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Franciosini G, Carlotti D, Cattani F, De Gregorio A, De Liso V, De Rosa F, Di Francesco M, Di Martino F, Felici G, Pensavalle JH, Leonardi MC, Marafini M, Muscato A, Paiar F, Patera V, Poortmans P, Sciubba A, Schiavi A, Toppi M, Traini G, Trigilio A, Sarti A. IOeRT conventional and FLASH treatment planning system implementation exploiting fast GPU Monte Carlo: The case of breast cancer. Phys Med 2024; 121:103346. [PMID: 38608421 DOI: 10.1016/j.ejmp.2024.103346] [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: 02/05/2024] [Revised: 03/13/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
Partial breast irradiation for the treatment of early-stage breast cancer patients can be performed by means of Intra Operative electron Radiation Therapy (IOeRT). One of the main limitations of this technique is the absence of a treatment planning system (TPS) that could greatly help in ensuring a proper coverage of the target volume during irradiation. An IOeRT TPS has been developed using a fast Monte Carlo (MC) and an ultrasound imaging system to provide the best irradiation strategy (electron beam energy, applicator position and bevel angle) and to facilitate the optimisation of dose prescription and delivery to the target volume while maximising the organs at risk sparing. The study has been performed in silico, exploiting MC simulations of a breast cancer treatment. Ultrasound-based input has been used to compute the absorbed dose maps in different irradiation strategies and a quantitative comparison between the different options was carried out using Dose Volume Histograms. The system was capable of exploring different beam energies and applicator positions in few minutes, identifying the best strategy with an overall computation time that was found to be completely compatible with clinical implementation. The systematic uncertainty related to tissue deformation during treatment delivery with respect to imaging acquisition was taken into account. The potential and feasibility of a GPU based full MC TPS implementation of IOeRT breast cancer treatments has been demonstrated in-silico. This long awaited tool will greatly improve the treatment safety and efficacy, overcoming the limits identified within the clinical trials carried out so far.
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Affiliation(s)
- G Franciosini
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy
| | - D Carlotti
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitatio Campus-Bio Medico, Rome, Italy
| | - F Cattani
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - A De Gregorio
- National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy; Sapienza, University of Rome, Department of Physics, Rome, Italy
| | - V De Liso
- S.I.T. Sordina IORT Technologies S.p.A, Aprilia, Italy
| | - F De Rosa
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy
| | | | - F Di Martino
- Centro Pisano Multidisciplinare sulla Ricerca e Implementazione Clinica della Flash Radiotherapy (CPFR), Pisa, Italy; University of Pisa, Department of Physics, Pisa, Italy; Azienda Ospedaliero Universitaria Pisa (AOUP), Fisica Sanitaria, Pisa, Italy; National Institute of Nuclear Physics, INFN, Section of Pisa, Pisa, Italy
| | - G Felici
- S.I.T. Sordina IORT Technologies S.p.A, Aprilia, Italy
| | - J Harold Pensavalle
- S.I.T. Sordina IORT Technologies S.p.A, Aprilia, Italy; Centro Pisano Multidisciplinare sulla Ricerca e Implementazione Clinica della Flash Radiotherapy (CPFR), Pisa, Italy; National Institute of Nuclear Physics, INFN, Section of Pisa, Pisa, Italy
| | - M C Leonardi
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - M Marafini
- National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy; Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Rome, Italy
| | - A Muscato
- National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy; Specialty School of Medical Physics, La Sapienza University of Rome, Rome, Italy
| | - F Paiar
- Centro Pisano Multidisciplinare sulla Ricerca e Implementazione Clinica della Flash Radiotherapy (CPFR), Pisa, Italy; Azienda Ospedaliero Universitaria Pisa (AOUP), Fisica Sanitaria, Pisa, Italy
| | - V Patera
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - A Sciubba
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Frascati National Laboratories (LNF), Rome, Italy
| | - A Schiavi
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy
| | - M Toppi
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy
| | - G Traini
- National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy
| | - A Trigilio
- Sapienza, University of Rome, Department of Physics, Rome, Italy; National Institute of Nuclear Physics, INFN, Frascati National Laboratories (LNF), Rome, Italy
| | - A Sarti
- Sapienza, University of Rome, Department of Scienze di Base e Applicate all'Ingegneria, Rome, Italy; National Institute of Nuclear Physics, INFN, Section of Rome I, Rome, Italy.
