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Ghosh S, Gurram L, Kumar A, Mulye G, Mittal P, Chopra S, Kharbanda D, Hande V, Ghadi Y, Scaria L, Dheera A, Varghese GB, Kole S, Ansari S, Mahantshetty U, Agarwal JP. Clinical Implementation of "Plan of the Day" Strategy in Definitive Radiation Therapy of Cervical Cancer: Online Adaptation to Address the Challenge of Organ Filling Reproducibility. Int J Radiat Oncol Biol Phys 2024; 118:605-615. [PMID: 37816473 DOI: 10.1016/j.ijrobp.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Definitive pelvic intensity modulated radiation therapy (IMRT) in cervical cancer is susceptible to geographic miss due to daily positional and volumetric variations in target and organs at risk. Hence, despite evidence of reduced acute and late treatment-related toxicities, implementation of image-guided IMRT (IG-IMRT) with a reasonable safety margin to encompass organ motion is challenging. METHODS AND MATERIALS In this prospective, nonrandomized phase 2 study, patients with cervical cancer International Federation of Gynecology and Obstetrics (2009) stage IB2-IIIB between the ages of 18 and 65 years were treated with definitive pelvic chemoradiotherapy with a prespecified organ (bladder and rectum) filling protocol. Reproducibility of organ filling was assessed along with the implementation of daily comprehensive adaptive image-guided radiotherapy (IGRT), with a library of 3 IMRT (volumetric modulated arc therapy) plans with incremental expansions of clinical target volume (CTV) to planning target volume (PTV) (primary) margins (small, 0.7 cm; adequate, 1 cm; and large, 1.5 cm) and a backup motion robust 3-dimensional conformal radiotherapy plan; the appropriate plan is chosen based on pretreatment cone beam computed tomography (CBCT) ("plan of the day" approach). RESULTS Fifty patients with a median age of 49 years (IQR, 45-56 years) received definitive radiation therapy (45-46 Gy in 23-25 fractions to pelvis, with simultaneous integrated boost to gross nodes in 15 patients) with the aforementioned IGRT protocol. In the analysis of 1171 CBCT images (in 1184 treatment sessions), the mean planning computed tomography (CT) and CBCT bladder volumes were 417 and 373 cc, respectively. Significant interfractional variation in bladder volume was noted with a mean absolute dispersion of 29.5% with respect to planning CT; significant influential random factors were postchemotherapy sessions (P ≤ .001), pre-CBCT protocol duration (P = .001), and grades of chemotherapy induced nausea vomiting (P = .001). Significantly higher variation in bladder filling was noted in patients with older age (P = .014) and larger planning CT bladder volume (P ≤ .001). Time trend analysis of fraction-wise bladder volume revealed an absolute systemic reduction of 16.3% in bladder volume means from the first to the fifth week. Variation in rectal diameter was much less pronounced, with 19.2% mean dispersion and without any significant factors affecting it. Although in 19% and 2% of sessions large IMRT PTV and 3-dimensional conformal radiotherapy were necessary to cover the primary target, respectively, reduction in treated volume was possible in 43% of sessions with small PTV selection instead of standard adequate PTV (36% sessions). Plan of the day selection had a moderate to strong correlation with nonabsolute dispersion of bladder filling (Spearman ρ =0.4; P = .001) and a weak (but significant) correlation with grades of acute toxicities. The planned protocol was well tolerated with no radiation-induced local grade 3 toxicity. CONCLUSIONS Interfractional variation in organ filling (especially bladder) is inevitable despite fixed pretreatment protocol in definitive settings (intact cervix). Despite the logistical challenges, adaptive IGRT in the form of plan of the day based on incremental CTV-to-PTV margins is a relatively simple and feasible strategy to minimize geometric uncertainties in radical IG-IMRT of cervical cancer.
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Affiliation(s)
- Suman Ghosh
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India.
| | - Amrendra Kumar
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Gargee Mulye
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Prachi Mittal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Disha Kharbanda
- Department of Radiation Oncology, Indraprastha Apollo Hospital, New Delhi, India
| | - Vinod Hande
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Yogesh Ghadi
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Libin Scaria
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - A Dheera
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - George Biju Varghese
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Satish Kole
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sahebuzzama Ansari
- Department of Radiation Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Umesh Mahantshetty
- Homi Bhabha Cancer Hospital, Visakhapatnam, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Bleeker M, Hulshof MCCM, Bel A, Sonke JJ, van der Horst A. Stomach Motion and Deformation: Implications for Preoperative Gastric Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:543-553. [PMID: 37633498 DOI: 10.1016/j.ijrobp.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE Selection and development of image guided strategies for preoperative gastric radiation therapy requires quantitative knowledge of the various sources of anatomic changes of the stomach. This study aims to investigate the magnitude of interfractional and intrafractional stomach motion and deformation using fiducial markers and 4-dimensional (4D) imaging. METHODS AND MATERIALS Fourteen patients who underwent preoperative gastric cancer radiation therapy received 2 to 6 fiducial markers distributed throughout the stomach (total of 54 markers) and additional imaging (ie, 1 planning 4D computed tomography [pCT], 20-25 pretreatment 4D cone beam [CB] CTs, 4-5 posttreatment 4D CBCTs). Marker coordinates on all end-exhale (EE) and end-inhale (EI) scans were obtained after a bony anatomy match. Interfractional marker displacements (ie, between EE pCT and all EE CBCTs) were evaluated for 5 anatomic regions (ie, cardia, small curvature, proximal and distal large curvature, and pylorus). Motion was defined as displacement of the center-of-mass of available markers (COMstomach), deformation as the average difference in marker-pair distances. Interfractional (ie, between EE pCT and all EE CBCTs), respiratory (between EE and EI pCT and CBCTs), and pre-post (pre- and posttreatment EE CBCTs) motion and deformation were quantified. RESULTS The interfractional marker displacement varied per anatomic region and direction, with systematic and random errors ranging from 1.6-8.8 mm and 2.2-8.2 mm, respectively. Respiratory motion varied per patient (median, 3-dimensional [3D] amplitude 5.2-20.0 mm) and day (interquartile range, 0.8-4.2 mm). Regarding COMstomach motion, respiratory motion was larger than interfractional motion (median, 10.9 vs 8.9 mm; P < .0001; Wilcoxon rank-sum), which was larger than pre-post motion (3.6 mm; P < .0001). Interfractional deformations (median, 5.8 mm) were significantly larger than pre-post deformations (2.6 mm; P < .0001), which were larger than respiratory deformation (1.8 mm; P < .0001). CONCLUSIONS The demonstrated sizable stomach motions and deformations during radiation therapy stress the need for generous nonuniform planning target volume margins for preoperative gastric cancer radiation therapy. These margins can be decreased by daily image guidance and adaptive radiation therapy.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Yock AD, Cooney A, Morales‐Paliza M, Shinohara E, Homann K. Empirical analysis of a plan-of-the-day strategy to approximate daily online reoptimization for prostate CBCT-guided adaptive radiotherapy. J Appl Clin Med Phys 2024; 25:e14221. [PMID: 38029380 PMCID: PMC10795443 DOI: 10.1002/acm2.14221] [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: 08/06/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE Adaptive radiotherapy (ART) can improve the dose delivered to the patient in the presence of anatomic variations. However, the required time, effort, and clinical resources are intensive. This work analyzed a plan-of-the-day (POD) approach on clinical patients treated with online ART to explore implementations that balance dosimetric benefit and clinical resource cost. METHODS Eight patients treated to the prostate and proximal seminal vesicles with 26 fractions of CBCT-guided, daily online ART were retrospectively analyzed. With a plan library composed of daily adaptive plans from the initial week of treatment and the original plan, the effect of a POD approach starting the following week was investigated by simulating use of these previously generated plans under 3- and 6-degree-of-freedom patient alignment. The plan selected for each treatment was that from the library that maximized the Dice similarity coefficient of the clinical target volume with that of the current treatment fraction. The resulting distribution of several target coverage and organ-at-risk dose metrics are described relative to those achieved with the daily online reoptimized adaptive technique. RESULTS The values of target coverage and organ-at-risk dose metrics varied across patients and metrics. The POD schemas closely approximated the reference values from a fully reoptimized adaptive plan yet required less than 20% of the reoptimization effort. The POD schemas also had a much greater effect on target coverage metrics than 6-degree-of-freedom registration did. Organ-at-risk dose metrics also varied considerably across patients but did not exhibit a consistent dependence on the particular schema. CONCLUSIONS POD schemas were able to achieve the vast majority of the dosimetric benefit of daily online ART with a small fraction of the online reoptimization effort. Strategies like this might allow for more practical and strategic implementation of ART so as to benefit a greater number of patients.
