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Claridge Mackonis E, Stensmyr R, Poldy R, White P, Moutrie Z, Gorjiara T, Seymour E, Erven T, Hardcastle N, Haworth A. Improving motion management in radiation therapy: findings from a workshop and survey in Australia and New Zealand. Phys Eng Sci Med 2024:10.1007/s13246-024-01405-0. [PMID: 38805104 DOI: 10.1007/s13246-024-01405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/09/2024] [Indexed: 05/29/2024]
Abstract
Motion management has become an integral part of radiation therapy. Multiple approaches to motion management have been reported in the literature. To allow the sharing of experiences on current practice and emerging technology, the University of Sydney and the New South Wales/Australian Capital Territory branch of the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) held a two-day motion management workshop. To inform the workshop program, participants were invited to complete a survey prior to the workshop on current use of motion management techniques and their opinion on the effectiveness of each approach. A post-workshop survey was also conducted, designed to capture changes in opinion as a result of workshop participation. The online workshop was the most well attended ever hosted by the ACPSEM, with over 300 participants and a response to the pre-workshop survey was received from at least 60% of the radiation therapy centres in Australia and New Zealand. Motion management is extensively used in the region with use of deep inspiration breath-hold (DIBH) reported by 98% of centres for left-sided breast treatments and 91% for at least some right-sided breast treatments. Surface guided radiation therapy (SGRT) was the most popular session at the workshop and survey results showed that the use of SGRT is likely to increase. The workshop provided an excellent opportunity for the exchange of knowledge and experience, with most survey respondents indicating that their participation would lead to improvements in the quality of delivery of treatments at their centres.
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Affiliation(s)
| | | | - Rachel Poldy
- Canberra Region Cancer Centre, Canberra, Australia
| | - Paul White
- South Eastern Sydney LHD, Randwick, Australia
| | - Zoë Moutrie
- South Western Sydney Cancer Services, Sydney, NSW, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- South Western Sydney Clinical School, University of NSW, Liverpool, NSW, Australia
| | | | | | - Tania Erven
- South Western Sydney Cancer Services, Sydney, NSW, Australia
| | - Nicholas Hardcastle
- Peter MacCallum Cancer Centres, Melbourne, Australia
- Institute of Medical Physics, University of Sydney, Camperdown, Australia
| | - Annette Haworth
- Institute of Medical Physics, University of Sydney, Camperdown, Australia
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Pierrard J, Deheneffe S, Dechambre D, Sterpin E, Geets X, Van Ooteghem G. Markerless liver online adaptive stereotactic radiotherapy: feasibility analysisCervantes. Phys Med Biol 2024; 69:095015. [PMID: 38565128 DOI: 10.1088/1361-6560/ad39a1] [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: 08/09/2023] [Accepted: 04/02/2024] [Indexed: 04/04/2024]
Abstract
Objective. Radio-opaque markers are recommended for image-guided radiotherapy in liver stereotactic ablative radiotherapy (SABR), but their implantation is invasive. We evaluate in thisin-silicostudy the feasibility of cone-beam computed tomography-guided stereotactic online-adaptive radiotherapy (CBCT-STAR) to propagate the target volumes without implanting radio-opaque markers and assess its consequence on the margin that should be used in that context.Approach. An emulator of a CBCT-STAR-dedicated treatment planning system was used to generate plans for 32 liver SABR patients. Three target volume propagation strategies were compared, analysing the volume difference between the GTVPropagatedand the GTVConventional, the vector lengths between their centres of mass (lCoM), and the 95th percentile of the Hausdorff distance between these two volumes (HD95). These propagation strategies were: (1) structure-guided deformable registration with deformable GTV propagation; (2) rigid registration with rigid GTV propagation; and (3) image-guided deformable registration with rigid GTV propagation. Adaptive margin calculation integrated propagation errors, while interfraction position errors were removed. Scheduled plans (PlanNon-adaptive) and daily-adapted plans (PlanAdaptive) were compared for each treatment fraction.Main results.The image-guided deformable registration with rigid GTV propagation was the best propagation strategy regarding tolCoM(mean: 4.3 +/- 2.1 mm), HD95 (mean 4.8 +/- 3.2 mm) and volume preservation between GTVPropagatedand GTVConventional. This resulted in a planning target volume (PTV) margin increase (+69.1% in volume on average). Online adaptation (PlanAdaptive) reduced the violation rate of the most important dose constraints ('priority 1 constraints', 4.2 versus 0.9%, respectively;p< 0.001) and even improved target volume coverage compared to non-adaptive plans (PlanNon-adaptive).Significance. Markerless CBCT-STAR for liver tumours is feasible using Image-guided deformable registration with rigid GTV propagation. Despite the cost in terms of PTV volumes, daily adaptation reduces constraints violation and restores target volumes coverage.
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Affiliation(s)
- Julien Pierrard
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), B-1200 Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, B-1200 Brussels, Belgium
| | - Stéphanie Deheneffe
- Radiation Oncology Department, CHU-UCL-Namur, Site Sainte-Elisabeth, B-5000 Namur, Belgium
| | - David Dechambre
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, B-1200 Brussels, Belgium
| | - Edmond Sterpin
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), B-1200 Brussels, Belgium
- KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Xavier Geets
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), B-1200 Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, B-1200 Brussels, Belgium
| | - Geneviève Van Ooteghem
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), B-1200 Brussels, Belgium
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, B-1200 Brussels, Belgium
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Uchinami Y, Miyamoto N, Abo D, Morita R, Ogawa K, Kakisaka T, Suzuki R, Miyazaki T, Taguchi H, Katoh N, Aoyama H. Real-time tumor-tracking radiotherapy with SyncTraX for primary liver tumors requiring isocenter shift†. JOURNAL OF RADIATION RESEARCH 2024; 65:92-99. [PMID: 37996094 PMCID: PMC10803168 DOI: 10.1093/jrr/rrad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/06/2023] [Indexed: 11/25/2023]
Abstract
The SyncTraX series enables real-time tumor-tracking radiotherapy through the real-time recognition of a fiducial marker using fluoroscopic images. In this system, the isocenter should be located within approximately 5-7.5 cm from the marker, depending on the version, owing to the limited field of view. If the marker is placed away from the tumor, the isocenter should be shifted toward the marker. This study aimed to investigate stereotactic body radiotherapy (SBRT) outcomes of primary liver tumors treated with SyncTraX in cases where the isocenter was shifted marginally or outside the planning target volume (PTV). Twelve patients with 13 liver tumors were included in the analysis. Their isocenter was shifted toward the marker and was placed marginally or outside the PTV. The prescribed doses were generally 40 Gy in four fractions or 48 Gy in eight fractions. The overall survival (OS) and local control (LC) rates were calculated using the Kaplan-Meier method. All patients completed the scheduled SBRT. The median distance between the fiducial marker and PTV centroid was 56.0 (interquartile range [IQR]: 52.7-66.7) mm. By shifting the isocenter toward the marker, the median distance between the marker and isocenter decreased to 34.0 (IQR: 33.4-39.7) mm. With a median follow-up period of 25.3 (range: 6.9-70.0) months, the 2-year OS and LC rates were 100.0% (95% confidence interval: 100-100). An isocenter shift makes SBRT with SyncTraX feasible in cases where the fiducial marker is distant from the tumor.
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Affiliation(s)
- Yusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
- Division of Applied Quantum Science and Engineering, Hokkaido University Faculty of Engineering, North 13 West 8, Kita-ku, Sapporo 060-8628, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
| | - Ryo Morita
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
| | - Koji Ogawa
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery, Hokkaido University Faculty of Medicine, North 15 West 7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
| | - Ryusuke Suzuki
- Department of Medical Physics, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
| | - Tomohiko Miyazaki
- Department of Radiation Oncology, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo 060-8648, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
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Sengupta C, Nguyen DT, Moodie T, Mason D, Luo J, Causer T, Liu SF, Brown E, Inskip L, Hazem M, Chao M, Wang T, Lee YY, van Gysen K, Sullivan E, Cosgriff E, Ramachandran P, Poulsen P, Booth J, O'Brien R, Greer P, Keall P. The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients. Radiother Oncol 2024; 190:110031. [PMID: 38008417 DOI: 10.1016/j.radonc.2023.110031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients. METHODS/MATERIALS The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone. RESULTS The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone. CONCLUSIONS This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.
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Affiliation(s)
| | | | | | - Daniel Mason
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Jianjie Luo
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Trent Causer
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Sau Fan Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | - Elizabeth Brown
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | - Maryam Hazem
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Menglei Chao
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Tim Wang
- Crown Princess Mary Cancer Centre, Australia
| | - Yoo Y Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | | | | | | | - Per Poulsen
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Australia; Institute of Medical Physics, The University of Sydney, Australia
| | - Ricky O'Brien
- Image X Institute, The University of Sydney, Australia; RMIT University, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Australia
| | - Paul Keall
- Image X Institute, The University of Sydney, Australia
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de la Pinta C, Sevillano D, Colmenares R, Barrio S, Olavarria A, Palomera A, Romera R, Cobos J, Muriel A, Fernández E, Perna LC, Albillos A, Sancho S. Are liver contour and bone fusion comparable to fiducials for IGRT in liver SBRT? Tech Innov Patient Support Radiat Oncol 2023; 27:100215. [PMID: 37744524 PMCID: PMC10511841 DOI: 10.1016/j.tipsro.2023.100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 05/28/2023] [Accepted: 06/19/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Liver stereotactic body radiotherapy (SBRT) is increasingly being used to treat tumours. The purpose of this study was to compare the differences in patient positioning when using implanted fiducials as surrogates compared to alternative methods based on liver contour or bone registration. Material and methods Eighteen patients treated with SBRT who underwent a fiducial placement procedure were included. Fiducial guidance was our gold standard to guide treatment in this study. After recording the displacements, when fusing the planning CT and CBCT performed in the treatment unit using fiducials, liver contour and bone reference, the differences between fiducials and liver contour and bone reference were calculated. Data from 88 CBCT were analyzed. The correlation between the displacements found with fiducials and those performed based on the liver contour and the nearest bone structure as references was determined. The mean, median, variance, range and standard deviation of the displacements with each of the fusion methods were obtained. μ, Ʃ, and σ values and margins were obtained. Results Lateral displacements of less than 3 mm with respect to the gold standard in 92% vs. 62.5% of cases using liver contour and bone references, respectively, with 93.2% vs. 65.9% in the AP axis and SI movement in 69.3% vs. 51.1%. The errors μ, σ and Ʃ of the fusions with hepatic contour and bone reference in SI were 0.26 mm, 4 mm and 3 mm, and 0.8 mm, 5 mm and 3 mm respectively. Conclusion Our study showed that displacements were smaller with the use of hepatic contour compared to bone reference and comparable to those obtained with the use of fiducials in the lateral, AP and SI motion axes. This would justify that hepatic contouring can be a guide in the treatment of patients in the absence of fiducials.