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Sethi A, Gros S, Brodin P, Ghavidel B, Chai X, Popovic M, Tomé WA, Trichter S, Yang X, Zhang H, Uhl V. Intraoperative radiation therapy with 50 kV x-rays: A multi-institutional review. J Appl Clin Med Phys 2024; 25:e14272. [PMID: 38279520 DOI: 10.1002/acm2.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 01/01/2024] [Indexed: 01/28/2024] Open
Abstract
This report covers clinical implementation of a low kV intraoperative radiation therapy (IORT) program with the INTRABEAM® System (Carl Zeiss Meditec AG, Jena, Germany). Based on collective user experience from eight institutions, we discuss best methods of INTRABEAM quality assurance (QA) tests, commissioning measurements, clinical workflow, treatment planning, and potential avenues for research. The guide provides pertinent background information and clinical justification for IORT. It describes the INTRABEAM system and commissioning measurements along with a TG100 risk management analysis to ensure safety and accuracy of the IORT program. Following safety checks, dosimetry measurements are performed for verification of field flatness and symmetry, x-ray output, and depth dose. Also discussed are dose linearity checks, beam isotropy, ion chamber measurements, calibration protocols, and in-vivo dosimetry with optically stimulated luminescence dosimeters OSLDs, and radiochromic film. Emphasis is placed on the importance of routine QA procedures (daily, monthly, and annual) performed at regular intervals for a successful IORT program. For safe and accurate dose delivery, tests of important components of IORT clinical workflow are emphasized, such as, dose prescription, pre-treatment QA, treatment setup, safety checks, radiation surveys, and independent checks of delivered dose. Challenges associated with in-vivo dose measurements are discussed, along with special treatment procedures and shielding requirements. The importance of treatment planning in IORT is reviewed with reference to a Monte Carlo-based commercial treatment planning system highlighting its main features and limitations. The report concludes with suggested topics for research including CT-based image-guided treatment planning and improved prescription dose accuracy. We hope that this multi-institutional report will serve as a guidance document on the clinical implementation and use of INTRABEAM IORT.
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Affiliation(s)
- Anil Sethi
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Sebastien Gros
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Beth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xuedong Chai
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Marija Popovic
- Department of Medical Physics, McGill University Health Center, Montreal, Quebec, Canada
| | - Wolfgang Axel Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Samuel Trichter
- Department of Radiation Oncology, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Valery Uhl
- Department of Radiation Oncology, Summit Medical Center, Emeryville, California, USA
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Roeder F, Fastner G, Fussl C, Sedlmayer F, Stana M, Berchtold J, Jäger T, Presl J, Schredl P, Emmanuel K, Colleselli D, Kotolacsi G, Scherer P, Steininger P, Gaisberger C. First clinical application of image-guided intraoperative electron radiation therapy with real time intraoperative dose calculation in recurrent rectal cancer: technical procedure. Radiat Oncol 2023; 18:186. [PMID: 37950314 PMCID: PMC10638784 DOI: 10.1186/s13014-023-02374-6] [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: 12/06/2022] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
Intraoperative radiation therapy (IORT) is a radiation technique applying a single fraction with a high dose during surgery. We report the first abdomino-pelvic application of an image-guided intraoperative electron radiation therapy with intraoperative real time dose calculation based on the individual intraoperative patient anatomy. A patient suffering from locoregionally recurrent rectal cancer after treatment with neoadjuvant re-chemoradiation was chosen for this approach. After surgical removal of the recurrence, an adequate IORT applicator was placed as usual. A novel mobile imaging device (ImagingRing, MedPhoton) was positioned around the patient covering the region to be treated with the IORT-applicator in place. It allowed the acquisition of three-dimensional intraoperative cone-beam computed tomography images suitable for dose calculation using an automated scaling (heuristic object and head scatter as well as hardening corrections) of Hounsfield units. After image acquisition confirmed the correct applicator position, the images were transferred to our treatment planning system for intraoperative dose calculation. Treatment could be accomplished using the calculated dose distribution. We herein describe the details of the procedure including necessary adjustments in the typically used IORT equipment and work flow. We further discuss the pros and cons of this new approach generally overcoming a decade long limitation of IORT procedures as well as future perspectives regarding IORT treatments.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Gerd Fastner
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Christoph Fussl
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Felix Sedlmayer
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
- Institute of Research and Development of Advanced Radiation Technologies (radART), Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Markus Stana
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Johannes Berchtold
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Tarkan Jäger
- Department of Visceral and Thoracic Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Jaroslav Presl
- Department of Visceral and Thoracic Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Philipp Schredl
