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Arumugam S, Young T, Jones C, Pryor D, Sidhom M. Treatment accuracy of standard linear accelerator-based prostate SBRT: the delivered dose assessment of patients treated within two major clinical trials using an in-house position monitoring system. Front Oncol 2024; 14:1372968. [PMID: 39184052 PMCID: PMC11341385 DOI: 10.3389/fonc.2024.1372968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 07/19/2024] [Indexed: 08/27/2024] Open
Abstract
Background and purpose The purpose of this study was to assess the dosimetric improvements achieved in prostate stereotactic body radiotherapy (SBRT) treatment within the PROMETHEUS and NINJA trials using an in-house real-time position monitoring system, SeedTracker. Methods and materials This study considered a total of 127 prostate SBRT patients treated in the PROMETHEUS (ACTRN12615000223538) and NINJA (ACTRN12618001806257) clinical trials. The SeedTracker position monitoring system was utilized for real-time position monitoring with a 3-mm position tolerance. The doses delivered to the clinical target volume (CTV), rectum, and bladder were assessed by incorporating the actual target position during treatment. The dose that would have been delivered without monitoring was also assessed by incorporating the observed position deviations. Results Treatment with position corrections resulted in a mean (range) CTV D99 difference of -0.3 (-1.0 to 0.0) Gy between the planned and delivered dose. Without corrections, this difference would have been -0.6 (-3.7 to 0.0) Gy. Not correcting for position deviations resulted in a statistically significant difference between the planned and delivered CTV D99 (p < 0.05). The mean (range) dose difference between the planned and delivered D2cc of the rectum and bladder for treatment with position corrections was -0.1 (-3.7 to 4.7) Gy and -0.1 (-1.7 to 0.5) Gy, respectively. Without corrections, these differences would have been -0.6 (-6.1 to 4.7) Gy and -0.2 (-2.5 to 0.9) Gy. Conclusions SeedTracker improved clinical dose volume compliance in prostate SBRT. Without monitoring and corrections, delivered dose would significantly differ from the planned dose.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Young
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
| | - Catherine Jones
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
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Xiao H, Han Q, Wei S, Du M, Deng X, Zhang N, Li C, Wang J, Qu A, Jiang P. Setup errors analysis in iterative kV CBCT: A clinical study of cervical cancer treated with Volumetric Modulated Arc Therapy. J Appl Clin Med Phys 2024:e14480. [PMID: 39120606 DOI: 10.1002/acm2.14480] [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: 04/06/2024] [Revised: 06/17/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVE This study aims to analyze setup errors in pelvic Volumetric Modulated Arc Therapy (VMAT) for patients with non-surgical primary cervical cancer, utilizing the onboard iterative kV cone beam CT (iCBCT) imaging system on the Varian Halcyon 2.0 ring gantry structure accelerator to enhance radiotherapy precision. METHOD We selected 132 cervical cancer patients who underwent VMAT with daily iCBCT imaging guidance. Before each treatment session, a registration method based on the bony structure was employed to acquire iCBCT images with the corresponding planning CT images. Following verification and adjustment of image registration results along the three axes (but not rotational), setup errors in the lateral (X-axis), longitudinal (Y-axis), and vertical (Z-axis) directions were recorded for each patient. Subsequently, we analyzed 3642 iCBCT image setup errors. RESULTS The mean setup errors for the X, Y, and Z axes were 4.50 ± 3.79 mm, 6.08 ± 6.30 mm, and 1.48 ± 2.23 mm, respectively. Before correction with iCBCT, setup margins based on the Van Herk formula for the X, Y, and Z axes were 6.28, 12.52, and 3.26 mm, respectively. In individuals aged 60 years and older, setup errors in the X and Y axes were significantly larger than those in the younger group (p < 0.05). Additionally, there is no significant linear correlation between setup errors and treatment fraction numbers. CONCLUSION Data analysis underscores the importance of precise Y-axis setup for cervical cancer patients undergoing VMAT. Radiotherapy centers without daily iCBCT should appropriately extend the planning target volume (PTV) along the Y-axis for cervical cancer patients receiving pelvic VMAT. Elderly patients exhibit significantly larger setup errors compared to younger counterparts. In conclusion, iCBCT-guided radiotherapy is recommended for cervical cancer patients undergoing VMAT to improve setup precision.
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Affiliation(s)
- Hui Xiao
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Qiman Han
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Shuhua Wei
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Minghao Du
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Xiuwen Deng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Nan Zhang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Chunxiao Li
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Ang Qu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, P. R. China
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3
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Arumugam S, Sidhom M. Robust Optimization for Prostate Radiation Therapy: Assessment of Delivered Dose by Incorporating Intrafraction Prostate Position Deviations. Adv Radiat Oncol 2024; 9:101455. [PMID: 38596454 PMCID: PMC11002539 DOI: 10.1016/j.adro.2024.101455] [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: 10/12/2023] [Accepted: 01/18/2024] [Indexed: 04/11/2024] Open
Abstract
Purpose To assess the robustness of the dose delivered to the clinical target volume (CTV) between planning target volume (PTV)-based and robust optimization planning approaches in localized prostate cancer radiation therapy. Methods and Materials Retrospective data of 20 patients with prostate cancer, including radiation therapy and real-time prostate position, were analyzed. Two sets of volumetric modulated arc therapy plans were generated per patient: PTV-based and robust optimization. PTV-based planning used a 7-mm CTV-PTV margin, whereas robust planning considered same-magnitude position deviations. Differences in CTV dose delivered to 99% volume (D99), PTV dose delivered to 95% volume (D95), and bladder and rectum V40 (volume receiving 40 Gy) and V60 (volume receiving 60 Gy) values were evaluated. The target position, determined by in-house position monitoring system, was incorporated for dose assessment with and without position deviation correction. Results In the robust optimization approach, compared with PTV-based planning, the mean (standard deviation) V40 and V60 values of the bladder were reduced by 5.2% (4.1%) and 5.1% (1.9%), respectively. Similarly, for the rectum, the reductions were 0.8% (0.5%) and 0.6% (0.6%). In corrected treatment scenarios, both planning approaches resulted in a mean (standard deviation) CTV D99 difference of 0.1 Gy (0.1 Gy). In the not corrected scenario, PTV-based planning reduced CTV D99 by 0.1 Gy (0.5 Gy), whereas robust planning reduced it by 0.2 Gy (0.6 Gy). There was no statistically significant difference observed in the planned and delivered rectum and bladder dose for both corrected and not corrected scenarios. Conclusions Robust optimization resulted in lower V40 and V60 values for the bladder compared with PTV-based planning. However, no difference in CTV dose accuracy was found between the 2 approaches.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, New South Wales, Australia
- South Western Sydney, Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Sidhom
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
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Liu Z, Yang B, Shen Y, Ni X, Tsaftaris SA, Zhou H. Long-short diffeomorphism memory network for weakly-supervised ultrasound landmark tracking. Med Image Anal 2024; 94:103138. [PMID: 38479152 DOI: 10.1016/j.media.2024.103138] [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: 07/03/2023] [Revised: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 04/16/2024]
Abstract
Ultrasound is a promising medical imaging modality benefiting from low-cost and real-time acquisition. Accurate tracking of an anatomical landmark has been of high interest for various clinical workflows such as minimally invasive surgery and ultrasound-guided radiation therapy. However, tracking an anatomical landmark accurately in ultrasound video is very challenging, due to landmark deformation, visual ambiguity and partial observation. In this paper, we propose a long-short diffeomorphism memory network (LSDM), which is a multi-task framework with an auxiliary learnable deformation prior to supporting accurate landmark tracking. Specifically, we design a novel diffeomorphic representation, which contains both long and short temporal information stored in separate memory banks for delineating motion margins and reducing cumulative errors. We further propose an expectation maximization memory alignment (EMMA) algorithm to iteratively optimize both the long and short deformation memory, updating the memory queue for mitigating local anatomical ambiguity. The proposed multi-task system can be trained in a weakly-supervised manner, which only requires few landmark annotations for tracking and zero annotation for deformation learning. We conduct extensive experiments on both public and private ultrasound landmark tracking datasets. Experimental results show that LSDM can achieve better or competitive landmark tracking performance with a strong generalization capability across different scanner types and different ultrasound modalities, compared with other state-of-the-art methods.
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Affiliation(s)
- Zhihua Liu
- School of Computing and Mathematical Sciences, University of Leicester, Leicester, LE1 7RH, UK
| | - Bin Yang
- Department of Cardiovascular Sciences, University Hospitals of Leicester NHS Trust, Leicester, LE1 9HN, UK; Nantong-Leicester Joint Institute of Kidney Science, Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Yan Shen
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Xuejun Ni
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Sotirios A Tsaftaris
- School of Engineering, The University of Edinburgh, Edinburgh EH9 3FG, UK; The Alan Turing Institute, London NW1 2DB, UK
| | - Huiyu Zhou
- School of Computing and Mathematical Sciences, University of Leicester, Leicester, LE1 7RH, UK.
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5
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Dupont F, Dechambre D, Sterpin E. Evaluation of safety margins for cone beam CT-based adaptive prostate radiotherapy. Phys Med 2024; 121:103368. [PMID: 38663348 DOI: 10.1016/j.ejmp.2024.103368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
Adaptive radiotherapy is characterized by the use of a daily imaging system, such as CBCT (Cone-Beam Computed Tomography) images to re-optimize the treatment based on the daily anatomy and position of the patient. By systematically re-delineating the Clinical Target Volume (CTV) at each fraction, target delineation uncertainty features a random component instead of a pure systematic. The goal of this work is to identify the random and systematic contributions of the delineation error and compute a new relevant Planning Target Volume (PTV) safety margin. 169 radiotherapy sessions from 10 prostate cancer patients treated on the Varian ETHOS treatment system have been analyzed. Intra-patient and inter-patient delineation variabilities were computed in six directions, by considering the prostate as a rigid, non-rotating volume. By doing so, we were able to directly compare the delineations done by the physicians on daily CBCT images with the initial delineation done on the CT-sim and MRI, and sort them by direction using the polar coordinates of the points. The computed variabilities were then used to compute a PTV margin based on Van Herk margin recipe. The total margin computed with random and systematic delineation uncertainties was of 2.7, 2.4, 5.6, 4.8, 4.9 and 3.6 mm in the left, right, anterior, posterior, cranial and caudal directions, respectively. According to our results, the gain offered by the separation of the delineation uncertainty into systematic and random contributions due to the adaptive delineation process justifies a reduction of the PTV margin down to 3 to 5 mm in every direction.