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Affiliation(s)
- Adam D. Yock
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Annie Cooney
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Manuel Morales‐Paliza
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Shinohara
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kenneth Homann
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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Azzarouali S, Goudschaal K, Visser J, Hulshof M, Admiraal M, van Wieringen N, Nieuwenhuijzen J, Wiersma J, Daniëls L, den Boer D, Bel A. Online adaptive radiotherapy for bladder cancer using a simultaneous integrated boost and fiducial markers. Radiat Oncol 2023; 18:165. [PMID: 37803392 PMCID: PMC10557331 DOI: 10.1186/s13014-023-02348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/10/2023] [Indexed: 10/08/2023] Open
Abstract
PURPOSE The aim was to assess the feasibility of online adaptive radiotherapy (oART) for bladder cancer using a focal boost by focusing on the quality of the online treatment plan and automatic target delineation, duration of the workflow and performance in the presence of fiducial markers for tumor bed localization. METHODS Fifteen patients with muscle invasive bladder cancer received daily oART with Cone Beam CT (CBCT), artificial intelligence (AI)-assisted automatic delineation of the daily anatomy and online plan reoptimization. The bladder and pelvic lymph nodes received a total dose of 40 Gy in 20 fractions, the tumor received an additional simultaneously integrated boost (SIB) of 15 Gy. The dose distribution of the reference plan was calculated for the daily anatomy, i.e. the scheduled plan. Simultaneously, a reoptimization of the plan was performed i.e. the adaptive plan. The target coverage and V95% outside the target were evaluated for both plans. The need for manual adjustments of the GTV delineation, the duration of the workflow and the influence of fiducial markers were assessed. RESULTS All 300 adaptive plans met the requirement of the CTV-coverage V95%≥98% for both the boost (55 Gy) and elective volume (40 Gy). For the scheduled plans the CTV-coverage was 53.5% and 98.5%, respectively. Significantly less tissue outside the targets received 55 Gy in case of the adaptive plans as compared to the scheduled plans. Manual corrections of the GTV were performed in 67% of the sessions. In 96% of these corrections the GTV was enlarged and resulted in a median improvement of 1% for the target coverage. The median on-couch time was 22 min. A third of the session time consisted of reoptimization of the treatment plan. Fiducial markers were visible on the CBCTs and aided the tumor localization. CONCLUSIONS AI-driven CBCT-guided oART aided by fiducial markers is feasible for bladder cancer radiotherapy treatment including a SIB. The quality of the adaptive plans met the clinical requirements and fiducial markers were visible enabling consistent daily tumor localization. Improved automatic delineation to lower the need for manual corrections and faster reoptimization would result in shorter session time.
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Affiliation(s)
- Sana Azzarouali
- Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands.
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Karin Goudschaal
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jorrit Visser
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Maarten Hulshof
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marjan Admiraal
- Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
| | - Niek van Wieringen
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jakko Nieuwenhuijzen
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Urology, Amsterdam, The Netherlands
| | - Jan Wiersma
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Laurien Daniëls
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Duncan den Boer
- Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
| | - Arjan Bel
- Cancer Center Amsterdam, Cancer Therapy, Treatment and quality of life, Amsterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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De Hertogh O. [Bladder preservation treatments for bladder cancer: Trimodality therapy, an overview of clinical practices in 2023]. Cancer Radiother 2023; 27:562-567. [PMID: 37481342 DOI: 10.1016/j.canrad.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 07/24/2023]
Abstract
Bladder cancer is the most frequent tumor of the urinary tract. Patients diagnosed at a stage when the tumor has spread into or through the muscle layer of the bladder wall are usually treated with cystectomy. The evolution of cancer treatments, related to the development of alternative treatment options to the historical surgical standard and to the implication of the patient as an actor in decision-making, trends towards organ and function preservation without sacrificing efficacy. Trimodality therapy, which is a maximal transurethral resection of the tumor followed by concurrent chemoradiation, is an interesting therapeutic alternative for patients unfit for surgery and for those wishing to benefit from organ preservation. Radiotherapy offers excellent treatment possibilities for muscle-invasive bladder cancer. In selected T2-stage patients fit for trimodality therapy, it has an equivalent oncological outcome compared to cystectomy while having less severe complications and offering organ preservation. It remains feasible in inoperable patients while offering significant perspectives of relapse-free survival. Finally, it also is an efficient palliative treatment in patients where mid-term local control and hemostasis are sought after.
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Affiliation(s)
- O De Hertogh
- Radiation oncology department, CHR Verviers East Belgium, 29, rue du Parc, 4800 Verviers, Belgique.
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Ghimire R, Moore KL, Branco D, Rash DL, Mayadev J, Ray X. Forecasting patient-specific dosimetric benefit from daily online adaptive radiotherapy for cervical cancer. Biomed Phys Eng Express 2023; 9:045030. [PMID: 37336202 DOI: 10.1088/2057-1976/acdf62] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/19/2023] [Indexed: 06/21/2023]
Abstract
Objective. Adaptive Radiotherapy (ART) is an emerging technique for treating cancer patients which facilitates higher delivery accuracy and has the potential to reduce toxicity. However, ART is also resource-intensive, Requiring extra human and machine time compared to standard treatment methods. In this analysis, we sought to predict the subset of node-negative cervical cancer patients with the greatest benefit from ART, so resources might be properly allocated to the highest-yield patients.Approach. CT images, initial plan data, and on-treatment Cone-Beam CT (CBCT) images for 20 retrospective cervical cancer patients were used to simulate doses from daily non-adaptive and adaptive techniques. We evaluated the coefficient of determination (R2) between dose and volume metrics from initial treatment plans and the dosimetric benefits to theBowelV40Gy,BowelV45Gy,BladderDmean,andRectumDmeanfrom adaptive radiotherapy using reduced 3 mm or 5 mm CTV-to-PTV margins. The LASSO technique was used to identify the most predictive metrics forBowelV40Gy.The three highest performing metrics were used to build multivariate models with leave-one-out validation forBowelV40Gy.Main results. Patients with higher initial bowel doses were correlated with the largest decreases in BowelV40Gyfrom daily adaptation (linear best fit R2= 0.77 for a 3 mm PTV margin and R2= 0.8 for a 5 mm PTV margin). Other metrics had intermediate or no correlation. Selected covariates for the multivariate model were differences in the initialBowelV40GyandBladderDmeanusing standard versus reduced margins and the initial bladder volume. Leave-one-out validation had an R2of 0.66 between predicted and true adaptiveBowelV40Gybenefits for both margins.Significance. The resulting models could be used to prospectively triage cervical cancer patients on or off daily adaptation to optimally manage clinical resources. Additionally, this work presents a critical foundation for predicting benefits from daily adaptation that can be extended to other patient cohorts.
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Affiliation(s)
- Rupesh Ghimire
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
| | - Kevin L Moore
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
| | - Daniela Branco
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
| | - Dominique L Rash
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
| | - Jyoti Mayadev
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
| | - Xenia Ray
- University of California San Diego Health, 3855 Health Sciences Drive La Jolla, CA 92093, United States of America
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An online adaptive plan library approach for intensity modulated proton therapy for head and neck cancer. Radiother Oncol 2022; 176:68-75. [PMID: 36150418 DOI: 10.1016/j.radonc.2022.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE In intensity modulated proton therapy (IMPT), the impact of setup errors and anatomical changes is commonly mitigated by robust optimization with population-based setup robustness (SR) settings and offline replanning. In this study we propose and evaluate an alternative approach based on daily plan selection from patient-specific pre-treatment established plan libraries (PLs). Clinical implementation of the PL strategy would be rather straightforward compared to daily online re-planning. MATERIALS AND METHODS For 15 head-and-neck cancer patients, the planning CT was used to generate a PL with 5 plans, robustly optimized for increasing SR: 0, 1, 2, 3, 5 mm, and 3% range robustness. Repeat CTs (rCTs) and realistic setup and range uncertainty distributions were used for simulation of treatment courses for the PL approach, treatments with fixed SR (fSR3) and a trigger-based offline adaptive schedule for 3 mm SR (fSR3OfA). Daily plan selection in the PL approach was based only on recomputed dose to the CTV on the rCT. RESULTS Compared to using fSR3 and fSR3OfA, the risk of xerostomia grade ≥ II & III and dysphagia ≥ grade III were significantly reduced with the PL. For 6/15 patients the risk of xerostomia and/or dysphagia ≥ grade II could be reduced by > 2% by using PL. For the other patients, adherence to target coverage constraints was often improved. fSR3OfA resulted in significantly improved coverage compared to PL for selected patients. CONCLUSION The proposed PL approach resulted in overall reduced NTCPs compared to fSR3 and fSR3OfA at limited cost in target coverage.