- Department of Visceral and Thoracic Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Klaus Emmanuel
- Department of Visceral and Thoracic Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Daniela Colleselli
- Department of Urology, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Gabriel Kotolacsi
- Department of Anesthesiology, Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Philipp Scherer
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Philipp Steininger
- Institute of Research and Development of Advanced Radiation Technologies (radART), Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
| | - Christoph Gaisberger
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
- Institute of Research and Development of Advanced Radiation Technologies (radART), Paracelsus Medical University, Müllner Hauptstrasse 48, Salzburg, Austria
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Ayala Alvarez DS, Watson PGF, Popovic M, Heng VJ, Evans MDC, Panet-Raymond V, Seuntjens J. Evaluation of Dosimetry Formalisms in Intraoperative Radiation Therapy of Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:763-773. [PMID: 37150259 DOI: 10.1016/j.ijrobp.2023.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE The intraoperative radiotherapy in newly diagnosed glioblastoma multiforme (INTRAGO) clinical trial assesses survival in patients with glioblastoma treated with intraoperative radiation therapy (IORT) using the INTRABEAM. Treatment planning for INTRABEAM relies on vendor-provided in-water depth dose curves obtained according to the TARGeted Intraoperative radioTherapy (TARGIT) dosimetry protocol. However, recent studies have shown discrepancies between the estimated TARGIT and delivered doses. This work evaluates the effect of the choice of dosimetry formalism on organs at risk (OAR) doses. METHODS AND MATERIALS A treatment planning framework for INTRABEAM was developed to retrospectively calculate the IORT dose in 8 INTRAGO patients. These patients received an IORT prescription dose of 20 to 30 Gy in addition to external beam radiation therapy. The IORT dose was obtained using (1) the TARGIT method; (2) the manufacturer's V4.0 method; (3) the CQ method, which uses an ionization chamber Monte Carlo (MC) calculated factor; (4) MC dose-to-water; and (5) MC dose-to-tissue. The IORT dose was converted to 2 Gy fractions equivalent dose. RESULTS According to the TARGIT method, the OAR dose constraints were respected in all cases. However, the other formalisms estimated a higher mean dose to OARs and revealed 1 case where the constraint for the brain stem was exceeded. The addition of the external beam radiation therapy and TARGIT IORT doses resulted in 10 cases of OARs exceeding the dose constraints. The more accurate MC calculation of dose-to-tissue led to the highest dosimetric differences, with 3, 3, 2, and 2 cases (out of 8) exceeding the dose constraint to the brain stem, optic chiasm, optic nerves, and lenses, respectively. Moreover, the mean cumulative dose to brain stem exceeded its constraint of 66 Gy with the MC dose-to-tissue method, which was not evident with the current INTRAGO clinical practice. CONCLUSIONS The current clinical approach of calculating the IORT dose with the TARGIT method may considerably underestimate doses to nearby OARs. In practice, OAR dose constraints may have been exceeded, as revealed by more accurate methods.
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Affiliation(s)
| | | | | | - Veng Jean Heng
- Department of Physics and Medical Physics Unit, McGill University, Montreal, QC, Canada
| | | | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Jan Seuntjens
- Medical Physics Unit and; Princess Margaret Cancer Centre, Radiation Medicine Program, University Health Network, Toronto, ON, Canada
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Dosimetric characteristics of the LIAC intraoperative radiotherapy beams: Assessment of sensitivity to measurement errors at the commissioning phase. Radiat Phys Chem Oxf Engl 1993 2023. [DOI: 10.1016/j.radphyschem.2022.110737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Tavallaie M, Hariri Tabrizi S, Heidarloo N. Implementation of pencil beam redefinition algorithm (PBRA) for intraoperative electron radiation therapy (IOERT) treatment planning. Phys Med 2022; 104:32-42. [PMID: 36356502 DOI: 10.1016/j.ejmp.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/01/2022] [Accepted: 10/22/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Similar to other radiation therapy techniques, intraoperative electron radiation therapy (IOERT) can benefit from an online treatment planning system (TPS). Among all the analytical electron dose calculation algorithms, pencil beam redefinition algorithm (PBRA) has shown an acceptable accuracy in inhomogeneities. The input dataset for PBRA includes electron planar fluence, mean direction and root mean square (RMS) spread about the mean direction which had been introduced based on the conventional linear accelerator geometry in former studies. Herein, three methods for implementing PBRA for IOERT system are presented. METHODS The initialization parameters were identified using Monte Carlo (MC) simulation of a dedicated IOERT system equipped with a cylindrical 10 cm applicator, irradiating a water phantom. Phase space distribution of electrons was recorded on a plane below the applicator. The input dataset was extracted for 2 × 2 mm2 pixels and energy bin width of 1 MeV. RESULTS PBRA was implemented with three initialization methods and compared to MC. The 3D gamma analysis of the algorithm with the Formula method, which was in best agreement with MC in a simple water phantom, showed passing rates of more than 99 % for all nominal energies and it was 97.1 % for 8 MeV in the presence of protecting disk and irregular surface. Implementing PBRA on CUDA C++ resulted in 5 s run time for 8 MeV nominal energy in a water phantom. CONCLUSIONS The agreement between PBRA dose calculation and MC is promising for the development of an intraoperative TPS for IOERT.