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Affiliation(s)
- C. de la Pinta
- Radiation Oncology Department. IRYCIS. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - D. Sevillano
- Medical Physics Department. Ramón y Cajal Hospital. IRYCIS, Crta Colmenar Viejo Km 9,100 28034, Madrid, Spain
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain
| | - R. Colmenares
- Medical Physics Department. Ramón y Cajal Hospital. IRYCIS, Crta Colmenar Viejo Km 9,100 28034, Madrid, Spain
| | - S. Barrio
- Radiation Therapist. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - A. Olavarria
- Radiology Department. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - A. Palomera
- Radiology Department. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - R. Romera
- Radiology Department. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - J. Cobos
- Radiology Department. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - A. Muriel
- Clinical Biostatistics Unit, Ramón y Cajal University Hospital, IRYCIS, CIBERESP. Universidad de Alcalá, Madrid, Spain
| | - E. Fernández
- Radiation Oncology Department. IRYCIS. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - LC. Perna
- Pathology Department. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
| | - A. Albillos
- Dept of Gastroenterology. Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBEREHD., Madrid, Spain
| | - S. Sancho
- Radiation Oncology Department. IRYCIS. Ramón y Cajal Hospital. Crta Colmenar Viejo Km 9,100. 28034, Madrid, Spain
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Guo B, Stephans K, Woody N, Antolak A, Moazzezi M, Xia P. Online verification of breath-hold reproducibility using kV-triggered imaging for liver stereotactic body radiation therapy. J Appl Clin Med Phys 2023; 24:e14045. [PMID: 37211920 PMCID: PMC10476975 DOI: 10.1002/acm2.14045] [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: 01/21/2023] [Revised: 04/10/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023] Open
Abstract
PURPOSE To introduce a new technique for online breath-hold verification for liver stereotactic body radiation therapy (SBRT) based on kilovoltage-triggered imaging and liver dome positions. MATERIAL AND METHODS Twenty-five liver SBRT patients treated with deep inspiration breath-hold were included in this IRB-approved study. To verify the breath-hold reproducibility during treatment, a KV-triggered image was acquired at the beginning of each breath-hold. The liver dome position was visually compared with the expected upper/lower liver boundaries created by expanding/contracting the liver contour 5 mm in the superior-inferior direction. If the liver dome was within the boundaries, delivery continued; otherwise, beam was held manually, and the patient was instructed to take another breath-hold until the liver dome fell within boundaries. The liver dome was delineated on each triggered image. The mean distance between the delineated liver dome to the projected planning liver contour was defined as liver dome position error edome . The mean and maximum edome of each patient were compared between no breath-hold verification (all triggered images) and with online breath-hold verification (triggered images without beam-hold). RESULTS Seven hundred thirteen breath-hold triggered images from 92 fractions were analyzed. For each patient, an average of 1.5 breath-holds (range 0-7 for all patients) resulted in beam-hold, accounting for 5% (0-18%) of all breath-holds; online breath-hold verification reduced the mean edome from 3.1 mm (1.3-6.1 mm) to 2.7 mm (1.2-5.2 mm) and the maximum edome from 8.6 mm (3.0-18.0 mm) to 6.7 mm (3.0-9.0 mm). The percentage of breath-holds with edome >5 mm was reduced from 15% (0-42%) without breath-hold verification to 11% (0-35%) with online breath-hold verification. online breath-hold verification eliminated breath-holds with edome >10 mm, which happened in 3% (0-17%) of all breath-holds. CONCLUSION It is clinically feasible to monitor the reproducibility of each breath-hold during liver SBRT treatment using triggered images and liver dome. Online breath-hold verification improves the treatment accuracy for liver SBRT.
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Affiliation(s)
- Bingqi Guo
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
| | - Kevin Stephans
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
| | - Neil Woody
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
| | - Alexander Antolak
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
| | - Mojtaba Moazzezi
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
| | - Ping Xia
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandOhioUSA
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Aznar MC, Carrasco de Fez P, Corradini S, Mast M, McNair H, Meattini I, Persson G, van Haaren P. ESTRO-ACROP guideline: Recommendations on implementation of breath-hold techniques in radiotherapy. Radiother Oncol 2023; 185:109734. [PMID: 37301263 DOI: 10.1016/j.radonc.2023.109734] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
The use of breath-hold techniques in radiotherapy, such as deep-inspiration breath hold, is increasing although guidelines for clinical implementation are lacking. In these recommendations, we aim to provide an overview of available technical solutions and guidance for best practice in the implementation phase. We will discuss specific challenges in different tumour sites including factors such as staff training and patient coaching, accuracy, and reproducibility. In addition, we aim to highlight the need for further research in specific patient groups. This report also reviews considerations for equipment, staff training and patient coaching, as well as image guidance for breath-hold treatments. Dedicated sections for specific indications, namely breast cancer, thoracic and abdominal tumours are also included.
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Affiliation(s)
- Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
| | - Pablo Carrasco de Fez
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Mirjam Mast
- Department of Radiotherapy, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - Helen McNair
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, UK
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Gitte Persson
- Department of Oncology, Herlev-Gentofte Hospital, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Denmark
| | - Paul van Haaren
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
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Moskalenko M, Jones BL, Mueller A, Lewis S, Shiao JC, Zakem SJ, Robin TP, Goodman KA. Fiducial Markers Allow Accurate and Reproducible Delivery of Liver Stereotactic Body Radiation Therapy. Curr Oncol 2023; 30:5054-5061. [PMID: 37232840 DOI: 10.3390/curroncol30050382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/29/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023] Open
Abstract
Fiducial markers are utilized for image guided radiotherapy (IGRT) alignment during the delivery of liver stereotactic body radiosurgery (SBRT). There are limited data demonstrating the impact of matching fiducials on the accuracy of liver SBRT. This study quantifies the benefit of fiducial-based alignment and improvements in inter-observer reliability. Nineteen patients with 24 liver lesions were treated with SBRT. Target localization was performed using fiducial markers on cone-beam computed tomography (CBCT). Each CBCT procedure was retrospectively realigned to match both the liver edge and fiducial markers. The shifts were recorded by seven independent observers. Inter-observer variability was analyzed by calculating the mean error and uncertainty for the set-up. The mean absolute Cartesian error observed from fiducial and liver edge-based alignment was 1.5 mm and 5.3 mm, respectively. The mean uncertainty from fiducial and liver edge-based alignment was 1.8 mm and 4.5 mm, respectively. An error of 5 mm or greater was observed 50% of the time when aligning to the liver surface versus 5% of the time when aligning to fiducial markers. Aligning to the liver edge significantly increased the error, resulting in increased shifts when compared to alignment to fiducials. Tumors of 3 cm or farther from the liver dome had higher mean errors when aligned without fiducials (4.8 cm vs. 4.4 cm, p = 0.003). Our data support the use of fiducial markers for safer and more accurate liver SBRT.
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Affiliation(s)
- Marina Moskalenko
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Bernard L Jones
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Adam Mueller
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Shirley Lewis
- Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India
| | - Jay C Shiao
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Sara J Zakem
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Paronetto C, den Toom W, Milder MTW, van Norden Y, Baak R, Heijmen BJM, Méndez Romero A. Inter- and intrafraction dose variations in robotic stereotactic body radiation therapy (SBRT) for perihilar cholangiocarcinoma in the prospective phase I STRONG trial. Front Oncol 2023; 13:1114737. [PMID: 36969072 PMCID: PMC10032458 DOI: 10.3389/fonc.2023.1114737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Using fiducial-marker-based robotic respiratory tumor tracking, we treated perihilar cholangiocarcinoma patients in the STRONG trial with 15 daily fractions of 4 Gy. For each of the included patients, in-room diagnostic-quality repeat CTs (rCT) were acquired pre- and post-dose delivery in 6 treatment fractions to analyze inter- and intrafraction dose variations. Planning CTs (pCTs) and rCTs were acquired in expiration breath-hold. Analogous to treatment, spine and fiducials were used to register rCTs with pCTs. In each rCT, all OARs were contoured, and the target was rigidly copied from the pCT based on grey values. The rCTs acquired were used to calculate the doses to be delivered through the treatment-unit settings. On average, target doses in rCTs and pCTs were similar. However, due to target displacements relative to the fiducials in rCTs, 10% of the rCTs showed PTV coverage losses of >10%. Although target coverages had been planned below desired values in order to protect OARs, many pre-rCTs contained OAR constraint violations: 44.4% for the 6 major constraints. Most OAR dose differences between pre- and post-rCTs were not statistically significant. The dose deviations observed in repeat CTs represent opportunities for more advanced adaptive approaches to enhancing SBRT treatment quality.
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Affiliation(s)
- Chiara Paronetto
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Radiotherapy, Istituto Oncologico Veneto (IOV), Padova, Italy
- *Correspondence: Chiara Paronetto, ,
| | - Wilhelm den Toom
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maaike T. W. Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Yvette van Norden
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rogier Baak
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ben J. M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alejandra Méndez Romero
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
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10
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Tascón-Vidarte JD, Stick LB, Josipovic M, Risum S, Jomier J, Erleben K, Vogelius IR, Darkner S. Accuracy and consistency of intensity-based deformable image registration in 4DCT for tumor motion estimation in liver radiotherapy planning. PLoS One 2022; 17:e0271064. [PMID: 35802593 PMCID: PMC9269460 DOI: 10.1371/journal.pone.0271064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/23/2022] [Indexed: 11/29/2022] Open
Abstract
We investigate the accuracy of intensity-based deformable image registration (DIR) for tumor localization in liver stereotactic body radiotherapy (SBRT). We included 4DCT scans to capture the breathing motion of eight patients receiving SBRT for liver metastases within a retrospective clinical study. Each patient had three fiducial markers implanted. The liver and the tumor were delineated in the mid-ventilation phase, and their positions in the other phases were estimated with deformable image registration. We tested referenced and sequential registrations strategies. The fiducial markers were the gold standard to evaluate registration accuracy. The registration errors related to measured versus estimated fiducial markers showed a mean value less than 1.6mm. The positions of some fiducial markers appeared not stable on the 4DCT throughout the respiratory phases. Markers’ center of mass tends to be a more reliable measurement. Distance errors of tumor location based on registration versus markers center of mass were less than 2mm. There were no statistically significant differences between the reference and the sequential registration, i.e., consistency and errors were comparable to resolution errors. We demonstrated that intensity-based DIR is accurate up to resolution level for locating the tumor in the liver during breathing motion.
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Affiliation(s)
| | | | | | | | | | - Kenny Erleben
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Sune Darkner
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
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11
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Pham TT, Whelan B, Oborn BM, Delaney GP, Vinod S, Brighi C, Barton M, Keall P. Magnetic resonance imaging (MRI) guided proton therapy: A review of the clinical challenges, potential benefits and pathway to implementation. Radiother Oncol 2022; 170:37-47. [DOI: 10.1016/j.radonc.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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12
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Kibe Y, Takeda A, Tsurugai Y, Eriguchi T, Oku Y, Kimura Y, Nakamura N. Feasibility of marker-less stereotactic body radiotherapy for hepatocellular carcinoma. Acta Oncol 2022; 61:104-110. [PMID: 34788194 DOI: 10.1080/0284186x.2021.2001566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The feasibility of marker-less stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC) has not yet been established, and, thus, was examined in the present study. MATERIAL AND METHODS We retrospectively investigated patients who received marker-less SBRT for locally untreated HCC tumors between July 2005 and December 2018. Radiotherapy planning CT was performed under fixation with vacuum cushions and abdominal compression. The clinical target volume (CTV) was equivalent to the gross tumor volume (GTV). The internal target volume (ITV) margin to CTV was determined from calculations based on the motion of the diaphragm. The planning target volume (PTV) margin to ITV was 5-6 mm. In the set-up, radiotherapy planning CT and linac-integrated cone-beam CT performed in the same imaging and fixation settings were merged by referring to the anatomical components surrounding target tumors. The primary endpoint was the 3-year cumulative local tumor progression rate. The upper limit of the 95% confidence interval for the 3-year cumulative local tumor progression rate was less than 7.0%, which was interpreted as favorable local control and feasible for marker-less SBRT. Local tumor progression was assessed by mRECIST. RESULTS We reviewed 180 patients treated with 35-40 Gy/5 fractions. The median follow-up time for the local tumor progression of censored tumors was 32.3 months (range, 0.3-104). The 3-year cumulative local tumor progression rate was 3.0% (95% CI, 1.1-6.5%). The 3-year overall survival rate was 71.6% (95% CI, 63.5-78.2%). Regarding acute hematologic toxicities, grade 3 hypoalbuminemia and thrombocytopenia were detected in 1 (0.6%) and 5 (2.9%) patients, respectively. Treatment-related death from SBRT was not observed. SBRT was initiated within 7 days after radiotherapy planning CT for 84% (152/180) of patients. CONCLUSIONS Marker-less SBRT for HCC achieved favorable local control that fulfilled the threshold. This result suggests that marker-less SBRT with appropriate settings is a feasible treatment strategy.
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Affiliation(s)
- Yuichi Kibe
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
- Radiation Oncology Division, St. Marianna University School of Medicine Hospital, Kawasaki, Kanagawa, Japan
| | - Atsuya Takeda
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Yuichiro Tsurugai
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Takahisa Eriguchi
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Yohei Oku
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Yuto Kimura
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Naoki Nakamura
- Radiation Oncology Division, St. Marianna University School of Medicine Hospital, Kawasaki, Kanagawa, Japan
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13
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Oyoshi H, Tachibana H, Someya T, Rachi T, Takeda Y, Ariji T. [A Preliminary Study of Optimal Imaging Acquisition Parameters for Fiducial Markers in Liver Stereotactic Body Radiotherapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2021; 77:1400-1410. [PMID: 34924476 DOI: 10.6009/jjrt.2021_jsrt_77.12.1400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In liver stereotactic body radiotherapy (SBRT) using fiducial markers, the accuracy of automatic image recognition of fiducial markers is important, and the imaging dose cannot be neglected in image-guided radiotherapy. Optimal imaging parameters of fiducial markers were investigated for automatic image recognition and imaging dose. We investigated automatic recognition with fiducial markers of different shapes and sizes. In addition, the optimum imaging conditions were examined based on the automatic recognition when the presence or absence of a filter, focal spot size, and phantom thickness were altered using the fiducial markers with a high automatic recognition. The results for different shapes and sizes of fiducial markers showed that larger markers were recognized more automatically, whereas shorter markers were recognized in the correct position. By using the filter, we were able to reduce the imaging dose by one third or one half compared to the case without the filter. The results for the focal spot size showed that using a larger size resulted in higher automatic recognition accuracy than using a smaller size. For the relationship between the automatically recognized imaging conditions and the air kerma when the phantom thickness was altered, it was necessary to keep the tube current-time product constant and increase the tube voltage in order to avoid poor recognition accuracy. The parameters we proposed are effective in shortening the treatment time and reducing the imaging dose because they allow us to acquire images with low doses and high accuracy of automatic recognition.
