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Chang C, Bohannon D, Tian Z, Wang Y, Mcdonald MW, Yu DS, Liu T, Zhou J, Yang X. A retrospective study on the investigation of potential dosimetric benefits of online adaptive proton therapy for head and neck cancer. J Appl Clin Med Phys 2024; 25:e14308. [PMID: 38368614 PMCID: PMC11087169 DOI: 10.1002/acm2.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/28/2023] [Accepted: 02/06/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE Proton therapy is sensitive to anatomical changes, often occurring in head-and-neck (HN) cancer patients. Although multiple studies have proposed online adaptive proton therapy (APT), there is still a concern in the radiotherapy community about the necessity of online APT. We have performed a retrospective study to investigate the potential dosimetric benefits of online APT for HN patients relative to the current offline APT. METHODS Our retrospective study has a patient cohort of 10 cases. To mimic online APT, we re-evaluated the dose of the in-use treatment plan on patients' actual treatment anatomy captured by cone-beam CT (CBCT) for each fraction and performed a templated-based automatic replanning if needed, assuming that these were performed online before treatment delivery. Cumulative dose of the simulated online APT course was calculated and compared with that of the actual offline APT course and the designed plan dose of the initial treatment plan (referred to as nominal plan). The ProKnow scoring system was employed and adapted for our study to quantify the actual quality of both courses against our planning goals. RESULTS The average score of the nominal plans over the 10 cases is 41.0, while those of the actual offline APT course and our simulated online course is 25.8 and 37.5, respectively. Compared to the offline APT course, our online course improved dose quality for all cases, with the score improvement ranging from 0.4 to 26.9 and an average improvement of 11.7. CONCLUSION The results of our retrospective study have demonstrated that online APT can better address anatomical changes for HN cancer patients than the current offline replanning practice. The advanced artificial intelligence based automatic replanning technology presents a promising avenue for extending potential benefits of online APT.
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Affiliation(s)
- Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Duncan Bohannon
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Zhen Tian
- Department of Radiation and Cellular OncologyUniversity of ChicagoChicagoIllinoisUSA
| | - Yinan Wang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Mark W. Mcdonald
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - David S. Yu
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Tian Liu
- Department of Radiation OncologyMount Sinai Medical CenterNew YorkNew YorkUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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Storm KS, Åström LM, Sibolt P, Behrens CP, Persson GF, Serup-Hansen E. ROAR-A: re-optimization based Online Adaptive Radiotherapy of anal cancer, a prospective phase II trial protocol. BMC Cancer 2024; 24:374. [PMID: 38528456 DOI: 10.1186/s12885-024-12111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Chemo-radiotherapy with curative intent for anal cancer has high complete remission rates, but acute treatment-related gastrointestinal (GI) toxicity is significant. Toxicity occurs due to irradiation of surrounding normal tissue. Current radiotherapy requires the addition of large planning margins to the radiation field to ensure target coverage regardless of the considerable organ motion in the pelvic region. This increases the irradiated volume and radiation dose to the surrounding normal tissue and thereby toxicity. Online adaptive radiotherapy uses artificial intelligence to adjust the treatment to the anatomy of the day. This allows for the reduction of planning margins, minimizing the irradiated volume and thereby radiation to the surrounding normal tissue.This study examines if cone beam computed tomography (CBCT)-guided oART with daily automated treatment re-planning can reduce acute gastrointestinal toxicity in patients with anal cancer. METHODS/DESIGN The study is a prospective, single-arm, phase II trial conducted at Copenhagen University Hospital, Herlev and Gentofte, Denmark. 205 patients with local only or locally advanced anal cancer, referred for radiotherapy with or without chemotherapy with curative intent, are planned for inclusion. Toxicity and quality of life are reported with Common Terminology Criteria of Adverse Events and patient-reported outcome questionnaires, before, during, and after treatment. The primary endpoint is a reduction in the incidence of acute treatment-related grade ≥ 2 diarrhea from 36 to 25% after daily online adaptive radiotherapy compared to standard radiotherapy. Secondary endpoints include all acute and late toxicity, overall survival, and reduction in treatment interruptions. RESULTS Accrual began in January 2022 and is expected to finish in January 2026. Primary endpoint results are expected to be available in April 2026. DISCUSSION This is the first study utilizing online adaptive radiotherapy to treat anal cancer. We hope to determine whether there is a clinical benefit for the patients, with significant reductions in acute GI toxicity without compromising treatment efficacy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05438836. Danish Ethical Committee: H-21028093.
