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Iramina H, Tsuneda M, Okamoto H, Kadoya N, Mukumoto N, Toyota M, Fukunaga J, Fujita Y, Tohyama N, Onishi H, Nakamura M. Multi-institutional questionnaire-based survey on online adaptive radiotherapy performed using commercial systems in Japan in 2023. Radiol Phys Technol 2024:10.1007/s12194-024-00828-4. [PMID: 39028438 DOI: 10.1007/s12194-024-00828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
In this study, we aimed to conduct a survey on the current clinical practice of, staffing for, commissioning of, and staff training for online adaptive radiotherapy (oART) in the institutions that installed commercial oART systems in Japan, and to share the information with institutions that will implement oART systems in future. A web-based questionnaire, containing 107 questions, was distributed to nine institutions in Japan. Data were collected from November to December 2023. Three institutions each with the MRIdian (ViewRay, Oakwood Village, OH, USA), Unity (Elekta AB, Stockholm, Sweden), and Ethos (Varian Medical Systems, Palo Alto, CA, USA) systems completed the questionnaire. One institution (MRIdian) had not performed oART by the response deadline. Each institution had installed only one oART system. Hypofractionation, and moderate hypofractionation or conventional fractionation were employed in the MRIdian/Unity and Ethos systems, respectively. The elapsed time for the oART process was faster with the Ethos than with the other systems. All institutions added additional staff for oART. Commissioning periods differed among the oART systems owing to provision of beam data from the vendors. Chambers used during commissioning measurements differed among the institutions. Institutional training was provided by all nine institutions. To the best of our knowledge, this was the first survey about oART performed using commercial systems in Japan. We believe that this study will provide useful information to institutions that installed, are installing, or are planning to install oART systems.
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Affiliation(s)
- Hiraku Iramina
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan
| | - Masato Tsuneda
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Hiroyuki Okamoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Noriyuki Kadoya
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai-Shi, Miyagi, 980-8574, Japan
| | - Nobutaka Mukumoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka-Shi, Osaka, 545-8585, Japan
| | - Masahiko Toyota
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Clinical Technology, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Junichi Fukunaga
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka-Shi, Fukuoka, 812-8582, Japan
| | - Yukio Fujita
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Naoki Tohyama
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-Shi, Yamanashi, 409-3898, Japan
| | - Mitsuhiro Nakamura
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan.
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan.
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Wong LM, Byrne M, van Dieren E, Zwart L, Ray X, Harms J, Aland T, Stanley D, Pawlicki T. Safety and Efficiency Analysis of Operational Decision-Making During Cone Beam Computed Tomography-Based Online Adaptive Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 119:1307-1316. [PMID: 38364949 DOI: 10.1016/j.ijrobp.2024.01.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/06/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE Cone beam computed tomography (CBCT)-based online adaptive radiation therapy (ART) is especially beneficial for patients with large interfractional anatomic changes. However, treatment planning and review decisions need to be made at the treatment console in real-time and may be delegated to clinical staff whose conventional scope of practice does not include making such decisions. Therefore, implementation can create new safety risks and inefficiencies. The objective of this work is to systematically analyze the safety and efficiency implications of human decision-making during the treatment session for CBCT-based online ART. METHODS AND MATERIALS The analysis was performed by applying the Systems-Theoretical Process Analysis technique and its extension for human decision-making. Four centers of different CBCT-based online ART practice models comprised the analysis team. RESULTS The general radiation therapy control structure was refined to model the interactions between routine treatment delivery staff and in-person or remote support staff. The treatment delivery staff perform 6 key control actions. Eighteen undesirable states of those control actions were identified as affecting safety and/or efficiency. In turn, 97 hazardous clinical scenarios were identified, with the control action "prepare and position patient" having the least number of scenarios and "delineate/edit influencer and target structures" having the most. Five of these are specific to either in-person or remote support during the treatment session, and 12 arise from staff support in general. CONCLUSIONS An optimally safe and efficient online ART program should require little to no support staff at the treatment console to reduce staff coordination. Uptraining of the staff already at the treatment console is needed to achieve this goal. Beyond the essential knowledge and skills such as contour editing and the selection of an optimal plan, uptraining should also target the specific cognitive biases identified in this work and the cognitive strategies to overcome these biases. Additionally, technological and organizational changes are necessary.