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Affiliation(s)
- Hajime Oyoshi
- Department of Radiology, National Cancer Center Hospital East
| | - Hidenobu Tachibana
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital East
| | - Takashi Someya
- Department of Radiology, National Cancer Center Hospital East
| | - Toshiya Rachi
- Department of Radiology, National Cancer Center Hospital East
| | - Youhei Takeda
- Department of Radiology, National Cancer Center Hospital East (Current address: Department of Radiology, Shinshu Ueda Medical Center)
| | - Takaki Ariji
- Department of Radiology, National Cancer Center Hospital East
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14
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Sharma M, Nano TF, Akkati M, Milano MT, Morin O, Feng M. A systematic review and meta-analysis of liver tumor position variability during SBRT using various motion management and IGRT strategies. Radiother Oncol 2021; 166:195-202. [PMID: 34843841 DOI: 10.1016/j.radonc.2021.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To suggest PTV margins for liver SBRT with different motion management strategies based on a systematic review and meta-analysis. METHODS In accordance with Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analyses (PRISMA), a systematic review in PubMed, Embase and Medline databases was performed for liver tumor position variability. From an initial 533 studies published before October 2020, 36 studies were categorized as 18 free-breathing (FB; npatients = 401), 9 abdominal compression (AC; npatients = 145) and 9 breath-hold (BH; npatients = 126). A meta-analysis was performed on inter- and intra-fraction position variability to report weighted-mean with 95% confidence interval (CI95) in superior-inferior (SI), left-right (LR) and anterior-posterior (AP) directions. Furthermore, weighted-mean ITV margins were computed for FB (nstudies = 15, npatients = 373) and AC (nstudies = 6, npatients = 97) and PTV margins were computed for FB (nstudies = 6, npatients = 95), AC (nstudies = 7, npatients = 106) and BH (nstudies = 8, npatients = 133). RESULTS The FB weighted-mean intra-fraction variability, ITV margins and weighted-standard-deviation in mm were SI-9.7, CI95 = 9.3-10.1, 13.5 ± 4.9; LR-5.4, CI95 = 5.3-5.6, 7.3 ± 7.9; and AP-4.2, CI95 = 4.0-4.4, 6.3 ± 7.6. The inter-fraction-based results were SI-4.7, CI95 = 4.3-5.1, 5.7 ± 1.7; LR-1.4, CI95 = 1.1-1.6, 3.6 ± 2.7; and AP-2.8, CI95 = 2.5-3.1, 4.8 ± 2.1. For AC intra-fraction results in mm were SI-1.8, CI95 = 1.6-2.0, 2.6 ± 1.2; LR-0.7, CI95 = 0.6-0.8, 1.7 ± 1.5; and AP-0.9, CI95 = 0.8-1.0, 1.9 ± 1.7. The inter-fraction results were SI-2.6, CI95 = 2.3-3.0, 5.2 ± 2.9; LR-1.9, CI95 = 1.7-2.1, 4.0 ± 2.2; and AP-2.9, CI95 = 2.5-3.2, 5.8 ± 2.7. For BH the inter-fraction variability, and the weighted-mean PTV margins and weighted-standard-deviation in mm were SI-2.4, CI95 = 2.1-2.7, 5.6 ± 2.9; LR-1.8, CI95 = 1.3-2.2, 5.5 ± 1.7; and AP-1.4; CI95 = 1.2-1.7, 6.1 ± 2.1. CONCLUSION Our meta-analysis suggests a symmetric weighted-mean PTV margin of 6 mm might be appropriate for BH. For AC and FB, asymmetric PTV margins (weighted-mean margin of 4 mm (AP), 6 mm (SI/LR)) might be appropriate. For FB, if larger (>ITV margin) intra-fraction variability observed, the additional intra- and inter-fraction variability should be accounted in the PTV margin.
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Affiliation(s)
- Manju Sharma
- University of California, San Francisco, United States.
| | - Tomi F Nano
- University of California, San Francisco, United States
| | | | | | - Olivier Morin
- University of California, San Francisco, United States
| | - Mary Feng
- University of California, San Francisco, United States
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15
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Lis M, Newhauser W, Donetti M, Wolf M, Steinsberger T, Paz A, Graeff C. Preliminary tests of dosimetric quality and projected therapeutic outcomes of multi-phase 4D radiotherapy with proton and carbon ion beams. Phys Med Biol 2021; 66. [PMID: 34740202 DOI: 10.1088/1361-6560/ac36e7] [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: 06/16/2021] [Accepted: 11/05/2021] [Indexed: 12/25/2022]
Abstract
Objective. The purpose of this study was to perform preliminary pre-clinical tests to compare the dosimetric quality of two approaches to treating moving tumors with ion beams: synchronously delivering the beam with the motion of a moving planning target volume (PTV) using the recently developed multi-phase 4D dose delivery (MP4D) approach, and asynchronously delivering the ion beam to a motion-encompassing internal tumor volume (ITV) combined with rescanning.Approach. We created 4D optimized treatment plans with proton and carbon ion beams for two patients who had previously received treatment for non-small cell lung cancer. For each patient, we created several treatment plans, using approaches with and without motion mitigation: MP4D, ITV with rescanning, static deliveries to a stationary PTV, and deliveries to a moving tumor without motion compensation. Two sets of plans were optimized with margins or robust uncertainty scenarios. Each treatment plan was delivered using a recently-developed motion-synchronized dose delivery system (M-DDS); dose distributions in water were compared to measurements using gamma index analysis to confirm the accuracy of the calculations. Reconstructed dose distributions on the patient CT were analyzed to assess the dosimetric quality of the deliveries (conformity, uniformity, tumor coverage, and extent of hotspots).Main results. Gamma index analysis pass rates confirmed the accuracy of dose calculations. Dose coverage was >95% for all static and MP4D treatments. The best conformity and the lowest lung doses were achieved with MP4D deliveries. Robust optimization led to higher lung doses compared to conventional optimization for ITV deliveries, but not for MP4D deliveries.Significance. We compared dosimetric quality for two approaches to treating moving tumors with ion beams. Our findings suggest that the MP4D approach, using an M-DDS, provides conformal motion mitigation, with full target coverage and lower OAR doses.
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Affiliation(s)
- Michelle Lis
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America.,Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Department of Electrical Engineering and Information Technology, Technical University of Darmstadt, German
| | - Wayne Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America.,Department of Radiation Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, United States of America
| | - Marco Donetti
- Research and Development Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Moritz Wolf
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Timo Steinsberger
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technical University of Darmstadt, Germany
| | - Athena Paz
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Christian Graeff
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
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16
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Beaton L, Daly M, Tregidgo HF, Grimes H, Moinuddin S, Stacey C, Znati S, Hague J, Bascal ZA, Wilde PE, Cooper S, Bandula S, Lewis AL, Clarkson MJ, Sharma RA. Radiopaque drug-eluting embolisation beads as fiducial markers for stereotactic liver radiotherapy. Br J Radiol 2021; 95:20210594. [PMID: 34762499 PMCID: PMC8822567 DOI: 10.1259/bjr.20210594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: To determine the feasibility of using radiopaque (RO) beads as direct tumour surrogates for image-guided radiotherapy (IGRT) in patients with liver tumours after transarterial chemoembolisation (TACE). Methods: A novel vandetanib-eluting RO bead was delivered via TACE as part of a first-in-human clinical trial in patients with either hepatocellular carcinoma or liver metastases from colorectal cancer. Following TACE, patients underwent simulated radiotherapy imaging with four-dimensional computed tomography (4D-CT) and cone-beam CT (CBCT) imaging. RO beads were contoured using automated thresholding, and feasibility of matching between the simulated radiotherapy planning dataset (AVE-IP image from 4D data) and CBCT scans assessed. Additional kV, MV, helical CT and CBCT images of RO beads were obtained using an in-house phantom. Stability of RO bead position was assessed by comparing 4D-CT imaging to CT scans taken 6–20 days following TACE. Results: Eight patients were treated and 4D-CT and CBCT images acquired. RO beads were visible on 4D-CT and CBCT images in all cases and matching successfully performed. Differences in centre of mass of RO beads between CBCT and simulated radiotherapy planning scans (AVE-IP dataset) were 2.0 mm mediolaterally, 1.7 mm anteroposteriorally and 3.5 mm craniocaudally. RO beads in the phantom were visible on all imaging modalities assessed. RO bead position remained stable up to 29 days post TACE. Conclusion: RO beads are visible on IGRT imaging modalities, showing minimal artefact. They can be used for on-set matching with CBCT and remain stable over time. Advances in knowledge: The role of RO beads as fiducial markers for stereotactic liver radiotherapy is feasible and warrants further exploration as a combination therapy approach.
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Affiliation(s)
- Laura Beaton
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Mairead Daly
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Henry Fj Tregidgo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Helen Grimes
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Syed Moinuddin
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Chris Stacey
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sami Znati
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Julian Hague
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Zainab A Bascal
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Paul E Wilde
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Sarah Cooper
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Steven Bandula
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew L Lewis
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Matthew J Clarkson
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ricky A Sharma
- University College London Cancer Institute, University College London, London, United Kingdom.,National Institute for Health Research University College London Hospitals Biomedical Centre, University College London Cancer Institute, London, United Kingdom
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17
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Zhou H, Li Y, Li J, Wu T, Chen Y, Shen Z. Radiation dosimetric influence by different target volume definition in Cyberknife lung cancer and abdomen stereotactic body radiotherapy. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2021. [DOI: 10.1080/16878507.2021.1967045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Han Zhou
- School of Electronic Science and Engineering, Nanjing University, Nanjing, China
- Department of Radiation Oncology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yikun Li
- Department of Radiation Oncology, Jinling Hospital, Nanjing University, Nanjing, China
| | - Jing Li
- Department of Radiation Oncology, Jinling Hospital, Nanjing University, Nanjing, China
| | - Tiancong Wu
- Department of Radiation Oncology, Jinling Hospital, Nanjing University, Nanjing, China
| | - Ying Chen
- School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Zetian Shen
- Department of Radiation Oncology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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18
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Ueda Y, Tsujii M, Ohira S, Sumida I, Miyazaki M, Teshima T. Residual Set Up Errors of the Surrogate-guided Registration Using Four-dimensional CT Images and Breath Holding Ones in Respiratory Gated Radiotherapy for Liver Cancer. In Vivo 2021; 35:2089-2098. [PMID: 34182484 DOI: 10.21873/invivo.12478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/02/2021] [Accepted: 05/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To evaluate the surrogate-guided registration accuracy of two computed tomography (CT) image sets, expiratory phase four-dimensional (Ex4D) CT and breath-holding CT (BHCT), in respiratory-gated radiotherapy for liver cancer. MATERIALS AND METHODS The surrogate-guided registration errors were defined as the differences between the diaphragm- and fiducial-guided registrations or the differences between upper and lower fiducial registrations in three directions: left-right (LR), anterior-posterior (AP), and cranio-caudal (CC). RESULTS The mean±SDs of the absolute errors for diaphragm-guided registration were 1.9±1.3, 2.7±1.8, and 2.6±1.7 mm with Ex4D and 1.8±1.8, 2.6±1.9, and 1.8±1.7 mm with BHCT in the LR, AP and CC directions, respectively (CC direction, p<0.01). In the fiducial-guided registration, there were no significant differences in any direction. In registration with Ex4D, there were positive correlations between registration errors and the respiratory irregularity during 4D scanning (correlation coefficient; diaphragm: 0.65, fiducial: 0.54). CONCLUSION BHCT has the advantage of accurate surrogate-guided registration compared with Ex4D.