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Affiliation(s)
- Katrine Smedegaard Storm
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, København, Denmark.
| | - Lina M Åström
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Patrik Sibolt
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Claus P Behrens
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Gitte F Persson
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, København, Denmark
| | - Eva Serup-Hansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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3
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Wegener S, Weick S, Schindhelm R, Tamihardja J, Sauer OA, Razinskas G. Feasibility of Ethos adaptive treatments of lung tumors and associated quality assurance. J Appl Clin Med Phys 2024:e14311. [PMID: 38386919 DOI: 10.1002/acm2.14311] [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: 07/25/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
MOTIVATION Online adaptive radiotherapy with Ethos is based on the anatomy determined from daily cone beam computed tomography (CBCT) images. Dose optimization and computation are performed on the density map of a synthetic CT (sCT), a deformable registration of the initial planning CT (pCT) onto the current CBCT. Large density changes as present in the lung region are challenging the system. METHODS Treatment plans for Ethos were created and delivered for 1, 2, and 3 cm diameter lung lesions in an anthropomorphic phantom, combining different insets in the pCT and during adaptive and non-adaptive treatment sessions. Primary and secondary dose calculations as well as back-projected dose from portal images were evaluated. RESULTS Density changes due to changed insets were not considered in the sCTs. This resulted in errors in the dose; for example, -15.9% of the mean dose for a plan when changing from a 3 cm inset in the pCT to 1 cm at the time of treatment. Secondary dose calculation is based on the sCT and could therefore not reveal these dose errors. However, dose calculation on the CBCT, either as a recalculation in the treatment planning system or as pre-treatment quality assurance (QA) before the treatment, indicated the differences. EPID in-vivo QA also reported discrepancies between calculated and delivered dose distributions. CONCLUSIONS An incorrect density distribution in the sCT has an impact on the dose calculation accuracy in the adaptive treatment workflow with the Ethos system. Additional quality checks of the sCT can detect such errors.
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Affiliation(s)
- Sonja Wegener
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
| | - Stefan Weick
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
| | - Robert Schindhelm
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
| | - Jörg Tamihardja
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
| | - Otto A Sauer
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
| | - Gary Razinskas
- Department of Radiotherapy and Radiation Oncology, University of Wurzburg, Wurzburg, Germany
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Roberfroid B, Barragán-Montero AM, Dechambre D, Sterpin E, Lee JA, Geets X. Comparison of Ethos template-based planning and AI-based dose prediction: General performance, patient optimality, and limitations. Phys Med 2023; 116:103178. [PMID: 38000099 DOI: 10.1016/j.ejmp.2023.103178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 10/19/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
PURPOSE Ethos proposes a template-based automatic dose planning (Etb) for online adaptive radiotherapy. This study evaluates the general performance of Etb for prostate cancer, as well as the ability to generate patient-optimal plans, by comparing it with another state-of-the-art automatic planning method, i.e., deep learning dose prediction followed by dose mimicking (DP + DM). MATERIALS General performances and capability to produce patient-optimal plan were investigated through two studies: Study-S1 generated plans for 45 patients using our initial Ethos clinical goals template (EG_init), and compared them to manually generated plans (MG). For study-S2, 10 patients which showed poor performances at study-S1 were selected. S2 compared the quality of plans generated with four different methods: 1) Ethos initial template (EG_init_selected), 2) Ethos updated template-based on S1 results (EG_upd_selected), 3) DP + DM, and 4) MG plans. RESULTS EG_init plans showed satisfactory performance for dose level above 50 Gy: reported mean metrics differences (EG_init minus MG) never exceeded 0.6 %. However, lower dose levels showed loosely optimized metrics, mean differences for V30Gy to rectum and V20Gy to anal canal were of 6.6 % and 13.0 %. EG_init_selected showed amplified differences in V30Gy to rectum and V20Gy to anal canal: 8.5 % and 16.9 %, respectively. These dropped to 5.7 % and 11.5 % for EG_upd_selected plans but strongly increased V60Gy to rectum for 2 patients. DP + DM plans achieved differences of 3.4 % and 4.6 % without compromising any V60Gy. CONCLUSION General performances of Etb were satisfactory. However, optimizing with template of goals might be limiting for some complex cases. Over our test patients, DP + DM outperformed the Etb approach.
