness parameters (4D robust optimization, 3 % range error and PTV-equivalent setup errors); systematic online adaptation with clinical robustness parameters; setup errors reduced to 4 mm and to 2 mm. Dose was accumulated on the planning CT. The number of patients treated with PT depended on the extra time needed for adaptation, assuming an 8-hours capacity (assuming 14 patients a day; thus minimum 34.2 min per treatment session if there is no or instantaneous adaptation). RESULTS Baseline NTCP gains (PT against XT without adaptation) equaled 6.9 %, 6.1 %, and 7.7 % for NTCP2ym, NTCPdysphagia and NTCPpneumonitis, respectively. Using instantaneous online adaptation and setup errors of 2 mm, the overall gains were then 10.7 %, 13.6 % and 12.4 %. Taking into account loss of capacity, 13.7 min was the maximum extra-time allowed to complete adaptation and maintain an advantage on all three metrics for the 2-mm setup error scenario. CONCLUSION This study highlights the critical importance of keeping short online adaptation times when using systems with limited capacity like PT.
Collapse
Affiliation(s)
- E Borderías-Villarroel
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - A Barragán-Montero
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - E Sterpin
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium; KU Leuven, Department of Oncology, Laboratory of external radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium.
| |
Collapse
|
4
|
Wong YM, Koh CWY, Lew KS, Chua CGA, Yeap PL, Zhang ET, Ong ALK, Tuan JKL, Ng BF, Lew WS, Lee JCL, Tan HQ. Deformable anthropomorphic pelvis phantom for dose accumulation verification. Phys Med Biol 2024; 69:12NT01. [PMID: 38821109 DOI: 10.1088/1361-6560/ad52e4] [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: 02/25/2024] [Accepted: 05/31/2024] [Indexed: 06/02/2024]
Abstract
Objective.The validation of deformable image registration (DIR) for contour propagation is often done using contour-based metrics. Meanwhile, dose accumulation requires evaluation of voxel mapping accuracy, which might not be accurately represented by contour-based metrics. By fabricating a deformable anthropomorphic pelvis phantom, we aim to (1) quantify the voxel mapping accuracy for various deformation scenarios, in high- and low-contrast regions, and (2) identify any correlation between dice similarity coefficient (DSC), a commonly used contour-based metric, and the voxel mapping accuracy for each organ.Approach. Four organs, i.e. pelvic bone, prostate, bladder and rectum (PBR), were 3D printed using PLA and a Polyjet digital material, and assembled. The latter three were implanted with glass bead and CT markers within or on their surfaces. Four deformation scenarios were simulated by varying the bladder and rectum volumes. For each scenario, nine DIRs with different parameters were performed on RayStation v10B. The voxel mapping accuracy was quantified by finding the discrepancy between true and mapped marker positions, termed the target registration error (TRE). Pearson correlation test was done between the DSC and mean TRE for each organ.Main results. For the first time, we fabricated a deformable phantom purely from 3D printing, which successfully reproduced realistic anatomical deformations. Overall, the voxel mapping accuracy dropped with increasing deformation magnitude, but improved when more organs were used to guide the DIR or limit the registration region. DSC was found to be a good indicator of voxel mapping accuracy for prostate and rectum, but a comparatively poorer one for bladder. DSC > 0.85/0.90 was established as the threshold of mean TRE ⩽ 0.3 cm for rectum/prostate. For bladder, extra metrics in addition to DSC should be considered.Significance. This work presented a 3D printed phantom, which enabled quantification of voxel mapping accuracy and evaluation of correlation between DSC and voxel mapping accuracy.
Collapse
Affiliation(s)
- Yun Ming Wong
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore, Singapore
| | - Calvin Wei Yang Koh
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Ai3 Lab, National Cancer Centre Singapore, Singapore, Singapore
| | - Kah Seng Lew
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore, Singapore
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Clifford Ghee Ann Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Ai3 Lab, National Cancer Centre Singapore, Singapore, Singapore
| | - Ping Lin Yeap
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Ee Teng Zhang
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, Singapore
- Singapore Centre for 3D Printing, Nanyang Technological University, Singapore, Singapore
| | - Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Ai3 Lab, National Cancer Centre Singapore, Singapore, Singapore
| | - Jeffrey Kit Loong Tuan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Ai3 Lab, National Cancer Centre Singapore, Singapore, Singapore
| | - Bing Feng Ng
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, Singapore
| | - Wen Siang Lew
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore, Singapore
| | - James Cheow Lei Lee
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore, Singapore
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Hong Qi Tan
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore, Singapore
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Ai3 Lab, National Cancer Centre Singapore, Singapore, Singapore
| |
Collapse
|
5
|
Fink C, Ristau J, Buchele C, Klüter S, Liermann J, Hoegen-Saßmannshausen P, Sandrini E, Lentz-Hommertgen A, Baumann L, Andratschke N, Baumgartl M, Li M, Reiner M, Corradini S, Hörner-Rieber J, Bonekamp D, Schlemmer HP, Belka C, Guckenberger M, Debus J, Koerber S. Stereotactic ultrahypofractionated MR-guided radiotherapy for localized prostate cancer - Acute toxicity and patient-reported outcomes in the prospective, multicenter SMILE phase II trial. Clin Transl Radiat Oncol 2024; 46:100771. [PMID: 38586081 PMCID: PMC10998039 DOI: 10.1016/j.ctro.2024.100771] [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: 09/22/2023] [Revised: 02/07/2024] [Accepted: 03/24/2024] [Indexed: 04/09/2024] Open
Abstract
Background Due to superior image quality and daily adaptive planning, MR-guided stereotactic body radiation therapy (MRgSBRT) has the potential to further widen the therapeutic window in radiotherapy of localized prostate cancer. This study reports on acute toxicity rates and patient-reported outcomes after MR-guided adaptive ultrahypofractionated radiotherapy for localized prostate cancer within the prospective, multicenter phase II SMILE trial. Materials and methods A total of 69 patients with localized prostate cancer underwent MRgSBRT with daily online plan adaptation. Inclusion criteria comprised a tumor stage ≤ T3a, serum PSA value ≤ 20 ng/ml, ISUP Grade group ≤ 4. A dose of 37.5 Gy was prescribed to the PTV in five fractions on alternating days with an optional simultaneous boost of 40 Gy to the dominant intraprostatic lesion defined by multiparametric MRI. Acute genitourinary (GU-) and gastrointestinal (GI-) toxicity, as defined by CTCAE v. 5.0 and RTOG as well as patient-reported outcomes according to EORTC QLQ-C30 and -PR25 scores were analyzed at completion of radiotherapy, 6 and 12 weeks after radiotherapy and compared to baseline symptoms. Results There were no toxicity-related treatment discontinuations. At the 12-week follow-up visit, no grade 3 + toxicities were reported according to CTCAE. Up until the 12-week visit, in total 16 patients (23 %) experienced a grade 2 GU or GI toxicity. Toxicity rates peaked at the end of radiation therapy and subsided within the 12-week follow-up period. At the 12-week follow-up visit, no residual grade 2 GU toxicities were reported and 1 patient (1 %) had residual grade 2 enteritic symptoms. With exception to a significant improvement in the emotional functioning score following MRgSBRT, no clinically meaningful changes in the global health status nor in relevant subscores were reported. Conclusion Daily online-adaptive MRgSBRT for localized prostate cancer resulted in an excellent overall toxicity profile without any major negative impact on quality of life.
Collapse
Affiliation(s)
- C.A. Fink
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - J. Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiation Oncology, Maria Hilf Hospital Mönchengladbach, Mönchengladbach, Germany
| | - C. Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - S. Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - J. Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - E. Sandrini
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - A. Lentz-Hommertgen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - L. Baumann
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M. Baumgartl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M. Li
- Department of Radiation Oncology, LMU University Hospital Munich, Munich, Germany
| | - M. Reiner
- Department of Radiation Oncology, LMU University Hospital Munich, Munich, Germany
| | - S. Corradini
- Department of Radiation Oncology, LMU University Hospital Munich, Munich, Germany
| | - J. Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - D. Bonekamp
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - H.-P. Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C. Belka
- Department of Radiation Oncology, LMU University Hospital Munich, Munich, Germany
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - J. Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - S.A. Koerber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiation Oncology, Barmherzige Brueder Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
6
|
Dupont F, Dechambre D, Sterpin E. Evaluation of safety margins for cone beam CT-based adaptive prostate radiotherapy. Phys Med 2024; 121:103368. [PMID: 38663348 DOI: 10.1016/j.ejmp.2024.103368] [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: 10/10/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
Adaptive radiotherapy is characterized by the use of a daily imaging system, such as CBCT (Cone-Beam Computed Tomography) images to re-optimize the treatment based on the daily anatomy and position of the patient. By systematically re-delineating the Clinical Target Volume (CTV) at each fraction, target delineation uncertainty features a random component instead of a pure systematic. The goal of this work is to identify the random and systematic contributions of the delineation error and compute a new relevant Planning Target Volume (PTV) safety margin. 169 radiotherapy sessions from 10 prostate cancer patients treated on the Varian ETHOS treatment system have been analyzed. Intra-patient and inter-patient delineation variabilities were computed in six directions, by considering the prostate as a rigid, non-rotating volume. By doing so, we were able to directly compare the delineations done by the physicians on daily CBCT images with the initial delineation done on the CT-sim and MRI, and sort them by direction using the polar coordinates of the points. The computed variabilities were then used to compute a PTV margin based on Van Herk margin recipe. The total margin computed with random and systematic delineation uncertainties was of 2.7, 2.4, 5.6, 4.8, 4.9 and 3.6 mm in the left, right, anterior, posterior, cranial and caudal directions, respectively. According to our results, the gain offered by the separation of the delineation uncertainty into systematic and random contributions due to the adaptive delineation process justifies a reduction of the PTV margin down to 3 to 5 mm in every direction.