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Affiliation(s)
- Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan;
| | - Mari Tsujii
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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19
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van de Lindt TN, Fast MF, van den Wollenberg W, Kaas J, Betgen A, Nowee ME, Jansen EP, Schneider C, van der Heide UA, Sonke JJ. Validation of a 4D-MRI guided liver stereotactic body radiation therapy strategy for implementation on the MR-linac. Phys Med Biol 2021; 66. [PMID: 33887708 DOI: 10.1088/1361-6560/abfada] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Purpose. Accurate tumor localization for image-guided liver stereotactic body radiation therapy (SBRT) is challenging due to respiratory motion and poor tumor visibility on conventional x-ray based images. Novel integrated MRI and radiotherapy systems enable direct in-room tumor visualization, potentially increasing treatment accuracy. As these systems currently do not provide a 4D image-guided radiotherapy strategy, we developed a 4D-MRI guided liver SBRT workflow and validated all steps for implementation on the Unity MR-linac.Materials and Methods. The proposed workflow consists of five steps: (1) acquisition of a daily 4D-MRI scan, (2) 4D-MRI to mid-position planning-CT rigid tumor registration, (3) calculation of daily tumor midP misalignment, (4) plan adaptation using adapt-to-position (ATP) with segment-weights optimization and (5) adapted plan delivery. The workflow was first validated in a motion phantom, performing regular motion at different baselines (±5 to ±10 mm) and patient-derived respiratory signals with varying degrees of irregularity. 4D-MRI derived respiratory signals and 4D-MRI to planning CT registrations were compared to the phantom input, and gamma and dose-area-histogram analyses were performed on the delivered dose distributions on film. Additionally, 4D-MRI to CT registration performance was evaluated in patient images using the full-circle method (transitivity analysis). Plan adaption was further analyzedin-silicoby creating adapted treatment plans for 15 patients with oligometastatic liver disease.Results. Phantom trajectories could be reliably extracted from 4D-MRI scans and 4D-MRI to CT registration showed submillimeter accuracy. The DAH-analysis demonstrated excellent coverage of the dose evaluation structures GTV and GTVTD. The median daily rigid 4D-MRI to midP-CT registration precision in patient images was <2 mm. The ATP strategy restored the target dose without increased exposure to the OARs and plan quality was independent from 3D shift distance in the range of 1-26 mm.Conclusions. The proposed 4D-MRI guided strategy showed excellent performance in all workflow tests in preparation of the clinical introduction on the Unity MR-linac.
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Affiliation(s)
- Tessa N van de Lindt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin F Fast
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jochem Kaas
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anja Betgen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marlies E Nowee
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Edwin Pm Jansen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Christoph Schneider
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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20
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Lee YYD, Nguyen DT, Moodie T, O'Brien R, McMaster A, Hickey A, Pritchard N, Poulsen P, Tabaksblat EM, Weber B, Worm E, Pryor D, Chu J, Hardcastle N, Booth J, Gebski V, Wang T, Keall P. Study protocol of the LARK (TROG 17.03) clinical trial: a phase II trial investigating the dosimetric impact of Liver Ablative Radiotherapy using Kilovoltage intrafraction monitoring. BMC Cancer 2021; 21:494. [PMID: 33941111 PMCID: PMC8091536 DOI: 10.1186/s12885-021-08184-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/13/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Stereotactic Ablative Body Radiotherapy (SABR) is a non-invasive treatment which allows delivery of an ablative radiation dose with high accuracy and precision. SABR is an established treatment for both primary and secondary liver malignancies, and technological advances have improved its efficacy and safety. Respiratory motion management to reduce tumour motion and image guidance to achieve targeting accuracy are crucial elements of liver SABR. This phase II multi-institutional TROG 17.03 study, Liver Ablative Radiotherapy using Kilovoltage intrafraction monitoring (LARK), aims to investigate and assess the dosimetric impact of the KIM real-time image guidance technology. KIM utilises standard linear accelerator equipment and therefore has the potential to be a widely available real-time image guidance technology for liver SABR. METHODS Forty-six patients with either hepatocellular carcinoma or oligometastatic disease to the liver suitable for and treated with SABR using Kilovoltage Intrafraction Monitoring (KIM) guidance will be included in the study. The dosimetric impact will be assessed by quantifying accumulated patient dose distribution with or without the KIM intervention. The patient treatment outcomes of local control, toxicity and quality of life will be measured. DISCUSSION Liver SABR is a highly effective treatment, but precise dose delivery is challenging due to organ motion. Currently, there is a lack of widely available options for performing real-time tumour localisation to assist with accurate delivery of liver SABR. This study will provide an assessment of the impact of KIM as a potential solution for real-time image guidance in liver SABR. TRIAL REGISTRATION This trial was registered on December 7th 2016 on ClinicalTrials.gov under the trial-ID NCT02984566 .
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Affiliation(s)
- Yoo Young Dominique Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
- The University of Sydney, Sydney, NSW, Australia.
| | - Doan Trang Nguyen
- The University of Sydney, Sydney, NSW, Australia
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
- ACRF Image X Institute, Sydney, NSW, Australia
| | - Trevor Moodie
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Sydney, NSW, Australia
| | - Ricky O'Brien
- ACRF Image X Institute, Sydney, NSW, Australia
- Radiation Physics Laboratory, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Anne McMaster
- Department of Radiation Oncology, Liverpool-Macarthur Cancer Therapy Centre, Sydney, NSW, Australia
| | - Andrew Hickey
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Sydney, NSW, Australia
| | - Nicole Pritchard
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Sydney, NSW, Australia
- Gamma Gurus Pty Ltd, Sydney, NSW, Australia
| | - Per Poulsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Esben Worm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Julie Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nicholas Hardcastle
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Jeremy Booth
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Sydney, NSW, Australia
| | - Val Gebski
- University of Sydney NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Tim Wang
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Sydney, NSW, Australia
| | - Paul Keall
- ACRF Image X Institute, Sydney, NSW, Australia
- Radiation Physics Laboratory, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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21
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Mizukami N, Yoda K. Markerless Liver Tumor Localization Using Internal Liver Volume Delineated By Four-Dimensional Cone-Beam CT. Cureus 2021; 13:e14465. [PMID: 33996324 PMCID: PMC8115189 DOI: 10.7759/cureus.14465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Markerless liver tumor localization has been proposed using an internal liver volume delineated by four-dimensional cone-beam CT (4D CBCT). Liver CT was performed under mid-ventilation breath hold, and transferred to a treatment planning system (TPS) to contour the gross target volume (GTV). Subsequently, liver 4D CBCT was performed and transferred to the TPS. After bone matching between the CT and the 4D CBCT, an internal liver volume was delineated on the liver CT volume as the union of liver volumes within a breathing cycle of the 4D CBCT volumes. Then, inhale liver volume was delineated on the 4D CBCT. Next, the internal target volume was defined by expanding the GTV by referring to the liver movement within the respiratory cycle of the 4D CBCT. Subsequently, all the delineated structures were transferred to the 4D CBCT unit. Immediately before treatment, 4D CBCT was performed again and the couch was repositioned so that the liver may move superiorly to the internal liver volume boundary and inferiorly to the inhale liver volume boundary during the respiratory cycle. The target localization accuracy of the proposed method was evaluated by comparing it to a published lipiodol-based technique. Both methods were applied to a single case in which lipiodol remained inside the tumor. 3D couch repositioning vectors for the two procedures were collected for 25 fraction data of the above same patient, and the differences in the vectors were calculated. The target localization deviations of the proposed method in reference to the lipiodol-based procedure were 0.7 mm ± 0.9 mm (SD) in the lateral direction, 2.0 mm ± 0.7 mm (SD) in the superior-inferior direction, and -2.1 mm ± 0.8 mm (SD) in the anterior-posterior direction. Markerless liver tumor localization is feasible by delineating the internal liver volume and the inhale liver volume using 4D CBCT.
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Affiliation(s)
- Naohisa Mizukami
- Department of Radiation Oncology, Yame General Hospital, Yame, JPN
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22
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Romesser PB, Tyagi N, Crane CH. Magnetic Resonance Imaging-Guided Adaptive Radiotherapy for Colorectal Liver Metastases. Cancers (Basel) 2021; 13:cancers13071636. [PMID: 33915810 PMCID: PMC8036824 DOI: 10.3390/cancers13071636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/22/2021] [Accepted: 03/28/2021] [Indexed: 12/16/2022] Open
Abstract
Technological advances have enabled well tolerated and effective radiation treatment for small liver metastases. Stereotactic ablative radiation therapy (SABR) refers to ablative dose delivery (>100 Gy BED) in five fractions or fewer. For larger tumors, the safe delivery of SABR can be challenging due to a more limited volume of healthy normal liver parenchyma and the proximity of the tumor to radiosensitive organs such as the stomach, duodenum, and large intestine. In addition to stereotactic treatment delivery, controlling respiratory motion, the use of image guidance, adaptive planning and increasing the number of radiation fractions are sometimes necessary for the safe delivery of SABR in these situations. Magnetic Resonance (MR) image-guided adaptive radiation therapy (MRgART) is a new and rapidly evolving treatment paradigm. MR imaging before, during and after treatment delivery facilitates direct visualization of both the tumor target and the adjacent normal healthy organs as well as potential intrafraction motion. Real time MR imaging facilitates non-invasive tumor tracking and treatment gating. While daily adaptive re-planning permits treatment plans to be adjusted based on the anatomy of the day. MRgART therapy is a promising radiation technology advance that can overcome many of the challenges of liver SABR and may facilitate the safe tumor dose escalation of colorectal liver metastases.
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Affiliation(s)
- Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
- Early Drug Development Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
- Correspondence:
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23
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Knybel L, Cvek J, Neuwirth R, Jiravsky O, Hecko J, Penhaker M, Sramko M, Kautzner J. Real-time measurement of ICD lead motion during stereotactic body radiotherapy of ventricular tachycardia. ACTA ACUST UNITED AC 2021; 26:128-137. [PMID: 34046223 DOI: 10.5603/rpor.a2021.0020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Background Here we aimed to evaluate the respiratory and cardiac-induced motion of a ICD lead used as surrogate in the heart during stereotactic body radiotherapy (SBRT) of ventricular tachycardia (VT). Data provides insight regarding motion and motion variations during treatment. Materials and methods We analyzed the log files of surrogate motion during SBRT of ventricular tachycardia performed in 20 patients. Evaluated parameters included the ICD lead motion amplitudes; intrafraction amplitude variability; correlation error between the ICD lead and external markers; and margin expansion in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions to cover 90% or 95% of all amplitudes. Results In the SI, LL, and AP directions, respectively, the mean motion amplitudes were 5.0 ± 2.6, 3.4. ± 1.9, and 3.1 ± 1.6 mm. The mean intrafraction amplitude variability was 2.6 ± 0.9, 1.9 ± 1.3, and 1.6 ± 0.8 mm in the SI, LL, and AP directions, respectively. The margins required to cover 95% of ICD lead motion amplitudes were 9.5, 6.7, and 5.5 mm in the SI, LL, and AP directions, respectively. The mean correlation error was 2.2 ± 0.9 mm. Conclusions Data from online tracking indicated motion irregularities and correlation errors, necessitating an increased CTV-PTV margin of 3 mm. In 35% of cases, the motion variability exceeded 3 mm in one or more directions. We recommend verifying the correlation between CTV and surrogate individually for every patient, especially for targets with posterobasal localization where we observed the highest difference between the lead and CTV motion.