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Affiliation(s)
- Florian Dupont
- UCLouvain, Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; Cliniques Universitaires Saint-Luc (CUSL), Nuclear Medicine Department, Brussels, Belgium.
| | - David Dechambre
- Cliniques Universitaires Saint-Luc (CUSL), Radiotherapy Department, Brussels, Belgium
| | - Edmond Sterpin
- UCLouvain, Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven (ParTICLe), Leuven, Belgium
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Aher P, Chirkute M, Kale P, Sonawane R, Singh A, Datta NR. Planning target volume margin in head and neck cancer patients undergoing radiation therapy: Estimations derived from own data and literature. Med Dosim 2024; 49:192-197. [PMID: 38195371 DOI: 10.1016/j.meddos.2023.12.001] [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: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/04/2023] [Indexed: 01/11/2024]
Abstract
Planning target volume (PTV) to deliver the desired dose to the clinical target volume (CTV) accounts for systematic (∑) and random (σ) errors during the planning and execution of intensity modulated radiation therapy (IMRT). As these errors vary at different departments, this study was conducted to determine the 3-dimensional PTV (PTV3D) margins for head and neck cancer (HNC) at our center. The same was also estimated from reported studies for a comparative assessment. A total of 77 patients with HNCs undergoing IMRT were included. Of these, 39 patients received radical RT and 38 received postoperative IMRT. An extended no action level protocol was implemented using on-board imaging. Shifts in the mediolateral (ML), anteroposterior (AP), and superoinferior (SI) directions of each patient were recorded for every fraction. PTV margins in each direction (ML, AP, SI) and PTV3D were calculated using van Herk's equation. Weighted PTV3D was also computed from the ∑ and σ errors in each direction published in the literature for HNC. Our patients were staged T2-4 (66/77) and N0 (39/77). In all, 2280 on-board images were acquired, and daily shifts in each direction were recorded. The PTV margins in the ML, AP, and SI directions were computed as 3.2 mm, 2.9 mm, and 2.6 mm, respectively. The PTV3D margin was estimated to be 6.5 mm. This compared well with the weighted median PTV3D of 7.2 mm (range: 3.2 to 9.9) computed from the 16 studies reported in the literature. To ensure ≥95% CTV dose coverage in 90% of HNC patients, PTV3D margin for our department was estimated as 6.5 mm. This agrees with the weighted median PTV3D margin of 7.2 mm computed from the 16 published studies in HNCs. Site-specific PTV3D margin estimations should be an integral component of the quality assurance protocol of each department to ensure adequate coverage of dose to CTV during IMRT.
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Affiliation(s)
- Pratik Aher
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Madhuri Chirkute
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Pournima Kale
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Rupesh Sonawane
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Ashok Singh
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Niloy Ranjan Datta
- Department of Radiotherapy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India.
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7
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Arumugam S, Young T, Do V, Chlap P, Tawfik C, Udovitch M, Wong K, Sidhom M. Assessment of intrafraction motion and its dosimetric impact on prostate radiotherapy using an in-house developed position monitoring system. Front Oncol 2023; 13:1082391. [PMID: 37519787 PMCID: PMC10375704 DOI: 10.3389/fonc.2023.1082391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Purpose To implement an in-house developed position monitoring software, SeedTracker, for conventional fractionation prostate radiotherapy, and study the effect on dosimetric impact and intrafraction motion. Methods Thirty definitive prostate radiotherapy patients with implanted fiducial markers were included in the study. All patients were treated with VMAT technique and plans were generated using the Pinnacle planning system using the 6MV beam model for Elekta linear accelerator. The target dose of 60 Gy in 20 fractions was prescribed for 29 of 30 patients, and one patient was treated with the target dose of 78 Gy in 39 fractions. The SeedTracker position monitoring system, which uses the x-ray images acquired during treatment delivery in the Elekta linear accelerator and associated XVI system, was used for online prostate position monitoring. The position tolerance for online verification was progressively reduced from 5 mm, 4 mm, and to 3 mm in 10 patient cohorts to effectively manage the treatment interruptions resulting from intrafraction motion in routine clinical practice. The delivered dose to target volumes and organs at risk in each of the treatment fractions was assessed by incorporating the observed target positions into the original treatment plan. Results In 27 of 30 patients, at least one gating event was observed, with a total of 177 occurrences of position deviation detected in 146 of 619 treatment fractions. In 5 mm, 4 mm, and 3 mm position tolerance cohorts, the position deviations were observed in 13%, 24%, and 33% of treatment fractions, respectively. Overall, the mean (range) deviation of -0.4 (-7.2 to 5.3) mm, -0.9 (-6.1 to 15.6) mm, and -1.7 (-7.0 to 6.1) mm was observed in Left-Right, Anterior-Posterior, and Superior-Inferior directions, respectively. The prostate CTV D99 would have been reduced by a maximum value of 1.3 Gy compared to the planned dose if position deviations were uncorrected, but with corrections, it was 0.3 Gy. Similarly, PTV D98 would have been reduced by a maximum value of 7.6 Gy uncorrected, with this difference reduced to 2.2 Gy with correction. The V60 to the rectum increased by a maximum of 1.0% uncorrected, which was reduced to 0.5%. Conclusion Online target position monitoring for conventional fractionation prostate radiotherapy was successfully implemented on a standard Linear accelerator using an in-house developed position monitoring software, with an improvement in resultant dose to prostate target volume.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Young
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Viet Do
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Phillip Chlap
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christine Tawfik
- Department of Radiation Therapy, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Mark Udovitch
- Department of Radiation Therapy, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Karen Wong
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
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8
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Arumugam S, Wong K, Do V, Sidhom M. Reducing the margin in prostate radiotherapy: optimizing radiotherapy with a general-purpose linear accelerator using an in-house position monitoring system. Front Oncol 2023; 13:1116999. [PMID: 37519807 PMCID: PMC10373585 DOI: 10.3389/fonc.2023.1116999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Purpose To study the feasibility of optimizing the Clinical Target Volume to Planning Target Volume (CTV-PTV) margin in prostate radiotherapy(RT) with a general-purpose linear accelerator using an in-house developed position monitoring system, SeedTracker. Methods A cohort of 30 patients having definitive prostate radiotherapy treated within an ethics-approved prospective trial was considered for this study. The intrafraction prostate motion and the position deviations were measured using SeedTracker system during each treatment fraction. Using this data the CTV-PTV margin required to cover 90% of the patients with a minimum of 95% of the prescription dose to CTV was calculated using van Herk's formula. The margin calculations were performed for treatment scenarios both with and without applying the position corrections for observed position deviations. The feasibility of margin reduction with real-time monitoring was studied by assessing the delivered dose that incorporates the actual target position during treatment delivery and comparing it with the planned dose. This assessment was performed for plans generated with reduced CTV-PTV margin in the range of 7mm-3mm. Results With real-time monitoring and position corrections applied the margin of 2.0mm, 2.1mm and 2.1mm in LR, AP and SI directions were required to meet the criteria of 90% population to receive 95% of the dose prescription to CTV. Without position corrections applied for observed position deviations a margin of 3.1mm, 4.0mm and 3.0mm was required in LR, AP and SI directions to meet the same criteria. A mean ± SD reduction of 0.5 ± 1.8% and 3 ± 7% of V60 for the rectum and bladder can be achieved for every 1mm reduction of PTV margin. With position corrections applied, the CTV D99 can be delivered within -0.2 ± 0.3 Gy of the planned dose for plans with a 3mm margin. Without applying corrections for position deviations the CTV D99 was reduced by a maximum of 1.1 ± 1.1 Gy for the 3mm margin plan and there was a statistically significant difference between planned and delivered dose for 3mm and 4mm margin plans. Conclusion This study demonstrates the feasibility of reducing the margin in prostate radiotherapy with SeedTracker system without compromising the dose delivery accuracy to CTV while reducing dose to critical structures.
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Affiliation(s)
- Sankar Arumugam
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW, Australia
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Karen Wong
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Viet Do
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
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9
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Pastor-Serrano O, Habraken S, Hoogeman M, Lathouwers D, Schaart D, Nomura Y, Xing L, Perkó Z. A probabilistic deep learning model of inter-fraction anatomical variations in radiotherapy. Phys Med Biol 2023; 68:085018. [PMID: 36958058 PMCID: PMC10481950 DOI: 10.1088/1361-6560/acc71d] [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: 09/20/2022] [Revised: 02/20/2023] [Accepted: 03/23/2023] [Indexed: 03/25/2023]
Abstract
Objective. In radiotherapy, the internal movement of organs between treatment sessions causes errors in the final radiation dose delivery. To assess the need for adaptation, motion models can be used to simulate dominant motion patterns and assess anatomical robustness before delivery. Traditionally, such models are based on principal component analysis (PCA) and are either patient-specific (requiring several scans per patient) or population-based, applying the same set of deformations to all patients. We present a hybrid approach which, based on population data, allows to predict patient-specific inter-fraction variations for an individual patient.Approach. We propose a deep learning probabilistic framework that generates deformation vector fields warping a patient's planning computed tomography (CT) into possible patient-specific anatomies. This daily anatomy model (DAM) uses few random variables capturing groups of correlated movements. Given a new planning CT, DAM estimates the joint distribution over the variables, with each sample from the distribution corresponding to a different deformation. We train our model using dataset of 312 CT pairs with prostate, bladder, and rectum delineations from 38 prostate cancer patients. For 2 additional patients (22 CTs), we compute the contour overlap between real and generated images, and compare the sampled and 'ground truth' distributions of volume and center of mass changes.Results. With a DICE score of 0.86 ± 0.05 and a distance between prostate contours of 1.09 ± 0.93 mm, DAM matches and improves upon previously published PCA-based models, using as few as 8 latent variables. The overlap between distributions further indicates that DAM's sampled movements match the range and frequency of clinically observed daily changes on repeat CTs.Significance. Conditioned only on planning CT values and organ contours of a new patient without any pre-processing, DAM can accurately deformations seen during following treatment sessions, enabling anatomically robust treatment planning and robustness evaluation against inter-fraction anatomical changes.