Collapse
Affiliation(s)
- Florian Dupont
- UCLouvain, Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; Cliniques Universitaires Saint-Luc (CUSL), Nuclear Medicine Department, Brussels, Belgium.
| | - David Dechambre
- Cliniques Universitaires Saint-Luc (CUSL), Radiotherapy Department, Brussels, Belgium
| | - Edmond Sterpin
- UCLouvain, Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven (ParTICLe), Leuven, Belgium
| |
Collapse
|
7
|
Nachbar M, Lo Russo M, Gani C, Boeke S, Wegener D, Paulsen F, Zips D, Roque T, Paragios N, Thorwarth D. Automatic AI-based contouring of prostate MRI for online adaptive radiotherapy. Z Med Phys 2024; 34:197-207. [PMID: 37263911 PMCID: PMC11156783 DOI: 10.1016/j.zemedi.2023.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND PURPOSE MR-guided radiotherapy (MRgRT) online plan adaptation accounts for tumor volume changes, interfraction motion and thus allows daily sparing of relevant organs at risk. Due to the high interfraction variability of bladder and rectum, patients with tumors in the pelvic region may strongly benefit from adaptive MRgRT. Currently, fast automatic annotation of anatomical structures is not available within the online MRgRT workflow. Therefore, the aim of this study was to train and validate a fast, accurate deep learning model for automatic MRI segmentation at the MR-Linac for future implementation in a clinical MRgRT workflow. MATERIALS AND METHODS For a total of 47 patients, T2w MRI data were acquired on a 1.5 T MR-Linac (Unity, Elekta) on five different days. Prostate, seminal vesicles, rectum, anal canal, bladder, penile bulb, body and bony structures were manually annotated. These training data consisting of 232 data sets in total was used for the generation of a deep learning based autocontouring model and validated on 20 unseen T2w-MRIs. For quantitative evaluation the validation set was contoured by a radiation oncologist as gold standard contours (GSC) and compared in MATLAB to the automatic contours (AIC). For the evaluation, dice similarity coefficients (DSC), and 95% Hausdorff distances (95% HD), added path length (APL) and surface DSC (sDSC) were calculated in a caudal-cranial window of ± 4 cm with respect to the prostate ends. For qualitative evaluation, five radiation oncologists scored the AIC on the possible usage within an online adaptive workflow as follows: (1) no modifications needed, (2) minor adjustments needed, (3) major adjustments/ multiple minor adjustments needed, (4) not usable. RESULTS The quantitative evaluation revealed a maximum median 95% HD of 6.9 mm for the rectum and minimum median 95% HD of 2.7 mm for the bladder. Maximal and minimal median DSC were detected for bladder with 0.97 and for penile bulb with 0.73, respectively. Using a tolerance level of 3 mm, the highest and lowest sDSC were determined for rectum (0.94) and anal canal (0.68), respectively. Qualitative evaluation resulted in a mean score of 1.2 for AICs over all organs and patients across all expert ratings. For the different autocontoured structures, the highest mean score of 1.0 was observed for anal canal, sacrum, femur left and right, and pelvis left, whereas for prostate the lowest mean score of 2.0 was detected. In total, 80% of the contours were rated be clinically acceptable, 16% to require minor and 4% major adjustments for online adaptive MRgRT. CONCLUSION In this study, an AI-based autocontouring was successfully trained for online adaptive MR-guided radiotherapy on the 1.5 T MR-Linac system. The developed model can automatically generate contours accepted by physicians (80%) or only with the need of minor corrections (16%) for the irradiation of primary prostate on the clinically employed sequences.
Collapse
Affiliation(s)
- Marcel Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Monica Lo Russo
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Nikos Paragios
- TheraPanacea, Paris, France; CentraleSupelec, University of Paris-Saclay, Gif-sur-Yvette, France
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| |
Collapse
|
8
|
van den Dobbelsteen M, Hackett SL, van Asselen B, Oolbekkink S, Raaymakers BW, de Boer JC. Treatment planning evaluation and experimental validation of the magnetic resonance-based intrafraction drift correction. Phys Imaging Radiat Oncol 2024; 30:100580. [PMID: 38707627 PMCID: PMC11068926 DOI: 10.1016/j.phro.2024.100580] [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: 03/01/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024] Open
Abstract
Background and purpose MRI-guided online adaptive treatments can account for interfractional variations, however intrafraction motion reduces treatment accuracy. Intrafraction plan adaptation methods, such as the Intrafraction Drift Correction (IDC) or sub-fractionation, are needed. IDC uses real-time automatic monitoring of the tumor position to initiate plan adaptations by repositioning segments. IDC is a fast adaptation method that occurs only when necessary and this method could enable margin reduction. This research provides a treatment planning evaluation and experimental validation of the IDC. Materials and methods An in silico treatment planning evaluation was performed for 13 prostate patients mid-treatment without and with intrafraction plan adaptation (IDC and sub-fractionation). The adaptation methods were evaluated using dose volume histogram (DVH) metrics. To experimentally verify IDC a treatment was mimicked whereby a motion phantom containing an EBT3 film moved mid-treatment, followed by repositioning of segments. In addition, the delivered treatment was irradiated on a diode array phantom for plan quality assurance purposes. Results The planning study showed benefits for using intrafraction adaptation methods relative to no adaptation, where the IDC and sub-fractionation showed consistently improved target coverage with median target coverages of 100.0%. The experimental results verified the IDC with high minimum gamma passing rates of 99.1% and small mean dose deviations of maximum 0.3%. Conclusion The straightforward and fast IDC technique showed DVH metrics consistent with the sub-fractionation method using segment weight re-optimization for prostate patients. The dosimetric and geometric accuracy was shown for a full IDC workflow using film and diode array dosimetry.
Collapse
Affiliation(s)
- Madelon van den Dobbelsteen
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Sara L. Hackett
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Bram van Asselen
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Stijn Oolbekkink
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Bas W. Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Johannes C.J. de Boer
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| |
Collapse
|
9
|
Hassan SP, de Leon J, Batumalai V, Moutrie Z, Hogan L, Ge Y, Stricker P, Jameson MG. Magnetic resonance guided adaptive post prostatectomy radiotherapy: Accumulated dose comparison of different workflows. J Appl Clin Med Phys 2024; 25:e14253. [PMID: 38394627 PMCID: PMC11005979 DOI: 10.1002/acm2.14253] [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: 05/17/2023] [Revised: 09/26/2023] [Accepted: 12/06/2023] [Indexed: 02/25/2024] Open
Abstract
PURPOSE The aim of this study was to assess the use of magnetic resonance guided adaptive radiotherapy (MRgART) in the post-prostatectomy setting; comparing dose accumulation for our initial seven patients treated with fully adaptive workflow on the Unity MR-Linac (MRL) and with non-adaptive plans generated offline. Additionally, we analyzed toxicity in patients receiving treatment. METHODS Seven patients were treated with MRgART. The prescription was 70-72 Gy in 35-36 fractions. Patients were treated with an adapt to shape (ATS) technique. For each clinically delivered plan, a non-adaptive plan based upon the reference plan was generated and compared to the associated clinically delivered plan. A total of 468 plans were analyzed. Concordance Index of target and Organs at Risk (OARs) for each fraction with reference contours was analyzed. Acute toxicity was then assessed at six-months following completion of treatment with Common Terminology for Adverse Events (CTCAE) Toxicity Criteria. RESULTS A total of 246 fractions were clinically delivered to seven patients; 234 fractions were delivered via MRgART and 12 fractions delivered via a traditional linear accelerator due to machine issues. Pre-treatment reference plans met CTV and OAR criteria. PTV coverage satisfaction was higher in the clinically delivered adaptive plans than non-adaptive comparison plans; 42.93% versus 7.27% respectively. Six-month CTCAE genitourinary and gastrointestinal toxicity was absent in most patients, and mild-to-moderate in a minority of patients (Grade 1 GU toxicity in one patient and Grade 2 GI toxicity in one patient). CONCLUSIONS Daily MRgART treatment consistently met planning criteria. Target volume variability in prostate bed treatment can be mitigated by using MRgART and deliver satisfactory coverage of CTV whilst minimizing dose to adjacent OARs and reducing toxicity.