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Affiliation(s)
- Mina Tavallaie
- Department of Medical Radiation Engineering, Shahid Beheshti University, Tehran, Iran.
| | - Sanaz Hariri Tabrizi
- Department of Medical Radiation Engineering, Shahid Beheshti University, Tehran, Iran.
| | - Nematollah Heidarloo
- Department of Medical Radiation Engineering, Shahid Beheshti University, Tehran, Iran
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Intra-Operative Electron Radiation Therapy: An Update of the Evidence Collected in 40 Years to Search for Models for Electron-FLASH Studies. Cancers (Basel) 2022; 14:cancers14153693. [PMID: 35954357 PMCID: PMC9367249 DOI: 10.3390/cancers14153693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/13/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Four decades ago, intraoperative electron radiation therapy (IOeRT) was developed to improve precision in local cancer treatment by combining real-time surgical exploration and resection with high-energy electron irradiation. The technology of ultra-high dose rate electron and other radiation beams known as FLASH irradiation sharply increases its interests, as data from preclinical experiments have proven a marked favorable effect on the therapeutic index: similar cancer control with a clearly improved tolerance of many normal tissues to high doses of irradiation. The knowledge and tools regarding technology, physics, biology, and preclinical results in heterogeneous cancers opens great opportunities towards the path of developing the first clinical applications of the emerging FLASH technology via clinical trials based on state-of-the-art medical practice with IOeRT. Abstract Introduction: The clinical practice and outcome results of intraoperative electron radiation therapy (IOeRT) in cancer patients have been extensively reported over 4 decades. Electron beams can be delivered in the promising FLASH dose rate. Methods and Materials: Several cancer models were approached by two alternative radiobiological strategies to optimize local cancer control: boost versus exclusive IOeRT. Clinical outcomes are revisited via a bibliometric search performed for the elaboration of ESTRO/ACROP IORT guidelines. Results: In the period 1982 to 2020, a total of 19,148 patients were registered in 116 publications concerning soft tissue sarcomas (9% of patients), unresected and borderline-resected pancreatic cancer (22%), locally recurrent and locally advanced rectal cancer (22%), and breast cancer (45%). Clinical outcomes following IOeRT doses in the range of 10 to 25 Gy (with or without external beam fractionated radiation therapy) show a wide range of local control from 40 to 100% depending upon cancer site, histology, stage, and treatment intensity. Constraints for normal tissue tolerance are important to maintain tumor control combined with acceptable levels of side effects. Conclusions: IOeRT represents an evidence-based approach for several tumor types. A specific risk analysis for local recurrences supports the identification of cancer models that are candidates for FLASH studies.
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Treatment Planning in Intraoperative Radiation Therapy (IORT): Where Should We Go? Cancers (Basel) 2022; 14:cancers14143532. [PMID: 35884591 PMCID: PMC9319593 DOI: 10.3390/cancers14143532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 02/04/2023] Open
Abstract
As opposed to external beam radiation therapy (EBRT), treatment planning systems (TPS) dedicated to intraoperative radiation therapy (IORT) were not subject to radical modifications in the last two decades. However, new treatment regimens such as ultrahigh dose rates and combination with multiple treatment modalities, as well as the prospected availability of dedicated in-room imaging, call for important new features in the next generation of treatment planning systems in IORT. Dosimetric accuracy should be guaranteed by means of advanced dose calculation algorithms, capable of modelling complex scattering phenomena and accounting for the non-tissue equivalent materials used to shape and compensate electron beams. Kilovoltage X-ray based IORT also presents special needs, including the correct description of extremely steep dose gradients and the accurate simulation of applicators. TPSs dedicated to IORT should also allow real-time imaging to be used for treatment adaptation at the time of irradiation. Other features implemented in TPSs should include deformable registration and capability of radiobiological planning, especially if unconventional irradiation schemes are used. Finally, patient safety requires that the multiple features be integrated in a comprehensive system in order to facilitate control of the whole process.