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Affiliation(s)
- Oscar Pastor-Serrano
- Delft University of Technology,
Department of Radiation Science & Technology, Delft, The
Netherlands
- Stanford University, Department of
Radiation Oncology, Stanford, CA, United States of America
| | - Steven Habraken
- Erasmus University Medical Center,
Department of Radiotherapy, Rotterdam, The Netherlands
- HollandPTC, Department of Medical
Physics and Informatics, Delft, The Netherlands
| | - Mischa Hoogeman
- Erasmus University Medical Center,
Department of Radiotherapy, Rotterdam, The Netherlands
- HollandPTC, Department of Medical
Physics and Informatics, Delft, The Netherlands
| | - Danny Lathouwers
- Delft University of Technology,
Department of Radiation Science & Technology, Delft, The
Netherlands
| | - Dennis Schaart
- Delft University of Technology,
Department of Radiation Science & Technology, Delft, The
Netherlands
- HollandPTC, Department of Medical
Physics and Informatics, Delft, The Netherlands
| | - Yusuke Nomura
- Stanford University, Department of
Radiation Oncology, Stanford, CA, United States of America
| | - Lei Xing
- Stanford University, Department of
Radiation Oncology, Stanford, CA, United States of America
| | - Zoltán Perkó
- Delft University of Technology,
Department of Radiation Science & Technology, Delft, The
Netherlands
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10
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Lnu A, Kumar P, Chauhan AK, Kumar P, Nigam J, Ns S, S N. Assessment of Setup Errors in Gynecological Malignancies Treated With Radiotherapy Using Onboard Imaging. Cureus 2023; 15:e37435. [PMID: 37056218 PMCID: PMC10088567 DOI: 10.7759/cureus.37435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 04/15/2023] Open
Abstract
Introduction Radiotherapy plays a vital role in the management of gynecological malignancies. However, maintaining patient position poses a challenge during daily radiotherapy treatment of these patients. This study identifies and calculates setup errors in interfraction radiotherapy and optimum clinical target volume-planning target volume (CTV-PTV) margins in patients with gynecological malignancies. Material and methods A total of 38 patients with gynecological malignancies were included in the study. They were treated with a dose of 50 Gy in 25 fractions for five weeks, followed by brachytherapy. All patients were immobilized using a 4-point thermoplastic cast. Anteroposterior and lateral images were taken thrice weekly for five weeks. Setup verification was done using kilovoltage images obtained using Varian On-board Imager (Varian Medical System, Inc., Palo Alto, CA). Manual matching was done utilizing bony landmarks such as the widest portion of the pelvic brim, anterior border of S1 vertebrae, and pubic symphysis in the X, Y, and Z axes, respectively. Results A total of 1140 images were taken. The individual systematic errors ranged from -0.24 to 0.17 cm (LR), -0.15 to 0.19 cm (AP) and -0.36 to 0.29 cm (CC) while the individual random errors ranged from 0.04 to 0.36 cm (LR), 0.06 to 0.33 cm (AP) and 0.10 to 0.29 cm (CC). The calculated CTV-PTV margins in LR, AP and CC directions were 0.17, 0.18, and 0.25 cm (ICRU-62); 0.28, 0.31 and 0.47 cm in LR, AP and CC directions (Stroom's), and 0.32, 0.36 and 0.55 cm (Van Herk) respectively. Conclusion Based on this study, the calculated CTV-PTV margin is 6 mm in gynecological malignancies, and the present protocol of 7 mm of PTV margin is optimum.
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Affiliation(s)
- Aparajeeta Lnu
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Piyush Kumar
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Arvind Kumar Chauhan
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Pavan Kumar
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Jitendra Nigam
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Silambarasan Ns
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Navitha S
- Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
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Rose C, Ebert MA, Mukwada G, Skorska M, Gill S. Intrafraction motion during CyberKnife® prostate SBRT: impact of imaging frequency and patient factors. Phys Eng Sci Med 2023; 46:669-685. [DOI: 10.1007/s13246-023-01242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
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Xu J, Wang T, Luo Y, Shang L, Mai X, Ruan J, Pan X, Chi F. Set-up errors of the neck are underestimated using the overall registration frame of head and neck in IMRT for NPC. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2023; 31:1067-1077. [PMID: 37393484 DOI: 10.3233/xst-230024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/03/2023]
Abstract
BACKGROUND There is no standardized registration frame of cone beam CT (CBCT) in intensity modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). The overall registration frame that covers the whole head and neck is the most commonly used CBCT registration frame for NPC patients in IMRT. OBJECTIVE To compare the set-up errors using different registration frames of CBCT for NPC to assess the set-up errors for different region of the commonly used clinical overall registration frame. METHODS 294 CBCT images of 59 NPC patients were collected. Four registration frames were used for matching. The set-up errors were obtained using an automatic matching algorithm and then compared. The expansion margin from the clinical target volume (CTV) to the planned target volume (PTV) in the four groups was also calculated. RESULTS The average range of the isocenter translation and rotation errors of four registration frames are 0.89∼2.41 mm and 0.49∼1.53°, respectively, which results in a significant difference in the set-up errors (p < 0.05). The set-up errors obtained from the overall frame are smaller than those obtained from the head, upper neck, and lower neck frames. The margin ranges of the overall, head, upper neck, and lower neck frames in three translation directions are 1.49∼2.39 mm, 1.92∼2.45 mm, 1.86∼3.54 mm and 3.02∼4.78 mm, respectively. The expansion margins calculated from the overall frame are not enough, especially for the lower neck. CONCLUSION Set-up errors of the neck are underestimated by the overall registration frame. Thus, it is important to improve the position immobilization of the neck, especially the lower neck. The margin of the target volume of the head and neck region should be expanded separately if circumstances permit.
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Affiliation(s)
- Junjie Xu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Tong Wang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Luo
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lintao Shang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiuying Mai
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Junjie Ruan
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaofen Pan
- Department of Oncology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Feng Chi
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
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Laughlin BS, Yu NY, Lo S, Duan J, Welchel Z, Tinnon K, Beckett M, Schild SE, Wong WW, Keole SR, Rwigema JCM, Vargas CE, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 2: Feasibility of Margin Reduction for Fractionated Radiation Treatment with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010040. [PMID: 36612040 PMCID: PMC9817842 DOI: 10.3390/cancers15010040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2−3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam CT (iCBCT) as image guidance on conventional linacs. Materials/Methods: Fourteen patients who received post-prostatectomy irradiation (8 with an endorectal balloon and 6 without a balloon) were included in this study. Treatment was delivered with volumetric modulated radiation therapy (VMAT). Fractional dose delivery was evaluated in 165 treatment fractions. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. PTV margins (0 mm, 2 mm, and 4 mm) were evaluated on daily iCBCT. CTV coverage and OAR dose parameters were assessed with each PTV margin. Results: CTV D100% was underdosed with a 0 mm margin in 32% of fractions in comparison with 2 mm (6%) and 4 mm (6%) PTV margin (p ≤ 0.001). CTV D95% > 95% was met in 93−94% fractions for all PTV expansions. CTV D95% > 95% was achieved in more patients with an endorectal balloon than those without: 0 mm—90/91 (99%) vs. 63/74 (85%); 2 mm—90/91 (99%) vs. 65/75 (87%); 4 mm—90/90 (100%) vs. 63/73 (86%). There was no difference in absolute median change in CTV D95% (0.32%) for 0-, 2-, and 4 mm margins. The maximum dose remained under 108% for 100% (0 mm), 97% (2 mm), and 98% (4 mm) of images. Rectal wall maximum dose remained under 108% for 100% (0 mm), 100% (2 mm), and 98% (4 mm) of images. Conclusions: With high-quality iCBCT image guidance, PTV margin accounting for inter-fractional uncertainties can be safely reduced for post-prostatectomy radiotherapy. For fractionated radiotherapy, an isotropic expansion of 2 mm and 4 mm may be considered for margin expansion with and without the endorectal balloon. Future application for margin reduction needs to be further evaluated and considered with the advent of shorter post-prostatectomy radiation courses.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Jingwei Duan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Radiation Oncology, University of Kentucky, Lexington, KY 40506, USA
| | - Zachary Welchel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Nuclear and Radiological Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | | | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
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Sun X, Dai Z, Xu M, Guo X, Su H, Li Y. Quantifying 6D tumor motion and calculating PTV margins during liver stereotactic radiotherapy with fiducial tracking. Front Oncol 2022; 12:1021119. [DOI: 10.3389/fonc.2022.1021119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
ObjectiveOur study aims to estimate intra-fraction six-dimensional (6D) tumor motion with rotational correction and the related correlations between motions of different degrees of freedom (DoF), as well as quantify sufficient anisotropic clinical target volume (CTV) to planning target volume (PTV) margins during stereotactic body radiotherapy (SBRT) of liver cancer with fiducial tracking technique.MethodsA cohort of 12 patients who were implanted with 3 or 4 golden markers were included in this study, and 495 orthogonal kilovoltage (kV) pairs of images acquired during the first fraction were used to extract the spacial position of each golden marker. Translational and rotational motions of tumor were calculated based on the marker coordinates by using an iterative closest point (ICP) algorithm. Moreover, the Pearson product-moment correlation coefficients (r) were applied to quantify the correlations between motions with different degrees of freedom (DoFs). The population mean displacement (MP¯), systematic error (Σ) and random error (σ) were obtained to calculate PTV margins based on published recipes.ResultsThe mean translational variability of tumors were 0.56, 1.24 and 3.38 mm in the left-right (LR, X), anterior-posterior (AP, Y), and superior-inferior (SI, Z) directions, respectively. The average rotational angles θX , θY and θZ around the three coordinate axes were 0.88, 1.24 and 1.12, respectively. (|r|>0.4) was obtainted between Y -Z , Y - θZ , Z -θZ and θX - θY . The PTV margins calculated based on 13 published recipes in X, Y, and Z directions were 1.08, 2.26 and 5.42 mm, and the 95% confidence interval (CI) of them were (0.88,1.28), (1.99,2.53) and (4.78,6.05), respectively.ConclusionsThe maximum translational motion was in SI direction, and the largest correlation coefficient of Y-Z was obtained. We recommend margins of 2, 3 and 7 mm in LR, AP and SI directions, respectively.
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Radonic S, Besserer J, Rohrer Bley C, Schneider U, Meier VS. A concept for anisotropic PTV margins including rotational setup uncertainties and its impact on the tumor control probability in canine brain tumors. Biomed Phys Eng Express 2022; 8. [PMID: 35981496 DOI: 10.1088/2057-1976/ac8a9f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In this modelling study, we pursued two main goals. The first was to establish a new CTV-to-PTV expansion which considers the closest and most critical organ at risk (OAR). The second goal was to investigate the impact of the planning target volume (PTV) margin size on the tumor control probability (TCP) and its dependence on the geometrical setup uncertainties. The aim was to achieve a smaller margin expansion close to the OAR while allowing a moderately larger expansion in less critical areas further away from the OAR and whilst maintaining the TCP. APPROACH Imaging data of radiation therapy plans from pet dogs which had undergone radiation therapy for brain tumor were used to estimate the clinic specific rotational setup uncertainties. A Monte-Carlo methodology using a voxel-based TCP model was used to quantify the implications of rotational setup uncertainties on the TCP. A combination of algorithms was utilized to establish a computational CTV-to-PTV expansion method based on probability density. This was achieved by choosing a center of rotation close to an OAR. All required software modules were developed and integrated into a software package that directly interacts with the Varian Eclipse treatment planning system. MAIN RESULTS Several uniform and non-isotropic PTVs were created. To ensure comparability and consistency, standardized RT plans with equal optimization constraints were defined, automatically applied and calculated on these targets. The resulting TCPs were then computed, evaluated and compared. SIGNIFICANCE The non-isotropic margins were found to result in larger TCPs with smaller margin excess volume. Further, we presented an additional application of the newly established CTV-to-PTV expansion method for radiation therapy of the spinal axis of human patients.