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Affiliation(s)
- Benjamin Roberfroid
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium.
| | - Ana M Barragán-Montero
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
| | - David Dechambre
- Cliniques universitaires Saint-Luc, Department of Radiation Oncology, Brussels, Belgium
| | - Edmond Sterpin
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium; KU Leuven - Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium
| | - John A Lee
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
| | - Xavier Geets
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; Cliniques universitaires Saint-Luc, Department of Radiation Oncology, Brussels, Belgium
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Nasser N, Yang GQ, Koo J, Bowers M, Greco K, Feygelman V, Moros EG, Caudell JJ, Redler G. A head and neck treatment planning strategy for a CBCT-guided ring-gantry online adaptive radiotherapy system. J Appl Clin Med Phys 2023; 24:e14134. [PMID: 37621133 PMCID: PMC10691641 DOI: 10.1002/acm2.14134] [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: 06/16/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE A planning strategy was developed and the utility of online-adaptation with the Ethos CBCT-guided ring-gantry adaptive radiotherapy (ART) system was evaluated using retrospective data from Head-and-neck (H&N) patients that required clinical offline adaptation during treatment. METHODS Clinical data were used to re-plan 20 H&N patients (10 sequential boost (SEQ) with separate base and boost plans plus 10 simultaneous integrated boost (SIB)). An optimal approach, robust to online adaptation, for Ethos-initial plans using clinical goal prioritization was developed. Anatomically-derived isodose-shaping helper structures, air-density override, goals for controlling hotspot location(s), and plan normalization were investigated. Online adaptation was simulated using clinical offline adaptive simulation-CTs to represent an on-treatment CBCT. Dosimetric comparisons were based on institutional guidelines for Clinical-initial versus Ethos-initial plans and Ethos-scheduled versus Ethos-adapted plans. Timing for five components of the online adaptive workflow was analyzed. RESULTS The Ethos H&N planning approach generated Ethos-initial SEQ plans with clinically comparable PTV coverage (average PTVHigh V100% = 98.3%, Dmin,0.03cc = 97.9% and D0.03cc = 105.5%) and OAR sparing. However, Ethos-initial SIB plans were clinically inferior (average PTVHigh V100% = 96.4%, Dmin,0.03cc = 93.7%, D0.03cc = 110.6%). Fixed-field IMRT was superior to VMAT for 93.3% of plans. Online adaptation succeeded in achieving conformal coverage to the new anatomy in both SEQ and SIB plans that was even superior to that achieved in the initial plans (which was due to the changes in anatomy that simplified the optimization). The average adaptive workflow duration for SIB, SEQ base and SEQ boost was 30:14, 22.56, and 14:03 (min: sec), respectively. CONCLUSIONS With an optimal planning approach, Ethos efficiently auto-generated dosimetrically comparable and clinically acceptable initial SEQ plans for H&N patients. Initial SIB plans were inferior and clinically unacceptable, but adapted SIB plans became clinically acceptable. Online adapted plans optimized dose to new anatomy and maintained target coverage/homogeneity with improved OAR sparing in a time-efficient manner.