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van der Bijl E, Remeijer P, Sonke JJ, van der Heide UA, Janssen T. Adaptive margins for online adaptive radiotherapy. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac9175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. In online adaptive radiotherapy a new plan is generated every fraction based on the organ and clinical target volume (CTV) delineations of that fraction. This allows for a planning target volume margin that does not need to be constant over the whole course of treatment, as is the case in conventional radiotherapy. This work aims to introduce an approach to update the margins each fraction based on the per-patient treatment history and explore the potential benefits of such adaptive margins. Approach. We introduce a novel methodology to implement adaptive margins, isotropic and anisotropic, during a treatment course based on the accumulated dose to the CTV. We then simulate treatment histories for treatments delivered in up to 20 fractions using various choices for the standard deviations of the systematic and random errors and homogeneous and inhomogeneous dose distributions. The treatment-averaged adaptive margin was compared to standard constant margins. The change in the minimum dose delivered to the CTV was compared on a patient and a population level. All simulations were performed within the van Herk approach and its known limitations. Main results. The population mean treatment-averaged margins are down to 70% and 55% of the corresponding necessary constant margins for the isotropic and anisotropic approach. The reduction increases with longer fractionation schemes and an inhomogeneous target dose distribution. Most of the benefit can be attributed to the elimination of the effective systematic error over the course of treatment. Interpatient differences in treatment-averaged margins were largest for the isotropic margins. For the 10% of patients that would receive a lower than prescribed dose to the CTV this minimum dose to the CTV is increased using the adaptive margin approaches. Significance. Adaptive margins can allow to reduce margins in most patients without compromising patients with greater than average target motion.
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den Boer D, den Hartogh MD, Kotte AN, van der Voort van Zyp JR, Noteboom JL, Bol GH, Willigenburg T, Werensteijn-Honingh AM, Jürgenliemk-Schulz IM, van Lier AL, Kroon PS. Comparison of Library of Plans with two daily adaptive strategies for whole bladder radiotherapy. Phys Imaging Radiat Oncol 2021; 20:82-87. [PMID: 34849413 PMCID: PMC8609047 DOI: 10.1016/j.phro.2021.11.002] [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: 03/25/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Whole bladder radiotherapy is challenging due to inter- and intrafraction size and shape changes. To account for these changes, currently a Library of Plans (LoP) technique is often applied, but daily adaptive radiotherapy is also increasingly becoming available. The aim of this study was to compare LoP with two magnetic resonance imaging guided radiotherapy (MRgRT) strategies by comparing target coverage and volume of healthy tissue inside the planning target volume (PTV) for whole bladder treatments. Methods and materials Data from 25 MRgRT lymph node oligometastases treatments (125 fractions) were used, with three MRI scans acquired at each fraction at 0, 15 and 30 min. Bladders were delineated and used to evaluate three strategies: 1) LoP with two plans for a 15 min fraction, 2) MRgRT15min for a 15 min fraction and 3) MRgRT30min for a 30 min fraction. The volumes of healthy tissue inside and bladder outside the PTV were analyzed on the simulated post-treatment images. Results MRgRT30min had 120% and 121% more healthy tissue inside the PTV than LoP and MRgRT15min. For LoP slightly more target outside the PTV was found than for MRgRT30min and MRgRT15min, with median 0% (range 0-23%) compared to 0% (0-20%) and 0% (0-10%), respectively. Conclusions Taking into account both target coverage and volume of healthy tissue inside the PTV, MRgRT15min performed better than LoP and MRgRT30min for whole bladder treatments. A 15 min daily adaptive radiotherapy workflow is needed to potentially benefit from replanning compared to LoP.
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Affiliation(s)
- Duncan den Boer
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
- Corresponding author at: Department of Radiotherapy, Amsterdam University Medical Centers, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands.
| | - Mariska D. den Hartogh
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Alexis N.T.J. Kotte
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | | | - Juus L. Noteboom
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Gijsbert H. Bol
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Thomas Willigenburg
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Anita M. Werensteijn-Honingh
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Astrid L.H.M.W. van Lier
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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Portner R, Bajaj A, Elumalai T, Huddart R, Murthy V, Nightingale H, Patel K, Sargos P, Song Y, Hoskin P, Choudhury A. A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer. Clin Transl Radiat Oncol 2021; 31:1-7. [PMID: 34466667 PMCID: PMC8385113 DOI: 10.1016/j.ctro.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.
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Affiliation(s)
- R. Portner
- The Christie NHS Foundation Trust, Manchester, UK
| | - A. Bajaj
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - T. Elumalai
- The Christie NHS Foundation Trust, Manchester, UK
| | - R. Huddart
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, UK
| | - V. Murthy
- Department of Radiation Oncology, ACTREC and Tata Memorial Hospital, Homi Bhabha National University, Mumbai, India
| | | | - K. Patel
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Sargos
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Y. Song
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - A. Choudhury
- The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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11
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Beekman C, Schaake E, Sonke JJ, Remeijer P. Deformation trajectory prediction using a neural network trained on finite element data-application to library of CTVs creation for cervical cancer. Phys Med Biol 2021; 66. [PMID: 34607325 DOI: 10.1088/1361-6560/ac2c9b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/04/2021] [Indexed: 11/12/2022]
Abstract
Purpose. We propose a neural network for fast prediction of realistic, time-parametrized deformations between pairs of input segmentations. The proposed method was used to generate a library of planning CTVs for cervical cancer radiotherapy.Methods.A 3D convolutional neural network (CNN) was introduced to predict a stationary velocity field given the distance maps of the cervix CTV in empty and full bladder anatomy. Diffeomorphic deformation trajectories between the two states were obtained by time integration. Intermediate deformation states were used to populate a library of cervix CTVs. The network was trained on cervix CTV deformations of 20 patients generated by finite element modeling (FEM). Validation was performed on FEM data of 9 healthy volunteers. Additionally, for these subjects, CTV deformations were observed in a series of repeat MR scans as the bladder filled from empty to full. Predicted and FEM libraries were compared, and benchmarked against the observed deformations. Finally, for an independent test set of 20 patients the predicted libraries were evaluated clinically, and compared to the current method.Results.The median Dice score over the validation subjects between the predicted and FEM libraries was >0.95 throughout the deformation, with a median 90 percentile surface distance of <3 mm. The ability to cover observed CTVs was similar for both the FEM-based and the proposed method, with residual offsets being about twice as large as the difference between the two methods. Clinical evaluation showed improved library properties over the method currently used in clinic.Conclusions.We proposed a CNN trained on FEM deformations, which predicts the deformation trajectory between two input states of the cervix CTV in one forward pass. We applied this to CTV library prediction for cervical cancer. The network is able to mimic FEM deformations well, while being much faster and simpler in use.