Collapse
Affiliation(s)
- Sean P. Hassan
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
| | | | - Vikneswary Batumalai
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
- Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Zoe Moutrie
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
- Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- South Western Sydney Cancer ServicesNew South Wales HealthSydneyAustralia
- Ingham Institute for Applied Medical ResearchSydneyAustralia
| | - Louise Hogan
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
- GenesisCareMurdochWestern AustraliaAustralia
| | - Yuanyuan Ge
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
| | - Phillip Stricker
- Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- Western Sydney UniversityPenrithNew South WalesAustralia
- St Vincent's Prostate Cancer Research CentreDarlinghurstNew South WalesAustralia
- Garvan Institute, DarlinghurstSydneyNew South WalesAustralia
- University of SydneyCamperdownNew South WalesAustralia
| | - Michael G. Jameson
- GenesisCareSt Vincent's HospitalSydneyNew South WalesAustralia
- Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongWollongongAustralia
| |
Collapse
|
10
|
Mohamad O, Zamboglou C, Zilli T, Murthy V, Aebersold DM, Loblaw A, Guckenberger M, Shelan M. Safety of Ultrahypofractionated Pelvic Nodal Irradiation in the Definitive Management of Prostate Cancer: Systematic Review and Meta-analysis. Int J Radiat Oncol Biol Phys 2024; 118:998-1010. [PMID: 37863241 DOI: 10.1016/j.ijrobp.2023.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE This systematic review and meta-analysis aimed to evaluate the evidence for ultrahypofractionated pelvic nodal irradiation in patients with prostate cancer, with a focus on reported acute and late toxicities. METHODS AND MATERIALS A comprehensive search was conducted in 5 electronic databases (PubMed, Scopus, Web of Science, Cochrane Library, ClinicalTrials.gov) from inception until March 23, 2023. Eligible publications included patients with intermediate- and high-risk and node-positive prostate cancer who underwent elective or therapeutic ultrahypofractionated pelvic nodal irradiation. Primary outcomes included the presence of grade ≥2 rates of acute and late gastrointestinal and genitourinary toxicity based on the Common Terminology Criteria for Adverse Events or Radiation Therapy Oncology Group scales. Quality assessment was performed using National Institutes of Health tools for noncontrolled beforeand after (single arm) clinical trials, as well as single-arm observational studies. Because all outcomes were categorical variables, proportion was calculated to estimate the effect size and compare the outcomes after the intervention. RESULTS We identified 16 publications that reported the use of ultrahypofractionated radiation therapy to treat the pelvis in prostate cancer. Seven publications met our criteria and were included in the meta-analysis, including 417 patients. The median total dose to the pelvic lymph nodes was 25 Gy (range, 25-28.5 Gy), with a median of 5 fractions. The prostate received a median dose of 40 Gy (range, 35-47.5 Gy). All studies used androgen deprivation therapy for a median duration of 18 months. The median follow-up period was 3 years (range, 0.5-5.6 years). The rates of acute grade ≥2 gastrointestinal and genitourinary toxicity were 8% (95% CI, 1%-15%) and 29% (95% CI, 18%-41%), respectively. For late grade ≥2 gastrointestinal and genitourinary toxicity, the rates were 13% (95% CI, 5%-21%) and 29% (95% CI, 17%-42%), respectively. CONCLUSIONS Ultrahypofractionated pelvic nodal irradiation appears to be a safe approach in terms of acute and late genitourinary and gastrointestinal toxicity.
Collapse
Affiliation(s)
- Osama Mohamad
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - Uwniversity of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Oncology Center, European University Cyprus, Limassol, Cyprus
| | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Vedang Murthy
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre and Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| |
Collapse
|
11
|
Wang B, Liu Y, Zhang J, Yin S, Liu B, Ding S, Qiu B, Deng X. Evaluating contouring accuracy and dosimetry impact of current MRI-guided adaptive radiation therapy for brain metastases: a retrospective study. J Neurooncol 2024; 167:123-132. [PMID: 38300388 PMCID: PMC10978730 DOI: 10.1007/s11060-024-04583-9] [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: 12/27/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) guided adaptive radiotherapy (MRgART) has gained increasing attention, showing clinical advantages over conventional radiotherapy. However, there are concerns regarding online target delineation and modification accuracy. In our study, we aimed to investigate the accuracy of brain metastases (BMs) contouring and its impact on dosimetry in 1.5 T MRI-guided online adaptive fractionated stereotactic radiotherapy (FSRT). METHODS Eighteen patients with 64 BMs were retrospectively evaluated. Pre-treatment 3.0 T MRI scans (gadolinium contrast-enhanced T1w, T1c) and initial 1.5 T MR-Linac scans (non-enhanced online-T1, T2, and FLAIR) were used for gross target volume (GTV) contouring. Five radiation oncologists independently contoured GTVs on pre-treatment T1c and initial online-T1, T2, and FLAIR images. We assessed intra-observer and inter-observer variations and analysed the dosimetry impact through treatment planning based on GTVs generated by online MRI, simulating the current online adaptive radiotherapy practice. RESULTS The average Dice Similarity Coefficient (DSC) for inter-observer comparison were 0.79, 0.54, 0.59, and 0.64 for pre-treatment T1c, online-T1, T2, and FLAIR, respectively. Inter-observer variations were significantly smaller for the 3.0 T pre-treatment T1c than for the contrast-free online 1.5 T MR scans (P < 0.001). Compared to the T1c contours, the average DSC index of intra-observer contouring was 0.52‒0.55 for online MRIs. For BMs larger than 3 cm3, visible on all image sets, the average DSC indices were 0.69, 0.71 and 0.64 for online-T1, T2, and FLAIR, respectively, compared to the pre-treatment T1c contour. For BMs < 3 cm3, the average visibility rates were 22.3%, 41.3%, and 51.8% for online-T1, T2, and FLAIR, respectively. Simulated adaptive planning showed an average prescription dose coverage of 63.4‒66.9% when evaluated by ground truth planning target volumes (PTVs) generated on pre-treatment T1c, reducing it from over 99% coverage by PTVs generated on online MRIs. CONCLUSIONS The accuracy of online target contouring was unsatisfactory for the current MRI-guided online adaptive FSRT. Small lesions had poor visibility on 1.5 T non-contrast-enhanced MR-Linac images. Contour inaccuracies caused a one-third drop in prescription dose coverage for the target volume. Future studies should explore the feasibility of contrast agent administration during daily treatment in MRI-guided online adaptive FSRT procedures.
Collapse
Affiliation(s)
- Bin Wang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Yimei Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Jun Zhang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Shaohan Yin
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Biaoshui Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Shouliang Ding
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Bo Qiu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China.
| | - Xiaowu Deng
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, Guangdong, 510060, People's Republic of China.
| |
Collapse
|
12
|
Wong JYK, Leung VWS, Hung RHM, Ng CKC. Comparative Study of Eclipse and RayStation Multi-Criteria Optimization-Based Prostate Radiotherapy Treatment Planning Quality. Diagnostics (Basel) 2024; 14:465. [PMID: 38472938 DOI: 10.3390/diagnostics14050465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Multi-criteria optimization (MCO) function has been available on commercial radiotherapy (RT) treatment planning systems to improve plan quality; however, no study has compared Eclipse and RayStation MCO functions for prostate RT planning. The purpose of this study was to compare prostate RT MCO plan qualities in terms of discrepancies between Pareto optimal and final deliverable plans, and dosimetric impact of final deliverable plans. In total, 25 computed tomography datasets of prostate cancer patients were used for Eclipse (version 16.1) and RayStation (version 12A) MCO-based plannings with doses received by 98% of planning target volume having 76 Gy prescription (PTV76D98%) and 50% of rectum (rectum D50%) selected as trade-off criteria. Pareto optimal and final deliverable plan discrepancies were determined based on PTV76D98% and rectum D50% percentage differences. Their final deliverable plans were compared in terms of doses received by PTV76 and other structures including rectum, and PTV76 homogeneity index (HI) and conformity index (CI), using a t-test. Both systems showed discrepancies between Pareto optimal and final deliverable plans (Eclipse: -0.89% (PTV76D98%) and -2.49% (Rectum D50%); RayStation: 3.56% (PTV76D98%) and -1.96% (Rectum D50%)). Statistically significantly different average values of PTV76D98%,HI and CI, and mean dose received by rectum (Eclipse: 76.07 Gy, 0.06, 1.05 and 39.36 Gy; RayStation: 70.43 Gy, 0.11, 0.87 and 51.65 Gy) are noted, respectively (p < 0.001). Eclipse MCO-based prostate RT plan quality appears better than that of RayStation.
Collapse
Affiliation(s)
- John Y K Wong
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Vincent W S Leung
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Rico H M Hung
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Curtise K C Ng
- Curtin Medical School, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
- Curtin Health Innovation Research Institute (CHIRI), Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| |
Collapse
|
13
|
Habrich J, Boeke S, Fritz V, Koerner E, Nikolaou K, Schick F, Gani C, Zips D, Thorwarth D. Reproducibility of diffusion-weighted magnetic resonance imaging in head and neck cancer assessed on a 1.5 T MR-Linac and comparison to parallel measurements on a 3 T diagnostic scanner. Radiother Oncol 2024; 191:110046. [PMID: 38070687 DOI: 10.1016/j.radonc.2023.110046] [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: 05/25/2023] [Revised: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND PURPOSE Before quantitative imaging biomarkers (QIBs) acquired with magnetic resonance imaging (MRI) can be used for interventional trials in radiotherapy (RT), technical validation of these QIBs is necessary. The aim of this study was to assess the reproducibility of apparent diffusion coefficient (ADC) values, derived from diffusion-weighted (DW) MRI, in head and neck cancer using a 1.5 T MR-Linac (MRL) by comparison to a 3 T diagnostic scanner (DS). MATERIAL AND METHODS DW-MRIs were acquired on MRL and DS for 15 head and neck cancer patients before RT and in week 2 and rigidly registered to the planning computed tomography. Mean ADC values were calculated for submandibular (SG) and parotid (PG) glands as well as target volumes (TV, gross tumor volume and lymph nodes), which were delineated based on computed tomography. Mean absolute ADC differences as well as within-subject coefficient of variation (wCV) and intraclass correlation coefficients (ICCs) were calculated for all volumes of interest. RESULTS A total of 23 datasets were analyzed. Mean ADC difference (DS-MRL) for SG, PG and TV resulted in 142, 254 and 93·10-6 mm2/s. wCVs/ICCs, comparing MRL and DS, were determined as 13.7 %/0.26, 24.4 %/0.23 and 16.1 %/0.73 for SG, PG and TV, respectively. CONCLUSION ADC values, measured on the 1.5 T MRL, showed reasonable reproducibility with an ADC underestimation in contrast to the DS. This ADC shift must be validated in further experiments and considered for future translation of QIB candidates from DS to MRL for response adaptive RT.