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Rahmanuddin S, Korn R, Cridebring D, Borazanci E, Brase J, Boswell W, Jamil A, Cai W, Sabir A, Motarjem P, Koay E, Mitra A, Goel A, Ho J, Chung V, Von Hoff DD. Role of 3D Volumetric and Perfusion Imaging for Detecting Early Changes in Pancreatic Adenocarcinoma. Front Oncol 2021; 11:678617. [PMID: 34568010 PMCID: PMC8456995 DOI: 10.3389/fonc.2021.678617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/13/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose There is a major shortage of reliable early detection methods for pancreatic cancer in high-risk groups. The focus of this preliminary study was to use Time Intensity-Density Curve (TIDC) and Marley Equation analyses, in conjunction with 3D volumetric and perfusion imaging to demonstrate their potential as imaging biomarkers to assist in the early detection of Pancreatic Ductal Adenocarcinoma (PDAC). Experimental Designs A quantitative retrospective and prospective study was done by analyzing multi-phase Computed Tomography (CT) images of 28 patients undergoing treatment at different stages of pancreatic adenocarcinoma using advanced 3D imaging software to identify the perfusion and radio density of tumors. Results TIDC and the Marley Equation proved useful in quantifying tumor aggressiveness. Perfusion delays in the venous phase can be linked to Vascular Endothelial Growth Factor (VEGF)-related activity which represents the active part of the tumor. 3D volume analysis of the multiphase CT scan of the patient showed clear changes in arterial and venous perfusion indicating the aggressive state of the tumor. Conclusion TIDC and 3D volumetric analysis can play a significant role in defining the response of the tumor to treatment and identifying early-stage aggressiveness.
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Affiliation(s)
- Syed Rahmanuddin
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Ronald Korn
- Virginia G Piper Cancer Center, Honor Health, Scottsdale, AZ, United States
| | - Derek Cridebring
- Molecular Medicine Division, Translational Genomics Research Institute (TGEN), Phoenix, AZ, United States
| | - Erkut Borazanci
- Virginia G Piper Cancer Center, Honor Health, Scottsdale, AZ, United States
| | - Jordyn Brase
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - William Boswell
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Asma Jamil
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Wenli Cai
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Aqsa Sabir
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Pejman Motarjem
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Eugene Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anirban Mitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ajay Goel
- Molecular Diagnostic and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Monrovia, CA, United States
| | - Joyce Ho
- Molecular Diagnostic and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Monrovia, CA, United States
| | - Vincent Chung
- Molecular Diagnostic and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Monrovia, CA, United States
| | - Daniel D Von Hoff
- National Medical Center & Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, United States.,Virginia G Piper Cancer Center, Honor Health, Scottsdale, AZ, United States.,Molecular Medicine Division, Translational Genomics Research Institute (TGEN), Phoenix, AZ, United States
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Santos J, Silva S, Sarmento S. Optimized method for in vivo dosimetry with small films in pelvic IOERT for rectal cancer. Phys Med 2020; 81:20-30. [PMID: 33338728 DOI: 10.1016/j.ejmp.2020.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Intra-Operative Electron Radiation Therapy (IOERT) is used to treat rectal cancer at our institution, and in vivo measurements with Gafchromic EBT3® films were introduced as quality assurance. The purpose of this work was to quantify the uncertainties associated with digitization of very small EBT3 films irradiated simultaneously, in order to optimize in vivo dosimetry for IOERT. METHODS Film samples of different sizes - M1 (5×5cm2), M2 (1.5×1.5 cm2), M3 (1.0×1.5 cm2) and M4 (0.75×1.5 cm2) - were used to quantify typical variations (uncertainties) due to scanner fluctuations, misalignment, film inhomogeneity, long-term effect of film cutting, small rotations, film curling, edge effects and the influence of opaque templates. Fitting functions and temporal validity of sensitometric curves were also assessed. RESULTS Film curling, intra-film variability and scanner fluctuations are important effects that need to be minimized or considered in the uncertainty budget. Small rotations, misalignments and film cutting have little or no influence on the readings. Most fitting functions perform well, but the quantity used for dose quantification determines over- or under-valuation of dose in the long term. Edge effects and the influence of opaque templates need to be well understood, to allow optimization of methodology to the intended purpose. CONCLUSION The proposed method allows practical and simultaneous digitization of up to ten small irradiated film samples, with an experimental uncertainty of 1%.