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Affiliation(s)
- Chris Beekman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eva Schaake
- 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
| | - Peter Remeijer
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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12
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Webster A, Hafeez S, Lewis R, Griffins C, Warren-Oseni K, Patel E, Hansen VN, Hall E, Huddart R, Miles E, McNair HA. The Development of Therapeutic Radiographers in Imaging and Adaptive Radiotherapy Through Clinical Trial Quality Assurance. Clin Oncol (R Coll Radiol) 2021; 33:461-467. [PMID: 33766503 DOI: 10.1016/j.clon.2021.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 02/06/2023]
Abstract
AIMS Adaptive radiotherapy (ART) is an emerging advanced treatment option for bladder cancer patients. Therapeutic radiographers (RTTs) are central to the successful delivery of this treatment. The purpose of this work was to evaluate the image-guided radiotherapy (IGRT) and ART experience of RTTs before participating in the RAIDER trial. A plan of the day (PoD) quality assurance programme was then implemented. Finally, the post-trial experience of RTTs was evaluated, together with the impact of trial quality assurance participation on their routine practice. MATERIALS AND METHODS A pre-trial questionnaire to assess the experience of the RTT staff group in IGRT and ART in bladder cancer was sent to each centre. Responses were grouped according to experience. The PoD quality assurance programme was implemented, and the RAIDER trial commenced. During stage 1 of the trial, RTTs reported difficulties in delivering PoD and the quality assurance programme was updated accordingly. A follow-up questionnaire was sent assessing experience in IGRT and ART post-trial. Any changes in routine practice were also recorded. RESULTS The experience of RTTs in IGRT and ART pre-trial varied. For centres deemed to have RTTs with more experience, the initial PoD quality assurance programme was streamlined. For RTTs without ART experience, the full quality assurance programme was implemented, of which 508 RTTs completed. The quality assurance programme was updated (as the trial recruited) and it was mandated that at least one representative RTT (regardless of pre-trial experience) participated in the update in real-time. The purpose of the updated quality assurance programme was to provide further support to RTTs in delivering a complex treatment. Engagement with the updated quality assurance programme was high, with RTTs in 24/33 centres participating in the real-time online workshop. All 33 UK centres reported all RTTs reviewed the updated training offline. Post-trial, the RTTs' experience in IGRT and ART was increased. CONCLUSION Overall, 508 RTTs undertook the PoD quality assurance programme. There was a high engagement of RTTs in the PoD quality assurance programme and trial. RTTs increased their experience in IGRT and ART and subsequently updated their practice for bladder cancer and other treatment sites.
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Affiliation(s)
- A Webster
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, London, UK.
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - R Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - C Griffins
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - E Patel
- University College Hospital, London, UK
| | - V N Hansen
- Odense University Hospital, Odense, Denmark
| | - E Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - R Huddart
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - E Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, London, UK
| | - H A McNair
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
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13
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Fonteyne V, Sargos P. What is the Optimal Dose, Fractionation and Volume for Bladder Radiotherapy? Clin Oncol (R Coll Radiol) 2021; 33:e245-e250. [PMID: 33832838 DOI: 10.1016/j.clon.2021.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 11/29/2022]
Abstract
External beam radiotherapy (EBRT), as part of a trimodality approach, is an attractive bladder-preserving alternative to radical cystectomy. Several EBRT regimens with different treatment volumes have been described with similar tumour control and, so far, clear recommendations on the optimal radiotherapy regimen and treatment volume are lacking. The current review summarises EBRT literature on dose prescription, fractionation as well as treatment volume in order to guide clinicians in their daily practice when treating patients with muscle-invasive bladder cancer. Taking into account literature on repopulation, continuous-course radiotherapy can be used safely in daily practice where a split-course should only be reserved for those patients who are fit enough to undergo a radical cystectomy in case of a poor early response. A recent meta-analysis has proven that hypofractionated radiotherapy is superior to conventional radiotherapy with regards to invasive locoregional control with similar toxicity profiles. In the absence of node-positive disease, the target volume can be restricted to the bladder. In order to compensate for organ motion, very large margins need to be applied in the absence of image-guided radiotherapy (IGRT). Therefore, the use of IGRT or an adaptive approach is recommended. Based on the available literature, one can conclude that moderate hypofractionated radiotherapy to a dose of 55 Gy in 20 fractions to the bladder only, delivered with IGRT, can be considered standard of care for patients with node-negative invasive bladder cancer.
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Affiliation(s)
- V Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.
| | - P Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
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14
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Sibolt P, Andersson LM, Calmels L, Sjöström D, Bjelkengren U, Geertsen P, Behrens CF. Clinical implementation of artificial intelligence-driven cone-beam computed tomography-guided online adaptive radiotherapy in the pelvic region. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 17:1-7. [PMID: 33898770 PMCID: PMC8057957 DOI: 10.1016/j.phro.2020.12.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 12/31/2022]
Abstract
Background and purpose Studies have demonstrated the potential of online adaptive radiotherapy (oART). However, routine use has been limited due to resource demanding solutions. This study reports on experiences with oART in the pelvic region using a novel cone-beam computed tomography (CBCT)-based, artificial intelligence (AI)-driven solution. Material and methods Automated pre-treatment planning for thirty-nine pelvic cases (bladder, rectum, anal, and prostate), and one hundred oART simulations were conducted in a pre-clinical release of Ethos (Varian Medical Systems, Palo Alto, CA). Plan quality, AI-segmentation accuracy, oART feasibility and an integrated calculation-based quality assurance solution were evaluated. Experiences from the first five clinical oART patients (three bladder, one rectum and one sarcoma) are reported. Results Auto-generated pre-treatment plans demonstrated similar planning target volume (PTV) coverage and organs at risk doses, compared to institution reference. More than 75% of AI-segmentations during simulated oART required none or minor editing and the adapted plan was superior in 88% of cases. Limitations in AI-segmentation correlated to cases where AI model training was lacking. The five first treated patients complied well with the median adaptive procedure duration of 17.6 min (from CBCT acceptance to treatment delivery start). The treated bladder patients demonstrated a 42% median primary PTV reduction, indicating a 24%-30% reduction in V45Gy to the bowel cavity, compared to non-ART. Conclusions A novel commercial oART solution was demonstrated feasible for various pelvic sites. Clinically acceptable AI-segmentation and auto-planning enabled adaptation within reasonable timeslots. Possibilities for reduced PTVs observed for bladder cancer indicated potential for toxicity reductions.
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Affiliation(s)
- Patrik Sibolt
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lina M Andersson
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lucie Calmels
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - David Sjöström
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Ulf Bjelkengren
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Poul Geertsen
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Claus F Behrens
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
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15
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Webster A, Appelt A, Eminowicz G. Image-Guided Radiotherapy for Pelvic Cancers: A Review of Current Evidence and Clinical Utilisation. Clin Oncol (R Coll Radiol) 2020; 32:805-816. [DOI: 10.1016/j.clon.2020.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
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16
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de Jong R, Crama KF, Visser J, van Wieringen N, Wiersma J, Geijsen ED, Bel A. Online adaptive radiotherapy compared to plan selection for rectal cancer: quantifying the benefit. Radiat Oncol 2020; 15:162. [PMID: 32641080 PMCID: PMC7371470 DOI: 10.1186/s13014-020-01597-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
Background To compare online adaptive radiation therapy (ART) to a clinically implemented plan selection strategy (PS) with respect to dose to the organs at risk (OAR) for rectal cancer. Methods The first 20 patients treated with PS between May–September 2016 were included. This resulted in 10 short (SCRT) and 10 long (LCRT) course radiotherapy treatment schedules with a total of 300 Conebeam CT scans (CBCT). New dual arc VMAT plans were generated using auto-planning for both the online ART and PS strategy. For each fraction bowel bag, bladder and mesorectum were delineated on daily Conebeam CTs. The dose distribution planned was used to calculate daily DVHs. Coverage of the CTV was calculated, as defined by the dose received by 99% of the CTV volume (D99%). The volume of normal tissue irradiated with 95% of the prescribed fraction dose was calculated by calculating the volume receiving 95% of the prescribed fraction or more dose minus the volume of the CTV. For each fraction the difference between the plan selection and online adaptive strategy of each DVH parameter was calculated, as well as the average difference per patient. Results Target coverage remained the same for online ART. The median volume of the normal tissue irradiated with 95% of the prescribed dose dropped from 642 cm3 (PS) to 237 cm3 (online-ART)(p < 0.001). Online ART reduced dose to the OARs for all tested dose levels for SCRT and LCRT (p < 0.001). For V15Gy of the bowel bag the median difference over all fractions of all patients was − 126 cm3 in LCRT, while the average difference per patient ranged from − 206 cm3 to − 40 cm3. For SCRT the median difference was − 62 cm3, while the range of the average difference per patient was − 105 cm3 to − 51 cm3. For V15Gy of the bladder the median difference over all fractions of all patients was 26% in LCRT, while the average difference per patient ranged from − 34 to 12%. For SCRT the median difference of V95% was − 8%, while the range of the average difference per patient was − 29 to 0%. Conclusions Online ART for rectal cancer reduces dose the OARs significantly compared to a clinically implemented plan selection strategy, without compromising target coverage. Trial registration Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center (W19_357 # 19.420; Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands).
