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Smolders A, Rivetti L, Vatterodt N, Korreman S, Lomax A, Sharma M, Studen A, Weber DC, Jeraj R, Albetini F. DiffuseRT: predicting likely anatomical deformations of patients undergoing radiotherapy. Phys Med Biol 2024; 69:155016. [PMID: 38986481 DOI: 10.1088/1361-6560/ad61b7] [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: 03/19/2024] [Accepted: 07/10/2024] [Indexed: 07/12/2024]
Abstract
Objective. Predicting potential deformations of patients can improve radiotherapy treatment planning. Here, we introduce new deep-learning models that predict likely anatomical changes during radiotherapy for head and neck cancer patients.Approach. Denoising diffusion probabilistic models (DDPMs) were developed to generate fraction-specific anatomical changes based on a reference cone-beam CT (CBCT), the fraction number and the dose distribution delivered. Three distinct DDPMs were developed: (1) theimage modelwas trained to directly generate likely future CBCTs, (2) the deformable vector field (DVF) model was trained to generate DVFs that deform a reference CBCT and (3) thehybrid modelwas trained similarly to the DVF model, but without relying on an external deformable registration algorithm. The models were trained on 9 patients with longitudinal CBCT images (224 CBCTs) and evaluated on 5 patients (152 CBCTs).Results. The generated images mainly exhibited random positioning shifts and small anatomical changes for early fractions. For later fractions, all models predicted weight losses in accordance with the training data. The distributions of volume and position changes of the body, esophagus, and parotids generated with the image and hybrid models were more similar to the ground truth distribution than the DVF model, evident from the lower Wasserstein distance achieved with the image (0.33) and hybrid model (0.30) compared to the DVF model (0.36). Generating several images for the same fraction did not yield the expected variability since the ground truth anatomical changes were only in 76% of the fractions within the 95% bounds predicted with the best model. Using the generated images for robust optimization of simplified proton therapy plans improved the worst-case clinical target volume V95 with 7% compared to optimizing with 3 mm set-up robustness while maintaining a similar integral dose.Significance. The newly developed DDPMs generate distributions similar to the real anatomical changes and have the potential to be used for robust anatomical optimization.
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Affiliation(s)
- A Smolders
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland
- Department of Physics, ETH Zurich, Switzerland
| | - L Rivetti
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - N Vatterodt
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - S Korreman
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - A Lomax
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland
- Department of Physics, ETH Zurich, Switzerland
| | - M Sharma
- Department of Radiation Oncology, University of California, San Francisco, CA, United States of America
| | - A Studen
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
- Jožef Stefan Institute, Ljubljana, Slovenia
| | - D C Weber
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - R Jeraj
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
- Jožef Stefan Institute, Ljubljana, Slovenia
- University of Wisconsin-Madison, Madison, WI, United States of America
| | - F Albetini
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland
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Kong W, Oud M, Habraken SJM, Huiskes M, Astreinidou E, Rasch CRN, Heijmen BJM, Breedveld S. SISS-MCO: large scale sparsity-induced spot selection for fast and fully-automated robust multi-criteria optimisation of proton plans. Phys Med Biol 2024; 69:055035. [PMID: 38224619 DOI: 10.1088/1361-6560/ad1e7a] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/15/2024] [Indexed: 01/17/2024]
Abstract
Objective.Intensity modulated proton therapy (IMPT) is an emerging treatment modality for cancer. However, treatment planning for IMPT is labour-intensive and time-consuming. We have developed a novel approach for multi-criteria optimisation (MCO) of robust IMPT plans (SISS-MCO) that is fully automated and fast, and we compare it for head and neck, cervix, and prostate tumours to a previously published method for automated robust MCO (IPBR-MCO, van de Water 2013).Approach.In both auto-planning approaches, the applied automated MCO of spot weights was performed with wish-list driven prioritised optimisation (Breedveld 2012). In SISS-MCO, spot weight MCO was applied once for every patient after sparsity-induced spot selection (SISS) for pre-selection of the most relevant spots from a large input set of candidate spots. IPBR-MCO had several iterations of spot re-sampling, each followed by MCO of the weights of the current spots.Main results.Compared to the published IPBR-MCO, the novel SISS-MCO resulted in similar or slightly superior plan quality. Optimisation times were reduced by a factor of 6 i.e. from 287 to 47 min. Numbers of spots and energy layers in the final plans were similar.Significance.The novel SISS-MCO automatically generated high-quality robust IMPT plans. Compared to a published algorithm for automated robust IMPT planning, optimisation times were reduced on average by a factor of 6. Moreover, SISS-MCO is a large scale approach; this enables optimisation of more complex wish-lists, and novel research opportunities in proton therapy.