Collapse
Affiliation(s)
- Jonas Habrich
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany.
| | - Simon Boeke
- German Cancer Consortium (DKTK), partner site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Victor Fritz
- Section for Experimental Radiology, Department of Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Elisa Koerner
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Fritz Schick
- Section for Experimental Radiology, Department of Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Zips
- German Cancer Consortium (DKTK), partner site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany; Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
14
|
di Franco F, Baudier T, Pialat PM, Munoz A, Martinon M, Pommier P, Sarrut D, Biston MC. Ultra-hypofractionated prostate cancer radiotherapy: Dosimetric impact of real-time intrafraction prostate motion and daily anatomical changes. Phys Med 2024; 118:103207. [PMID: 38215607 DOI: 10.1016/j.ejmp.2024.103207] [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: 03/14/2023] [Revised: 11/28/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024] Open
Abstract
PURPOSE To retrospectively assess the differences between planned and delivered dose during ultra-hypofractionated (UHF) prostate cancer treatments, by evaluating the dosimetric impact of daily anatomical variations alone, and in combination with prostate intrafraction motion. METHODS Prostate intrafraction motion was recorded with a transperineal ultrasound probe in 15 patients treated by UHF radiotherapy (36.25 Gy/5 fractions). The dosimetric objective was to cover 99 % of the clinical target volume with the 100 % prescription isodose line. After treatment, planning CT (pCT) images were deformably registered onto daily Cone Beam CT to generate pseudo-CT for dose accumulation (accumulated CT, aCT). The interplay effect was accounted by synchronizing prostatic shifts and beam geometry. Finally, the shifted dose maps were accumulated (moved-accumulated CT, maCT). RESULTS No significant change in daily CTV volumes was observed. Conversely, CTV V100% was 98.2 ± 0.8 % and 94.7 ± 2.6 % on aCT and maCT, respectively, compared with 99.5 ± 0.2 % on pCT (p < 0.0001). Bladder volume was smaller than planned in 76 % of fractions and D5cc was 33.8 ± 3.2 Gy and 34.4 ± 3.4 Gy on aCT (p = 0.02) and maCT (p = 0.01) compared with the pCT (36.0 ± 1.1 Gy). The rectum was smaller than planned in 50.3 % of fractions, but the dosimetric differences were not statistically significant, except for D1cc, found smaller on the maCT (33.2 ± 3.2 Gy, p = 0.02) compared with the pCT (35.3 ± 0.7 Gy). CONCLUSIONS Anatomical variations and prostate movements had more important dosimetric impact than anatomical variations alone, although, in some cases, the two phenomena compensated. Therefore, an efficient IGRT protocol is required for treatment implementation to reduce setup errors and control intrafraction motion.
Collapse
Affiliation(s)
- Francesca di Franco
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France; Univ. Grenoble Alpes, CNRS, Grenoble INP, LPSC UMR5821, 38000 Grenoble, France.
| | - Thomas Baudier
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France
| | | | - Alexandre Munoz
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France
| | | | - Pascal Pommier
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France
| | - David Sarrut
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France
| | - Marie-Claude Biston
- Centre Léon Bérard, 28 rue Laennec 69373, LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France
| |
Collapse
|
15
|
Winter JD, Reddy V, Li W, Craig T, Raman S. Impact of technological advances in treatment planning, image guidance, and treatment delivery on target margin design for prostate cancer radiotherapy: an updated review. Br J Radiol 2024; 97:31-40. [PMID: 38263844 PMCID: PMC11027310 DOI: 10.1093/bjr/tqad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/22/2023] [Accepted: 11/21/2023] [Indexed: 01/25/2024] Open
Abstract
Recent innovations in image guidance, treatment delivery, and adaptive radiotherapy (RT) have created a new paradigm for planning target volume (PTV) margin design for patients with prostate cancer. We performed a review of the recent literature on PTV margin selection and design for intact prostate RT, excluding post-operative RT, brachytherapy, and proton therapy. Our review describes the increased focus on prostate and seminal vesicles as heterogenous deforming structures with further emergence of intra-prostatic GTV boost and concurrent pelvic lymph node treatment. To capture recent innovations, we highlight the evolution in cone beam CT guidance, and increasing use of MRI for improved target delineation and image registration and supporting online adaptive RT. Moreover, we summarize new and evolving image-guidance treatment platforms as well as recent reports of novel immobilization strategies and motion tracking. Our report also captures recent implementations of artificial intelligence to support image guidance and adaptive RT. To characterize the clinical impact of PTV margin changes via model-based risk estimates and clinical trials, we highlight recent high impact reports. Our report focusses on topics in the context of PTV margins but also showcase studies attempting to move beyond the PTV margin recipes with robust optimization and probabilistic planning approaches. Although guidelines exist for target margins conventional using CT-based image guidance, further validation is required to understand the optimal margins for online adaptation either alone or combined with real-time motion compensation to minimize systematic and random uncertainties in the treatment of patients with prostate cancer.
Collapse
Affiliation(s)
- Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Varun Reddy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| |
Collapse
|
16
|
Thomas C, Dregely I, Oksuz I, Guerrero Urbano T, Greener T, King AP, Barrington SF. Effect of synthetic CT on dose-derived toxicity predictors for MR-only prostate radiotherapy. BJR Open 2024; 6:tzae014. [PMID: 38948455 PMCID: PMC11213647 DOI: 10.1093/bjro/tzae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 02/09/2024] [Accepted: 05/25/2024] [Indexed: 07/02/2024] Open
Abstract
Objectives Toxicity-driven adaptive radiotherapy (RT) is enhanced by the superior soft tissue contrast of magnetic resonance (MR) imaging compared with conventional computed tomography (CT). However, in an MR-only RT pathway synthetic CTs (sCT) are required for dose calculation. This study evaluates 3 sCT approaches for accurate rectal toxicity prediction in prostate RT. Methods Thirty-six patients had MR (T2-weighted acquisition optimized for anatomical delineation, and T1-Dixon) with same day standard-of-care planning CT for prostate RT. Multiple sCT were created per patient using bulk density (BD), tissue stratification (TS, from T1-Dixon) and deep-learning (DL) artificial intelligence (AI) (from T2-weighted) approaches for dose distribution calculation and creation of rectal dose volume histograms (DVH) and dose surface maps (DSM) to assess grade-2 (G2) rectal bleeding risk. Results Maximum absolute errors using sCT for DVH-based G2 rectal bleeding risk (risk range 1.6% to 6.1%) were 0.6% (BD), 0.3% (TS) and 0.1% (DL). DSM-derived risk prediction errors followed a similar pattern. DL sCT has voxel-wise density generated from T2-weighted MR and improved accuracy for both risk-prediction methods. Conclusions DL improves dosimetric and predicted risk calculation accuracy. Both TS and DL methods are clinically suitable for sCT generation in toxicity-guided RT, however, DL offers increased accuracy and offers efficiencies by removing the need for T1-Dixon MR. Advances in knowledge This study demonstrates novel insights regarding the effect of sCT on predictive toxicity metrics, demonstrating clear accuracy improvement with increased sCT resolution. Accuracy of toxicity calculation in MR-only RT should be assessed for all treatment sites where dose to critical structures will guide adaptive-RT strategies. Clinical trial registration number Patient data were taken from an ethically approved (UK Health Research Authority) clinical trial run at Guy's and St Thomas' NHS Foundation Trust. Study Name: MR-simulation in Radiotherapy for Prostate Cancer. ClinicalTrials.gov Identifier: NCT03238170.