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Affiliation(s)
- R de Jong
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - K F Crama
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - J Visser
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van Wieringen
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - J Wiersma
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - E D Geijsen
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - A Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
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17
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Bleeker M, Goudschaal K, Bel A, Sonke JJ, Hulshof MCCM, van der Horst A. Feasibility of cone beam CT-guided library of plans strategy in pre-operative gastric cancer radiotherapy. Radiother Oncol 2020; 149:49-54. [PMID: 32387491 DOI: 10.1016/j.radonc.2020.04.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The stomach displays large anatomical changes in size, shape and position, which implies the need for plan adaptation for gastric cancer patients who receive pre-operative radiotherapy. We evaluated the feasibility and necessity of a CBCT-guided library of plans (LoP) strategy in gastric cancer radiotherapy. METHODS Eight gastric cancer patients treated with 24-25 fractions of single-plan radiotherapy with daily CBCT imaging were included. The target was delineated on the pre-treatment CT and first 5 CBCTs to create a patient-specific LoP. Plan selections were performed by 12 observers in a training stage (2-3 CBCTs per patient) and an assessment stage (17 CBCTs per patient). The observers were asked to select the smallest plan that encompassed the target on the CBCT. A total of 136 plan selections were evaluated in the assessment stage. RESULTS Delineations on CBCTs showed that in 90% of the 40 delineated fractions part of the CTV was outside the PTV based on the pre-treatment CT. At least two-thirds of the observers agreed on the selected plan in 65.2% and 70% of the fractions in the training stage and the assessment stage, respectively. For each patient, at least two different plans from the LoP were the most selected plan. CONCLUSION A CBCT-guided patient-specific LoP strategy is feasible for gastric cancer patients, yielding good agreement in plan selections. Unless generous margins are used to avoid frequent geometric misses, it is likely that part of the target will be missed with single-plan radiotherapy.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Karin Goudschaal
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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18
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Witjes JA, Babjuk M, Bellmunt J, Bruins HM, De Reijke TM, De Santis M, Gillessen S, James N, Maclennan S, Palou J, Powles T, Ribal MJ, Shariat SF, Der Kwast TV, Xylinas E, Agarwal N, Arends T, Bamias A, Birtle A, Black PC, Bochner BH, Bolla M, Boormans JL, Bossi A, Briganti A, Brummelhuis I, Burger M, Castellano D, Cathomas R, Chiti A, Choudhury A, Compérat E, Crabb S, Culine S, De Bari B, De Blok W, J L De Visschere P, Decaestecker K, Dimitropoulos K, Dominguez-Escrig JL, Fanti S, Fonteyne V, Frydenberg M, Futterer JJ, Gakis G, Geavlete B, Gontero P, Grubmüller B, Hafeez S, Hansel DE, Hartmann A, Hayne D, Henry AM, Hernandez V, Herr H, Herrmann K, Hoskin P, Huguet J, Jereczek-Fossa BA, Jones R, Kamat AM, Khoo V, Kiltie AE, Krege S, Ladoire S, Lara PC, Leliveld A, Linares-Espinós E, Løgager V, Lorch A, Loriot Y, Meijer R, Mir MC, Moschini M, Mostafid H, Müller AC, Müller CR, N'Dow J, Necchi A, Neuzillet Y, Oddens JR, Oldenburg J, Osanto S, J G Oyen W, Pacheco-Figueiredo L, Pappot H, Patel MI, Pieters BR, Plass K, Remzi M, Retz M, Richenberg J, Rink M, Roghmann F, Rosenberg JE, Rouprêt M, Rouvière O, Salembier C, Salminen A, Sargos P, Sengupta S, Sherif A, Smeenk RJ, Smits A, Stenzl A, Thalmann GN, Tombal B, Turkbey B, Lauridsen SV, Valdagni R, Van Der Heijden AG, Van Poppel H, Vartolomei MD, Veskimäe E, Vilaseca A, Rivera FAV, Wiegel T, Wiklund P, Williams A, Zigeuner R, Horwich A. EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort †: Under the Auspices of the EAU-ESMO Guidelines Committees. Eur Urol 2020; 77:223-250. [PMID: 31753752 DOI: 10.1016/j.eururo.2019.09.035] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/26/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts prior to voting during a consensus conference. SETTING Online Delphi survey and consensus conference. PARTICIPANTS The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), and 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS Overall, 116 statements were included in the Delphi survey. Of these statements, 33 (28%) achieved level 1 consensus and 49 (42%) achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease, and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time when further evidence is available to guide our approach. PATIENT SUMMARY This report summarises findings from an international, multistakeholder project organised by the EAU and ESMO. In this project, a steering committee identified areas of bladder cancer management where there is currently no good-quality evidence to guide treatment decisions. From this, they developed a series of proposed statements, 71 of which achieved consensus by a large group of experts in the field of bladder cancer. It is anticipated that these statements will provide further guidance to health care professionals and could help improve patient outcomes until a time when good-quality evidence is available.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marek Babjuk
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Joaquim Bellmunt
- IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain; Harvard Medical School, Boston, Massachusetts, USA
| | - H Maxim Bruins
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theo M De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Maria De Santis
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Charité University Hospital, Berlin, Germany
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Division of Oncology and Haematology, Kantonsspital St Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | - Nicholas James
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Juan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tom Powles
- The Royal Free NHS Trust, London, UK; Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Maria J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Shahrokh F Shariat
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, New York, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Theo Van Der Kwast
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Paris Descartes University, Paris, France
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah (NCI-CCC), Salt Lake City, Utah, USA
| | - Tom Arends
- Urology Department, Canisius-Wilhelmina Ziekenhuis Nijmegen, The Netherlands
| | - Aristotle Bamias
- 2nd Propaedeutic Dept of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Alison Birtle
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK
| | - Peter C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, British Colombia, Canada
| | - Bernard H Bochner
- Department of Urology, Weill Cornell Medical College, New York, New York, USA; Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michel Bolla
- Emeritus Professor of Radiation Oncology, Grenoble - Alpes University, Grenoble, France
| | - Joost L Boormans
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alberto Bossi
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | - Alberto Briganti
- Department of Urology, Urological Research Institute, Milan; Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Iris Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Max Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Daniel Castellano
- Medical Oncology Department, 12 de Octubre University Hospital (CIBERONC), Madrid, Spain
| | - Richard Cathomas
- Departement Innere Medizin, Abteilung Onkologie und Hämatologie, Kantonsspital Graubünden, Chur, Switzerland
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - Eva Compérat
- Department of Pathology, Tenon hospital, HUEP, Paris, France; Sorbonne University, Paris, France
| | - Simon Crabb
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - Stephane Culine
- Department of Cancer Medicine, Hôpital Saint Louis, Paris, France
| | - Berardino De Bari
- Radiation Oncology Department, Centre Hospitalier Régional Universitaire "Jean Minjoz" of Besançon, INSERM UMR 1098, Besançon, France; Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
| | - Willem De Blok
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter J L De Visschere
- Department of Radiology and Nuclear Medicine, Division of Genitourinary Radiology and Mammography, Ghent University Hospital, Ghent, Belgium
| | | | | | | | - Stefano Fanti
- Department of Nuclear Medicine, Policlinico S Orsola, University of Bologna, Italy
| | - Valerie Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium
| | - Mark Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Jurgen J Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Georgios Gakis
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Würzburg, Germany
| | - Bogdan Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | | | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Donna E Hansel
- Department of Urology, University of California, San Diego Pathology, La Jolla, California, USA
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Dickon Hayne