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Affiliation(s)
- W Kong
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - M Oud
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S J M Habraken
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - M Huiskes
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
- HollandPTC, Delft, The Netherlands
| | - B J M Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center , Rotterdam, The Netherlands
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Bohannon D, Janopaul-Naylor J, Rudra S, Yang X, Chang CW, Wang Y, Ma C, Patel SA, McDonald MW, Zhou J. Prediction of plan adaptation in head and neck cancer proton therapy using clinical, radiographic, and dosimetric features. Acta Oncol 2023:1-8. [PMID: 37335043 DOI: 10.1080/0284186x.2023.2224050] [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: 01/23/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Because proton head and neck (HN) treatments are sensitive to anatomical changes, plan adaptation (re-plan) during the treatment course is needed for a significant portion of patients. We aim to predict re-plan at plan review stage for HN proton therapy with a neural network (NN) model trained with patients' dosimetric and clinical features. The model can serve as a valuable tool for planners to assess the probability of needing to revise the current plan. METHODS AND MATERIALS Mean beam dose heterogeneity index (BHI), defined as the ratio of the maximum beam dose to the prescription dose, plan robustness features (clinical target volume (CTV), V100 changes, and V100 > 95% passing rates in 21 robust evaluation scenarios), as well as clinical features (e.g., age, tumor site, and surgery/chemotherapy status) were gathered from 171 patients treated at our proton center in 2020, with a median age of 64 and stages from I-IVc across 13 HN sites. Statistical analyses of dosimetric parameters and clinical features were conducted between re-plan and no-replan groups. A NN was trained and tested using these features. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the prediction model. A sensitivity analysis was done to determine feature importance. RESULTS Mean BHI in the re-plan group was significantly higher than the no-replan group (p < .01). Tumor site (p < .01), chemotherapy status (p < .01), and surgery status (p < .01) were significantly correlated to re-plan. The model had sensitivities/specificities of 75.0%/77.4%, respectively, and an area under the ROC curve of .855. CONCLUSION There are several dosimetric and clinical features that correlate to re-plans, and NNs trained with these features can be used to predict HN re-plans, which can be used to reduce re-plan rate by improving plan quality.
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Affiliation(s)
- D Bohannon
- Department of Nuclear and Radiological Engineering, Georgia institute of Technology, Atlanta, GA, USA
| | - J Janopaul-Naylor
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S Rudra
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C W Chang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Y Wang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C Ma
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S A Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - M W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - J Zhou
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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Qiu Z, Olberg S, den Hertog D, Ajdari A, Bortfeld T, Pursley J. Online adaptive planning methods for intensity-modulated radiotherapy. Phys Med Biol 2023; 68:10.1088/1361-6560/accdb2. [PMID: 37068488 PMCID: PMC10637515 DOI: 10.1088/1361-6560/accdb2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/17/2023] [Indexed: 04/19/2023]
Abstract
Online adaptive radiation therapy aims at adapting a patient's treatment plan to their current anatomy to account for inter-fraction variations before daily treatment delivery. As this process needs to be accomplished while the patient is immobilized on the treatment couch, it requires time-efficient adaptive planning methods to generate a quality daily treatment plan rapidly. The conventional planning methods do not meet the time requirement of online adaptive radiation therapy because they often involve excessive human intervention, significantly prolonging the planning phase. This article reviews the planning strategies employed by current commercial online adaptive radiation therapy systems, research on online adaptive planning, and artificial intelligence's potential application to online adaptive planning.