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Affiliation(s)
- Nour Nasser
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - George Q. Yang
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jihye Koo
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Mark Bowers
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Kevin Greco
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | | | - Eduardo G. Moros
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jimmy J. Caudell
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Gage Redler
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
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Pogue JA, Cardenas CE, Harms J, Soike MH, Kole AJ, Schneider CS, Veale C, Popple R, Belliveau JG, McDonald AM, Stanley DN. Benchmarking Automated Machine Learning-Enhanced Planning With Ethos Against Manual and Knowledge-Based Planning for Locally Advanced Lung Cancer. Adv Radiat Oncol 2023; 8:101292. [PMID: 37457825 PMCID: PMC10344691 DOI: 10.1016/j.adro.2023.101292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose Currently, there is insufficient guidance for standard fractionation lung planning using the Varian Ethos adaptive treatment planning system and its unique intelligent optimization engine. Here, we address this gap in knowledge by developing a methodology to automatically generate high-quality Ethos treatment plans for locally advanced lung cancer. Methods and Materials Fifty patients previously treated with manually generated Eclipse plans for inoperable stage IIIA-IIIC non-small cell lung cancer were included in this institutional review board-approved retrospective study. Fifteen patient plans were used to iteratively optimize a planning template for the Daily Adaptive vs Non-Adaptive External Beam Radiation Therapy With Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer: A Prospective Randomized Trial of an Individualized Approach for Toxicity Reduction (ARTIA-Lung); the remaining 35 patients were automatically replanned without intervention. Ethos plan quality was benchmarked against clinical plans and reoptimized knowledge-based RapidPlan (RP) plans, then judged using standard dose-volume histogram metrics, adherence to clinical trial objectives, and qualitative review. Results Given equal prescription target coverage, Ethos-generated plans showed improved primary and nodal planning target volume V95% coverage (P < .001) and reduced lung gross tumor volume V5 Gy and esophagus D0.03 cc metrics (P ≤ .003) but increased mean esophagus and brachial plexus D0.03 cc metrics (P < .001) compared with RP plans. Eighty percent, 49%, and 51% of Ethos, clinical, and RP plans, respectively, were "per protocol" or met "variation acceptable" ARTIA-Lung planning metrics. Three radiation oncologists qualitatively scored Ethos plans, and 78% of plans were clinically acceptable to all reviewing physicians, with no plans receiving scores requiring major changes. Conclusions A standard Ethos template produced lung radiation therapy plans with similar quality to RP plans, elucidating a viable approach for automated plan generation in the Ethos adaptive workspace.
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Affiliation(s)
- Joel A. Pogue
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlos E. Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael H. Soike
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adam J. Kole
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Craig S. Schneider
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher Veale
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean-Guy Belliveau
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew M. McDonald
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
- University of Alabama at Birmingham Institute for Cancer Outcomes and Survivorship, Birmingham, Alabama
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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Lin M, Kavanaugh JA, Kim M, Cardenas CE, Rong Y. Physicists should perform reference planning for CBCT guided online adaptive radiotherapy. J Appl Clin Med Phys 2023; 24:e14163. [PMID: 37776261 PMCID: PMC10562033 DOI: 10.1002/acm2.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 10/02/2023] Open
Affiliation(s)
- Mu‐Han Lin
- Radiation OncologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | | | - Minsun Kim
- Radiation OncologyUniversity of WashingtonSeattleWashingtonUSA
| | - Carlos E. Cardenas
- Radiation OncologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Yi Rong
- RadiationOncologyMayo ClinicPhoenixArizonaUSA
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Price AT, Kang KH, Reynoso FJ, Laugeman E, Abraham CD, Huang J, Hilliard J, Knutson NC, Henke LE. In silico trial of simulation-free hippocampal-avoidance whole brain adaptive radiotherapy. Phys Imaging Radiat Oncol 2023; 28:100491. [PMID: 37772278 PMCID: PMC10523006 DOI: 10.1016/j.phro.2023.100491] [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: 06/06/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023] Open