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Affiliation(s)
- Lawrence M Wong
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.
| | - Mikel Byrne
- Icon Cancer Centre, South Brisbane, Queensland, Australia
| | - Erik van Dieren
- Department of Radiotherapy, Medical Spectrum Twente, Enschede, Netherlands
| | - Lisanne Zwart
- Department of Radiotherapy, Medical Spectrum Twente, Enschede, Netherlands
| | - Xenia Ray
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California
| | - Joseph Harms
- Department of Radiation Oncology/ Medical Physics, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Trent Aland
- Icon Cancer Centre, South Brisbane, Queensland, Australia
| | - Dennis Stanley
- Department of Radiation Oncology/ Medical Physics, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California
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Wang YF, Price MJ, Elliston CD, Munbodh R, Spina CS, Horowitz DP, Kachnic LA. Enhancing Safety in AI-Driven Cone Beam CT-based Online Adaptive Radiation Therapy: Development and Implementation of an Interdisciplinary Workflow. Adv Radiat Oncol 2024; 9:101399. [PMID: 38292890 PMCID: PMC10823112 DOI: 10.1016/j.adro.2023.101399] [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: 06/20/2023] [Accepted: 10/11/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose The emerging online adaptive radiation therapy (OART) treatment strategy based on cone beam computed tomography allows for real-time replanning according to a patient's current anatomy. However, implementing this procedure requires a new approach across the patient's care path and monitoring of the "black box" adaptation process. This study identifies high-risk failure modes (FMs) associated with AI-driven OART and proposes an interdisciplinary workflow to mitigate potential medical errors from highly automated processes, enhance treatment efficiency, and reduce the burden on clinicians. Methods and Materials An interdisciplinary working group was formed to identify safety concerns in each process step using failure mode and effects analysis (FMEA). Based on the FMEA results, the team designed standardized procedures and safety checklists to prevent errors and ensure successful task completion. The Risk Priority Numbers (RPNs) for the top twenty FMs were calculated before and after implementing the proposed workflow to evaluate its effectiveness. Three hundred seventy-four adaptive sessions across 5 treatment sites were performed, and each session was evaluated for treatment safety and FMEA assessment. Results The OART workflow has 4 components, each with 4, 8, 13, and 4 sequentially executed tasks and safety checklists. Site-specific template preparation, which includes disease-specific physician directives and Intelligent Optimization Engine template testing, is one of the new procedures introduced. The interdisciplinary workflow significantly reduced the RPNs of the high-risk FMs, with an average decrease of 110 (maximum reduction of 305.5 and minimum reduction of 27.4). Conclusions This study underscores the importance of addressing high-risk FMs associated with AI-driven OART and emphasizes the significance of safety measures in its implementation. By proposing a structured interdisciplinary workflow and integrated checklists, the study provides valuable insights into ensuring the safe and efficient delivery of OART while facilitating its effective integration into clinical practice.
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Affiliation(s)
- Yi-Fang Wang
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Michael J. Price
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Carl D. Elliston
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Reshma Munbodh
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Catherine S. Spina
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - David P. Horowitz
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Lisa A. Kachnic
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
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Wegener S, Schindhelm R, Tamihardja J, Sauer OA, Razinskas G. Evaluation of the Ethos synthetic computed tomography for bolus-covered surfaces. Phys Med 2023; 113:102662. [PMID: 37572393 DOI: 10.1016/j.ejmp.2023.102662] [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: 11/24/2022] [Revised: 07/07/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023] Open
Abstract
PURPOSE Ethos allows online adaption of radiotherapy treatment plans. Dose is calculated on synthetic computed tomographies (sCT), CT-like images generated by deforming planning CTs (pCT) onto daily cone beam CTs (CBCT) acquired during treatment sessions. Errors in sCT density distribution may lead to dose calculation errors. sCT correctness was investigated for bolus-covered surfaces. METHODS pCTs were recorded of a slab phantom covered with bolus of different thicknesses and with air gaps introduced by spacer rings of variable diameters and heights. Treatment plans were irradiated following the adaptive workflow with different bolus configurations present in the pCT and CBCT. sCT densities were compared to those of the pCT for the same air gap size. Additionally, the neck region of an anthropomorphic phantom was imaged using a plane standard bolus versus an individual bolus adapted to the phantom's outer contour. RESULTS Varying bolus thickness by 5 mm between pCT and CBCT was reproduced in the sCT within 2 mm accuracy. Different air gaps in pCT and CBCT resulted in highly variable bolus thickness in the sCT with a typical error of 5 mm or more. In extreme cases, air gaps were filled with bolus material density in the sCT or the phantom was unrealistically deformed near changed bolus geometries. Changes in bolus thickness and deformation also occurred in the anthropomorphic phantom. CONCLUSION sCTs must be critically examined and included in plan-specific quality assurance. The use of tight-fitting air gap-free bolus should be preferred to increase the similarity between sCT and CBCT.
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Affiliation(s)
- Sonja Wegener
- University Hospital Wurzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany.
| | - Robert Schindhelm
- University Hospital Wurzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany
| | - Jörg Tamihardja
- University Hospital Wurzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany
| | - Otto A Sauer
- University Hospital Wurzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany
| | - Gary Razinskas
- University Hospital Wurzburg, Department of Radiation Oncology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany
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