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Affiliation(s)
- Stephan Radonic
- Department of Physics, University of Zurich Faculty of Science, Winterthurerstrasse 190, Zurich, ZH, 8057, SWITZERLAND
| | - Jürgen Besserer
- Radiotherapy Hirslanden, Hirslanden Klinik Hirslanden, Witelikerstrasse 40, Zurich, Zürich, 8032, SWITZERLAND
| | - Carla Rohrer Bley
- Division of Radiation Oncology, Small Animal Department, University of Zurich Vetsuisse Faculty, Winterthurerstrasse 260, Zurich, Zürich, 8057, SWITZERLAND
| | - Uwe Schneider
- Radiotherapy Hirslanden, Hirslanden Klinik Hirslanden, Witellikerstrasse 40, Zurich, Zürich, 8032, SWITZERLAND
| | - Valeria Sabina Meier
- Division of Radiation Oncology, Small Animal Department, University of Zurich Vetsuisse Faculty, Winterthrerstrasse 260, Zurich, Zürich, 8057, SWITZERLAND
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Seminal vesicle inter- and intra-fraction motion during radiotherapy for prostate cancer: a review. Radiother Oncol 2022; 169:15-24. [DOI: 10.1016/j.radonc.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 01/04/2023]
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17
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Li Y, Wu W, He R, Lu Y, Zhang Y, Wang L, Zhang X. Using 4DCBCT simulation and guidance to evaluate inter-fractional tumor variance during SABR for lung tumor within the lower lobe. Sci Rep 2021; 11:19976. [PMID: 34620950 PMCID: PMC8497481 DOI: 10.1038/s41598-021-99489-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 09/23/2021] [Indexed: 12/25/2022] Open
Abstract
Inter-fractional tumor variance would lead to insufficient dosage or overdose in tumor region during lung cancer radiotherapy. However, previous works have not considered influence of inter-fractional tumor amplitude variance at treatment position due to lack of effective evaluation method during radiotherapy, especially for lung tumor within the lower lobe. Our objective was to investigate inter-fractional tumor baseline shift and amplitude variance due to respiratory motion with 4DCBCT simulation and guidance during stereotactic ablative body radiotherapy (SABR) for lung tumor. Subject included 19 patients with lung tumor within the lower lobe. 4DCBCT-simulated images at treatment position were acquired sequentially to determine internal tumor volume (ITV) and reference tumor motion at simulation process. Compared with reference tumor motion, 95 4DCBCT-guided images were acquired during each treatment to evaluate inter-fractional tumor baseline shift and amplitude variance, which were − 0.0 ± 1.3 mm and − 0.2 ± 1.4 mm in left–right(LR) direction, 0.9 ± 2.3 mm and 0.4 ± 2.9 mm in superior-inferior (SI) direction, 0.1 ± 1.5 mm and − 0.4 ± 2.0 mm in anterior–posterior (AP) direction. ITV margin were 3.5 mm, 7.5 mm and 5.3 mm in LR, SI and AP directions with van Herk’s (Int J Radiat Oncol Biol Phys 52(5):1407–1422, 2002) formula. 4DCBCT simulation and guidance is a reliable method to evaluate inter-fractional tumor variance during SABR for lung tumor within the lower lobe. ITV margin of 3.5 mm, 7.5 mm and 5.3 mm in LR, SI and AP directions would ensure greater tumor coverage during SABR for lung tumor within the lower lobe.
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Affiliation(s)
- Yi Li
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Wenjing Wu
- Department of Radiological Health, Xi'an Center for Disease Control and Prevention, Xi'an, 710054, China.
| | - Ruixin He
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yongkai Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yuemei Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Long Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xiaozhi Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
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Evaluation of PTV margins in IMRT for head and neck cancer and prostate cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396919000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose:The aim of this study was to evaluate planning target volume (PTV) margins for two different locations using an electronic portal imaging device (EPID) to ensure that the correct radiation dose is delivered to the tumour when using intensity-modulated radiation therapy (IMRT).Materials and methods:Setup data were collected from 40 patients treated with IMRT for head and neck cancer (HN) (20 patients) and prostate cancer (20 patients). Setup errors from 720 registration images were analysed to evaluate systematic and random errors. Thereafter, optimal PTV margins were calculated based on International Commission on Radiation Units and Measurements 62 (ICRU), Stroom and Parker formulas compared with the Van Herk’s recipe.Results:To calculate the margins around the PTV, several different formulas have been used. Setup margins ranged between 2–4·3, 2·2–4·6 and 2·1–4·7 mm in X, Y and Z directions, respectively, for HN cases. Similarly, for the prostate site, setup margins ranged between 3·7–8·3, 3·2–6·8 and 3·3–8·2 mm in X, Y and Z directions.Conclusion:To ensure better coverage of target volume, we adopted a PTV margin of 5 mm for HN PTVs and 10 mm for prostate PTVs in our department.
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Kuperman VY, Lubich LM. Impact of target dose inhomogeneity on BED and EUD in lung SBRT. Phys Med Biol 2021; 66:01NT02. [PMID: 33576337 DOI: 10.1088/1361-6560/abd0d1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the effect of dose heterogeneity in the treatment target on biologically effective dose (BED) for frequently used hypofractionation regimens in stereotactic body radiation therapy (SBRT). METHODS In the case of non-uniform target dose, BED in the planning target volume (PTV) is determined by using the linear-quadratic model. An expression for BED is obtained for an arbitrary dose distribution in the PTV in the case of small variance of the target dose. Another analytical expression for BED is obtained by assuming a Gaussian dose distribution in the target. RESULTS Analytical expressions for BED as a function of the variance of the target dose have been derived. It is shown that a relatively small dose inhomogeneity (<5%-6%) can cause a significant reduction (i.e. >10%) in the corresponding BED and equivalent uniform dose (EUD) compared to the case of uniform target dose. CONCLUSIONS Small variations in the absorbed dose can significantly reduce BED and EUD in the PTV. The effect of dose non-uniformity on BED increases with increasing dose per fraction. The observed reduction in BED compared to that for uniform target dose can be several times greater for SBRT than for standard fractionation with dose per fraction varying between 1.8 and 2 Gy.
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Affiliation(s)
- Vadim Y Kuperman
- Medical Physics Support, Inc., Tampa, FL 33634, United States of America
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Utena Y, Takatsu J, Sugimoto S, Sasai K. Trajectory log analysis and cone-beam CT-based daily dose calculation to investigate the dosimetric accuracy of intensity-modulated radiotherapy for gynecologic cancer. J Appl Clin Med Phys 2021; 22:108-117. [PMID: 33426810 PMCID: PMC7882102 DOI: 10.1002/acm2.13163] [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: 04/07/2020] [Revised: 11/13/2020] [Accepted: 12/15/2020] [Indexed: 11/21/2022] Open
Abstract
This study evaluated unexpected dosimetric errors caused by machine control accuracy, patient setup errors, and patient weight changes/internal organ deformations. Trajectory log files for 13 gynecologic plans with seven‐ or nine‐beam dynamic multileaf collimator (MLC) intensity‐modulated radiation therapy (IMRT), and differences between expected and actual MLC positions and MUs were evaluated. Effects of patient setup errors on dosimetry were estimated by in‐house software. To simulate residual patient setup errors after image‐guided patient repositioning, planned dose distributions were recalculated (blurred dose) after the positions were randomly moved in three dimensions 0–2 mm (translation) and 0°–2° (rotation) 28 times per patient. Differences between planned and blurred doses in the clinical target volume (CTV) D98% and D2% were evaluated. Daily delivered doses were calculated from cone‐beam computed tomography by the Hounsfield unit‐to‐density conversion method. Fractional and accumulated dose differences between original plans and actual delivery were evaluated by CTV D98% and D2%. The significance of accumulated doses was tested by the paired t test. Trajectory log file analysis showed that MLC positional errors were −0.01 ± 0.02 mm and MU delivery errors were 0.10 ± 0.10 MU. Differences in CTV D98% and D2% were <0.5% for simulated patient setup errors. Differences in CTV D98% and D2% were 2.4% or less between the fractional planned and delivered doses, but were 1.7% or less for the accumulated dose. Dosimetric errors were primarily caused by patient weight changes and internal organ deformation in gynecologic radiation therapy.
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Affiliation(s)
- Yohei Utena
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.,Department of Radiology, Toranomon Hospital, Tokyo, Japan
| | - Jun Takatsu
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Satoru Sugimoto
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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A comparative study of prostate PTV margins for patients using hydrogel spacer or rectal balloon in proton therapy. Phys Med 2021; 81:47-51. [DOI: 10.1016/j.ejmp.2020.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/24/2020] [Accepted: 11/25/2020] [Indexed: 01/28/2023] Open
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Chang Y, Xiao F, Quan H, Yang Z. Evaluation of OAR dose sparing and plan robustness of beam-specific PTV in lung cancer IMRT treatment. Radiat Oncol 2020; 15:241. [PMID: 33069253 PMCID: PMC7568374 DOI: 10.1186/s13014-020-01686-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Margins are employed in radiotherapy treatment planning to mitigate the dosimetric effects of geometric uncertainties for the clinical target volume (CTV). Here, we proposed a margin concept that takes into consideration the beam direction, thereby generating a beam-specific planning target volume (BSPTV) on a beam entrance view. The total merged BSPTV was considered a target for optimization. We investigated the impact of this novel approach for lung intensity-modulated radiotherapy (IMRT) treatment, and compared the treatment plans generated using BSPTV with general PTV. METHODS AND MATERIALS We generated the BSPTV by expanding the CTV perpendicularly to the incident beam direction using the 2D version of van Herk's margin concept. The BSPTV and general PTV margin were analyzed using digital phantom simulation. Fifteen lung cancer patients were used in the planning study. First, all patient targets were performed with the CTV projection area analysis to select the suitable beam angles. Then, BSPTV was generated according to the selected beam angles. IMRT plans were optimized with the general PTV and BSPTV as the target volumes, respectively. The dosimetry metrics were calculated and evaluated between these two plans. The plan robustness of both plans for setup uncertainties was evaluated using worst-case analysis. RESULTS Both general PTV and BSPTV plans satisfied the CTV coverage. In addition, the BSPTV plans improved the sparing of high doses to target-surrounding lung tissues compared to the general PTV plans. Both Dmean of Ring PTV and Ring BSPTV were significantly lower in BSPTV plans (38.89 Gy and 39.43 Gy) compared to the general PTV plans (40.27 Gy and 40.68 Gy). The V20, V5, and mean lung dose of the affected lung were significant lower in BSPTV plans (16.20%, 28.75% and 8.93 Gy) compared to general PTV plans (16.69%, 29.22% and 9.18 Gy). In uncertainty scenarios, about 80% of target coverage was achieved for both general PTV and BSPTV plans. CONCLUSIONS The results suggested that plan robustness can be guaranteed in both the BSPTV and general PTV plans. However, the BSPTV plan spared normal tissues, such as the lungs, significantly better compared to the general PTV plans.