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Affiliation(s)
- Lukas Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | | | - Otakar Jiravsky
- Department of Cardiology, Podlesi Hospital, Trinec, Czech Republic
| | - Jan Hecko
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Penhaker
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Sramko
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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24
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Dutta D, Kataki KJ, George S, Reddy SK, Sashidharan A, Kannan R, Madhavan R, Nair H, Tatineni T, Holla R. Prospective evaluation of fiducial marker placement quality and toxicity in liver CyberKnife stereotactic body radiotherapy. Radiat Oncol J 2020; 38:253-261. [PMID: 33249803 PMCID: PMC7785839 DOI: 10.3857/roj.2020.00472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Evaluate morbidities and “quality” of fiducial marker placement in primary liver tumours (hepatocellular carcinoma [HCC]) for CyberKnife. Materials and Methods Thirty-six HCC with portal vein thrombosis (PVT) were evaluated for “quality” of fiducial placement, placement time, pain score, complications, recovery time and factors influencing placement. Results One hundred eight fiducials were placed in 36 patients. Fiducial placement radiation oncologist score was “good” in 24 (67%), “fair” in 4 (11%), and “poor” in 3(8%) patients. Concordance with radiologist score in “poor”, “fair”, and “good” score was 2/2 (100%), 4/5 (80%), and 24/27 (89%), respectively (p=0.001). Child-Pugh score (p=0.080), performance status (PS) (p=0.014) and accrued during “learning curve” (p=0.013) affected placement score. Mean placement time (p=0.055), recovery time (p=0.025) was longer and higher major complications (p=0.009) with poor PS. Liver segment involved (p=0.484) and the Barcelona Clinic Liver Cancer (BCLC) stage did not influence placement score. “Good” placement score was 30% in first cohort whereas 93% in last cohort (p=0.023). Time for placement was 42.2 and 14.3 minutes, respectively (p=0.069). Post-fiducial pain score 0–1 in 26 patients (72%) and pain score 3–4 was in 2 (6%). Five patients (14%) admitted in “day-care” (2 mild pneumothorax, 3 pain). Mortality in 1 patient (3%) admitted for hemothorax. Conclusion Fiducial placement is safe and in experienced hands, “quality” of placement is “good” in majority. Major complications and admission after fiducial placement are rare. Complications, fiducial placement time, recovery time is more during the “learning curve”. Poor Child-Pugh score, extensive liver involvement, poor PS have higher probability of complications.
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Affiliation(s)
- Debnarayan Dutta
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | | | - Shibu George
- Department of Radiology, Amrita Institute of Medical Science, Kochi, India
| | - Sruthi K Reddy
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | - Ajay Sashidharan
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | - Rajesh Kannan
- Department of Radiology, Amrita Institute of Medical Science, Kochi, India
| | - Ram Madhavan
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | - Haridas Nair
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | - Tushar Tatineni
- Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, India
| | - Raghavendra Holla
- Department of Medical Physics, Amrita Institute of Medical Science, Kochi, India
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25
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Abstract
Stereotactic ablative radiotherapy (SABR) commonly is used for small liver metastases. Modern conformal radiotherapy techniques, including 3-dimensional conformal radiotherapy and intensity-modulated radiation therapy, enable the safe delivery of SABR to small liver volumes. For larger tumors, the safe delivery of SABR can be challenging due to a more limited volume of healthy normal liver parenchyma and the proximity of the tumor to radiosensitive organs, such as the stomach, duodenum, and large intestine. Controlling respiratory motion, the use of image guidance, and increasing the number of radiation fractions sometimes are necessary for the safe delivery of SABR in these situations.
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Affiliation(s)
- Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box #22, New York, NY 10065, USA; Early Drug Development Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box #22, New York, NY 10065, USA
| | - Brian P Neal
- Medical Physics, ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box #22, New York, NY 10065, USA.
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26
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Ono S, Ueda Y, Ohira S, Isono M, Sumida I, Inui S, Morimoto M, Ashida R, Miyazaki M, Ogawa K, Teshima T. Detectability of fiducials' positions for real-time target tracking system equipping with a standard linac for multiple fiducial markers. J Appl Clin Med Phys 2020; 21:153-162. [PMID: 33058408 PMCID: PMC7700931 DOI: 10.1002/acm2.13050] [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: 05/26/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To investigate the detectability of fiducial markers' positions for real-time target tracking system equipping with a standard linac. The hypothesis is that the detectability depends on the type of fiducial marker and the gantry angle of acquired triggered images. METHODS Three types of ball fiducials and four slim fiducials with lengths of 3 and 5 mm were prepared for this study. Triggered images with three similar fiducials were acquired at every 10° during the conformal arc irradiation to detect the target position. Although only one type of arrangement was prepared for the ball fiducials, a three-type arrangement was prepared for the slim fiducials, such as parallel, orthogonal, and oblique with 45° to the gantry-couch direction. To measure the detectability of the real-time target tracking system for each fiducial and arrangement, detected marker positions were compared with expected marker positions at every angle of acquired triggered images. RESULTS For the ball-type fiducial, the maximum difference between the detected marker positions and expected marker positions was 0.3 mm in all directions. For the slim fiducial arranged parallel and oblique with 45°, the maximum difference was 0.4 mm in all directions. When each slim fiducial was arranged orthogonal to the gantry-couch direction, the maximum difference was 1.5 mm for the length of 3 mm, and 3.2 mm for the length of 5 mm. CONCLUSIONS The detectability of fiducial markers' positions for the real-time target tracking system equipping with a standard linac depends on the form and insertion angles of the fiducials.
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Affiliation(s)
- Shunsuke Ono
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masaru Isono
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiro Morimoto
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Reiko Ashida
- Department of Cancer survey and gastrointestinal oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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27
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Dhont J, Verellen D, Mollaert I, Vanreusel V, Vandemeulebroucke J. RealDRR - Rendering of realistic digitally reconstructed radiographs using locally trained image-to-image translation. Radiother Oncol 2020; 153:213-219. [PMID: 33039426 DOI: 10.1016/j.radonc.2020.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Digitally reconstructed radiographs (DRRs) represent valuable patient-specific pre-treatment training data for tumor tracking algorithms. However, using current rendering methods, the similarity of the DRRs to real X-ray images is limited, requires time-consuming measurements and/or are computationally expensive. In this study we present RealDRR, a novel framework for highly realistic and computationally efficient DRR rendering. MATERIALS AND METHODS RealDRR consists of two components applied sequentially to render a DRR. First, a raytracer is applied for forward projection from 3D CT data to a 2D image. Second, a conditional Generative Adverserial Network (cGAN) is applied to translate the 2D forward projection to a realistic 2D DRR. The planning CT and CBCT projections from a CIRS thorax phantom and 6 radiotherapy patients (3 prostate, 3 brain) were split in training and test sets for evaluating the intra-patient, inter-patient and inter-anatomical region generalization performance of the trained framework. Several image similarity metrics, as well as a verification based on template matching, were used between the rendered DRRs and respective CBCT projections in the test sets, and results were compared to those of a current state-of-the-art DRR rendering method. RESULTS When trained on 800 CBCT projection images from two patients and tested on a third unseen patient from either anatomical region, RealDRR outperformed the current state-of-the-art with statistical significance on all metrics (two-sample t-test, p < 0.05). Once trained, the framework is able to render 100 highly realistic DRRs in under two minutes. CONCLUSION A novel framework for realistic and efficient DRR rendering was proposed. As the framework requires a reasonable amount of computational resources, the internal parameters can be tailored to imaging systems and protocols through on-site training on retrospective imaging data.
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Affiliation(s)
- Jennifer Dhont
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, Brussels, Belgium; Imec, Leuven, Belgium; Faculty of Medicine and Pharmaceutical Sciences, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Dirk Verellen
- Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | | | - Jef Vandemeulebroucke
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, Brussels, Belgium; Imec, Leuven, Belgium
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28
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Image-guided Radiotherapy to Manage Respiratory Motion: Lung and Liver. Clin Oncol (R Coll Radiol) 2020; 32:792-804. [PMID: 33036840 DOI: 10.1016/j.clon.2020.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/26/2020] [Accepted: 09/18/2020] [Indexed: 12/25/2022]
Abstract
Organ motion as a result of respiratory and cardiac motion poses significant challenges for the accurate delivery of radiotherapy to both the thorax and the upper abdomen. Modern imaging techniques during radiotherapy simulation and delivery now permit better quantification of organ motion, which in turn reduces tumour and organ at risk position uncertainty. These imaging advances, coupled with respiratory correlated radiotherapy delivery techniques, have led to the development of a range of approaches to manage respiratory motion. This review summarises the key strategies of image-guided respiratory motion management with a focus on lung and liver radiotherapy.
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29
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Stick LB, Vogelius IR, Risum S, Josipovic M. Intrafractional fiducial marker position variations in stereotactic liver radiotherapy during voluntary deep inspiration breath-hold. Br J Radiol 2020; 93:20200859. [PMID: 32915653 DOI: 10.1259/bjr.20200859] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To evaluate intrafractional fiducial marker position variations during stereotactic body radiotherapy (SBRT) in patients treated for liver metastases in visually guided, voluntary deep inspiration breath-hold (DIBH). METHODS 10 patients with implanted fiducial markers were studied. Respiratory coaching with visual guidance was used to ensure comfortable voluntary breath-holds for SBRT imaging and delivery. Three DIBH CTs were acquired for treatment planning. Pre- and post-treatment CBCTs were acquired for each of the three treatment fractions. Per-fraction marker position was evaluated on planar 2D kV images acquired during treatment fractions for 4 of the 10 patients. RESULTS The median difference in marker position was 0.3 cm (range, 0.0-0.9 cm) between the three DIBH CTs and 0.3 cm (range, 0.1 to 1.4 cm) between pre- and post-treatment CBCTs. The maximum intrafractional variation in marker position in craniocaudal (CC) direction on planar kV images was 0.7 to 1.3 cm and up to 1.0 cm during a single DIBH. CONCLUSION Difference in marker position of up to 1.0 cm was observed during a single DIBH despite use of narrow external gating window and visual feedback. Stability examination on pre-treatment DIBH CTs was not sufficient to guarantee per-fraction stability. Evaluation of differences in marker position on pre- and post-treatment CBCT did not always reveal the full magnitude of the intrafractional variation. ADVANCES IN KNOWLEDGE To increase treatment accuracy, it is necessary to apply real-time monitoring of the tumour or a reliable internal surrogate when delivering liver SBRT in voluntary DIBH.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe Risum
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mirjana Josipovic
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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30
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Wang T, Inubushi S, Ikeo N, Mukai T, Okumura K, Akasaka H, Yada R, Yoshida K, Miyawaki D, Ishihara T, Nakaoka A, Sasaki R. Novel artifact-robust and highly visible zinc solid fiducial marker for kilovoltage x-ray image-guided radiation therapy. Med Phys 2020; 47:4703-4710. [PMID: 32696571 DOI: 10.1002/mp.14412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To develop a novel biocompatible solid fiducial marker that prevents radiopaque imaging artifacts and also maintains high imaging contrast for kilovoltage x-ray image-guided radiation therapy. METHODS The fiducial marker was made of pure zinc. An in-house water-equivalent phantom was designed to evaluate artifacts and visibility under various simulated treatment scenarios. Image artifacts were quantitatively assessed in terms of the metal artifact index (MAI) on kilovoltage computed tomography (CT) and cone-beam CT (CBCT) scans. Marker visibility was evaluated on two types of kilovoltage planar x-ray images in terms of the contrast-to-background ratio (CBR). Comparisons with a conventional gold fiducial marker were conducted. RESULTS The use of zinc rather than a gold marker mitigates imaging artifacts. The MAI near the zinc marker decreased by 76, 79, and 77 % in CT, and by 77 (81), 74 (80), and 79 (85) % in CBCT full-fan (half-fan) scans, when using one-, two-, and three-marker phantom settings, respectively. The high-contrast part of the zinc marker exhibited CBRs above 2.00 for 28/32 exposures under four (lung, tissue, low-density bone, and high-density bone) different simulation scenarios, making its visibility comparable to that of the gold marker (30/32 exposures with CBRs > 2.00). CONCLUSIONS We developed a biocompatible, artifact-robust, and highly visible solid zinc fiducial marker. Although further evaluation is needed in clinical settings, our findings suggest its feasibility and benefits for kilovoltage x-ray image-guided radiation therapy.