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Affiliation(s)
- Joana Santos
- Physics and Astronomy Department, Faculty of Sciences, University of Porto, Portugal; Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Sofia Silva
- Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal; Medical Physics Service, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Sandra Sarmento
- Management, Outcomes Research and Economics in Healthcare Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal; Medical Physics Service, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal.
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11
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AlZu’bi S, Shehab M, Al-Ayyoub M, Jararweh Y, Gupta B. Parallel implementation for 3D medical volume fuzzy segmentation. Pattern Recognit Lett 2020. [DOI: 10.1016/j.patrec.2018.07.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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12
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García-Vázquez V, Calvo FA, Ledesma-Carbayo MJ, Sole CV, Calvo-Haro J, Desco M, Pascau J. Intraoperative computed tomography imaging for dose calculation in intraoperative electron radiation therapy: Initial clinical observations. PLoS One 2020; 15:e0227155. [PMID: 31923183 PMCID: PMC6953834 DOI: 10.1371/journal.pone.0227155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022] Open
Abstract
In intraoperative electron radiation therapy (IOERT) the energy of the electron beam is selected under the conventional assumption of water-equivalent tissues at the applicator end. However, the treatment field can deviate from the theoretic flat irradiation surface, thus altering dose profiles. This patient-based study explored the feasibility of acquiring intraoperative computed tomography (CT) studies for calculating three-dimensional dose distributions with two factors not included in the conventional assumption, namely the air gap from the applicator end to the irradiation surface and tissue heterogeneity. In addition, dose distributions under the conventional assumption and from preoperative CT studies (both also updated with intraoperative data) were calculated to explore whether there are other alternatives to intraoperative CT studies that can provide similar dose distributions. The IOERT protocol was modified to incorporate the acquisition of intraoperative CT studies before radiation delivery in six patients. Three studies were not valid to calculate dose distributions due to the presence of metal artefacts. For the remaining three cases, the average gamma pass rates between the doses calculated from intraoperative CT studies and those obtained assuming water-equivalent tissues or from preoperative CT studies were 73.4% and 74.0% respectively. The agreement increased when the air gap was included in the conventional assumption (98.1%) or in the preoperative CT images (98.4%). Therefore, this factor was the one mostly influencing the dose distributions of this study. Our experience has shown that intraoperative CT studies are not recommended when the procedure includes the use of shielding discs or surgical retractors unless metal artefacts are removed. IOERT dose distributions calculated under the conventional assumption or from preoperative CT studies may be inaccurate unless the air gap (which depends on the surface irregularities of the irradiated volume and on the applicator pose) is included in the calculations.