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Affiliation(s)
- Yu Chang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Feng Xiao
- Department of Medical Physics, School of Physics and Technology, Wuhan University, Wuhan, 430072, China
| | - Hong Quan
- Department of Medical Physics, School of Physics and Technology, Wuhan University, Wuhan, 430072, China.
| | - Zhiyong Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Savanović M, Štrbac B. Assessment of robustness of institutional applied clinical target volume (CTV) to planning target volume (PTV) margin in cervical cancer using biological models. Med Dosim 2020; 46:51-56. [PMID: 32873469 DOI: 10.1016/j.meddos.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/09/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
The aim of this study is to investigate the robustness of our institutionally applied clinical target volume (CTV)-to-planning target volume (PTV) margins in cervical cancer patients in terms of an equivalent uniform dose (EUD) based on tumor control probability (TCP). We simulated target motion using 25 IMRT cervical cancer plans to demonstrate the effect of geometrical uncertainties on the EUD and TCP. The different components of the total geometrical uncertainties budget were estimated. The biological effects were compared by calculating the EUDs from the trial DVHs. The impact of geometric uncertainties was calculated as a percentage of the difference between 〖EUD〗_static and 〖EUD〗_motion, where the 〖EUD〗_static is the EUD calculated from the target DVHs and 〖EUD〗_motion is averaged, over a 1000 calculated EUDs for each of the analyzed IMRT treatment plans. The multivariate nonlinear regression was used to find the predicted difference between the static and motion EUD. The estimate of the systematic and random motion errors were Σ_(total(SI,LR,AP)) (mm)=(2.6; 2.5; 1.8) and σ_(total(SI,LR,AP)) (mm)=(3.4; 1.4; 3.4). For average 〈EUD〉_motion=44.3 Gy (over 25 patients) we have found a TCP decrease of about 1%, %(ΔTCP)≈1% for predefined PTV margin. According to the calculated EUD motion-distributions, for particular patients, the CTV does receive the prescribed EUD of 45 Gy. The predicted difference in EUD showed that our isotropic margin of 10 mm is large enough to absorb geometric uncertainties and ensure dose coverage of the moving CTV in the cervical cancer patients.
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Affiliation(s)
- Milovan Savanović
- Faculty of Medicine, University of Paris-Saclay, 94276 Le Kremlin-Bicêtre, France; Department of Radiation Oncology, Tenon Hospital, 75020 Paris, France.
| | - Bojan Štrbac
- Hermitage Medical Clinic, Physics department, Old Lucan Rd. Dublin 20, Ireland
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Wieser HP, Karger CP, Wahl N, Bangert M. Impact of Gaussian uncertainty assumptions on probabilistic optimization in particle therapy. ACTA ACUST UNITED AC 2020; 65:145007. [DOI: 10.1088/1361-6560/ab8d77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Safety and efficacy of reduced dose and margins to involved lymph node metastases in locally advanced NSCLC patients. Radiother Oncol 2020; 143:66-72. [DOI: 10.1016/j.radonc.2019.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
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26
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Ding Y, Ma P, Li W, Wei X, Qiu X, Hu D, Wu Y, Wei W, Zeng F, Wang X, Wang X. Effect of Surgical Mask on Setup Error in Head and Neck Radiotherapy. Technol Cancer Res Treat 2020; 19:1533033820974021. [PMID: 33327884 PMCID: PMC7750894 DOI: 10.1177/1533033820974021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/29/2020] [Accepted: 10/19/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE With the widespread prevalence of Corona Virus Disease 2019 (COVID-19), cancer patients are suggested to wear a surgical mask during radiation treatment. In this study, cone beam CT (CBCT) was used to investigate the effect of surgical mask on setup errors in head and neck radiotherapy. METHODS A total of 91 patients with head and neck tumors were selected. CBCT was performed to localize target volume after patient set up. The images obtained by CBCT before treatment were automatically registered with CT images and manually fine-tuned. The setup errors of patients in 6 directions of Vrt, Lng, Lat, Pitch, Roll and Rotation were recorded. The patients were divided into groups according to whether they wore the surgical mask, the type of immobilization mask used and the location of the isocenter. The setup errors of patients were calculated. A t-test was performed to detect whether it was statistically significant. RESULTS In the 4 groups, the standard deviation in the directions of Lng and Pitch of the with surgical mask group were all higher than that in the without surgical mask group. In the head-neck-shoulder mask group, the mean in the Lng direction of the with surgical mask group was larger than that of the without surgical mask group. In the lateral isocenter group, the mean in the Lng and Pitch directions of the with surgical mask group were larger than that of the without surgical mask group. The t-test results showed that there was significant difference in the setup error between the 2 groups (p = 0.043 and p = 0.013, respectively) only in the Lng and Pitch directions of the head-neck-shoulder mask group. In addition, the setup error of 6 patients with immobilization open masks exhibited no distinguished difference from that of the patients with regular immobilization masks. CONCLUSION In the head and neck radiotherapy patients, the setup error was affected by wearing surgical mask. It is recommended that the immobilization open mask should be used when the patient cannot finish the whole treatment with a surgical mask.
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Affiliation(s)
- Yi Ding
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Pingping Ma
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- College of Nuclear Science and Technology, University of South China, Hengyang, Hunan, China
| | - Wei Li
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xueyan Wei
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoping Qiu
- College of Nuclear Science and Technology, University of South China, Hengyang, Hunan, China
| | - Desheng Hu
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuan Wu
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Wei
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Fanyu Zeng
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaohong Wang
- Department of Radiation Oncology, Hubei Cancer Hospital, TongJi Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiao Wang
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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van Diessen JNA, La Fontaine M, van den Heuvel MM, van Werkhoven E, Walraven I, Vogel WV, Belderbos JSA, Sonke JJ. Local and regional treatment response by 18FDG-PET-CT-scans 4 weeks after concurrent hypofractionated chemoradiotherapy in locally advanced NSCLC. Radiother Oncol 2019; 143:30-36. [PMID: 31767474 DOI: 10.1016/j.radonc.2019.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/13/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE To investigate associations of early post-treatment 18Fluorodeoxyglucose-positron-emission-tomography (FDG-PET)-scans with local (LF), regional (RF), distant failure (DF) and overall survival (OS) in locally advanced non-small cell lung cancer (LA-NSCLC)-patients treated with concurrent chemoradiotherapy. MATERIALS AND METHODS Forty-seven stage IIIA-B NSCLC-patients included in a randomized phase II-trial (NTR2230) received 66 Gy (24x2.75 Gy) with low dose Cisplatin +/- Cetuximab. FDG-PET-scans were performed at baseline and 4 weeks post-treatment (range, 1.6-10.1). SUVmax, SUVmean, metabolic tumor volume (MTV), total lesion glycolysis (TLG) and gross tumor volume were calculated separately for the primary tumor and the involved lymph nodes to generate baseline, post-treatment, and relative response metrics defined as (metricpre-metricpost)/metricpre. Univariable cox regression analyses were performed to investigate associations between PET-metrics and outcomes. RESULTS Metrics resulted from the post-treatment scan and relative response were associated with outcome, but baseline metrics were not. Primary tumor metrics were stronger associated with all outcomes than lymph node metrics. Both the volumetric (TLG/MTV) and intensity (SUVmax/SUVmean) PET-metrics were associated with OS. The intensity metrics were associated with LF, while the volumetric PET-metrics were associated with RF/DF. This was in contrast to the nodal metrics, demonstrating only an association between RF and the relative response of TLG/MTV. No preference was found between PET volumetric and intensity metrics associated with outcome. CONCLUSION Early post-treatment PET-metrics are associated with treatment outcome in LA-NSCLC patients treated with chemoradiotherapy. Both volumetric and intensity PET-metrics are useful, but more for the primary tumor than for lymph nodes.
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Affiliation(s)
- Judi N A van Diessen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew La Fontaine
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michel M van den Heuvel
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Walraven
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - José S A Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Stereotactic Body Radiation Therapy Boost for Intermediate-Risk Prostate Cancer: A Phase 1 Dose-Escalation Study. Int J Radiat Oncol Biol Phys 2019; 104:1066-1073. [PMID: 31002941 DOI: 10.1016/j.ijrobp.2019.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE High-dose-rate brachytherapy boost plus external beam radiation therapy is an established option for intermediate-risk prostate cancer (PCa). Stereotactic body radiation therapy (SBRT) boost can potentially mimic high-dose-rate boost and could be a viable alternative. Here we report the long-term outcomes of a phase 1 dose-escalation trial of single-fraction SBRT boost. METHODS AND MATERIALS Patients had intermediate-risk PCa and were accrued to 3 different SBRT single-fraction dose-level cohorts (10 Gy, 12.5 Gy, and 15 Gy). All received supplemental radiation therapy afterwards (37.5 Gy in 15 fractions). Three gold fiducials were implanted for image guidance. Patients were simulated and treated with a foley catheter and intrarectal balloon. A T2 magnetic resonance imaging scan was used for contouring, and a cine magnetic resonance imaging scan was used to calculate patient-specific internal target volume margins. Toxicity and quality-of-life data were collected using Common Terminology Criteria for Adverse Events v3.0 and the Expanded Prostate Cancer Index Composite. RESULTS 30 patients were accrued, 10 in each cohort. Median follow-up was 72 months. 60% had unfavorable intermediate-risk PCa. Two patients in the 15 Gy cohort developed late grade ≥3 gastrointestinal and genitourinary toxicity, with 1 patient suffering from a grade-4 rectal fistula after a rectal ulcer was biopsied repeatedly. Two patients had biochemical failure. Median PSA nadir was 0.4 ng/mL with 10 Gy, 0.09 ng/mL with 12.5 Gy and 0.07 ng/mL with 15 Gy. Median PSA at 4 years as well as proportion achieving a nadir <0.2 ng/mL improved significantly with higher doses. There was no significant change in quality of life from baseline in any of the domains, and the minimal clinically important change was not statistically different between the 3 cohorts. CONCLUSIONS Other than a grade 4 toxicity, which may in part be due to repeated biopsies of a rectal ulcer, single-fraction SBRT boost was feasible and well tolerated. Larger studies are warranted to better document the outcomes of such an approach.