Abstract
Background and Purpose Hippocampal-avoidance whole brain radiotherapy (HA-WBRT) can be a time-consuming process compared to conventional whole brain techniques, thus potentially limiting widespread utilization. Therefore, we evaluated the in silico clinical feasibility, via dose-volume metrics and timing, by leveraging a computed tomography (CT)-based commercial adaptive radiotherapy (ART) platform and workflow in order to create and deliver patient-specific, simulation-free HA-WBRT. Materials and methods Ten patients previously treated for central nervous system cancers with cone-beam computed tomography (CBCT) imaging were included in this study. The CBCT was the adaptive image-of-the-day to simulate first fraction on-board imaging. Initial contours defined on the MRI were rigidly matched to the CBCT. Online ART was used to create treatment plans at first fraction. Dose-volume metrics of these simulation-free plans were compared to standard-workflow HA-WBRT plans on each patient CT simulation dataset. Timing data for the adaptive planning sessions were recorded. Results For all ten patients, simulation-free HA-WBRT plans were successfully created utilizing the online ART workflow and met all constraints. The median hippocampi D100% was 7.8 Gy (6.6-8.8 Gy) in the adaptive plan vs 8.1 Gy (7.7-8.4 Gy) in the standard workflow plan. All plans required adaptation at first fraction due to both a failing hippocampal constraint (6/10 adaptive fractions) and sub-optimal target coverage (6/10 adaptive fractions). Median time for the adaptive session was 45.2 min (34.0-53.8 min). Conclusions Simulation-free HA-WBRT, with commercially available systems, was clinically feasible via plan-quality metrics and timing, in silico.
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Affiliation(s)
- Alex T. Price
- Corresponding author at: Department of Radiation Oncology, University Hospitals Seidman Cancer Center, 11100 Euclid Ave, Cleveland OH 44106, USA
| | - Kylie H. Kang
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Francisco J. Reynoso
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Christopher D. Abraham
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Jessica Hilliard
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
| | - Nels C. Knutson
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave, St. Louis, MO 63108, USA
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Liu H, Schaal D, Curry H, Clark R, Magliari A, Kupelian P, Khuntia D, Beriwal S. Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction. Radiat Oncol 2023; 18:144. [PMID: 37660057 PMCID: PMC10475190 DOI: 10.1186/s13014-023-02340-2] [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: 04/10/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Abstract
Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.
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Affiliation(s)
- Hefei Liu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | - Ryan Clark
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc, Palo Alto, CA, USA.
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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El-qmache A, McLellan J. Investigating the feasibility of using Ethos generated treatment plans for head and neck cancer patients. Tech Innov Patient Support Radiat Oncol 2023; 27:100216. [PMID: 37744525 PMCID: PMC10511846 DOI: 10.1016/j.tipsro.2023.100216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/08/2023] [Accepted: 06/26/2023] [Indexed: 09/26/2023] Open
Abstract
The Varian Ethos treatment platform is designed to automatically create complex RT treatment plans, reducing both workload and operator variability in plan quality. The aim of this study is to evaluate the quality of Ethos-generated head and neck (H&N) treatment plans. Ethos plans were created for ten previous H&N patients and these were compared with the original clinical plans generated in Eclipse. Ethos automatically creates several plans with different field arrangements for each patient. All plans were compared quantitatively using: dose-volume metrics; dose conformity; dose heterogeneity and monitor units (MU). In addition, two H&N Oncologists assessed the clinical acceptability of the Ethos plans. Consultant 1 judged there to be at least three clinically acceptable Ethos plans for 9 out of 10 patients reviewed. Consultant 2 approved of at least two Ethos plans for 5 out of 5 patients reviewed. The Ethos plans' average dose metrics were comparable to the clinical plans. The average plan MU was similar for Eclipse and Ethos VMAT plans. The average plan MU for Ethos IMRT plans was larger with respect to all VMAT plans. The Ethos Treatment Planning system is capable of automatically creating good quality treatment plans for a range of H&N cancer patients.