Collapse
Affiliation(s)
- Christopher Thomas
- School of Biomedical Engineering & Imaging Sciences, King’s College London, SE17EH London, United Kingdom
- Medical Physics Department, Guy’s and St Thomas’ Hospital NHS Foundation Trust, SE17EH London, United Kingdom
| | - Isabel Dregely
- School of Biomedical Engineering & Imaging Sciences, King’s College London, SE17EH London, United Kingdom
- Computer Science, UAS Technikum Wien, 1200 Vienna, Austria
| | - Ilkay Oksuz
- School of Biomedical Engineering & Imaging Sciences, King’s College London, SE17EH London, United Kingdom
- Computer Engineering Department, Istanbul Technical University, 34485 Istanbul, Turkey
| | - Teresa Guerrero Urbano
- Clinical Oncology, Guy’s and St Thomas’ Hospital NHS Foundation Trust, SE17EH London, United Kingdom
| | - Tony Greener
- Medical Physics Department, Guy’s and St Thomas’ Hospital NHS Foundation Trust, SE17EH London, United Kingdom
| | - Andrew P King
- School of Biomedical Engineering & Imaging Sciences, King’s College London, SE17EH London, United Kingdom
| | - Sally F Barrington
- School of Biomedical Engineering & Imaging Sciences, King’s College London, SE17EH London, United Kingdom
- King’s College London and Guy’s and St Thomas’ PET Centre, School of Biomedical Engineering and Imaging Sciences, King’s College London, King’s Health Partners, SE17EH London, United Kingdom
| |
Collapse
|
17
|
Kim J, Sung J, Lee SJ, Cho KS, Chung BH, Yang D, Kim J, Kim JW. Optimal planning target margin for prostate radiotherapy based on interfractional and intrafractional variability assessment during 1.5T MRI-guided radiotherapy. Front Oncol 2023; 13:1337626. [PMID: 38173837 PMCID: PMC10761547 DOI: 10.3389/fonc.2023.1337626] [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: 11/13/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction We analyzed daily pre-treatment- (PRE) and real-time motion monitoring- (MM) MRI scans of patients receiving definitive prostate radiotherapy (RT) with 1.5 T MRI guidance to assess interfractional and intrafractional variability of the prostate and suggest optimal planning target volume (PTV) margin. Materials and methods Rigid registration between PRE-MRI and planning CT images based on the pelvic bone and prostate anatomy were performed. Interfractional setup margin (SM) and interobserver variability (IO) were assessed by comparing the centroid values of prostate contours delineated on PRE-MRIs. MM-MRIs were used for internal margin (IM) assessment, and PTV margin was calculated using the van Herk formula. Results We delineated 400 prostate contours on PRE-MRI images. SM was 0.57 ± 0.42, 2.45 ± 1.98, and 2.28 ± 2.08 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively, after bone localization and 0.76 ± 0.57, 1.89 ± 1.60, and 2.02 ± 1.79 mm in the LR, AP, and SI directions, respectively, after prostate localization. IO was 1.06 ± 0.58, 2.32 ± 1.08, and 3.30 ± 1.85 mm in the LR, AP, and SI directions, respectively, after bone localization and 1.11 ± 0.55, 2.13 ± 1.07, and 3.53 ± 1.65 mm in the LR, AP, and SI directions, respectively, after prostate localization. Average IM was 2.12 ± 0.86, 2.24 ± 1.07, and 2.84 ± 0.88 mm in the LR, AP, and SI directions, respectively. Calculated PTV margin was 2.21, 5.16, and 5.40 mm in the LR, AP, and SI directions, respectively. Conclusions Movements in the SI direction were the largest source of variability in definitive prostate RT, and interobserver variability was a non-negligible source of margin. The optimal PTV margin should also consider the internal margin.
Collapse
Affiliation(s)
- Jina Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Sung
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Jin Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Su Cho
- Department of Urology, Prostate Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Ha Chung
- Department of Urology, Prostate Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongjoon Yang
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
18
|
Lorenzen EL, Celik B, Sarup N, Dysager L, Christiansen RL, Bertelsen AS, Bernchou U, Agergaard SN, Konrad ML, Brink C, Mahmood F, Schytte T, Nyborg CJ. An open-source nnU-net algorithm for automatic segmentation of MRI scans in the male pelvis for adaptive radiotherapy. Front Oncol 2023; 13:1285725. [PMID: 38023233 PMCID: PMC10654998 DOI: 10.3389/fonc.2023.1285725] [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: 08/30/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Adaptive MRI-guided radiotherapy (MRIgRT) requires accurate and efficient segmentation of organs and targets on MRI scans. Manual segmentation is time-consuming and variable, while deformable image registration (DIR)-based contour propagation may not account for large anatomical changes. Therefore, we developed and evaluated an automatic segmentation method using the nnU-net framework. Methods The network was trained on 38 patients (76 scans) with localized prostate cancer and tested on 30 patients (60 scans) with localized prostate, metastatic prostate, or bladder cancer treated at a 1.5 T MRI-linac at our institution. The performance of the network was compared with the current clinical workflow based on DIR. The segmentation accuracy was evaluated using the Dice similarity coefficient (DSC), mean surface distance (MSD), and Hausdorff distance (HD) metrics. Results The trained network successfully segmented all 600 structures in the test set. High similarity was obtained for most structures, with 90% of the contours having a DSC above 0.9 and 86% having an MSD below 1 mm. The largest discrepancies were found in the sigmoid and colon structures. Stratified analysis on cancer type showed that the best performance was seen in the same type of patients that the model was trained on (localized prostate). Especially in patients with bladder cancer, the performance was lower for the bladder and the surrounding organs. A complete automatic delineation workflow took approximately 1 minute. Compared with contour transfer based on the clinically used DIR algorithm, the nnU-net performed statistically better across all organs, with the most significant gain in using the nnU-net seen for organs subject to more considerable volumetric changes due to variation in the filling of the rectum, bladder, bowel, and sigmoid. Conclusion We successfully trained and tested a network for automatically segmenting organs and targets for MRIgRT in the male pelvis region. Good test results were seen for the trained nnU-net, with test results outperforming the current clinical practice using DIR-based contour propagation at the 1.5 T MRI-linac. The trained network is sufficiently fast and accurate for clinical use in an online setting for MRIgRT. The model is provided as open-source.
Collapse
Affiliation(s)
- Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bahar Celik
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Nis Sarup
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Lars Dysager
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | | | - Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Nielsen Agergaard
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Maximilian Lukas Konrad
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Faisal Mahmood
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | |
Collapse
|
19
|
Wan L, Jiang Y, Zhu X, Wu H, Zhao W. Quantitative assessment of adaptive radiotherapy for prostate cancer using deep learning: Bladder dose as a decision criterion. Med Phys 2023; 50:6479-6489. [PMID: 37696263 DOI: 10.1002/mp.16710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/02/2023] [Accepted: 08/19/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Adaptive radiotherapy (ART) can incorporate anatomical variations in a reoptimized treatment plan for fractionated radiotherapy. An automatic solution to objectively determine whether ART should be performed immediately after the daily image acquisition is highly desirable. PURPOSE We investigate a quantitative criterion for whether ART should be performed in prostate cancer radiotherapy by synthesizing pseudo-CT (sCT) images and evaluating dosimetric impact on treatment planning using deep learning approaches. METHOD AND MATERIALS Planning CT (pCT) and daily cone-beam CT (CBCT) data sets of 74 patients are used to train (60 patients) and evaluate (14 patients) a cycle adversarial generative network (CycleGAN) that performs the task of synthesizing high-quality sCT from daily CBCT. Automatic delineation (AD) of the bladder is performed on the sCT using the U-net. The combination of sCT and AD allows us to perform dose calculations based on the up-to-date bladder anatomy to determine whether the original treatment plan (ori-plan) is still applicable. For positive cases that the patients' anatomical changes and the associated dose calculations warrant re-planning, we made rapid plan revisions (re-plan) based on the ori-plan. RESULTS The mean absolute error within the region-of-interests (i.e., body, bladder, fat, muscle) between the sCT and pCT are 41.2, 25.1, 26.5, and 29.0HU, respectively. Taking the calculated results of pCT doses as the standard, for PTV, the gamma passing rates of sCT doses at 1 mm/1%, 2 mm/2% are 87.92%, 98.78%, respectively. The Dice coefficients of the AD-contours are 0.93 on pCT and 0.91 on sCT. According to the result of dose calculation, we found when the bladder volume underwent a substantial change (79.7%), the bladder dose is still within the safe limit, suggesting it is insufficient to solely use the bladder volume change as a criterion to determine whether adaptive treatment needs to be done. After AD-contours of the bladder using sCT, there are two cases whose bladder doseD mean > 4000 cGy ${{\mathrm{D}}}_{{\mathrm{mean}}} > 4000{\mathrm{\ cGy}}$ . For the two cases, we perform re-planning to reduce the bladder dose toD mean = 3841 cGy ${{\mathrm{D}}}_{{\mathrm{mean}}} = 3841{\mathrm{\ cGy}}$ ,D mean = 3580 cGy ${{\mathrm{D}}}_{{\mathrm{mean}}} = 3580{\mathrm{\ cGy\ }}$ under the condition that the PTV meets the prescribed dose. CONCLUSION We provide a dose accurate adaptive workflow for prostate cancer patients by using deep learning approaches, and implement ART that adapts to bladder dose. Of note, the specific replanning criterion for whether ART needs to be performed can adapt to different centers' choices based on their experience and daily observations.
Collapse
Affiliation(s)
- Luping Wan
- School of Physics, Beihang University, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
- Zhongfa Aviation Institute, Beihang University, Hangzhou, China
| | - Yin Jiang
- School of Physics, Beihang University, Beijing, China
- Zhongfa Aviation Institute, Beihang University, Hangzhou, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Hao Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Wei Zhao
- School of Physics, Beihang University, Beijing, China
- Zhongfa Aviation Institute, Beihang University, Hangzhou, China
| |
Collapse
|
20
|
Brennsæter JA, Dahle TJ, Moi JN, Svanberg IF, Haaland GS, Pilskog S. Reduction of PTV margins for elective pelvic lymph nodes in online adaptive radiotherapy of prostate cancer patients. Acta Oncol 2023; 62:1208-1214. [PMID: 37682727 DOI: 10.1080/0284186x.2023.2252584] [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: 04/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Cone beam CT (CBCT) based online adaptive radiotherapy (oART) is a new development in radiotherapy. With oART, the requirements for planning target volume (PTV) margins differ from standard therapy because motion occurs during a session. In this study, we aim to evaluate a margin reduction for locally advanced prostate patients treated with oART. MATERIAL AND METHODS Intrafraction motion of the elective pelvic lymph nodes was evaluated by two radiation therapists (RTTs) for 150 fractions from 10 prostate patients treated with oART. PTV margins of 3, 4 and 5 mm where added to these lymph nodes for all patients. The seven first patients were treated with 5 mm PTV margin, while the last three patients were treated with 4 mm margin. After treatment, the RTTs reviewed the verification CBCTs and evaluated whether the various PTV margins would have covered the adapted clinical target volume, scoring each fraction as approved, inconclusive or rejected. Couch shifts corresponding to the rigid prostate match between the CBCTs were analyzed with respect to the RTT evaluation. RESULTS The RTTs approved a 4 mm margin in 95% of the fractions, while 2% of the fractions were rejected. For a 3 mm margin, 57% of the fractions were approved, while 5% were rejected. The scoring from the two RTTs was consistent; e.g., for 3 mm, one RTT approved 58% of the fractions, while the other approved 55%. If the couch was moved less than 2 mm in any direction, 70% of the fractions were approved for a 3 mm margin, compared to 32% for shifts greater than 2 mm. CONCLUSION It is safe to reduce the PTV margin from 5 to 4 mm for the elective pelvic lymph nodes for prostate patients treated with oART. Further margin reductions can be motivated for patients presenting little intrafraction motion.