- Department of Urology, UWA Medical School, University of Western Australia, Perth, Australia
| | - Ann M Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Virginia Hernandez
- Department of Urology, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Harry Herr
- Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - Peter Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Mount Vernon Centre for Cancer Treatment, London, UK
| | - Jorge Huguet
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barbara A Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Rob Jones
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ashish M Kamat
- Department of Urology - Division of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Vincent Khoo
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Medicine, University of Melbourne; Monash University, Melbourne, Australia
| | - Anne E Kiltie
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Susanne Krege
- Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - Pedro C Lara
- Department of Oncology, Hospital Universitario San Roque; Universidad Fernando Pessoa, Canarias, Spain
| | - Annemarie Leliveld
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vibeke Løgager
- Department of Radiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yohann Loriot
- Département de Médecine Oncologique, Gustave Roussy, INSERM U981, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Richard Meijer
- UMC Utrecht Cancer Center, MS Oncologic Urology, Utrecht, The Netherlands
| | - M Carmen Mir
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Marco Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | | | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Andrea Necchi
- Department of Medical Oncology, Istituto Nazionale Tumori of Milan, Milan, Italy
| | - Yann Neuzillet
- Department of Urology, Hospital Foch, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Jorg R Oddens
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Susanne Osanto
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wim J G Oyen
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Luís Pacheco-Figueiredo
- Department of Urology, Centro Hospitalar São João, Porto, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Helle Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Manish I Patel
- Department of Urology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Bradley R Pieters
- Department Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Plass
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Mesut Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Margitta Retz
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Jonathan Richenberg
- Department of Imaging and Nuclear Medicine, Royal Sussex County Hospital, Brighton, UK; Brighton and Sussex Medical School, Brighton, UK
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Roghmann
- Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Morgan Rouprêt
- Department of Urology, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Olivier Rouvière
- Hospices Civils de Lyon, Service d'Imagerie Urinaire et Vasculaire, Hôpital Edouard Herriot, Lyon, France; Université de Lyon, Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
| | - Carl Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Belgium
| | - Antti Salminen
- Department of Urology, University Hospital of Turku, Finland
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Shomik Sengupta
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia; Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå university, Umeå, Sweden
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anita Smits
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - George N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Bertrand Tombal
- Division of Urology, IREC, Cliniques Universitaires Saint Luc, UCL, Brussels, Belgium
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Susanne Vahr Lauridsen
- Department of Urology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Riccardo Valdagni
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Mihai D Vartolomei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Antoni Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Franklin A Vives Rivera
- Clinica HematoOncologica Bonadona Prevenir, Universidad Metropolitana, Clinica Club de Leones, Barranquilla, Colombia
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter Wiklund
- Icahn School of Medicine, Mount Sinai Health System New York City, New York, USA; Department of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Andrew Williams
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - Richard Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - Alan Horwich
- Emeritus Professor, The Institute of Cancer Research, London, UK
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19
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de Jong R, Visser J, Crama KF, van Wieringen N, Wiersma J, Geijsen ED, Bel A. Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy. Radiat Oncol 2020; 15:13. [PMID: 31931829 PMCID: PMC6958623 DOI: 10.1186/s13014-020-1461-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/06/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To compare target coverage and dose to the organs at risk in two approaches to rectal cancer: a clinically implemented adaptive radiotherapy (ART) strategy using plan selection, and a non-adaptive (non-ART) strategy. METHODS The inclusion of the first 20 patients receiving adaptive radiotherapy produced 10 patients with a long treatment schedule (25x2Gy) and 10 patients with a short schedule (5X5Gy). We prepared a library of three plans with different anterior PTV margins to the upper mesorectum, and selected the most appropriate plan on daily Conebeam CT scans (CBCT). We also created a non-adaptive treatment plan with a 20 mm margin. Bowel bag, bladder and target volume were delineated on CBCT. Daily DHVs were calculated based on the dose distribution of the selected and non-adaptive plans. Coverage of the target volume was compared per fraction between the ART and non-ART plans, as was the dose to the bladder and small bowel, assessing the following dose levels: V15Gy, V30Gy, V40Gy, V15Gy and V95% for long treatment schedules, and V15Gy and V95% for short ones. RESULTS Target volume coverage was maintained from 98.3% (non-ART) to 99.0% (ART)(p = 0.878). In the small bowel, ART appeared to have produced significant reductions in the long treatment schedule at V15Gy, V40Gy, V45Gy and V95% (p < 0.05), but with small absolute differences. The DVH parameters tested for the short treatment schedule did not differ significantly. In the bladder, all DVH parameters in both schedules showed significant reductions (p < 0.05), also with small absolute differences. CONCLUSIONS The adaptive treatment maintained target coverage and reduced dose to the organs at risk. TRIAL REGISTRATION Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center, W19_194 # 19.233.
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Affiliation(s)
- R de Jong
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - J Visser
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - K F Crama
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van Wieringen
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - J Wiersma
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - E D Geijsen
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - A Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
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20
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Horwich A, Babjuk M, Bellmunt J, Bruins HM, De Reijke TM, De Santis M, Gillessen S, James N, Maclennan S, Palou J, Powles T, Ribal MJ, Shariat SF, Van Der Kwast T, Xylinas E, Agarwal N, Arends T, Bamias A, Birtle A, Black PC, Bochner BH, Bolla M, Boormans JL, Bossi A, Briganti A, Brummelhuis I, Burger M, Castellano D, Cathomas R, Chiti A, Choudhury A, Compérat E, Crabb S, Culine S, De Bari B, DeBlok W, De Visschere PJL, Decaestecker K, Dimitropoulos K, Dominguez-Escrig JL, Fanti S, Fonteyne V, Frydenberg M, Futterer JJ, Gakis G, Geavlete B, Gontero P, Grubmüller B, Hafeez S, Hansel DE, Hartmann A, Hayne D, Henry AM, Hernandez V, Herr H, Herrmann K, Hoskin P, Huguet J, Jereczek-Fossa BA, Jones R, Kamat AM, Khoo V, Kiltie AE, Krege S, Ladoire S, Lara PC, Leliveld A, Linares-Espinós E, Løgager V, Lorch A, Loriot Y, Meijer R, Carmen Mir M, Moschini M, Mostafid H, Müller AC, Müller CR, N'Dow J, Necchi A, Neuzillet Y, Oddens JR, Oldenburg J, Osanto S, Oyen WJG, Pacheco-Figueiredo L, Pappot H, Patel MI, Pieters BR, Plass K, Remzi M, Retz M, Richenberg J, Rink M, Roghmann F, Rosenberg JE, Rouprêt M, Rouvière O, Salembier C, Salminen A, Sargos P, Sengupta S, Sherif A, Smeenk RJ, Smits A, Stenzl A, Thalmann GN, Tombal B, Turkbey B, Vahr Lauridsen S, Valdagni R, Van Der Heijden AG, Van Poppel H, Vartolomei MD, Veskimäe E, Vilaseca A, Vives Rivera FA, Wiegel T, Wiklund P, Williams A, Zigeuner R, Witjes JA. EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†. Ann Oncol 2019; 30:1697-1727. [PMID: 31740927 PMCID: PMC7360152 DOI: 10.1093/annonc/mdz296] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference. SETTING Online Delphi survey and consensus conference. PARTICIPANTS The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.
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Affiliation(s)
- A Horwich
- Emeritus Professor, The Institute of Cancer Research, London, UK; Emeritus Professor, The Institute of Cancer Research, London, UK.