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Yock AD, Mohan R, Flampouri S, Bosch W, Taylor PA, Gladstone D, Kim S, Sohn J, Wallace R, Xiao Y, Buchsbaum J. Robustness Analysis for External Beam Radiation Therapy Treatment Plans: Describing Uncertainty Scenarios and Reporting Their Dosimetric Consequences. Pract Radiat Oncol 2019; 9:200-207. [PMID: 30562614 PMCID: PMC6571070 DOI: 10.1016/j.prro.2018.12.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/24/2018] [Accepted: 12/08/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE With external beam radiation therapy, uncertainties in treatment planning and delivery can result in an undesirable dose distribution delivered to the patient that can compromise the benefit of treatment. Techniques including geometric margins and probabilistic optimization have been used effectively to mitigate the effects of uncertainties. However, their broad application is inconsistent and can compromise the conclusions derived from cross-technique and cross-modality comparisons. METHODS AND MATERIALS Conventional methods to deal with treatment planning and delivery uncertainties are described, and robustness analysis is presented as a framework that is applicable across treatment techniques and modalities. RESULTS This report identifies elements that are imperative to include when conducting a robustness analysis and describing uncertainties and their dosimetric effects. CONCLUSION The robustness analysis approach described here is presented to promote reliable plan evaluation and dose reporting, particularly during clinical trials conducted across institutions and treatment modalities.
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Affiliation(s)
- Adam D Yock
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Radhe Mohan
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Stella Flampouri
- University of Florida, Health Proton Therapy Institute, Jacksonville, Florida
| | | | - Paige A Taylor
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - David Gladstone
- Geisel School of Medicine at Dartmouth, Hannover, New Hampshire
| | - Siyong Kim
- Virginia Commonwealth University, Richmond, Virginia
| | - Jason Sohn
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Ying Xiao
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeff Buchsbaum
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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Ballhausen H, Li M, Reiner M, Belka C. Dosimetric impact of intrafraction motion on boosts on intraprostatic lesions: a simulation based on actual motion data from real time ultrasound tracking. Radiat Oncol 2019; 14:81. [PMID: 31096991 PMCID: PMC6524311 DOI: 10.1186/s13014-019-1285-1] [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: 10/18/2018] [Accepted: 04/25/2019] [Indexed: 01/24/2023] Open
Abstract
Background Intrafraction motion is particularly problematic in case of small target volumes and narrow margins. Here we simulate the dose coverage of intraprostatic lesions (IPL) by simultaneous integrated boosts (SIB). For this purpose, we use a large sample of actual intrafraction motion data. Methods Fifty-three h of intra-fraction motion of the prostate were recorded in real-time by 4D ultrasound (4DUS) during 720 fractions in 28 patients. We simulate spherical IPLs with 3, 5, and 7 mm radius and matching spherical SIBs with 0, 2, and 5 mm safety margins. The volumetric overlap between IPLs and SIBs is calculated. Dose volume histograms (DVH) are estimated by Monte Carlo simulation. Results On average, the distance of the prostate was 1.3 mm from its initial position over all fractions and patients. Average volumetric overlap was 73, 82, and 87% of IPL volume in case of 3, 5, and 7 mm IPLs and SIBs without safety margins. These improved to 95% or more in case of 2 mm safety margins and 98% or more in case of 5 mm safety margins. DVHs showed that 80% of the IPL volume received 60, 72, and 79% of maximum dose in case of 3, 5, and 7 mm IPLs and SIBs without safety margins. These improved to 94% or more given moderately sized safety margins of 2 mm. Conclusions On average over all fractions and patients, the dose coverage would have been acceptable even for small target volumes such as IPLs of radius 3 to 7 mm and narrow fields. Moderate safety margins of 2 mm could have ensured a delivery of 90% or more of the SIB dose to the IPL. In this case, SIB volume would have been considerably larger than IPL volume, but still considerably smaller than the overall PTV of the prostate. Electronic supplementary material The online version of this article (10.1186/s13014-019-1285-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Minglun Li
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician. Semin Radiat Oncol 2019; 29:258-273. [PMID: 31027643 DOI: 10.1016/j.semradonc.2019.02.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."
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Yong S, Ying C, Fen Z, Ling L, Yanli L, Qinying Y, Min Z, Chengjian L, Dong L. Analysis of upper and middle segment esophageal setup errors and planning of target margins based on cone beam computed tomography for esophageal radiation with immobilized thermoplastic film. PRECISION RADIATION ONCOLOGY 2019. [DOI: 10.1002/pro6.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Shi Yong
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Chen Ying
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Zhang Fen
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Li Ling
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Liu Yanli
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Yan Qinying
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Zhang Min
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Li Chengjian
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
| | - Li Dong
- Department of Radiation OncologyTengzhou Central People's Hospital Tengzhou China
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Su Z, Li Z, Henderson R, Hoppe B, Nichols RC, Bryant C, Mendenhall W, Mendenhall N. PTV margin analysis for prostate patients treated with initial pelvic nodal IMRT and prostate proton boost. ACTA ACUST UNITED AC 2019; 64:04NT04. [DOI: 10.1088/1361-6560/aafd75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Landry G, Hua CH. Current state and future applications of radiological image guidance for particle therapy. Med Phys 2018; 45:e1086-e1095. [PMID: 30421805 DOI: 10.1002/mp.12744] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/25/2017] [Accepted: 11/30/2017] [Indexed: 12/27/2022] Open
Abstract
In this review paper, we first give a short overview of radiological image guidance in photon radiotherapy, placing emphasis on the fact that linac based radiotherapy has outpaced particle therapy in the adoption of volumetric image guidance. While cone beam computed tomography (CBCT) has been an established technique in linac treatment rooms for almost two decades, the widespread adoption of volumetric image guidance in particle therapy, whether by means of CBCT or in-room CT imaging, is recent. This lag may be attributable to the bespoke nature and lower number of particle therapy installations, as well as the differences in geometry between those installations and linac treatment rooms. In addition, for particle therapy the so called shift invariance of the dose distribution rarely applies. An overview of the different volumetric image guidance solutions found at modern particle therapy facilities is provided, covering gantry, nozzle, C-arm, and couch-mounted CBCT as well different in-room CT configurations. A summary of the use of in-room volumetric imaging data beyond anatomy-based positioning is also presented as well as the necessary corrections to CBCT images for accurate water equivalent thickness calculation. Finally, the use of non-ionizing imaging modalities is discussed.
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Affiliation(s)
- Guillaume Landry
- Faculty of Physics, Department of Medical Physics, Ludwig-Maximilians-Universität München (LMU Munich), 85748, Garching b. München, Germany
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
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De Luca V, Banerjee J, Hallack A, Kondo S, Makhinya M, Nouri D, Royer L, Cifor A, Dardenne G, Goksel O, Gooding MJ, Klink C, Krupa A, Le Bras A, Marchal M, Moelker A, Niessen WJ, Papiez BW, Rothberg A, Schnabel J, van Walsum T, Harris E, Lediju Bell MA, Tanner C. Evaluation of 2D and 3D ultrasound tracking algorithms and impact on ultrasound-guided liver radiotherapy margins. Med Phys 2018; 45:4986-5003. [PMID: 30168159 DOI: 10.1002/mp.13152] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Compensation for respiratory motion is important during abdominal cancer treatments. In this work we report the results of the 2015 MICCAI Challenge on Liver Ultrasound Tracking and extend the 2D results to relate them to clinical relevance in form of reducing treatment margins and hence sparing healthy tissues, while maintaining full duty cycle. METHODS We describe methodologies for estimating and temporally predicting respiratory liver motion from continuous ultrasound imaging, used during ultrasound-guided radiation therapy. Furthermore, we investigated the trade-off between tracking accuracy and runtime in combination with temporal prediction strategies and their impact on treatment margins. RESULTS Based on 2D ultrasound sequences from 39 volunteers, a mean tracking accuracy of 0.9 mm was achieved when combining the results from the 4 challenge submissions (1.2 to 3.3 mm). The two submissions for the 3D sequences from 14 volunteers provided mean accuracies of 1.7 and 1.8 mm. In combination with temporal prediction, using the faster (41 vs 228 ms) but less accurate (1.4 vs 0.9 mm) tracking method resulted in substantially reduced treatment margins (70% vs 39%) in contrast to mid-ventilation margins, as it avoided non-linear temporal prediction by keeping the treatment system latency low (150 vs 400 ms). Acceleration of the best tracking method would improve the margin reduction to 75%. CONCLUSIONS Liver motion estimation and prediction during free-breathing from 2D ultrasound images can substantially reduce the in-plane motion uncertainty and hence treatment margins. Employing an accurate tracking method while avoiding non-linear temporal prediction would be favorable. This approach has the potential to shorten treatment time compared to breath-hold and gated approaches, and increase treatment efficiency and safety.
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Affiliation(s)
- Valeria De Luca
- Computer Vision Laboratory, ETH Zurich, Zürich, Switzerland
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | | | - Andre Hallack
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | | | - Maxim Makhinya
- Computer Vision Laboratory, ETH Zurich, Zürich, Switzerland
| | | | - Lucas Royer
- Institut de Recherche Technologique b-com, Rennes, France
| | | | | | - Orcun Goksel
- Computer Vision Laboratory, ETH Zurich, Zürich, Switzerland
| | | | - Camiel Klink
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Maud Marchal
- Institut de Recherche Technologique b-com, Rennes, France
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Wiro J Niessen
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Julia Schnabel
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Theo van Walsum
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Muyinatu A Lediju Bell
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, USA
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Hunt A, Hansen VN, Oelfke U, Nill S, Hafeez S. Adaptive Radiotherapy Enabled by MRI Guidance. Clin Oncol (R Coll Radiol) 2018; 30:711-719. [PMID: 30201276 DOI: 10.1016/j.clon.2018.08.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/10/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Abstract
Adaptive radiotherapy (ART) strategies systematically monitor variations in target and neighbouring structures to inform treatment-plan modification during radiotherapy. This is necessary because a single plan designed before treatment is insufficient to capture the actual dose delivered to the target and adjacent critical structures during the course of radiotherapy. Magnetic resonance imaging (MRI) provides superior soft-tissue image contrast over current standard X-ray-based technologies without additional radiation exposure. With integrated MRI and radiotherapy platforms permitting motion monitoring during treatment delivery, it is possible that adaption can be informed by real-time anatomical imaging. This allows greater treatment accuracy in terms of dose delivered to target with smaller, individualised treatment margins. The use of functional MRI sequences would permit ART to be informed by imaging biomarkers, so allowing both personalised geometric and biological adaption. In this review, we discuss ART solutions enabled by MRI guidance and its potential gains for our patients across tumour types.