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Affiliation(s)
- Tianyuan Wang
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Sachiko Inubushi
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Naoko Ikeo
- Department of Mechanical Engineering, Kobe University Graduate School of Engineering Faculty of Engineering, 1-1 Rokkodai-cho, Kobe, Hyogo, 657-8501, Japan
| | - Toshiji Mukai
- Department of Mechanical Engineering, Kobe University Graduate School of Engineering Faculty of Engineering, 1-1 Rokkodai-cho, Kobe, Hyogo, 657-8501, Japan
| | - Keisuke Okumura
- Centre for Radiology and Radiation Oncology, Kobe University Hospital, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroaki Akasaka
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Ryuichi Yada
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Kenji Yoshida
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Daisuke Miyawaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Takeaki Ishihara
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Ai Nakaoka
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuouku, Kobe, Hyogo, 650-0017, Japan
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Lee MT. Editorial to 'Factors affecting target motion in stereotactic body radiotherapy of liver cancer using CyberKnife'. J Med Imaging Radiat Oncol 2020; 64:460-461. [PMID: 32500665 DOI: 10.1111/1754-9485.13046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mark T Lee
- Liverpool Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Schmitt D, Blanck O, Gauer T, Fix MK, Brunner TB, Fleckenstein J, Loutfi-Krauss B, Manser P, Werner R, Wilhelm ML, Baus WW, Moustakis C. Technological quality requirements for stereotactic radiotherapy : Expert review group consensus from the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. Strahlenther Onkol 2020; 196:421-443. [PMID: 32211939 PMCID: PMC7182540 DOI: 10.1007/s00066-020-01583-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 12/25/2022]
Abstract
This review details and discusses the technological quality requirements to ensure the desired quality for stereotactic radiotherapy using photon external beam radiotherapy as defined by the DEGRO Working Group Radiosurgery and Stereotactic Radiotherapy and the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. The covered aspects of this review are 1) imaging for target volume definition, 2) patient positioning and target volume localization, 3) motion management, 4) collimation of the irradiation and beam directions, 5) dose calculation, 6) treatment unit accuracy, and 7) dedicated quality assurance measures. For each part, an expert review for current state-of-the-art techniques and their particular technological quality requirement to reach the necessary accuracy for stereotactic radiotherapy divided into intracranial stereotactic radiosurgery in one single fraction (SRS), intracranial fractionated stereotactic radiotherapy (FSRT), and extracranial stereotactic body radiotherapy (SBRT) is presented. All recommendations and suggestions for all mentioned aspects of stereotactic radiotherapy are formulated and related uncertainties and potential sources of error discussed. Additionally, further research and development needs in terms of insufficient data and unsolved problems for stereotactic radiotherapy are identified, which will serve as a basis for the future assignments of the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. The review was group peer-reviewed, and consensus was obtained through multiple working group meetings.
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Affiliation(s)
- Daniela Schmitt
- Klinik für Radioonkologie und Strahlentherapie, National Center for Radiation Research in Oncology (NCRO), Heidelberger Institut für Radioonkologie (HIRO), Universitätsklinikum Heidelberg, Heidelberg, Germany.
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Tobias Gauer
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michael K Fix
- Abteilung für Medizinische Strahlenphysik und Universitätsklinik für Radio-Onkologie, Inselspital-Universitätsspital Bern, Universität Bern, Bern, Switzerland
| | - Thomas B Brunner
- Universitätsklinik für Strahlentherapie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Jens Fleckenstein
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Britta Loutfi-Krauss
- Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Peter Manser
- Abteilung für Medizinische Strahlenphysik und Universitätsklinik für Radio-Onkologie, Inselspital-Universitätsspital Bern, Universität Bern, Bern, Switzerland
| | - Rene Werner
- Institut für Computational Neuroscience, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maria-Lisa Wilhelm
- Klinik für Strahlentherapie, Universitätsmedizin Rostock, Rostock, Germany
| | - Wolfgang W Baus
- Klinik für Radioonkologie, CyberKnife- und Strahlentherapie, Universitätsklinikum Köln, Cologne, Germany
| | - Christos Moustakis
- Klinik für Strahlentherapie-Radioonkologie, Universitätsklinikum Münster, Münster, Germany
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Boateng F, Ngwa W. Delivery of Nanoparticle-Based Radiosensitizers for Radiotherapy Applications. Int J Mol Sci 2019; 21:ijms21010273. [PMID: 31906108 PMCID: PMC6981554 DOI: 10.3390/ijms21010273] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/21/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
Nanoparticle-based radiosensitization of cancerous cells is evolving as a favorable modality for enhancing radiotherapeutic ratio, and as an effective tool for increasing the outcome of concomitant chemoradiotherapy. Nevertheless, delivery of sufficient concentrations of nanoparticles (NPs) or nanoparticle-based radiosensitizers (NBRs) to the targeted tumor without or with limited systemic side effects on healthy tissues/organs remains a challenge that many investigators continue to explore. With current systemic intravenous delivery of a drug, even targeted nanoparticles with great prospect of reaching targeted distant tumor sites, only a portion of the administered NPs/drug dosage can reach the tumor, despite the enhanced permeability and retention (EPR) effect. The rest of the targeted NPs/drug remain in systemic circulation, resulting in systemic toxicity, which can decrease the general health of patients. However, the dose from ionizing radiation is generally delivered across normal tissues to the tumor cells (especially external beam radiotherapy), which limits dose escalation, making radiotherapy (RT) somewhat unsafe for some diseased sites despite the emerging development in RT equipment and technologies. Since radiation cannot discriminate healthy tissue from diseased tissue, the radiation doses delivered across healthy tissues (even with nanoparticles delivered via systemic administration) are likely to increase injury to normal tissues by accelerating DNA damage, thereby creating free radicals that can result in secondary tumors. As a result, other delivery routes, such as inhalation of nanoparticles (for lung cancers), localized delivery via intratumoral injection, and implants loaded with nanoparticles for local radiosensitization, have been studied. Herein, we review the current NP delivery techniques; precise systemic delivery (injection/infusion and inhalation), and localized delivery (intratumoral injection and local implants) of NBRs/NPs. The current challenges, opportunities, and future prospects for delivery of nanoparticle-based radiosensitizers are also discussed.
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Affiliation(s)
- Francis Boateng
- TIDTAC LLC, Orlando, FL 32828, USA
- Correspondence: ; Tel.: +1-7745264723
| | - Wilfred Ngwa
- TIDTAC LLC, Orlando, FL 32828, USA
- Department of Physics and Applied Physics, University of Massachusetts Lowell Lowell, MA 01854, USA
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Radiation Oncology, Harvard Medical School, Boston, MA 02115, USA
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Jaccard M, Champion A, Dubouloz A, Picardi C, Plojoux J, Soccal P, Miralbell R, Dipasquale G, Caparrotti F. Clinical experience with lung-specific electromagnetic transponders for real-time tumor tracking in lung stereotactic body radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 12:30-37. [PMID: 33458292 PMCID: PMC7807938 DOI: 10.1016/j.phro.2019.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/07/2019] [Accepted: 11/13/2019] [Indexed: 11/20/2022]
Abstract
7 patients were implanted with lung-specific electromagnetic transponders (EMT). We report no complications from implantation and no migration of the EMT. 7 non-small cell lung cancer patients underwent SBRT using EMT real-time tracking. SBRT was delivered in free-breathing (FB) or in deep inspiration breath-hold (DIBH).
Background and purposes Motion management is crucial for optimal stereotactic body radiotherapy (SBRT) of moving targets. We aimed to describe our clinical experience with real-time tracking of lung-specific electromagnetic transponders (EMTs) for SBRT of early stage non-small cell lung cancer in free-breathing (FB) or deep inspiration breath-hold (DIBH). Material and methods Seven patients were implanted with EMTs. Simulation for SBRT was performed in FB and in DIBH. We prescribed 60 Gy in 3, 5 or 8 fractions to the tumor and delivered SBRT with volumetric modulated arcs and a 6 MV flattening filter free photon beam. Patients’ setup at the linac was performed using EMT positions and cone-beam CT (CBCT) verification. Four patients were treated in DIBH because of a dosimetric benefit. We analysed patient alignment and treatment delivery parameters using DIBH or FB and EMT real-time tracking. Results There were no complications from the EMT implantation. Visual inspection of CBCT before and/or after SBRT revealed good alignment of structures and EMTs. The median setup time was 9.8 min (range: 4.6–34.1 min) and the median session time was 14.7 min (range: 7.3–36.5 min). EMT positions in lungs remained stable during overall treatment and allowed real-time tracking both in FB and in DIBH SBRT. The treatment beam was gated when EMT centroid position exceeded tolerance thresholds ensuring correct delivery of radiation to the tumor. Conclusion Using EMTs for real-time tracking of tumor motion during lung SBRT proved to be safe, accurate and easy to integrate clinically for treatments in FB or DIBH.
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Affiliation(s)
- Maud Jaccard
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
- Corresponding author at: Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland.
| | - Ambroise Champion
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
| | - Angèle Dubouloz
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
| | - Cristina Picardi
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
| | - Jérôme Plojoux
- Department of Pneumology, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Paola Soccal
- Department of Pneumology, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
- Radiation Oncology, Teknon Oncologic Institute, Carrer de Vilana 12, 08022 Barcelona, Spain
| | - Giovanna Dipasquale
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
| | - Francesca Caparrotti
- Department of Radiation Oncology, Geneva University Hospital, 53 Av. de la Roseraie, 1205 Geneva, Switzerland
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35
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Teboh RF, Srinivasan S, Ng SP, Aliru ML, Herman JM. Setup Management for Stereotactic Body Radiation Therapy of Patients With Pancreatic Cancer Treated via the Breath-Hold Technique. Pract Radiat Oncol 2019; 10:e280-e289. [PMID: 31669403 DOI: 10.1016/j.prro.2019.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Active Breathing Coordinator (Elekta AB, Crawley, UK) is a motion management strategy for radiation treatment. During setup, aligning the patient to the bony spine alone does not necessarily lead to an accurate alignment to soft tissue targets, and further adjustment is necessary. Determining a safe range of values for such adjustments is an important quality assurance measure and was the purpose of this study, with focus on stereotactic body radiation therapy in patients with pancreatic cancer. METHODS AND MATERIALS The retrospective study included 19 previously treated patients. For each fraction, a free-breathing cone beam computed tomography scan was registered to a reference breath-hold computed tomography for alignment to the spine. Two perpendicular breath-hold kV projection images were then acquired and compared with corresponding reference digitally reconstructed radiographs for additional alignment with a surrogate fiducial marker. By comparing the breath-hold kV projection images from subsequent treatment fractions with those from the first fraction, we derived the 3-dimensional variability of the fiducial position with respect to the reference image. RESULTS We observed intrafraction setup error to be within 2.0 mm. For interfraction, we observed average reproducibility of 1.7 ± 0.8 mm, 2.0 ± 1.4 mm, and 3.2 ± 2.5 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. The average excursion values from free breathing spine to breath-hold fiducial alignment were 1.5 ± 1.4 mm, 2.0 ± 1.9 mm, and 3.0 ± 2.0 mm in the LR, AP and SI directions, respectively. The observed ranges of average excursions among all patients were 0.2 to 5.1 mm, 0.1 to 5. 9 mm, and 0.6 to 7.8 mm in the LR, AP, and SI directions, respectively. CONCLUSIONS This study demonstrates that intrafraction targeting errors can be within 2 mm, and interfraction shifts from free-breathing spine to Active Breathing Coordinator breath-hold target can be as high as 8 mm. Values that deviate significantly would need further investigation to rule out factors such as local progression, bowel gas, or fiducial shift before treatment.
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Affiliation(s)
- Roland Forbang Teboh
- Johns Hopkins University School of Medicine, Baltimore, Maryland; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey.
| | - Senthamizhchelvan Srinivasan
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Memorial Health care system, Chattanooga, Tennessee
| | | | | | - Joseph M Herman
- Johns Hopkins University School of Medicine, Baltimore, Maryland; MD Anderson Cancer Center, Houston, Texas
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36
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Scher N, Bollet M, Bouilhol G, Tannouri R, Khemiri I, Vouillaume A, Sellami N, Von Eyben R, Vannetzel JM, Darmon I, Rotenberg L, Lamallem H, Bauduceau O, Foster D, Toledano A. Safety and efficacy of fiducial marker implantation for robotic stereotactic body radiation therapy with fiducial tracking. Radiat Oncol 2019; 14:167. [PMID: 31519194 PMCID: PMC6743112 DOI: 10.1186/s13014-019-1373-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/02/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose The purpose of this study was to assess the feasibility, efficacy and toxicity of fiducial marker implantation and tracking in CyberKnife® stereotactic radiation therapy (SBRT) applied to extracranial locations. Materials and method This is a retrospective, single-centre, observational study to collect the data of all patients treated by stereotactic radiation therapy with fiducial marker tracking at extracranial locations, conducted between June 2014 and November 2017. Information regarding the implantation procedure, the types of toxicity related to marker implantation and the number of markers implanted/tracked during treatment were collected. Complication rates were evaluated using the CTCAE v4 [Common Terminology Criteria for Adverse Events] scale. The technical success rate was based on the ability to optimally track the tumor throughout all treatment fractions. Results Out of 2505 patients treated by stereotactic radiation therapy, 25% received treatment with fiducial marker tracking. The total number of implantation procedures was 616 and 1543 fiducial markers were implanted. The implantation-related complication rate was 3%, with 16 Grade 1 events and 4 Grade 2 events. The number of treated patients and the number of implanted markers has gradually increased since the technique was first implemented. The median treatment time was 27 min (range 10–76). 1295 fiducials were effectively tracked throughout all treatment fractions, corresponding to a technical success rate of 84%. The difference between the number of fiducials implanted and those tracked during treatment decreased significantly as the site’s experience increased. Conclusion Fiducial marker implantation and tracking is feasible, well-tolerated, and technically effective technique in SBRT for extracranial tumors.