Collapse
Affiliation(s)
- John Alfred Brennsæter
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Tordis Johnsen Dahle
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Jannicke Nøkling Moi
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Gry Sandvik Haaland
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| |
Collapse
|
21
|
Bernchou U, Schytte T, Bertelsen A, Lorenzen EL, Brink C, Mahmood F. Impact of abdominal compression on intra-fractional motion and delivered dose in magnetic resonance image-guided adaptive radiation ablation of adrenal gland metastases. Phys Med 2023; 114:102682. [PMID: 37717398 DOI: 10.1016/j.ejmp.2023.102682] [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: 06/30/2023] [Revised: 08/08/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023] Open
Abstract
PURPOSE The current study investigated the impact of abdominal compression on motion and the delivered dose during non-gated, magnetic resonance image (MRI)-guided radiation ablation of adrenal gland metastases. METHODS Thirty-one patients with adrenal gland metastases treated to 45-60 Gy in 3-8 fractions on a 1.5 T MRI-linac were included in the study. The patients were breathing freely (n = 14) or with motion restricted by using an abdominal compression belt (n = 17). The time-resolved position of the target in online 2D cine MR images acquired during treatment was assessed and used to estimate the dose delivered to the GTV and abutting luminal organs at risk (OAR). RESULTS The median (range) 3D root-mean-square target position error was significantly higher in patients treated without a compression belt [2.9 (1.9-5.6) mm] compared to patients using the belt [2.1 (1.2-3.5) mm] (P < 0.01). The median (range) GTV V95% was significantly reduced from planned 98.6 (65.9-100) % to delivered 96.5 (64.5-99.9) % due to motion (P < 0.01). Most prominent dose reductions were found in patients showing either large target drift or respiration motion and were mainly treated without abdominal compression. Motion did not lead to an increased number of constraint violations for luminal OAR. CONCLUSIONS Acceptable target coverage and dose to OAR was observed in the vast majority of patients despite intra-fractional motion during adaptive MRI-guided radiation ablation. The use of abdominal compression significantly reduced the target position error and prevented the most prominent target coverage degradations and is, therefore, recommended as motion management at MRI-linacs.
Collapse
Affiliation(s)
- Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark; Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Anders Bertelsen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| | - Faisal Mahmood
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| |
Collapse
|
22
|
Hanke L, Tang H, Schröder C, Windisch P, Kudura K, Shelan M, Buchali A, Bodis S, Förster R, Zwahlen DR. Dose-Volume Histogram Parameters and Quality of Life in Patients with Prostate Cancer Treated with Surgery and High-Dose Volumetric-Intensity-Modulated Arc Therapy to the Prostate Bed. Cancers (Basel) 2023; 15:3454. [PMID: 37444564 DOI: 10.3390/cancers15133454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Prostate bed radiotherapy (RT) is a major affecter of patients' long-term quality of life (QoL). To ensure the best possible outcome of these patients, dose constraints are key for optimal RT planning and delivery. However, establishing refined dose constraints requires access to patient-level data. Therefore, we aimed to provide such data on the relationship between OAR and gastrointestinal (GI) as well as genitourinary (GU) QoL outcomes of a homogenous patient cohort who received dose-intensified post-operative RT to the prostate bed. Furthermore, we aimed to conduct an exploratory analysis of the resulting data. METHODS Patients who were treated with prostate bed RT between 2010 and 2020 were inquired about their QoL based on the Expanded Prostate Cancer Index Composite (EPIC). Those (n = 99) who received volumetric arc therapy (VMAT) of at least 70 Gy to the prostate bed were included. Dose-volume histogram (DVH) parameters were gathered and correlated with the EPIC scores. RESULTS The median age at the time of prostate bed RT was 68.9 years, and patients were inquired about their QoL in the median 2.3 years after RT. The median pre-RT prostate-specific antigen (PSA) serum level was 0.35 ng/mL. The median duration between surgery and RT was 1.5 years. The median prescribed dose to the prostate bed was 72 Gy. A total of 61.6% received prostate bed RT only. For the bladder, the highest level of statistical correlation (p < 0.01) was seen for V10-20Gy, Dmean and Dmedian with urinary QoL. For bladder wall, the highest level of statistically significant correlation (p < 0.01) was seen for V5-25Gy, Dmean and Dmedian with urinary QoL. Penile bulb V70Gy was statistically significantly correlated with sexual QoL (p < 0.05). A larger rectal volume was significantly correlated with improved bowel QoL (p < 0.05). Sigmoid and urethral DVH parameters as well as the surgical approach were not statistically significantly correlated with QoL. CONCLUSION Specific dose constraints for bladder volumes receiving low doses seem desirable for the further optimization of prostate bed RT. This may be particularly relevant in the context of the aspiration of establishing focal RT of prostate cancer and its local recurrences. Our comprehensive dataset may aid future researchers in achieving these goals.
Collapse
Affiliation(s)
- Luca Hanke
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Hongjian Tang
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Christina Schröder
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Paul Windisch
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Ken Kudura
- Department of Nuclear Medicine, Sankt Clara Hospital, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - André Buchali
- Department of Radiation Oncology, University Hospital Ruppin-Brandenburg, Fehrbelliner Strasse 38, 16816 Neuruppin, Germany
| | - Stephan Bodis
- Department of Radiation Oncology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Robert Förster
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Daniel R Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| |
Collapse
|
23
|
Qiu Z, Olberg S, den Hertog D, Ajdari A, Bortfeld T, Pursley J. Online adaptive planning methods for intensity-modulated radiotherapy. Phys Med Biol 2023; 68:10.1088/1361-6560/accdb2. [PMID: 37068488 PMCID: PMC10637515 DOI: 10.1088/1361-6560/accdb2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/17/2023] [Indexed: 04/19/2023]
Abstract
Online adaptive radiation therapy aims at adapting a patient's treatment plan to their current anatomy to account for inter-fraction variations before daily treatment delivery. As this process needs to be accomplished while the patient is immobilized on the treatment couch, it requires time-efficient adaptive planning methods to generate a quality daily treatment plan rapidly. The conventional planning methods do not meet the time requirement of online adaptive radiation therapy because they often involve excessive human intervention, significantly prolonging the planning phase. This article reviews the planning strategies employed by current commercial online adaptive radiation therapy systems, research on online adaptive planning, and artificial intelligence's potential application to online adaptive planning.
Collapse
Affiliation(s)
- Zihang Qiu
- Department of Business Analytics, University of Amsterdam, The Netherlands
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Sven Olberg
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Dick den Hertog
- Department of Business Analytics, University of Amsterdam, The Netherlands
| | - Ali Ajdari
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| |
Collapse
|
24
|
Klaar R, Rabe M, Gaass T, Schneider MJ, Benlala I, Eze C, Corradini S, Belka C, Landry G, Kurz C, Dinkel J. Ventilation and perfusion MRI at a 0.35 T MR-Linac: feasibility and reproducibility study. Radiat Oncol 2023; 18:58. [PMID: 37013541 PMCID: PMC10069152 DOI: 10.1186/s13014-023-02244-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/07/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Hybrid devices that combine radiation therapy and MR-imaging have been introduced in the clinical routine for the treatment of lung cancer. This opened up not only possibilities in terms of accurate tumor tracking, dose delivery and adapted treatment planning, but also functional lung imaging. The aim of this study was to show the feasibility of Non-uniform Fourier Decomposition (NuFD) MRI at a 0.35 T MR-Linac as a potential treatment response assessment tool, and propose two signal normalization strategies for enhancing the reproducibility of the results. METHODS Ten healthy volunteers (median age 28 ± 8 years, five female, five male) were repeatedly scanned at a 0.35 T MR-Linac using an optimized 2D+t balanced steady-state free precession (bSSFP) sequence for two coronal slice positions. Image series were acquired in normal free breathing with breaks inside and outside the scanner as well as deep and shallow breathing. Ventilation- and perfusion-weighted maps were generated for each image series using NuFD. For intra-volunteer ventilation map reproducibility, a normalization factor was defined based on the linear correlation of the ventilation signal and diaphragm position of each scan as well as the diaphragm motion amplitude of a reference scan. This allowed for the correction of signal dependency on the diaphragm motion amplitude, which varies with breathing patterns. The second strategy, which can be used for ventilation and perfusion, eliminates the dependency on the signal amplitude by normalizing the ventilation/perfusion maps with the average ventilation/perfusion signal within a selected region-of-interest (ROI). The position and size dependency of this ROI was analyzed. To evaluate the performance of both approaches, the normalized ventilation/perfusion-weighted maps were compared and the deviation of the mean ventilation/perfusion signal from the reference was calculated for each scan. Wilcoxon signed-rank tests were performed to test whether the normalization methods can significantly improve the reproducibility of the ventilation/perfusion maps. RESULTS The ventilation- and perfusion-weighted maps generated with the NuFD algorithm demonstrated a mostly homogenous distribution of signal intensity as expected for healthy volunteers regardless of the breathing maneuver and slice position. Evaluation of the ROI's size and position dependency showed small differences in the performance. Applying both normalization strategies improved the reproducibility of the ventilation by reducing the median deviation of all scans to 9.1%, 5.7% and 8.6% for the diaphragm-based, the best and worst performing ROI-based normalization, respectively, compared to 29.5% for the non-normalized scans. The significance of this improvement was confirmed by the Wilcoxon signed rank test with [Formula: see text] at [Formula: see text]. A comparison of the techniques against each other revealed a significant difference in the performance between best ROI-based normalization and worst ROI ([Formula: see text]) and between best ROI-based normalization and scaling factor ([Formula: see text]), but not between scaling factor and worst ROI ([Formula: see text]). Using the ROI-based approach for the perfusion-maps, the uncorrected deviation of 10.2% was reduced to 5.3%, which was shown to be significant ([Formula: see text]). CONCLUSIONS Using NuFD for non-contrast enhanced functional lung MRI at a 0.35 T MR-Linac is feasible and produces plausible ventilation- and perfusion-weighted maps for volunteers without history of chronic pulmonary diseases utilizing different breathing patterns. The reproducibility of the results in repeated scans significantly benefits from the introduction of the two normalization strategies, making NuFD a potential candidate for fast and robust early treatment response assessment of lung cancer patients during MR-guided radiotherapy.