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Affiliation(s)
- Zihang Qiu
- Department of Business Analytics, University of Amsterdam, The Netherlands
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Sven Olberg
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Dick den Hertog
- Department of Business Analytics, University of Amsterdam, The Netherlands
| | - Ali Ajdari
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
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Uh J, Jordan JA, Pappo AS, Krasin MJ, Hua C. Adaptive Proton Therapy for Pediatric Parameningeal Rhabdomyosarcoma: On-Treatment Anatomic Changes and Timing to Replanning. Clin Oncol (R Coll Radiol) 2023; 35:245-254. [PMID: 36764878 PMCID: PMC10783810 DOI: 10.1016/j.clon.2023.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/16/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE To characterize on-treatment changes in GTV morphology in children with parameningeal rhabdomyosarcoma receiving upfront proton therapy with concurrent chemotherapy and thereby provide guidance on the timing of on-treatment imaging and adaptive replanning. METHODS AND MATERIALS GTV was delineated on 86 simulation and weekly MR images of 15 prospectively enrolled patients (aged 1-21 years). Temporal changes from baseline in volume and surface (95% Hausdorff distance) were analyzed in relation to the need for plan verification and the resultant doses with hypothetical no treatment adaptation. RESULTS The median time was 6 days from the initiation of chemotherapy to CT+MR simulation and 15 days from the simulation to the start of radiotherapy. All but 1 patient showed a continuous decrease in GTV (0.16-1.52%/day) after simulation. At 3 weeks from simulation, 10 of 15 patients exhibited a significant reduction in volume (median, 20%; range, 6-29%). Without replanning, these changes could lead to a reduction in CTV V95 by 7-14% (n = 2) and/or an increase in D0.01 cc/Dmean of adjacent organs at risk by 6-21% of the prescribed target dose (n = 7). Significant dosimetric consequences occurred in cases with (1) a considerable weight gain, (2) shrinkage of the skin surface, or (3) tumor regression in the oral or nasal cavity and sinus that altered air-tissue components in the beam path. The subsequent GTV and dosimetry after 3 weeks from simulation (4 weeks from chemotherapy initiation) demonstrated a relatively stable trend. CONCLUSIONS On-treatment imaging at 3 weeks after simulation is recommended, if the simulation is performed at 1 week after the initiation of chemotherapy, to detect significant anatomic changes that could result in >5% deviation from planned target coverage and/or organ doses in pediatric patients with parameningeal rhabdomyosarcoma receiving early proton therapy.
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Affiliation(s)
- J Uh
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | - J A Jordan
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - A S Pappo
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M J Krasin
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Bobić M, Lalonde A, Nesteruk KP, Lee H, Nenoff L, Gorissen BL, Bertolet A, Busse PM, Chan AW, Winey BA, Sharp GC, Verburg JM, Lomax AJ, Paganetti H. Large anatomical changes in head-and-neck cancers – a dosimetric comparison of online and offline adaptive proton therapy. Clin Transl Radiat Oncol 2023; 40:100625. [PMID: 37090849 PMCID: PMC10120292 DOI: 10.1016/j.ctro.2023.100625] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Purpose This work evaluates an online adaptive (OA) workflow for head-and-neck (H&N) intensity-modulated proton therapy (IMPT) and compares it with full offline replanning (FOR) in patients with large anatomical changes. Methods IMPT treatment plans are created retrospectively for a cohort of eight H&N cancer patients that previously required replanning during the course of treatment due to large anatomical changes. Daily cone-beam CTs (CBCT) are acquired and corrected for scatter, resulting in 253 analyzed fractions. To simulate the FOR workflow, nominal plans are created on the planning-CT and delivered until a repeated-CT is acquired; at this point, a new plan is created on the repeated-CT. To simulate the OA workflow, nominal plans are created on the planning-CT and adapted at each fraction using a simple beamlet weight-tuning technique. Dose distributions are calculated on the CBCTs with Monte Carlo for both delivery methods. The total treatment dose is accumulated on the planning-CT. Results Daily OA improved target coverage compared to FOR despite using smaller target margins. In the high-risk CTV, the median D98 degradation was 1.1 % and 2.1 % for OA and FOR, respectively. In the low-risk CTV, the same metrics yield 1.3 % and 5.2 % for OA and FOR, respectively. Smaller setup margins of OA reduced the dose to all OARs, which was most relevant for the parotid glands. Conclusion Daily OA can maintain prescription doses and constraints over the course of fractionated treatment, even in cases of large anatomical changes, reducing the necessity for manual replanning in H&N IMPT.
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7
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Huiskes M, Astreinidou E, Kong W, Breedveld S, Heijmen B, Rasch C. Dosimetric impact of adaptive proton therapy in head and neck cancer - A review. Clin Transl Radiat Oncol 2023; 39:100598. [PMID: 36860581 PMCID: PMC9969246 DOI: 10.1016/j.ctro.2023.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 02/18/2023] Open
Abstract
Background Intensity Modulated Proton Therapy (IMPT) in head and neck cancer (HNC) is susceptible to anatomical changes and patient set-up inaccuracies during the radiotherapy course, which can cause discrepancies between planned and delivered dose. The discrepancies can be counteracted by adaptive replanning strategies. This article reviews the observed dosimetric impact of adaptive proton therapy (APT) and the timing to perform a plan adaptation in IMPT in HNC. Methods A literature search of articles published in PubMed/MEDLINE, EMBASE and Web of Science from January 2010 to March 2022 was performed. Among a total of 59 records assessed for possible eligibility, ten articles were included in this review. Results Included studies reported on target coverage deterioration in IMPT plans during the RT course, which was recovered with the application of an APT approach. All APT plans showed an average improved target coverage for the high- and low-dose targets as compared to the accumulated dose on the planned plans. Dose improvements up to 2.5 Gy (3.5 %) and up to 4.0 Gy (7.1 %) in the D98 of the high- and low dose targets were observed with APT. Doses to the organs at risk (OARs) remained equal or decreased slightly after APT was applied. In the included studies, APT was largely performed once, which resulted in the largest target coverage improvement, but eventual additional APT improved the target coverage further. There is no data showing what is the most appropriate timing for APT. Conclusion APT during IMPT for HNC patients improves target coverage. The largest improvement in target coverage was found with a single adaptive intervention, and an eventual second or more frequent APT application improved the target coverage further. Doses to the OARs remained equal or decreased slightly after applying APT. The most optimal timing for APT is yet to be determined.