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Affiliation(s)
- Nathaniel Scher
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France.
| | - Marc Bollet
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France.,Rafael Institute, Center for Predictive Medicine, 3 boulevard Bineau, Levallois-Perret, France
| | - Gauthier Bouilhol
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Remi Tannouri
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Imane Khemiri
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Aurelie Vouillaume
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Noura Sellami
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Rie Von Eyben
- Department of Statistical Analysis, Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, California, USA
| | - Jean-Michel Vannetzel
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Ilan Darmon
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Luc Rotenberg
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Hanah Lamallem
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France.,Rafael Institute, Center for Predictive Medicine, 3 boulevard Bineau, Levallois-Perret, France
| | - Olivier Bauduceau
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France.,Rafael Institute, Center for Predictive Medicine, 3 boulevard Bineau, Levallois-Perret, France
| | - Denis Foster
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France
| | - Alain Toledano
- Hartmann Radiotherapy Institute, Levallois-Perret, 4 rue Kleber, Levallois-Perret, France.,Rafael Institute, Center for Predictive Medicine, 3 boulevard Bineau, Levallois-Perret, France
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van de Lindt T, Fast M, van Kranen S, Nowee M, Jansen E, van der Heide U, Sonke J. MRI-guided mid-position liver radiotherapy: Validation of image processing and registration steps. Radiother Oncol 2019; 138:132-140. [DOI: 10.1016/j.radonc.2019.06.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/22/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022]
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38
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Bertholet J, Knopf A, Eiben B, McClelland J, Grimwood A, Harris E, Menten M, Poulsen P, Nguyen DT, Keall P, Oelfke U. Real-time intrafraction motion monitoring in external beam radiotherapy. Phys Med Biol 2019; 64:15TR01. [PMID: 31226704 PMCID: PMC7655120 DOI: 10.1088/1361-6560/ab2ba8] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/10/2019] [Accepted: 06/21/2019] [Indexed: 12/25/2022]
Abstract
Radiotherapy (RT) aims to deliver a spatially conformal dose of radiation to tumours while maximizing the dose sparing to healthy tissues. However, the internal patient anatomy is constantly moving due to respiratory, cardiac, gastrointestinal and urinary activity. The long term goal of the RT community to 'see what we treat, as we treat' and to act on this information instantaneously has resulted in rapid technological innovation. Specialized treatment machines, such as robotic or gimbal-steered linear accelerators (linac) with in-room imaging suites, have been developed specifically for real-time treatment adaptation. Additional equipment, such as stereoscopic kilovoltage (kV) imaging, ultrasound transducers and electromagnetic transponders, has been developed for intrafraction motion monitoring on conventional linacs. Magnetic resonance imaging (MRI) has been integrated with cobalt treatment units and more recently with linacs. In addition to hardware innovation, software development has played a substantial role in the development of motion monitoring methods based on respiratory motion surrogates and planar kV or Megavoltage (MV) imaging that is available on standard equipped linacs. In this paper, we review and compare the different intrafraction motion monitoring methods proposed in the literature and demonstrated in real-time on clinical data as well as their possible future developments. We then discuss general considerations on validation and quality assurance for clinical implementation. Besides photon RT, particle therapy is increasingly used to treat moving targets. However, transferring motion monitoring technologies from linacs to particle beam lines presents substantial challenges. Lessons learned from the implementation of real-time intrafraction monitoring for photon RT will be used as a basis to discuss the implementation of these methods for particle RT.
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Affiliation(s)
- Jenny Bertholet
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS
Foundation Trust, London, United
Kingdom
- Author to whom any correspondence should be
addressed
| | - Antje Knopf
- Department of Radiation Oncology,
University Medical Center
Groningen, University of Groningen, The
Netherlands
| | - Björn Eiben
- Department of Medical Physics and Biomedical
Engineering, Centre for Medical Image Computing, University College London, London,
United Kingdom
| | - Jamie McClelland
- Department of Medical Physics and Biomedical
Engineering, Centre for Medical Image Computing, University College London, London,
United Kingdom
| | - Alexander Grimwood
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS
Foundation Trust, London, United
Kingdom
| | - Emma Harris
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS
Foundation Trust, London, United
Kingdom
| | - Martin Menten
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS
Foundation Trust, London, United
Kingdom
| | - Per Poulsen
- Department of Oncology, Aarhus University Hospital, Aarhus,
Denmark
| | - Doan Trang Nguyen
- ACRF Image X Institute, University of Sydney, Sydney,
Australia
- School of Biomedical Engineering,
University of Technology
Sydney, Sydney, Australia
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, Sydney,
Australia
| | - Uwe Oelfke
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS
Foundation Trust, London, United
Kingdom
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39
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Nakayama M, Uehara K, Nishimura H, Tamura S, Munetomo Y, Tsudou S, Mayahara H, Mukumoto N, Geso M, Sasaki R. Retrospective assessment of a single fiducial marker tracking regimen with robotic stereotactic body radiation therapy for liver tumours. Rep Pract Oncol Radiother 2019; 24:383-391. [PMID: 31297039 DOI: 10.1016/j.rpor.2019.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 03/22/2019] [Accepted: 06/01/2019] [Indexed: 12/25/2022] Open
Abstract
Aim To investigate tumour motion tracking uncertainties in the CyberKnife Synchrony system with single fiducial marker in liver tumours. Background In the fiducial-based CyberKnife real-time tumour motion tracking system, multiple fiducial markers are generally used to enable translation and rotation corrections during tracking. However, sometimes a single fiducial marker is employed when rotation corrections are not estimated during treatment. Materials and methods Data were analysed for 32 patients with liver tumours where one fiducial marker was implanted. Four-dimensional computed tomography (CT) scans were performed to determine the internal target volume (ITV). Before the first treatment fraction, the CT scans were repeated and the marker migration was determined. Log files generated by the Synchrony system were obtained after each treatment and the correlation model errors were calculated. Intra-fractional spine rotations were examined on the spine alignment images before and after each treatment. Results The mean (standard deviation) ITV margin was 4.1 (2.3) mm, which correlated weakly with the distance between the fiducial marker and the tumour. The mean migration distance of the marker was 1.5 (0.7) mm. The overall mean correlation model error was 1.03 (0.37) mm in the radial direction. The overall mean spine rotations were 0.27° (0.31), 0.25° (0.22), and 0.23° (0.26) for roll, pitch, and yaw, respectively. The treatment time was moderately associated with the correlation model errors and weakly related to spine rotation in the roll and yaw planes. Conclusions More caution and an additional safety margins are required when tracking a single fiducial marker.
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Key Words
- AP, anterior–posterior
- CTV, clinical target volume
- CyberKnife
- Fiducial marker tracking
- GTV, gross tumour volume
- ITV, internal target volume
- LED, light-emitting diode
- LR, left–right
- Liver tumour
- PTV, planning target volume
- SBRT, stereotactic body radiation therapy
- SD, standard deviation
- SI, superior–inferior
- Synchrony system
- XST, Xsight Spine Tracking
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Affiliation(s)
- Masao Nakayama
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuou-ku, Kobe City, Hyogo 650-0017, Japan.,Discipline of Medical Radiations, School of Biomedical & Health Sciences, RMIT University, Bundoora Campus, Victoria 3083, Australia
| | - Kazuyuki Uehara
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, 8-5-1 Minatojima-nakamachi, Chuou-ku, Kobe City, Hyogo 650-0046, Japan
| | - Hideki Nishimura
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuou-ku, Kobe City, Hyogo 650-0017, Japan
| | - Shuhei Tamura
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, 8-5-1 Minatojima-nakamachi, Chuou-ku, Kobe City, Hyogo 650-0046, Japan
| | - Yoshiki Munetomo
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, 8-5-1 Minatojima-nakamachi, Chuou-ku, Kobe City, Hyogo 650-0046, Japan
| | - Shinji Tsudou
- Department of Radiation Oncology, Hyogo Cancer Center, 13-70 Kitaojicho, Akashi City, Hyogo 637-8558, Japan
| | - Hiroshi Mayahara
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, 8-5-1 Minatojima-nakamachi, Chuou-ku, Kobe City, Hyogo 650-0046, Japan
| | - Naritoshi Mukumoto
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuou-ku, Kobe City, Hyogo 650-0017, Japan
| | - Moshi Geso
- Discipline of Medical Radiations, School of Biomedical & Health Sciences, RMIT University, Bundoora Campus, Victoria 3083, Australia
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuou-ku, Kobe City, Hyogo 650-0017, Japan
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Liu M, Cygler JE, Vandervoort E. Geometrical tracking accuracy and appropriate PTV margins for robotic radiosurgery of liver lesions by SBRT. Acta Oncol 2019; 58:906-915. [PMID: 30799669 DOI: 10.1080/0284186x.2019.1578896] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To assess the geometrical accuracy and estimate adequate PTV margins for liver treatments using the Synchrony respiratory tracking system. Material and methods: Treatment log files are analyzed for 72 liver patients to assess tracking accuracy. The tracking error is calculated as the quadratic sum of the correlation, the predictor and the beam positioning errors. Treatment target rotations and rigid body errors reported by the system are also evaluated. The impact of uncorrected rotations is assessed by rotating the planned dose distribution and reassessing target coverage. Total PTV margins are estimated by summing in quadrature tracking errors and rigid body errors. Relationships are explored between tracking errors, model linearity and motion amplitudes of internal and external markers. Results: Margins of 3, 2, 2 mm in SUP-INF, LT-RT and ANT-POST directions, respectively, are sufficient to account for tracking and beam positioning errors for 95% of patients. If rigid body error is also considered, margins increase to 4 mm isotropic. Rotations could not be corrected for 92% of patients due to imperfect fiducial implantation and limitations in the magnitude of corrections that the system can apply. Uncorrected rotations would lead to average estimated dose reductions of 2.7% ± 5.8% of the prescribed dose for D99 of GTVs (5 mm PTV expansion) in which the target was well covered in the original plan (28 of 31 GTVs). 80% of tracking models exhibit near linear correlation between internal and external marker motions with small tracking errors (<2.2 mm). Conclusions: Isotropic PTV margins considering tracking errors and target rigid body errors could be used for liver SBRT treatments if rotational corrections can be calculated accurately so that systematic rotational offsets can be avoided. The linearity of the internal and external breathing motions might be useful for other types of treatment modalities for liver cancer.
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Affiliation(s)
- Ming Liu
- Department of Physics, Carleton University, Ottawa, Canada
| | - Joanna E. Cygler
- Department of Physics, Carleton University, Ottawa, Canada
- Department of Medical Physics, The Ottawa Hospital Cancer Centre, Ottawa, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Eric Vandervoort
- Department of Physics, Carleton University, Ottawa, Canada
- Department of Medical Physics, The Ottawa Hospital Cancer Centre, Ottawa, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
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CyberKnife MLC-based treatment planning for abdominal and pelvic SBRT: Analysis of multiple dosimetric parameters, overall scoring index and clinical scoring. Phys Med 2018; 56:25-33. [DOI: 10.1016/j.ejmp.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 12/31/2022] Open
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Woolcot T, Kousi E, Wells E, Aitken K, Taylor H, Schmidt MA. An evaluation of systematic errors on marker-based registration of computed tomography and magnetic resonance images of the liver. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 7:27-31. [PMID: 33458402 PMCID: PMC7807725 DOI: 10.1016/j.phro.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 07/20/2018] [Accepted: 08/17/2018] [Indexed: 11/22/2022]
Abstract
We demonstrated a general method to evaluate systematic errors related to Magnetic Resonance (MR) imaging sequences in marker-based co-registration of MR and Computed Tomography (CT) images, and investigated the effect of MR image quality in the co-registration process using clinical MR and CT protocols for stereotactic ablative body radiotherapy (SABR) planning of the liver. Small systematic errors (under 1.6 mm) were detected, unlikely to be a clinical risk to liver SABR. The least favourable marker configuration was found to be a co-planar arrangement parallel to the transaxial image plane.