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Affiliation(s)
- Adam El-qmache
- Radiotherapy Physics, Medical Physics, Aberdeen Royal Infirmary, Foresterhill Health Campus, Foresterhill Rd, Aberdeen, Scotland AB25 2ZN, United Kingdom
| | - John McLellan
- Radiotherapy Physics, Medical Physics, Aberdeen Royal Infirmary, Foresterhill Health Campus, Foresterhill Rd, Aberdeen, Scotland AB25 2ZN, United Kingdom
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11
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Saddik MZ, Hassan FF. Dosimetric comparison between intensity-modulated radiation therapy and volumetric-modulated arc therapy to enhance bladder and bowel. J Med Life 2023; 16:1381-1387. [PMID: 38107703 PMCID: PMC10719795 DOI: 10.25122/jml-2022-0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/20/2023] [Indexed: 12/19/2023] Open
Abstract
Prostate cancer is the second most common cancer in men. Two common radiotherapy techniques, intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc radiotherapy (VMAT), are used for treatment. This study aimed to compare the two techniques for sparing the bladder and bowel. Computed tomography data from prostate cancer patients were analyzed to define the clinical target volume (CTV) and planning target volume (PTV). Treatment plans were generated with Monte Carlo algorithms, and dosimetric analysis was performed using the Monaco Treatment Planning System (TPS). We compared IMRT and VMAT for prostate cancer PTV coverage (% Ref. Volume), with VMAT showing slightly better coverage (98.885±1.704) compared to IMRT (98.594±0.923). VMAT also demonstrated improved PTV conformity. Additionally, VMAT was superior in sparing the bladder (% V4500<40%), while IMRT performed better in bowel preservation (mean Ref. volume CC<195).
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Affiliation(s)
- May Zeki Saddik
- Department of Pharmacology/ Medical Physics/ and Clinical Biochemistry, College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Fatihea Fatihalla Hassan
- Department of Pharmacology/ Medical Physics/ and Clinical Biochemistry, College of Medicine, Hawler Medical University, Erbil, Iraq
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12
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Delaby N, Barateau A, Chiavassa S, Biston MC, Chartier P, Graulières E, Guinement L, Huger S, Lacornerie T, Millardet-Martin C, Sottiaux A, Caron J, Gensanne D, Pointreau Y, Coutte A, Biau J, Serre AA, Castelli J, Tomsej M, Garcia R, Khamphan C, Badey A. Practical and technical key challenges in head and neck adaptive radiotherapy: The GORTEC point of view. Phys Med 2023; 109:102568. [PMID: 37015168 DOI: 10.1016/j.ejmp.2023.102568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 02/15/2023] [Accepted: 03/18/2023] [Indexed: 04/05/2023] Open
Abstract
Anatomical variations occur during head and neck (H&N) radiotherapy (RT) treatment. These variations may result in underdosage to the target volume or overdosage to the organ at risk. Replanning during the treatment course can be triggered to overcome this issue. Due to technological, methodological and clinical evolutions, tools for adaptive RT (ART) are becoming increasingly sophisticated. The aim of this paper is to give an overview of the key steps of an H&N ART workflow and tools from the point of view of a group of French-speaking medical physicists and physicians (from GORTEC). Focuses are made on image registration, segmentation, estimation of the delivered dose of the day, workflow and quality assurance for an implementation of H&N offline and online ART. Practical recommendations are given to assist physicians and medical physicists in a clinical workflow.