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Affiliation(s)
- Verónica García-Vázquez
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- * E-mail: (VGV); (JP)
| | - Felipe A. Calvo
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Departamento de Oncología, Hospital General Universitario Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
- Clínica Universidad de Navarra, Madrid, Comunidad de Madrid, Spain
| | - María J. Ledesma-Carbayo
- Biomedical Image Technologies Laboratory (BIT), Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Comunidad de Madrid, Spain
- CIBER-BBN, Madrid, Comunidad de Madrid, Spain
| | - Claudio V. Sole
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Department of Radiation Oncology, Instituto de Radiomedicina, Santiago, Región Metropolitana de Santiago, Chile
| | - José Calvo-Haro
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Comunidad de Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Comunidad de Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Comunidad de Madrid, Spain
| | - Javier Pascau
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Comunidad de Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Comunidad de Madrid, Spain
- * E-mail: (VGV); (JP)
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Djukelic M, Waterhouse D, Toh R, Tan H, Rowshanfarzad P, Joseph D, Ebert MA. Evaluation of a mobile C-arm cone-beam CT in interstitial high-dose-rate prostate brachytherapy treatment planning. J Med Radiat Sci 2019; 66:112-121. [PMID: 30945476 PMCID: PMC6545480 DOI: 10.1002/jmrs.331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction The aim of this study was to evaluate the suitability of using cone‐beam computed tomography (CBCT) obtained with a mobile C‐arm X‐ray fluoroscopy unit as a single modality for planning of high‐dose‐rate (HDR) prostate brachytherapy treatments. Methods The feasibility of using CBCT images obtained using a Siemens Arcadis Orbic 3D mobile C‐arm was evaluated. A retrospective clinical study was undertaken of six participants undergoing HDR prostate brachytherapy. Plans generated using images from a Toshiba Aquilion One LB CT were compared with those generated using CBCT images. After rigid spatial registration, the plans were compared based on various parameters such as dose‐volume histograms, overlap quantities and metrics, and dose constraints. Results Provided they were within the limited field of view, the brachytherapy catheters and fiducial markers were clearly visible in the CBCT images and thus, localisable and identifiable in the treatment planning process. The Siemens CBCT underestimated CT numbers leading to poorer tissue contrast which exacerbated the difficulties in delineation of the target tumour and the surrounding organs at risk. Between CT‐ and CBCT‐based plans, the mean difference of CTV‐D90 was 1.58 Gy, CTV‐V100 was 12.13%, rectum‐V80 was 0.06% and urethra‐V120 was −0.70%. Conclusion It was not feasible to solely utilise the Siemens Arcadis Orbic 3D for HDR prostate brachytherapy treatment planning due to suboptimal organ delineation. However, the methods in this study could be used to evaluate other mobile CBCT imaging devices for feasibility in HDR brachytherapy treatment planning since the results indicated that it may not be necessary to have standard quality CT images for treatment planning.
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Affiliation(s)
- Mario Djukelic
- Department of Medical Technology and Physics, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Department of Physics, The University of Western Australia, Crawley, WA, Australia
| | - David Waterhouse
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Ryan Toh
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Hendrick Tan
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Pejman Rowshanfarzad
- Department of Physics, The University of Western Australia, Crawley, WA, Australia
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Martin A Ebert
- Department of Physics, The University of Western Australia, Crawley, WA, Australia.,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Nachabe R, Strauss K, Schueler B, Bydon M. Radiation dose and image quality comparison during spine surgery with two different, intraoperative 3D imaging navigation systems. J Appl Clin Med Phys 2019; 20:136-145. [PMID: 30677233 PMCID: PMC6370984 DOI: 10.1002/acm2.12534] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/07/2018] [Accepted: 12/22/2018] [Indexed: 12/20/2022] Open
Abstract
Careful protocol selection is required during intraoperative three-dimensional (3D) imaging for spine surgery to manage patient radiation dose and achieve clinical image quality. Radiation dose and image quality of a Medtronic O-arm commonly used during spine surgery, and a Philips hybrid operating room equipped with XperCT C-arm 3D cone-beam CT (hCBCT) are compared. The mobile O-arm (mCBCT) offers three different radiation dose settings (low, standard, and high), for four different patient sizes (small, medium, large, and extra large). The patient's radiation dose rate is constant during the entire 3D scan. In contrast, C-CBCT spine imaging uses three different field of views (27, 37, and 48 cm) using automatic exposure control (AEC) that modulates the patient's radiation dose rate during the 3D scan based on changing patient thickness. hCBCT uses additional x-ray beam filtration. Small, medium, and large trunk phantoms designed to mimic spine and soft tissue were imaged to assess radiation dose and image quality of the two systems. The estimated measured "patient" dose for the small, medium, and large phantoms imaged by the mCBCT considering all the dose settings ranged from 9.4-27.6 mGy, 8.9-33.3 mGy, and 13.8-40.6 mGy, respectively. The "patient" dose values for the same phantoms imaged with hCBCT were 2.8-4.6 mGy, 5.7-10.0 mGy, and 11.0-15.2 mGy. The CNR for the small, medium, and large phantoms was 2.9 to 3.7, 2.0 to 3.0, and 2.5 to 2.6 times higher with the hCBCT system, respectively. Hounsfield unit accuracy, noise, and uniformity of hCBCT exceeded the performance of the mCBCT; spatial resolution was comparable. Added x-ray beam filtration and AEC capability achieved clinical image quality for intraoperative spine surgery at reduced radiation dose to the patient in comparison to a reference O-arm system without these capabilities.