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Affiliation(s)
- A Hunt
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - V N Hansen
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - U Oelfke
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Nill
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Hafeez
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
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Mohandass P, Khanna D, Kumar TM, Thiyagaraj T, Saravanan C, Bhalla NK, Puri A. Study to Compare the Effect of Different Registration Methods on Patient Setup Uncertainties in Cone-beam Computed Tomography during Volumetric Modulated Arc Therapy for Breast Cancer Patients. J Med Phys 2018; 43:207-213. [PMID: 30636845 PMCID: PMC6299751 DOI: 10.4103/jmp.jmp_67_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/02/2018] [Accepted: 10/12/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study compared three different methods used in registering cone-beam computed tomography (CBCT) image set with planning CT image set for determining patient setup uncertainties during volumetric modulated arc therapy (VMAT) for breast cancer patients. MATERIALS AND METHODS Seven breast cancer patients treated with 50 Gy in 25 fractions using VMAT technique were chosen for this study. A total of 105 CBCT scans were acquired by image guidance protocol for patient setup verification. Approved plans' CT images were used as the reference image sets for registration with their corresponding CBCT image sets. Setup errors in mediolateral, craniocaudal, and anteroposterior direction were determined using gray-scale matching between the reference CT images and onboard CBCT images. Patient setup verification was performed using clip-box registration (CBR) method during online imaging. Considering the CBR method as the reference, two more registrations were performed using mask registration (MR) method and dual registration (DR) (CBR + MR) method in the offline mode. For comparison, systematic error (∑), random error (σ), mean displacement vector (R), mean setup error (M), and registration time (R t) were analyzed. Post hoc Tukey's honest significant difference test was performed for multiple comparisons. RESULTS Systematic and random errors were less in CBR as compared to MR and DR (P > 0.05). The mean displacement error and mean setup errors were less in CBR as compared to MR and DR (P > 0.05). Increased R t was observed in DR as compared to CBR and MR (P < 0.05). In addition, multiple comparisons did not show any significant difference in patient setup error (P > 0.05). CONCLUSION For breast VMAT plan delivery, all three registration methods show insignificant variation in patient setup error. One can use any of the three registration methods for patient setup verification.
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Affiliation(s)
- P. Mohandass
- Department of Physics, Karunya Institute of Technology and Sciences, Coimbatore, Tamil Nadu, India
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
| | - D. Khanna
- Department of Physics, Karunya Institute of Technology and Sciences, Coimbatore, Tamil Nadu, India
| | - T. Manoj Kumar
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
| | - T. Thiyagaraj
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
| | - C. Saravanan
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
| | - Narendra Kumar Bhalla
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
| | - Abhishek Puri
- Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India
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Hysing LB, Ekanger C, Zolnay Á, Helle SI, Rasi M, Heijmen BJ, Sikora M, Söhn M, Muren LP, Thörnqvist S. Statistical motion modelling for robust evaluation of clinically delivered accumulated dose distributions after curative radiotherapy of locally advanced prostate cancer. Radiother Oncol 2018; 128:327-335. [DOI: 10.1016/j.radonc.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 05/16/2018] [Accepted: 06/04/2018] [Indexed: 12/25/2022]
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Kashani R, Olsen JR. Magnetic Resonance Imaging for Target Delineation and Daily Treatment Modification. Semin Radiat Oncol 2018; 28:178-184. [DOI: 10.1016/j.semradonc.2018.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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40
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Hirose K, Sato M, Hatayama Y, Kawaguchi H, Komai F, Sohma M, Obara H, Suzuki M, Tanaka M, Fujioka I, Ichise K, Takai Y, Aoki M. The potential failure risk of the cone-beam computed tomography-based planning target volume margin definition for prostate image-guided radiotherapy based on a prospective single-institutional hybrid analysis. Radiat Oncol 2018; 13:106. [PMID: 29880006 PMCID: PMC5992771 DOI: 10.1186/s13014-018-1043-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study was to evaluate the impact of markerless on-board kilovoltage (kV) cone-beam computed tomography (CBCT)-based positioning uncertainty on determination of the planning target volume (PTV) margin by comparison with kV on-board imaging (OBI) with gold fiducial markers (FMs), and to validate a methodology for the evaluation of PTV margins for markerless kV-CBCT in prostate image-guided radiotherapy (IGRT). Methods A total of 1177 pre- and 1177 post-treatment kV-OBI and 1177 pre- and 206 post-treatment kV-CBCT images were analyzed in 25 patients who received prostate IGRT with daily localization by implanted FMs. Intrafractional motion of the prostate was evaluated between each pre- and post-treatment image with these two different techniques. The differences in prostate deviations and intrafractional motions between matching by FM in kV-OBI (OBI-FM) and matching by soft tissues in kV-CBCT (CBCT-ST) were compared by Bland-Altman limits of agreement. Compensated PTV margins were determined and compensated by references. Results Mean differences between OBI-FM and CBCT-ST in the anterior to posterior (AP), superior to inferior (SI), and left to right (LR) directions were − 0.43 ± 1.45, − 0.09 ± 1.65, and − 0.12 ± 0.80 mm, respectively, with R2 = 0.85, 0.88, and 0.83, respectively. Intrafractional motions obtained from CBCT-ST were 0.00 ± 1.46, 0.02 ± 1.49, and 0.15 ± 0.64 mm, respectively, which were smaller than the results from OBI-FM, with 0.43 ± 1.90, 0.12 ± 1.98, and 0.26 ± 0.80 mm, respectively, with R2 = 0.42, 0.33, and 0.16, respectively. Bland-Altman analysis showed a significant proportional bias. PTV margins of 1.5 mm, 1.4 mm, and 0.9 mm for CBCT-ST were calculated from the values of CBCT-ST, which were also smaller than the values of 3.15 mm, 3.66 mm, and 1.60 mm from OBI-FM. The practical PTV margin for CBCT-ST was compensated with the values from OBI-FM as 4.1 mm, 4.8 mm, and 2.2 mm. Conclusions PTV margins calculated from CBCT-ST might be underestimated compared to the true PTV margins. To determine a reliable CBCT-ST-based PTV margin, at least the systemic error Σ and the random error σ for on-line matching errors need to be investigated by supportive preliminary FM evaluation at least once.
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Affiliation(s)
- Katsumi Hirose
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan. .,Department of Radiation Oncology, Southern Tohoku BNCT Research Center, 7-10, Yatsuyamada, Koriyama, Fukushima, 963-8052, Japan.
| | - Mariko Sato
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yoshiomi Hatayama
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hideo Kawaguchi
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Fumio Komai
- Division of Radiology, Hirosaki University Hospital, 53 Hon-cho, Hirosaki, Aomori, 036-8563, Japan
| | - Makoto Sohma
- Division of Radiology, Hirosaki University Hospital, 53 Hon-cho, Hirosaki, Aomori, 036-8563, Japan
| | - Hideki Obara
- Division of Radiology, Hirosaki University Hospital, 53 Hon-cho, Hirosaki, Aomori, 036-8563, Japan
| | - Masashi Suzuki
- Division of Radiology, Hirosaki University Hospital, 53 Hon-cho, Hirosaki, Aomori, 036-8563, Japan
| | - Mitsuki Tanaka
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Ichitaro Fujioka
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Koji Ichise
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yoshihiro Takai
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.,Department of Radiation Oncology, Southern Tohoku BNCT Research Center, 7-10, Yatsuyamada, Koriyama, Fukushima, 963-8052, Japan
| | - Masahiko Aoki
- Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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Brooks CJ, Bernier L, Hansen VN, Tait DM. Target volume motion during anal cancer image guided radiotherapy using cone-beam computed tomography. Br J Radiol 2018; 91:20170654. [PMID: 29393674 PMCID: PMC6190785 DOI: 10.1259/bjr.20170654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Literature regarding image-guidance and interfractional motion of the anal canal (AC) during anal cancer radiotherapy is sparse. This study investigates interfractional AC motion during anal cancer radiotherapy. METHODS Bone matched cone beam CT (CBCT) images were acquired for 20 patients receiving anal cancer radiotherapy allowing population systematic and random error calculations. 12 were selected to investigate interfractional AC motion. Primary anal gross tumour volume and clinical target volume (CTVa) were contoured on each CBCT. CBCT CTVa volumes were compared to planning CTVa. CBCT CTVa volumes were combined into a CBCT-CTVa envelope for each patient. Maximum distortion between each orthogonal border of the planning CTVa and CBCT-CTVa envelope was measured. Frequency, volume and location of CBCT-CTVa envelope beyond the planning target volume (PTVa) was analysed. RESULTS Population systematic and random errors were 1 and 3 mm respectively. 112 CBCTs were analysed in the interfractional motion study. CTVa varied between each imaging session particularly T location patients of anorectal origin. CTVa border expansions ≥ 1 cm were seen inferiorly, anteriorly, posteriorly and left direction. The CBCT-CTVa envelope fell beyond the PTVa ≥ 50% imaging sessions (n = 5). Of these CBCT CTVa distortions beyond PTVa, 44% and 32% were in the upper and lower thirds of PTVa respectively. CONCLUSION The AC is susceptible to volume changes and shape deformations. Care must be taken when calculating or considering reducing the PTV margin to the anus. Advances in knowledge: Within a limited field of research, this study provides further knowledge of how the AC deforms during anal cancer radiotherapy.