Collapse
Affiliation(s)
- Rabea Klaar
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Moritz Rabe
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Gaass
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Moritz J. Schneider
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
- Antaros Medical AB, BioVenture Hub, Mölndal, Sweden
| | - Ilyes Benlala
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, F-33600 Pessac, France
- CHU Bordeaux, Service d’Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d’Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, F-33600 Pessac, France
- INSERM, U1045, Centre de Recherche Cardio-thoracique de Bordeaux, F-33600 Pessac, France
| | - Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| |
Collapse
|
25
|
Merten R, Fischer M, Christiansen H, Hellms S, von Klot CAJ, Thomas NH, Knöchelmann AC. Using a Further Planning MRI after Neoadjuvant Androgen Deprivation Therapy Significantly Reduces the Radiation Exposure of Organs at Risk in External Beam Radiotherapy of Prostate Cancer. J Clin Med 2023; 12:jcm12020574. [PMID: 36675503 PMCID: PMC9860985 DOI: 10.3390/jcm12020574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/01/2023] [Accepted: 01/07/2023] [Indexed: 01/13/2023] Open
Abstract
Radiotherapy for prostate cancer is often preceded by neoadjuvant androgen deprivation therapy (ADT), which leads to a reduction in the size of the prostate. This study examines whether it is relevant for treatment planning to acquire a second planning magnetic resonance imaging (MRI) after ADT (=MRI 2) or whether it can be planned without disadvantage based on an MRI acquired before starting ADT (=MRI 1). The imaging data for the radiotherapy treatment planning of 17 patients with prostate cancer who received two planning MRIs (before and after neoadjuvant ADT) were analyzed as follows: detailed comparable radiation plans were created separately, each based on the planning CT scan and either MRI 1 or MRI 2. After ADT for an average of 17.2 weeks, the prostate was reduced in size by an average of 24%. By using MRI 2 for treatment planning, the V60Gy of the rectum could be significantly relieved by an average of 15% with the same coverage of the target volume, and the V70Gy by as much as 33% (compared to using MRI 1 alone). Using a second MRI for treatment planning after neoadjuvant ADT in prostate cancer leads to a significant relief for the organs at risk, especially in the high dose range, with the same irradiation of the target volume, and should therefore be carried out regularly. Waiting for the prostate to shrink after a few months of ADT contributes to relief for the organs at risk and to lowering the toxicity. However, the use of reduced target volumes requires an image-guided application, and the oncological outcome needs to be verified in further studies.
Collapse
Affiliation(s)
- Roland Merten
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
- Correspondence: ; Tel.: +49-511-532-2574
| | - Mirko Fischer
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Hans Christiansen
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Susanne Hellms
- Institute for Radiology, Hannover Medical School, 30625 Hannover, Germany
| | | | - Nele Henrike Thomas
- Institute for Biostatistics, Hannover Medical School, 30625 Hannover, Germany
| | | |
Collapse
|
26
|
Picton M, Crawford D, Jameson M, Alvares S, Hogan L, Loo C, Moutrie Z, Jelen U, Pagulayan C, Dunkerley N, Twentyman T, de Leon J, Batumalai V. Introduction of radiation therapist‐led adaptive treatments on a 1.5 T
MR
‐Linac. J Med Radiat Sci 2022; 70 Suppl 2:94-98. [PMID: 36572532 PMCID: PMC10122921 DOI: 10.1002/jmrs.643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022] Open
Abstract
The introduction of magnetic resonance (MR) linear accelerators (MR-Linac) marks the beginning of a new era in radiotherapy. MR-Linac systems are currently being operated by teams of radiation therapists (RTs), radiation oncology medical physicists (ROMPs) and radiation oncologists (ROs) due to the diverse and complex tasks required to deliver treatment. This is resource-intensive and logistically challenging. RT-led service delivery at the treatment console is paramount to simplify the process and make the best use of this technology for suitable patients with commonly treated anatomical sites. This article will discuss the experiences of our department in developing and implementing an RT-led workflow on the 1.5 T MR-Linac.
Collapse
Affiliation(s)
| | | | - Michael Jameson
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Kensington New South Wales Australia
| | | | - Louise Hogan
- GenesisCare Alexandria New South Wales Australia
| | - Conrad Loo
- GenesisCare Alexandria New South Wales Australia
| | - Zoe Moutrie
- GenesisCare Alexandria New South Wales Australia
- Department of Radiation Oncology South West Sydney Local Health District Sydney New South Wales Australia
| | | | | | | | | | | | - Vikneswary Batumalai
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Kensington New South Wales Australia
| |
Collapse
|
27
|
Gurusamy VM, Al-Hammadi N, Caparrotti P, Divakar SR, Hammoud RW, Shaikh G. Real-world clinical outcomes with daily image-guided IMRT in extremity soft tissue sarcomas. Cancer Treat Res Commun 2022; 33:100655. [PMID: 36356354 DOI: 10.1016/j.ctarc.2022.100655] [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: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE We report the clinical outcomes of patients with soft tissue sarcomas (STS) arising in extremities treated with image-guided intensity modulated radiotherapy (IG-IMRT) at our institute. Local control of the tumors treated with RT was the primary end point of this study. Analyzing overall survival and long-term toxicities were the secondary objectives. METHODS AND MATERIALS The database of the patients with STS who received wide local excision and IG-IMRT at our institution from January 2012 to December 2020 was reviewed. Radiation was offered either preoperatively or postoperatively as part of multi-modality treatment. RESULTS Thirty-three consecutive patients were identified and included for analysis. Twenty-eight patients (84.8%) received postoperative adjuvant radiotherapy. Dedicated MRI simulation studies were performed in 31 patients (93.9%) in the treatment position. RapidArc IMRT technique was used in 31 patients (93.9%). A total of 2954 images were acquired during 991 treatment sessions. Errors exceeding 1 mm in the x, y and z directions were corrected online before the treatment. With a median follow-up of 36 months, two patients (6.1%) developed local recurrence. The 3-year local control was 90.9% (95% CI, 0.76 - 0.98), and the 5-year overall survival was 71.7% (95% CI, 0.44 - 0.88). One patient (3.03%) sustained a pathological fracture during the follow-up period. CONCLUSION Our results showed that IMRT with daily imaging offered excellent local control with acceptable long-term toxicity, as well as being feasible and practical to implement in our routine clinical practice.
Collapse
Affiliation(s)
- Venkada Manickam Gurusamy
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar.
| | - Noora Al-Hammadi
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Palmira Caparrotti
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Saju Raveendran Divakar
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Rabih Wafiq Hammoud
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Ghazia Shaikh
- Department of Radiation Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
28
|
Åström LM, Behrens CP, Storm KS, Sibolt P, Serup-Hansen E. Online adaptive radiotherapy of anal cancer: Normal tissue sparing, target propagation methods, and first clinical experience. Radiother Oncol 2022; 176:92-98. [PMID: 36174846 DOI: 10.1016/j.radonc.2022.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Online adaptive radiotherapy (oART) potentially spares OARs as PTV margins are reduced. This study evaluates dosimetric benefits, compared to standard non-adaptive radiotherapy (non-ART), target propagation methods, and first clinical treatments of CBCT-guided oART of anal cancer. MATERIALS AND METHODS Treatment plans with standard non-ART and reduced oART PTV margins were retrospectively generated for 23 consecutive patients with anal cancer. For five patients randomly selected among the 23 patients, weekly CBCT-guided oART sessions were simulated, where the targets were either deformed or rigidly propagated. Preferred target propagation method and dose to OARs were evaluated. Ten consecutive patients with anal cancer were treated with CBCT-guided oART. Target propagation methods and oART procedure time were evaluated. RESULTS For the retrospective treatment plans, oART resulted in median reductions in bowel bag V45Gy of 11.4 % and bladder V35Gy of 16.1%. Corresponding values for the simulated sessions were 7.5% and 27.1%. In the simulated sessions, 35% of all targets were deformed while 65% were rigidly propagated. Manual editing and rigid propagation were necessary to obtain acceptable target coverage. In the clinical treatments, the primary and some elective targets were rigidly propagated, while other targets were deformed. The median oART procedure time, measured from CBCT acquisition to completion of plan review and QA, was 23 min. CONCLUSIONS Simulated oART reduced the dose to OARs, indicating potential reduction in toxicity. Rigid propagation of targets was necessary to reduce the need for manual edit. Clinical treatments demonstrated that oART of anal cancer is feasible but time-consuming.