| | - M Babjuk
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - J Bellmunt
- IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain; Harvard Medical School, Boston, USA
| | - H M Bruins
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - T M De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - M De Santis
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Charité University Hospital, Berlin, Germany
| | - S Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK; Division of Oncology and Haematology, Kantonsspital St Gallen, St Gallen; University of Bern, Bern, Switzerland
| | - N James
- University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
| | - S Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - J Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T Powles
- The Royal Free NHS Trust, London; Barts Cancer Institute, Queen Mary University of London, London, UK
| | - M J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - S F Shariat
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York; Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - T Van Der Kwast
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - E Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris; Paris Descartes University, Paris, France
| | - N Agarwal
- Huntsman Cancer Institute, University of Utah (NCI-CCC), Salt Lake City, USA
| | - T Arends
- Urology Department, Canisius-Wilhelmina Ziekenhuis Nijmegen, Nijmegen, The Netherlands
| | - A Bamias
- 2nd Propaedeutic Dept of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - A Birtle
- Division of Cancer Sciences, University of Manchester, Manchester; Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK
| | - P C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada
| | - B H Bochner
- Department of Urology, Weill Cornell Medical College, New York; Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Bolla
- Emeritus Professor of Radiation Oncology, Grenoble - Alpes University, Grenoble, France
| | - J L Boormans
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A Bossi
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | - A Briganti
- Department of Urology, Urological Research Institute, Milan; Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - I Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - M Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - D Castellano
- Medical Oncology Department, 12 de Octubre University Hospital (CIBERONC), Madrid, Spain
| | - R Cathomas
- Department Innere Medizin, Abteilung Onkologie und Hämatologie, Kantonsspital Graubünden, Chur, Switzerland
| | - A Chiti
- Department of Biomedical Sciences, Humanitas University, Milan; Humanitas Research Hospital, Milan, Italy
| | - A Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK
| | - E Compérat
- Department of Pathology, Tenon Hospital, HUEP, Paris; Sorbonne University, Paris, France
| | - S Crabb
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - S Culine
- Department of Cancer Medicine, Hôpital Saint Louis, Paris
| | - B De Bari
- Radiation Oncology Department, Centre Hospitalier Régional Universitaire "Jean Minjoz" of Besançon, INSERM UMR 1098, Besançon, France; Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
| | - W DeBlok
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P J L De Visschere
- Department of Radiology and Nuclear Medicine, Division of Genitourinary Radiology and Mammography, Ghent University Hospital, Ghent
| | - K Decaestecker
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - K Dimitropoulos
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - J L Dominguez-Escrig
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - S Fanti
- Department of Nuclear Medicine, Policlinico S Orsola, University of Bologna, Bologna, Italy
| | - V Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium
| | - M Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - J J Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G Gakis
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Würzburg, Germany
| | - B Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania
| | - P Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - B Grubmüller
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - D E Hansel
- Department of Urology, University of California, San Diego Pathology, La Jolla, USA
| | - A Hartmann
- Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - D Hayne
- Department of Urology, UWA Medical School, University of Western Australia, Perth, Australia
| | - A M Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - V Hernandez
- Department of Urology, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - H Herr
- Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - K Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - P Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK; Mount Vernon Centre for Cancer Treatment, London, UK
| | - J Huguet
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B A Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - R Jones
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - A M Kamat
- Department of Urology - Division of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, USA
| | - V Khoo
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Medicine, University of Melbourne, Melbourne; Monash University, Melbourne, Australia
| | - A E Kiltie
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - S Krege
- Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - S Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - P C Lara
- Department of Oncology, Hospital Universitario San Roque, Canarias; Universidad Fernando Pessoa, Canarias, Spain
| | - A Leliveld
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - V Løgager
- Department of Radiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - A Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Y Loriot
- Département de Médecine Oncologique, Gustave Roussy, INSERM U981, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - R Meijer
- UMC Utrecht Cancer Center, MS Oncologic Urology, Utrecht, The Netherlands
| | - M Carmen Mir
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - M Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - H Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - A-C Müller
- Department of Radiation Oncology, Eberhard Karls University, Tübingen, Germany
| | - C R Müller
- Cancer Treatment Centre, Sorlandet Hospital, Kristiansand, Norway
| | - J N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - A Necchi
- Department of Medical Oncology, Istituto Nazionale Tumori of Milan, Milan, Italy
| | - Y Neuzillet
- Department of Urology, Hospital Foch, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - J R Oddens
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - J Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - S Osanto
- Department of Clinical Oncology, Leiden University Medical Center, Leiden
| | - W J G Oyen
- Department of Biomedical Sciences, Humanitas University, Milan; Humanitas Research Hospital, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - L Pacheco-Figueiredo
- Department of Urology, Centro Hospitalar São João, Porto; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - H Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - M I Patel
- Department of Urology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - B R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam
| | - K Plass
- EAU Guidelines Office, Arnhem, The Netherlands
| | - M Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - M Retz
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - J Richenberg
- Department of Imaging and Nuclear Medicine, Royal Sussex County Hospital, Brighton; Brighton and Sussex Medical School, Brighton, UK
| | - M Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - F Roghmann
- Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany
| | - J E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York; Weill Cornell Medical College, New York, USA
| | - M Rouprêt
- Department of Urology, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris
| | - O Rouvière
- Hospices Civils de Lyon, Service d'Imagerie Urinaire et Vasculaire, Hôpital Edouard Herriot, Lyon; Université de Lyon, Université Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - C Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Brussels, Belgium
| | - A Salminen
- Department of Urology, University Hospital of Turku, Turku, Finland
| | - P Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - S Sengupta
- Department of Surgery, Austin Health, University of Melbourne, Melbourne; Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - A Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - R J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Smits
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - A Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - G N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, Berne, Switzerland
| | - B Tombal
- Division of Urology, IREC, Cliniques Universitaires Saint Luc, UCL, Brussels, Belgium
| | - B Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, USA
| | - S Vahr Lauridsen
- Department of Urology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - R Valdagni
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - H Van Poppel
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - M D Vartolomei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
| | - E Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - A Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - F A Vives Rivera
- Clinica HematoOncologica Bonadona Prevenir, Universidad Metropolitana, Clinica Club de Leones, Barranquilla, Colombia
| | - T Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - P Wiklund
- Icahn School of Medicine, Mount Sinai Health System, New York City, USA; Department of Urology, Karolinska Institutet, Stockholm, Sweden
| | - A Williams
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - R Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - J A Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen
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Patel E, Tsang Y, Baker A, Callender J, Hafeez S, Hall E, Hansen VN, Lewis R, McNair H, Miles E, Huddart R. Quality assuring "Plan of the day" selection in a multicentre adaptive bladder trial: Implementation of a pre-accrual IGRT guidance and assessment module. Clin Transl Radiat Oncol 2019; 19:27-32. [PMID: 31388568 PMCID: PMC6675972 DOI: 10.1016/j.ctro.2019.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Hypofractionated bladder RT with or without image guided adaptive planning (HYBRID) is a multicentre clinical trial investigating "Plan of the Day" (PoD) adaptive radiotherapy for bladder cancer. To ensure correct PoD selection a pre-accrual guidance and assessment module was developed as part of an image guided radiotherapy quality assurance (IGRT QA) credentialing programme. This study aimed to evaluate its feasibility and effectiveness across multiple recruiting centres. MATERIALS AND METHODS Individuals from participating centres remotely accessed an image database in order to complete the PoD module. An assessment score of ≥83% was required in order to receive QA approval. A questionnaire was used to gather user feedback on the module. PoD decisions for the first patient at each recruiting centre were retrospectively reviewed for protocol adherence. RESULTS 71 radiation therapists (RTTs) from 10 centres completed the PoD module. The median assessment score was 92% (Range: 58-100%) with 79% of RTTs passing the assessment on first attempt. All questionnaire respondents reported that the PoD module prepared them for plan selection. In 51/60 of on-trial treatments reviewed, the PoD selected by the centre agreed with QA reviewers. CONCLUSIONS The PoD QA module was successfully implemented in a multicentre trial and enabled pre-accrual assessment of protocol understanding. This increased operator confidence and resulted in appropriate PoD selection on-trial.
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Affiliation(s)
- Emma Patel
- Radiotherapy Physics Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yat Tsang
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Angela Baker
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Shaista Hafeez
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Vibeke Nordmark Hansen
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Helen McNair
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Robert Huddart
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Magallon-Baro A, Granton PV, Milder MTW, Loi M, Zolnay AG, Nuyttens JJ, Hoogeman MS. A model-based patient selection tool to identify who may be at risk of exceeding dose tolerances during pancreatic SBRT. Radiother Oncol 2019; 141:116-122. [PMID: 31606227 DOI: 10.1016/j.radonc.2019.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/04/2019] [Accepted: 09/19/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Locally advanced pancreatic cancer (LAPC) patients are prone to experience daily anatomical variations, which can lead to additional doses in organs-at-risk (OAR) during SBRT. A patient selection tool was developed to identify who may be at risk of exceeding dose tolerances, by quantifying the dosimetric impact of daily variations using an OAR motion model. MATERIALS AND METHODS The study included 133 CT scans from 35 LAPC patients. By following a leave-one-out approach, an OAR motion model trained with the remaining 34 subjects variations was used to simulate organ deformations on the left-out patient planning CT anatomy. Dose-volume histograms obtained from planned doses sampled on simulated organs resulted in the probability of exceeding OAR dose-constraints due to anatomical variations. Simulated probabilities were clustered with a threshold per organ according to clinical observations. If the prediction of at least one OAR was above the established thresholds, the patient was classified as being at risk. RESULTS Clinically, in 20/35 patients at least one OAR exceeded dose-constraints in the daily CTs. The model-based prediction had an accuracy of 89%, 71%, 91% in estimating the risk of exceeding dose tolerances for the duodenum, stomach and bowel, respectively. By combining the three predictions, our approach resulted in a correct patient classification for 29/35 patients (83%) when compared with clinical observations. CONCLUSIONS Our model-based patient selection tool is able to predict who might be at risk of exceeding dose-constraints during SBRT. It is a promising tool to tailor LAPC treatments, e.g. by employing online adaptive SBRT; and hence, to minimize toxicity of patients being at risk.