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Affiliation(s)
- Thomas Woolcot
- Brighton and Sussex University Hospitals NHS Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - Evanthia Kousi
- CR-UK and EPSRC Cancer Imaging Centre, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Downs Rd, Sutton, Surrey SM2 5PT, UK
- Corresponding author at: The Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, Surrey SM2 5PT, UK.
| | - Emma Wells
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Katharine Aitken
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Helen Taylor
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Maria A. Schmidt
- CR-UK and EPSRC Cancer Imaging Centre, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Downs Rd, Sutton, Surrey SM2 5PT, UK
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A Prospective Cohort Study of Gated Stereotactic Liver Radiation Therapy Using Continuous Internal Electromagnetic Motion Monitoring. Int J Radiat Oncol Biol Phys 2018; 101:366-375. [DOI: 10.1016/j.ijrobp.2018.02.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/12/2023]
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Mast M, Kouwenhoven E, Roos J, van Geen S, van Egmond J, van Santvoort J, de Boer L, Florijn M, Kalidien Y, Nobel N, Rovers L, van der Togt W, de Vet S, van der Voort van Zyp N, Wenmakers F, van Wingerden J, Ceha H. Two years' experience with inspiration breath-hold in liver SBRT. Tech Innov Patient Support Radiat Oncol 2018; 7:1-5. [PMID: 32095574 PMCID: PMC7033777 DOI: 10.1016/j.tipsro.2018.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/24/2018] [Accepted: 04/26/2018] [Indexed: 12/22/2022] Open
Abstract
The workflow of inspiration breath-hold SBRT for liver metastases is described. Inspiration breath-hold in liver SBRT is feasible for 95% of the patients. An individual margin recipe for inspiration breath-hold liver SBRT is explained. Margin reduction of 10 mm using inspiration breath-hold compared to free breathing.
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Affiliation(s)
- M Mast
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - E Kouwenhoven
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - J Roos
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - S van Geen
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - J van Egmond
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - J van Santvoort
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - L de Boer
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - M Florijn
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - Y Kalidien
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - N Nobel
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - L Rovers
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - W van der Togt
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - S de Vet
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - N van der Voort van Zyp
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - F Wenmakers
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - J van Wingerden
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
| | - H Ceha
- Radiation Therapy Department, Haaglanden Medical Center, Burg Banninglaan 1, 2262 BA Leidschendam, The Netherlands
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van de Lindt T, Sonke JJ, Nowee M, Jansen E, van Pelt V, van der Heide U, Fast M. A Self-Sorting Coronal 4D-MRI Method for Daily Image Guidance of Liver Lesions on an MR-LINAC. Int J Radiat Oncol Biol Phys 2018; 102:875-884. [PMID: 30054104 DOI: 10.1016/j.ijrobp.2018.05.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/04/2018] [Accepted: 05/10/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Novel hybrid MR-LINAC devices provide MRI's superior soft-tissue contrast in the treatment room and thus have the potential to increase accuracy of liver stereotactic body radiation therapy (SBRT). Requirements for daily position verification using 4-dimensional MRI include tumor visibility and short acquisition-reconstruction time (preferably <5 min). The proposed method provides fast acquisition-reconstruction time and the flexibility to vary T1- and T2-weighting, using standard imaging sequences for straightforward implementation on an MR-LINAC. METHODS AND MATERIALS Images were acquired using a coronal 2-dimensional, multislice, single-shot turbo spin-echo (TSE) and turbo field-echo (TFE) sequence, which were repeated 30 times. An image-based self-sorting signal (ImS) was extracted from the data, and rigid registration of the diaphragm per slice position was performed and corrected for amplitude variation in the anteroposterior direction. Data were sorted into 10 bins according to amplitude and phase. ImS was validated in 4 healthy volunteers against a navigator signal. Positional variations within bins, missing data, and smoothness of the liver dome were compared between amplitude and phase binning in 10 volunteers. Tumor contrast and registration were investigated in 3 patients. RESULTS Each ImS was found to be in excellent agreement with the navigator signal with a correlation coefficient of >0.95 and binning differences of <1 bin. Better liver dome smoothness per bin in case of amplitude binning compared with that in phase binning (2.0-2.6 mm vs 2.4-3.7 mm, respectively) is a tradeoff for more missing data (3.5%-17.5% vs 3.5%-4.7%, respectively). Liver lesions were visible in almost all coronal TSE and TFE images, but the lesion boundary was better defined in the TSE images. Rigid registrations could be performed on the tumor area. CONCLUSIONS An efficient self-sorted 4-dimensional MRI method was developed and validated using standard sequences and fast reconstruction on a LINAC-integrated MRI scanner providing good tumor visibility for daily image-guided liver stereotactic body radiation therapy.
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Affiliation(s)
- Tessa van de Lindt
- 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.
| | - Marlies Nowee
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Edwin Jansen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Vivian van Pelt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin Fast
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Kurosu K, Sumida I, Suzuki O, Shiomi H, Ota S, Otani K, Tamari K, Seo Y, Ogawa K. Dosimetric and clinical effects of interfraction and intrafraction correlation errors during marker-based real-time tumor tracking for liver SBRT. JOURNAL OF RADIATION RESEARCH 2018; 59:164-172. [PMID: 29253275 PMCID: PMC5951116 DOI: 10.1093/jrr/rrx067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/13/2017] [Indexed: 06/07/2023]
Abstract
Correlation model error (CME) between the internal target and the external surrogate, and marker-tumor correlation error (MTCE) between the tumor and the implanted marker occur during marker-based real-time tumor tracking. The effects of these intrafraction and interfraction errors on the dose coverage in the clinical target volume (CTV) and on tumor control probability (TCP) for hepatocellular carcinoma (HCC) were evaluated in this study. Eight HCC patients treated with non-isocentric dose delivery by a robotic radiosurgery system were enrolled. The CMEs were extracted from the treatment log file, and the MTCEs were calculated from the preceding study. The CMEs and MTCEs were randomly added to each beam's robot position, and the changes in the TCP and the 2%, 95% and 99% dose coverage values for the CTV (D2, D95 and D99) were simulated. The data were statistically analyzed as a function of the CTV to planning target volume (PTV) margin, the dose fraction and the marker-tumor distance. Significant differences were observed in the majority of the CTV D2, D95 and D99 values and the TCP values. However, a linear regression revealed that ∆CTV D2, D95 and D99 have a weak correlation with ∆TCP. A dose-difference metric would be unable to detect a critical error for tumor control if the coverage changes for the CTV and ∆TCP were weakly correlated. Because the simulated TCP-based parameter determination was based on the dose simulation, including predicted interfraction and intrafraction errors, we concluded that a 95th percentile TCP-based parameter determination would be a robust strategy for ensuring tumor control while reducing doses to normal structures.
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Affiliation(s)
- Keita Kurosu
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Radiology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroya Shiomi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Seiichi Ota
- Department of Radiology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keisuke Otani
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keisuke Tamari
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Nakayama M, Nishimura H, Mayahara H, Nakamura M, Uehara K, Tsudou S, Harada A, Akasaka H, Sasaki R. Clinical log data analysis for assessing the accuracy of the CyberKnife fiducial-free lung tumor tracking system. Pract Radiat Oncol 2018; 8:e63-e70. [DOI: 10.1016/j.prro.2017.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/11/2017] [Accepted: 10/27/2017] [Indexed: 11/30/2022]
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Liang Z, Liu H, Xue J, Hu B, Zhu B, Li Q, Zhang S, Wu G. Evaluation of the intra- and interfractional tumor motion and variability by fiducial-based real-time tracking in liver stereotactic body radiation therapy. J Appl Clin Med Phys 2018; 19:94-100. [PMID: 29493095 PMCID: PMC5978939 DOI: 10.1002/acm2.12292] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Tumor motion amplitude varies during treatment. The purpose of the study was to evaluate the intra- and interfraction tumor motion and variability in patients with liver cancer treated with fiducial-based real-time tracking stereotactic body radiotherapy (SBRT). METHODS Fourteen liver patients were treated with SBRT using a CyberKnife. Two to four fiducial markers implanted near the tumor were used for real-time monitoring using the Synchrony system. The tumor motion information during treatment was extracted from the log files recorded by the Synchrony system. Logfile-based amplitudes in the superior-posterior (SI), left-right (LR) and anterior-posterior (AP) directions were compared to the 4DCT-based amplitudes. The intra- and interfraction amplitude variations and the incidence of baseline shifts were analyzed for 66 fractions administered to 14 patients. RESULTS The median (range) logfile-based liver motion amplitudes for all patients were 11.9 (5.1-17.3) mm, 1.3 (0.4-4) mm and 3.8 (0.9-7.7) mm in the SI, LR and AP directions, respectively. Compared with the logfile-based amplitude, the 4DCT-based amplitude was underestimated (P < 0.05). The median (range) intra- and interfraction liver motion amplitude variations were 4.3 (1.6-6.0) mm (SI), 0.5 (0.2-2.2) mm(LR) and 1.5 (0.3-3.3) mm (AP) and 1.7 (0.5-4.6) mm (SI), 0.3 (0.1-3.0) mm (LR) and 0.7 (0.3-2.7) mm (AP), respectively. Baseline shifts exceeding 2 mm, 3 mm and 5 mm were observed in 27.3%, 7.6% and 3% of the measurements, respectively, within 10 min, and in 66.7%, 38.1% and 19%, respectively, within 30 min for the square root of the sum of the squares of the distances in the SI, LR and AP directions (3D). The tumor motion amplitude was found to be correlated with the baseline shift. CONCLUSIONS Most patients showed significant intra- and interfraction liver motion amplitude variations over the entire course of radiation. More caution is needed for patients with large tumor motion amplitudes.
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Affiliation(s)
- Zhiwen Liang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongyuan Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Xue
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Hu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Zhu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qin Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhao YT, Liu ZK, Wu QW, Dai JR, Zhang T, Jia AY, Jin J, Wang SL, Li YX, Wang WH. Observation of different tumor motion magnitude within liver and estimate of internal motion margins in postoperative patients with hepatocellular carcinoma. Cancer Manag Res 2017; 9:839-848. [PMID: 29276406 PMCID: PMC5731437 DOI: 10.2147/cmar.s147185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Aims To assess motion magnitude in different parts of the liver through surgical clips in postoperative patients with hepatocellular carcinoma and to examine the correlation between the clip and diaphragm motion. Methods Four-dimensional computed tomography images from 30 liver cancer patients under thermoplastic mask immobilization were selected for this study. Three to seven surgical clips were placed in the resection cavity of each patient. The liver volume on computed tomography image was divided into the right upper (RU), right middle (RM), right lower (RL), hilar, and left lobes. Agreement between the clip and diaphragm motion was assessed by calculating intraclass correlation coefficient, and Bland–Altman analysis (Diff). Furthermore, population-based and patient-specific margins for internal motion were evaluated. Results The clips located in the RU lobe showed the largest motion, (7.5±1.6) mm, which was significantly more than in the RM lobe (5.7±2.8 mm, p=0.019), RL lobe (4.8±3.3 mm, p=0.017), and hilar lobe (4.7±2.7 mm, p<0.001) in the cranial–caudal direction. The mean intraclass correlation coefficient values between the clip and diaphragm motion were 0.915, 0.735, 0.678, 0.670, and the mean Diff values between them were 0.1±0.8 mm, 2.3±1.4 mm, 3.1±2.0 mm, 2.4±1.5 mm, when clips were located in the RU lobe, RM lobe, RL lobe, and hilar lobe, respectively. The clip and diaphragm motions had high concordance when clips were located in the RU lobe. Internal margin can be reduced from 5 mm in the cranial–caudal direction based on patient population average and to 3 mm based on patient-specific margins. Conclusions The motion magnitude of clips varied significantly depending on their location within the liver. The diaphragm was a more appropriate surrogate for tumor located in the RU lobe than for other lobes.
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Affiliation(s)
- Yu-Ting Zhao
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Kai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiu-Wen Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jian-Rong Dai
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Angela Y Jia
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Hu Wang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
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Takayesu JSK, Tringale KR, Marshall DC, Burkeen J, Valasek MA, Hemming A, Atwood T, Simpson D, Hattangadi-Gluth J. Bullet fragment fiducials in stereotactic body radiotherapy as a bridge to transplant for hepatocellular carcinoma. Acta Oncol 2017; 56:1324-1327. [PMID: 28497999 DOI: 10.1080/0284186x.2017.1324208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jamie S. K. Takayesu
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Kathryn R. Tringale
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Deborah C. Marshall
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey Burkeen
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Mark A. Valasek
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Alan Hemming
- Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Todd Atwood
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Daniel Simpson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Jona Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
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