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Affiliation(s)
- Rami Nachabe
- Image Guided Therapy SystemsPhilips HealthcareBestThe Netherlands
| | - Keith Strauss
- Department of RadiologyCincinnati Children's HospitalCincinnatiOHUSA
| | - Beth Schueler
- Department of Neurologic RadiologyMayo ClinicRochesterMNUSA
| | - Mohamad Bydon
- Department of Neurologic SurgeryMayo ClinicRochesterMNUSA
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García-Vázquez V, Sesé-Lucio B, Calvo FA, Vaquero JJ, Desco M, Pascau J. Surface scanning for 3D dose calculation in intraoperative electron radiation therapy. Radiat Oncol 2018; 13:243. [PMID: 30526626 PMCID: PMC6286593 DOI: 10.1186/s13014-018-1181-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/12/2018] [Indexed: 02/03/2023] Open
Abstract
Background Dose calculations in intraoperative electron radiation therapy (IOERT) rely on the conventional assumption of water-equivalent tissues at the applicator end, which defines a flat irradiation surface. However, the shape of the irradiation surface modifies the dose distribution. Our study explores, for the first time, the use of surface scanning methods for three-dimensional dose calculation of IOERT. Methods Two different three-dimensional scanning technologies were evaluated in a simulated IOERT scenario: a tracked conoscopic holography sensor (ConoProbe) and a structured-light three-dimensional scanner (Artec). Dose distributions obtained from computed tomography studies of the surgical field (gold standard) were compared with those calculated under the conventional assumption or from pseudo-computed tomography studies based on surfaces. Results In the simulated IOERT scenario, the conventional assumption led to an average gamma pass rate of 39.9% for dose values greater than 10% (two configurations, with and without blood in the surgical field). Results improved when considering surfaces in the dose calculation (88.5% for ConoProbe and 92.9% for Artec). Conclusions More accurate three-dimensional dose distributions were obtained when considering surfaces in the dose calculation of the simulated surgical field. The structured-light three-dimensional scanner provided the best results in terms of dose distributions. The findings obtained in this specific experimental setup warrant further research on surface scanning in the IOERT context owing to the clinical interest of improving the documentation of the actual IOERT scenario.
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Affiliation(s)
- Verónica García-Vázquez
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.
| | - Begoña Sesé-Lucio
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Felipe A Calvo
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Oncología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.,Clínica Universidad de Navarra, Madrid, Spain
| | - Juan J Vaquero
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Javier Pascau
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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Schneider F, Bludau F, Clausen S, Fleckenstein J, Obertacke U, Wenz F. Precision IORT – Image guided intraoperative radiation therapy (igIORT) using online treatment planning including tissue heterogeneity correction. Phys Med 2017; 37:82-87. [DOI: 10.1016/j.ejmp.2017.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/17/2017] [Accepted: 04/14/2017] [Indexed: 12/30/2022] Open
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17
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Calvo FA. Intraoperative irradiation: precision medicine for quality cancer control promotion. Radiat Oncol 2017; 12:36. [PMID: 28148287 PMCID: PMC5288888 DOI: 10.1186/s13014-017-0764-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/05/2017] [Indexed: 12/21/2022] Open
Abstract
Intraoperative irradiation was implemented 4 decades ago, pioneering the efforts to improve precision in local cancer therapy by combining real-time surgical exploration/resection with high single dose radiotherapy (Gunderson et al., Intraoperative irradiation: techniques and results, 2011). Clinical and technical developments have led to very precise radiation dose deposit. The ability to deliver a very precise dose of radiation is an essential element of contemporary multidisciplinary individualized oncology. This issue of Radiation Oncology contains a collection of expert review articles and updates with relevant data regarding intraoperative radiotherapy. Technology, physics, biology of single dose and clinical results in a variety of cancer sites and histologies are described and analyzed. The state of the art for advanced cancer care through medical innovation opens a significant opportunity for individualize cancer management across a broad spectrum of clinical practice. The advantage for tailoring diagnostic and treatment decisions in an individualized fashion will translate into precise medical treatment.
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Affiliation(s)
- Felipe A Calvo
- Department of Radiation Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain. .,Instituto de Investigación Sanitaria Gregorio Marañon, Grupo Oncologia Interdisciplinar y Biotecnológica. Proyecto PI15/02121, Madrid, Spain. .,Instituto de Salud Carlos III. Ministerio de Economía y Competitividad. Gobierno de España, Madrid, Spain.
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