Collapse
Affiliation(s)
- Lina M Åström
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Health Technology, Technical University of Denmark, Roskilde, Denmark.
| | - Claus P Behrens
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Katrine Smedegaard Storm
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Patrik Sibolt
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Eva Serup-Hansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| |
Collapse
|
29
|
Hsu SH, Han Z, Leeman JE, Hu YH, Mak RH, Sudhyadhom A. Synthetic CT generation for MRI-guided adaptive radiotherapy in prostate cancer. Front Oncol 2022; 12:969463. [PMID: 36212472 PMCID: PMC9539763 DOI: 10.3389/fonc.2022.969463] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/26/2022] [Indexed: 11/21/2022] Open
Abstract
Current MRI-guided adaptive radiotherapy (MRgART) workflows require fraction-specific electron and/or mass density maps, which are created by deformable image registration (DIR) between the simulation CT images and daily MR images. Manual density overrides may also be needed where DIR-produced results are inaccurate. This approach slows the adaptive radiotherapy workflow and introduces additional dosimetric uncertainties, especially in the presence of the magnetic field. This study investigated a method based on a conditional generative adversarial network (cGAN) with a multi-planar method to generate synthetic CT images from low-field MR images to improve efficiency in MRgART workflows for prostate cancer. Fifty-seven male patients, who received MRI-guided radiation therapy to the pelvis using the ViewRay MRIdian Linac, were selected. Forty-five cases were randomly assigned to the training cohort with the remaining twelve cases assigned to the validation/testing cohort. All patient datasets had a semi-paired DIR-deformed CT-sim image and 0.35T MR image acquired using a true fast imaging with steady-state precession (TrueFISP) sequence. Synthetic CT images were compared with deformed CT images to evaluate image quality and dosimetric accuracy. To evaluate the dosimetric accuracy of this method, clinical plans were recalculated on synthetic CT images in the MRIdian treatment planning system. Dose volume histograms for planning target volumes (PTVs) and organs-at-risk (OARs) and dose distributions using gamma analyses were evaluated. The mean-absolute-errors (MAEs) in CT numbers were 30.1 ± 4.2 HU, 19.6 ± 2.3 HU and 158.5 ± 26.0 HU for the whole pelvis, soft tissue, and bone, respectively. The peak signal-to-noise ratio was 35.2 ± 1.7 and the structural index similarity measure was 0.9758 ± 0.0035. The dosimetric difference was on average less than 1% for all PTV and OAR metrics. Plans showed good agreement with gamma pass rates of 99% and 99.9% for 1%/1 mm and 2%/2 mm, respectively. Our study demonstrates the potential of using synthetic CT images created with a multi-planar cGAN method from 0.35T MRI TrueFISP images for the MRgART treatment of prostate radiotherapy. Future work will validate the method in a large cohort of patients and investigate the limitations of the method in the adaptive workflow.
Collapse
|
30
|
Shin DS, Kim TH, Rah JE, Kim D, Yang HJ, Lee SB, Lim YK, Jeong J, Kim H, Shin D, Son J. Assessment of a Therapeutic X-ray Radiation Dose Measurement System Based on a Flexible Copper Indium Gallium Selenide Solar Cell. SENSORS (BASEL, SWITZERLAND) 2022; 22:5819. [PMID: 35957376 PMCID: PMC9370937 DOI: 10.3390/s22155819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/02/2022] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
Several detectors have been developed to measure radiation doses during radiotherapy. However, most detectors are not flexible. Consequently, the airgaps between the patient surface and detector could reduce the measurement accuracy. Thus, this study proposes a dose measurement system based on a flexible copper indium gallium selenide (CIGS) solar cell. Our system comprises a customized CIGS solar cell (with a size 10 × 10 cm2 and thickness 0.33 mm), voltage amplifier, data acquisition module, and laptop with in-house software. In the study, the dosimetric characteristics, such as dose linearity, dose rate independence, energy independence, and field size output, of the dose measurement system in therapeutic X-ray radiation were quantified. For dose linearity, the slope of the linear fitted curve and the R-square value were 1.00 and 0.9999, respectively. The differences in the measured signals according to changes in the dose rates and photon energies were <2% and <3%, respectively. The field size output measured using our system exhibited a substantial increase as the field size increased, contrary to that measured using the ion chamber/film. Our findings demonstrate that our system has good dosimetric characteristics as a flexible in vivo dosimeter. Furthermore, the size and shape of the solar cell can be easily customized, which is an advantage over other flexible dosimeters based on an a-Si solar cell.
Collapse
Affiliation(s)
- Dong-Seok Shin
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Tae-Ho Kim
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Jeong-Eun Rah
- Department of Radiation Oncology, Myongji Hospital, Goyang 10475, Korea
| | - Dohyeon Kim
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Hye Jeong Yang
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Se Byeong Lee
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Young Kyung Lim
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Jonghwi Jeong
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Haksoo Kim
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Dongho Shin
- Proton Therapy Center, National Cancer Center, Goyang 10408, Korea
| | - Jaeman Son
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Korea
| |
Collapse
|
31
|
Poon DMC, Yuan J, Yang B, Wong OL, Chiu ST, Chiu G, Cheung KY, Yu SK, Yung RWH. A Prospective Study of Stereotactic Body Radiotherapy (SBRT) with Concomitant Whole-Pelvic Radiotherapy (WPRT) for High-Risk Localized Prostate Cancer Patients Using 1.5 Tesla Magnetic Resonance Guidance: The Preliminary Clinical Outcome. Cancers (Basel) 2022; 14:cancers14143484. [PMID: 35884553 PMCID: PMC9321843 DOI: 10.3390/cancers14143484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Conventionally fractionated whole-pelvic nodal radiotherapy (WPRT) improves clinical outcome compared to prostate-only RT in high-risk prostate cancer (HR-PC). MR-guided stereotactic body radiotherapy (MRgSBRT) with concomitant WPRT represents a novel radiotherapy (RT) paradigm for HR-PC, potentially improving online image guidance and clinical outcomes. This study aims to report the preliminary clinical experiences and treatment outcome of 1.5 Tesla adaptive MRgSBRT with concomitant WPRT in HR-PC patients. Materials and methods: Forty-two consecutive HR-PC patients (72.5 ± 6.8 years) were prospectively enrolled, treated by online adaptive MRgSBRT (8 Gy(prostate)/5 Gy(WPRT) × 5 fractions) combined with androgen deprivation therapy (ADT) and followed up (median: 251 days, range: 20−609 days). Clinical outcomes were measured by gastrointestinal (GI) and genitourinary (GU) toxicities according to the Common Terminology Criteria for Adverse Events (CTCAE) Scale v. 5.0, patient-reported quality of life (QoL) with EPIC (Expanded Prostate Cancer Index Composite) questionnaire, and prostate-specific antigen (PSA) responses. Results: All MRgSBRT fractions achieved planning objectives and dose specifications of the targets and organs at risk, and they were successfully delivered. The maximum cumulative acute GI/GU grade 1 and 2 toxicity rates were 19.0%/81.0% and 2.4%/7.1%, respectively. The subacute (>30 days) GI/GU grade 1 and 2 toxicity rates were 21.4%/64.3% and 2.4%/2.4%, respectively. No grade 3 toxicities were reported. QoL showed insignificant changes in urinary, bowel, sexual, and hormonal domain scores during the follow-up period. All patients had early post-MRgSBRT biochemical responses, while biochemical recurrence (PSA nadir + 2 ng/mL) occurred in one patient at month 18. Conclusions: To our knowledge, this is the first prospective study that showed the clinical outcomes of MRgSBRT with concomitant WPRT in HR-PC patients. The early results suggested favorable treatment-related toxicities and encouraging patient-reported QoLs, but long-term follow-up is needed to confirm our early results.
Collapse
Affiliation(s)
- Darren M C Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Jing Yuan
- Research Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Bin Yang
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Oi-Lei Wong
- Research Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Sin-Ting Chiu
- Department of Radiotherapy, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - George Chiu
- Department of Radiotherapy, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Kin-Yin Cheung
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Siu-Ki Yu
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| | - Raymond W H Yung
- Research Department, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR, China
| |
Collapse
|
32
|
Yang B, Yuan J, Poon DM, Geng H, Lam WW, Cheung KY, Yu SK. Assessment of planning target volume margins in 1.5 T magnetic resonance‐guided stereotactic body radiation therapy for localized prostate cancer. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bin Yang
- Medical Physics Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Jing Yuan
- Research Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Darren M.C. Poon
- Comprehensive Oncology Centre Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Hui Geng
- Medical Physics Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Wai Wang Lam
- Medical Physics Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Kin Yin Cheung
- Medical Physics Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| | - Siu Ki Yu
- Medical Physics Department Hong Kong Sanatorium & Hospital Happy Valley Hong Kong China
| |
Collapse
|