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Affiliation(s)
- Corrinne J Brooks
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Laurence Bernier
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Vibeke N Hansen
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Diana M Tait
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, Sutton, UK
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Determination of Intrafraction Prostate Motion During External Beam Radiation Therapy With a Transperineal 4-Dimensional Ultrasound Real-Time Tracking System. Int J Radiat Oncol Biol Phys 2018; 101:136-143. [DOI: 10.1016/j.ijrobp.2018.01.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 12/08/2017] [Accepted: 01/10/2018] [Indexed: 11/21/2022]
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43
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Emmerich J, Laun FB, Pfaffenberger A, Schilling R, Denoix M, Maier F, Sterzing F, Bostel T, Straub S. Technical Note: On the size of susceptibility-induced MR image distortions in prostate and cervix in the context of MR-guided radiation therapy. Med Phys 2018; 45:1586-1593. [DOI: 10.1002/mp.12785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 12/11/2017] [Accepted: 01/14/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Julian Emmerich
- Department of Medical Physics in Radiology; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Frederik B. Laun
- Department of Medical Physics in Radiology; German Cancer Research Center (DKFZ); Heidelberg Germany
- Institute of Radiology; University Hospital Erlangen; Erlangen Germany
| | - Asja Pfaffenberger
- Department of Medical Physics in Radiation Oncology; German Cancer Research Center (DKFZ); Heidelberg Germany
| | | | - Michael Denoix
- Department of Medical Physics in Radiology; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Florian Maier
- Department of Medical Physics in Radiology; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Florian Sterzing
- Clinical Cooperation Unit Radiation Oncology; German Cancer Research Center (DKFZ); Heidelberg Germany
- Department of Radiation Oncology; University Hospital Heidelberg; Heidelberg Germany
- National Center for Research in Radiation Oncology; Heidelberg Institute for Radiation Oncology (HIRO); Heidelberg Germany
| | - Tilman Bostel
- Clinical Cooperation Unit Radiation Oncology; German Cancer Research Center (DKFZ); Heidelberg Germany
- Department of Radiation Oncology; University Hospital Heidelberg; Heidelberg Germany
- National Center for Research in Radiation Oncology; Heidelberg Institute for Radiation Oncology (HIRO); Heidelberg Germany
| | - Sina Straub
- Department of Medical Physics in Radiology; German Cancer Research Center (DKFZ); Heidelberg Germany
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Bell K, Dzierma Y, Morlo M, Nüsken F, Licht N, Rübe C. Image guidance in clinical practice – Influence of positioning inaccuracy on the dose distribution for prostate cancer. Phys Med 2018. [DOI: 10.1016/j.ejmp.2018.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Witte MG, Sonke JJ, Siebers J, Deasy JO, van Herk M. Beyond the margin recipe: the probability of correct target dosage and tumor control in the presence of a dose limiting structure. Phys Med Biol 2017; 62:7874-7888. [PMID: 28832334 DOI: 10.1088/1361-6560/aa87fe] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the past, hypothetical spherical target volumes and ideally conformal dose distributions were analyzed to establish the safety of planning target volume (PTV) margins. In this work we extended these models to estimate how alternative methods of shaping dose distributions could lead to clinical improvements. Based on a spherical clinical target volume (CTV) and Gaussian distributions of systematic and random geometrical uncertainties, idealized 3D dose distributions were optimized to exhibit specific stochastic properties. A nearby spherical organ at risk (OAR) was introduced to explore the benefit of non-spherical dose distributions. Optimizing for the same minimum dose safety criterion as implied by the generally accepted use of a PTV, the extent of the high dose region in one direction could be reduced by half provided that dose in other directions is sufficiently compensated. Further reduction of this unilateral dosimetric margin decreased the target dose confidence, however the actual minimum CTV dose at 90% confidence typically exceeded the minimum PTV dose by 20% of prescription. Incorporation of smooth dose-effect relations within the optimization led to more concentrated dose distributions compared to the use of a PTV, with an improved balance between the probability of tumor cell kill and the risk of geometrical miss, and lower dose to surrounding tissues. Tumor control rate improvements in excess of 20% were found to be common for equal integral dose, while at the same time evading a nearby OAR. These results were robust against uncertainties in dose-effect relations and target heterogeneity, and did not depend on 'shoulders' or 'horns' in the dose distributions.
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Affiliation(s)
- Marnix G Witte
- The Netherlands Cancer Institute, Amsterdam, Netherlands
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Hamatani N, Sumida I, Takahashi Y, Oda M, Seo Y, Isohashi F, Tamari K, Ogawa K. Three-dimensional dose prediction and validation with the radiobiological gamma index based on a relative seriality model for head-and-neck IMRT. JOURNAL OF RADIATION RESEARCH 2017; 58:701-709. [PMID: 28430990 PMCID: PMC5737806 DOI: 10.1093/jrr/rrx017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 11/30/2016] [Indexed: 06/07/2023]
Abstract
This study proposes a quality assurance (QA) method incorporating radiobiological factors based on the QUANTEC-determined tumor control probability and the normal tissue complication probability (NTCP) of head-and-neck intensity-modulated radiation therapy (HN-IMRT). Per-beam measurements were conducted for 20 cases using a 2D detector array. Three-dimensional predicted dose distributions within targets and organs at risk were reconstructed based on the per-beam QA results derived from differences between planned and measured doses. Under the predicted dose distributions, the differences between the physical and radiobiological gamma indices (PGI and RGI, respectively) based on the relative seriality (RS) model were evaluated. The NTCP values in the RS and Niemierko models were compared. The dose covers 98% (D98%) of the clinical target volume (CTV) decreased by 3.2% (P < 0.001), and the mean dose of the ipsilateral parotid increased by 6.3% (P < 0.001) compared with the original dose. RGI passing rates in the CTV and brain stem were greater than PGI ones by 5.8% (P < 0.001) and 2.0% (P < 0.001), respectively. The RS model's average NTCP values for the ipsilateral and contralateral parotids under the original dose were smaller than those of the Niemierko model by 9.0% (P < 0.001) and 7.0% (P < 0.001), respectively. The 3D predicted dose evaluation with RGI based on the RS model was introduced for QA of HN-IMRT, leading to dose evaluation for each organ with consideration of the radiobiological effect. This method constitutes a rational way to perform QA of HN-IMRT in clinical practice.
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Affiliation(s)
- Noriaki Hamatani
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Yutaka Takahashi
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Michio Oda
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
- Department of Radiology, Osaka University Hospital, 2-15 Yamada-oka, Suita, Osaka 565-0871,Japan
| | - Yuji Seo
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Keisuke Tamari
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, 2-2 (D10) Yamada-oka, Suita, Osaka 565-0871, Japan
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Bhattacharjee A, Jose J, Vishwakarma GK, Kumar R. Joint modeling of missing and mismeasured measurements for computing radiotherapy margins. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2017. [DOI: 10.1016/j.cegh.2016.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Apolle R, Rehm M, Bortfeld T, Baumann M, Troost EGC. The clinical target volume in lung, head-and-neck, and esophageal cancer: Lessons from pathological measurement and recurrence analysis. Clin Transl Radiat Oncol 2017; 3:1-8. [PMID: 29658006 PMCID: PMC5893525 DOI: 10.1016/j.ctro.2017.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy research has achieved remarkable progress in target volume definition. Advances in medical imaging facilitate more precise localization of the gross tumor volume, alongside a more detailed understanding of the geometric uncertainties associated with treatment delivery that has enabled robust safety margins to be customized to the specific treatment scenario at hand. By contrast, the clinical target volume, meant to encompass gross tumor, as well as, adjacent sub-clinical disease, has evolved very little. It is more often defined by clinician experience and institutional convention than on a patient-specific basis. This disparity arises from the inherent invisibility of sub-clinical disease in current medical imaging. Its incidence and expanse can only be ascertained via indirect means. This article reviews two such strategies: histopathological measurements on resection specimen and analyses of locoregional recurrences after radiotherapy.
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Affiliation(s)
- Rudi Apolle
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany
| | - Maximilian Rehm
- OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Baumann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Esther G C Troost
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany.,Department of Radiation Oncology, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
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Sumida I, Yamaguchi H, Das IJ, Anetai Y, Kizaki H, Aboshi K, Tsujii M, Yamada Y, Tamari K, Seo Y, Isohashi F, Yoshioka Y, Ogawa K. Robust plan optimization using edge-enhanced intensity for intrafraction organ deformation in prostate intensity-modulated radiation therapy. PLoS One 2017; 12:e0173643. [PMID: 28282417 PMCID: PMC5345858 DOI: 10.1371/journal.pone.0173643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 02/23/2017] [Indexed: 11/18/2022] Open
Abstract
This study evaluated a method for prostate intensity-modulated radiation therapy (IMRT) based on edge-enhanced (EE) intensity in the presence of intrafraction organ deformation using the data of 37 patients treated with step-and-shoot IMRT. On the assumption that the patient setup error was already accounted for by image guidance, only organ deformation over the treatment course was considered. Once the clinical target volume (CTV), rectum, and bladder were delineated and assigned dose constraints for dose optimization, each voxel in the CTV derived from the DICOM RT-dose grid could have a stochastic dose from the different voxel location according to the probability density function as an organ deformation. The stochastic dose for the CTV was calculated as the mean dose at the location through changing the voxel location randomly 1000 times. In the EE approach, the underdose region in the CTV was delineated and optimized with higher dose constraints that resulted in an edge-enhanced intensity beam to the CTV. This was compared to a planning target volume (PTV) margin (PM) approach in which a CTV to PTV margin equivalent to the magnitude of organ deformation was added to obtain an optimized dose distribution. The total monitor units, number of segments, and conformity index were compared between the two approaches, and the dose based on the organ deformation of the CTV, rectum, and bladder was evaluated. The total monitor units, number of segments, and conformity index were significantly lower with the EE approach than with the PM approach, while maintaining the dose coverage to the CTV with organ deformation. The dose to the rectum and bladder were significantly reduced in the EE approach compared with the PM approach. We conclude that the EE approach is superior to the PM with regard to intrafraction organ deformation.
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Affiliation(s)
- Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
| | - Hajime Yamaguchi
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Indra J. Das
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, United States of America
| | - Yusuke Anetai
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hisao Kizaki
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Keiko Aboshi
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Mari Tsujii
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Yuji Yamada
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Keisuke Tamari
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Vilotte F, Antoine M, Bobin M, Latorzeff I, Supiot S, Richaud P, Thomas L, Leduc N, Guérif S, Iriondo-Alberdi J, de Crevoisier R, Sargos P. Post-Prostatectomy Image-Guided Radiotherapy: The Invisible Target Concept. Front Oncol 2017; 7:34. [PMID: 28337425 PMCID: PMC5343009 DOI: 10.3389/fonc.2017.00034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
In the era of intensity-modulated radiation therapy, image-guided radiotherapy (IGRT) appears crucial to control dose delivery and to promote dose escalation while allowing healthy tissue sparing. The place of IGRT following radical prostatectomy is poorly described in the literature. This review aims to highlight some key points on the different IGRT techniques applicable to prostatic bed radiotherapy. Furthermore, methods used to evaluate target motion and to reduce planning target volume margins will also be explored.
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Affiliation(s)
- Florent Vilotte
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
| | - Mickael Antoine
- Department of Medical Physics, Institut Bergonié , Bordeaux Cedex , France
| | - Maxime Bobin
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
| | - Igor Latorzeff
- Department of Radiotherapy, Groupe ONCORAD, Clinique Pasteur , Toulouse , France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de L'Ouest René Gauducheau , Nantes , France
| | - Pierre Richaud
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
| | - Laurence Thomas
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
| | - Nicolas Leduc
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
| | - Stephane Guérif
- Department of Radiotherapy, CHU de Poitier , Poitiers , France
| | | | | | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié , Bordeaux Cedex , France
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