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13
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Stanley DN, Harms J, Pogue JA, Belliveau JG, Marcrom SR, McDonald AM, Dobelbower MC, Boggs DH, Soike MH, Fiveash JA, Popple RA, Cardenas CE. A roadmap for implementation of kV-CBCT online adaptive radiation therapy and initial first year experiences. J Appl Clin Med Phys 2023:e13961. [PMID: 36920871 DOI: 10.1002/acm2.13961] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/12/2023] [Accepted: 02/23/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Online Adaptive Radiation Therapy (oART) follows a different treatment paradigm than conventional radiotherapy, and because of this, the resources, implementation, and workflows needed are unique. The purpose of this report is to outline our institution's experience establishing, organizing, and implementing an oART program using the Ethos therapy system. METHODS We include resources used, operational models utilized, program creation timelines, and our institutional experiences with the implementation and operation of an oART program. Additionally, we provide a detailed summary of our first year's clinical experience where we delivered over 1000 daily adaptive fractions. For all treatments, the different stages of online adaption, primary patient set-up, initial kV-CBCT acquisition, contouring review and edit of influencer structures, target review and edits, plan evaluation and selection, Mobius3D 2nd check and adaptive QA, 2nd kV-CBCT for positional verification, treatment delivery, and patient leaving the room, were analyzed. RESULTS We retrospectively analyzed data from 97 patients treated from August 2021-August 2022. One thousand six hundred seventy seven individual fractions were treated and analyzed, 632(38%) were non-adaptive and 1045(62%) were adaptive. Seventy four of the 97 patients (76%) were treated with standard fractionation and 23 (24%) received stereotactic treatments. For the adaptive treatments, the generated adaptive plan was selected in 92% of treatments. On average(±std), adaptive sessions took 34.52 ± 11.42 min from start to finish. The entire adaptive process (from start of contour generation to verification CBCT), performed by the physicist (and physician on select days), was 19.84 ± 8.21 min. CONCLUSION We present our institution's experience commissioning an oART program using the Ethos therapy system. It took us 12 months from project inception to the treatment of our first patient and 12 months to treat 1000 adaptive fractions. Retrospective analysis of delivered fractions showed that the average overall treatment time was approximately 35 min and the average time for the adaptive component of treatment was approximately 20 min.
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Affiliation(s)
- Dennis N Stanley
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Joel A Pogue
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Jean-Guy Belliveau
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Samuel R Marcrom
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Andrew M McDonald
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Michael C Dobelbower
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Michael H Soike
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - John A Fiveash
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Carlos E Cardenas
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
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14
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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.
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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
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15
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Byrne M, Archibald-Heeren B, Hu Y, Greer P, Luo S, Aland T. Assessment of semi-automated stereotactic treatment planning for online adaptive radiotherapy in ethos. Med Dosim 2022; 47:342-347. [PMID: 36127189 DOI: 10.1016/j.meddos.2022.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The Ethos treatment planning system allows for the rapid generation of online adaptive treatment plans while the patient is on the treatment couch. One promising application of online adaptive radiotherapy is its use in stereotactic radiotherapy. The purpose of this study was to ensure the Ethos treatment planning system (TPS) can produce clinically acceptable stereotactic plans, that are non-inferior to those from the Eclipse TPS. METHOD Forty patients that received previous stereotactic radiotherapy treatment on a Halcyon, 20 of which were lung cases, and 20 that were brain cases, were replanned using the Ethos TPS. The generated IMRT and VMAT plans were compared to the clinical Eclipse VMAT plan. RESULTS This study found that the Ethos TPS can produce VMAT plans of equivalent quality (target coverage, conformity and OAR doses) to those from the Eclipse TPS for lung SBRT and brain SRT. The IMRT plans produced by the Ethos planning system were marginally inferior to Eclipse VMAT plans, with the differences likely primarily due to beam geometry rather than the optimization system. Ethos plans were generally more modulated than Eclipse plans. With careful selection of optimization structures and reduction in the body contour, VMAT plan generation time could be reduced by 87%. CONCLUSION Ethos can generate stereotactic VMAT plans that are equivalent to those from Eclipse in the timeframe required for online adaptive radiotherapy.
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Affiliation(s)
- Mikel Byrne
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia; University of Newcastle, Newcastle, NSW, Australia.
| | - Ben Archibald-Heeren
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
| | - Yunfei Hu
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
| | - Peter Greer
- University of Newcastle, Newcastle, NSW, Australia; Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Suhuai Luo
- University of Newcastle, Newcastle, NSW, Australia
| | - Trent Aland
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
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