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Affiliation(s)
- Alba Magallon-Baro
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands.
| | - Patrick V Granton
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Maaike T W Milder
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Mauro Loi
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Andras G Zolnay
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Joost J Nuyttens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Mischa S Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
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État des lieux de la radiothérapie adaptative en 2019 : de la mise en place à l’utilisation clinique. Cancer Radiother 2019; 23:581-591. [DOI: 10.1016/j.canrad.2019.07.142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/12/2019] [Indexed: 12/20/2022]
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Rigaud B, Simon A, Castelli J, Lafond C, Acosta O, Haigron P, Cazoulat G, de Crevoisier R. Deformable image registration for radiation therapy: principle, methods, applications and evaluation. Acta Oncol 2019; 58:1225-1237. [PMID: 31155990 DOI: 10.1080/0284186x.2019.1620331] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Deformable image registration (DIR) is increasingly used in the field of radiation therapy (RT) to account for anatomical deformations. The aims of this paper are to describe the main applications of DIR in RT and discuss current DIR evaluation methods. Methods: Articles on DIR published from January 2000 to October 2018 were extracted from PubMed and Science Direct. Our search was restricted to articles that report data obtained from humans, were written in English, and address DIR methods for RT. A total of 207 articles were selected from among 2506 identified in the search process. Results: At planning, DIR is used for organ delineation using atlas-based segmentation, deformation-based planning target volume definition, functional planning and magnetic resonance imaging-based dose calculation. In image-guided RT, DIR is used for contour propagation and dose calculation on per-treatment imaging. DIR is also used to determine the accumulated dose from fraction to fraction in external beam RT and brachytherapy, both for dose reporting and adaptive RT. In the case of re-irradiation, DIR can be used to estimate the cumulated dose of the two irradiations. Finally, DIR can be used to predict toxicity in voxel-wise population analysis. However, the evaluation of DIR remains an open issue, especially when dealing with complex cases such as the disappearance of matter. To quantify DIR uncertainties, most evaluation methods are limited to geometry-based metrics. Software companies have now integrated DIR tools into treatment planning systems for clinical use, such as contour propagation and fraction dose accumulation. Conclusions: DIR is increasingly important in RT applications, from planning to toxicity prediction. DIR is routinely used to reduce the workload of contour propagation. However, its use for complex dosimetric applications must be carefully evaluated by combining quantitative and qualitative analyses.
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Affiliation(s)
- Bastien Rigaud
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Antoine Simon
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Joël Castelli
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Caroline Lafond
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Oscar Acosta
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Pascal Haigron
- CLCC Eugène Marquis, University of Rennes, Inserm , Rennes , France
| | - Guillaume Cazoulat
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Corradini S, Alongi F, Andratschke N, Belka C, Boldrini L, Cellini F, Debus J, Guckenberger M, Hörner-Rieber J, Lagerwaard FJ, Mazzola R, Palacios MA, Philippens MEP, Raaijmakers CPJ, Terhaard CHJ, Valentini V, Niyazi M. MR-guidance in clinical reality: current treatment challenges and future perspectives. Radiat Oncol 2019; 14:92. [PMID: 31167658 PMCID: PMC6551911 DOI: 10.1186/s13014-019-1308-y] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022] Open
Abstract
Magnetic Resonance-guided radiotherapy (MRgRT) marks the beginning of a new era. MR is a versatile and suitable imaging modality for radiotherapy, as it enables direct visualization of the tumor and the surrounding organs at risk. Moreover, MRgRT provides real-time imaging to characterize and eventually track anatomical motion. Nevertheless, the successful translation of new technologies into clinical practice remains challenging. To date, the initial availability of next-generation hybrid MR-linac (MRL) systems is still limited and therefore, the focus of the present preview was on the initial applicability in current clinical practice and on future perspectives of this new technology for different treatment sites.MRgRT can be considered a groundbreaking new technology that is capable of creating new perspectives towards an individualized, patient-oriented planning and treatment approach, especially due to the ability to use daily online adaptation strategies. Furthermore, MRL systems overcome the limitations of conventional image-guided radiotherapy, especially in soft tissue, where target and organs at risk need accurate definition. Nevertheless, some concerns remain regarding the additional time needed to re-optimize dose distributions online, the reliability of the gating and tracking procedures and the interpretation of functional MR imaging markers and their potential changes during the course of treatment. Due to its continuous technological improvement and rapid clinical large-scale application in several anatomical settings, further studies may confirm the potential disruptive role of MRgRT in the evolving oncological environment.
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Affiliation(s)
- S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - F. Alongi
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - C. Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - L. Boldrini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - F. Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - J. Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - J. Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - F. J. Lagerwaard
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - R. Mazzola
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - M. A. Palacios
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - M. E. P. Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. P. J. Raaijmakers
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. H. J. Terhaard
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - V. Valentini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - M. Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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Posiewnik M, Piotrowski T. A review of cone-beam CT applications for adaptive radiotherapy of prostate cancer. Phys Med 2019; 59:13-21. [DOI: 10.1016/j.ejmp.2019.02.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/29/2019] [Accepted: 02/15/2019] [Indexed: 11/26/2022] Open
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Krishnan A, Tsang YM, Stewart-Lord A. The impact of intra-fractional bladder filling on "Plan of the day" adaptive bladder radiotherapy. Tech Innov Patient Support Radiat Oncol 2019; 9:31-34. [PMID: 32095593 PMCID: PMC7033786 DOI: 10.1016/j.tipsro.2019.01.001] [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: 08/26/2018] [Revised: 12/22/2018] [Accepted: 01/03/2019] [Indexed: 01/04/2023] Open
Abstract
A retrospective audit on the "Plan of the day" (POD) selection and intra-fractional bladder fillings were carried out on twenty adaptive bladder radiotherapy patients at a single institution. Treatment time, differences in bladder volume and displacement of outer bladder wall expansion over the treatment fraction were analysed. Average treatment time was 8.9 min. The mean percentage difference in bladder volume pre and post treatment was 13.7%, resulting in expansion of the bladder predominately in the superior and anterior directions. This audit confirmed that the institution's POD process sufficed without being significantly affected by the intra-fractional bladder filings.
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Affiliation(s)
- Aisling Krishnan
- East and North Hertfordshire NHS Trust, Radiotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, United Kingdom
| | - Yat Man Tsang
- East and North Hertfordshire NHS Trust, Radiotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, United Kingdom
| | - Adéle Stewart-Lord
- School of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, United Kingdom
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Pre-clinical experience of an adaptive plan library strategy in radiotherapy of rectal cancer: An inter-observer study. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 6:89-93. [PMID: 33458395 PMCID: PMC7807563 DOI: 10.1016/j.phro.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/28/2018] [Accepted: 06/01/2018] [Indexed: 12/14/2022]
Abstract
Background and purpose The clinical target volume (CTV) in radiotherapy of rectal cancer is subject to large deformations. With a plan library strategy, the treatment may be adapted to these deformations. The purpose of this study was to determine feasibility and consistency in plan selection for a plan library strategy in radiotherapy of rectal cancer. Material and methods Thirty rectal cancer patients were included in this retrospective study with in total 150 CBCT scans. A library of CTVs was constructed with in-house built software using population statistics on daily rectal deformations. The library consisted of five plans based on: the original CTV, two larger, and two smaller CTVs. An inter-observer study (study-I) was performed to test the consistency in plan choices between four observers (all RTTs). After five months the observers were asked to re-evaluate (study-II) the same set of scans based on refined guidelines. Results In study-I the observers reached accordance with the majority choice in 69% of cases. This improved to 87% in study-II. The consensus meeting revealed that inconsistency in choices mainly arose from inadequate instructions, which were later clarified and formulated more accurately. Conclusion Plan selection based on daily CBCT scans for rectal cancer patients is feasible, and can be performed consistently by well-trained RTTs.
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