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Affiliation(s)
- Merle Huiskes
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands,Corresponding author at: Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, P.O. Box 9600, Postal zone K1-P, 2300 RC Leiden, the Netherlands.
| | - Eleftheria Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Wens Kong
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Coen Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands,HollandPTC, Delft, the Netherlands
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An online adaptive plan library approach for intensity modulated proton therapy for head and neck cancer. Radiother Oncol 2022; 176:68-75. [PMID: 36150418 DOI: 10.1016/j.radonc.2022.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE In intensity modulated proton therapy (IMPT), the impact of setup errors and anatomical changes is commonly mitigated by robust optimization with population-based setup robustness (SR) settings and offline replanning. In this study we propose and evaluate an alternative approach based on daily plan selection from patient-specific pre-treatment established plan libraries (PLs). Clinical implementation of the PL strategy would be rather straightforward compared to daily online re-planning. MATERIALS AND METHODS For 15 head-and-neck cancer patients, the planning CT was used to generate a PL with 5 plans, robustly optimized for increasing SR: 0, 1, 2, 3, 5 mm, and 3% range robustness. Repeat CTs (rCTs) and realistic setup and range uncertainty distributions were used for simulation of treatment courses for the PL approach, treatments with fixed SR (fSR3) and a trigger-based offline adaptive schedule for 3 mm SR (fSR3OfA). Daily plan selection in the PL approach was based only on recomputed dose to the CTV on the rCT. RESULTS Compared to using fSR3 and fSR3OfA, the risk of xerostomia grade ≥ II & III and dysphagia ≥ grade III were significantly reduced with the PL. For 6/15 patients the risk of xerostomia and/or dysphagia ≥ grade II could be reduced by > 2% by using PL. For the other patients, adherence to target coverage constraints was often improved. fSR3OfA resulted in significantly improved coverage compared to PL for selected patients. CONCLUSION The proposed PL approach resulted in overall reduced NTCPs compared to fSR3 and fSR3OfA at limited cost in target coverage.
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Tattenberg S, Madden TM, Bortfeld T, Parodi K, Verburg J. Range uncertainty reductions in proton therapy may lead to the feasibility of novel beam arrangements which improve organ-at-risk sparing. Med Phys 2022; 49:4693-4704. [PMID: 35362163 DOI: 10.1002/mp.15644] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE In proton therapy, dose distributions are currently often conformed to organs at risk (OARs) using the less sharp dose fall-off at the lateral beam edge to reduce the effects of uncertainties in the in vivo proton range. However, range uncertainty reductions may make greater use of the sharper dose fall-off at the distal beam edge feasible, potentially improving OAR sparing. We quantified the benefits of such novel beam arrangements. METHODS For each of 10 brain or skull base cases, five treatment plans robust to 2 mm setup and 0%-4% range uncertainty were created for the traditional clinical beam arrangement and a novel beam arrangement making greater use of the distal beam edge to conform the dose distribution to the brainstem. Metrics including the brainstem normal tissue complication probability (NTCP) with the endpoint of necrosis were determined for all plans and all setup and range uncertainty scenarios. RESULTS For the traditional beam arrangement, reducing the range uncertainty from the current level of approximately 4% to a potentially achievable level of 1% reduced the brainstem NTCP by up to 0.9 percentage points in the nominal and up to 1.5 percentage points in the worst-case scenario. Switching to the novel beam arrangement at 1% range uncertainty improved these values by a factor of 2, that is, to 1.8 percentage points and 3.2 percentage points, respectively. The novel beam arrangement achieved a lower brainstem NTCP in all cases starting at a range uncertainty of 2%. CONCLUSION The benefits of novel beam arrangements may be of the same magnitude or even exceed the direct benefits of range uncertainty reductions. Indirect effects may therefore contribute markedly to the benefits of reducing proton range uncertainties.
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Affiliation(s)
- Sebastian Tattenberg
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching, Germany
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas M Madden
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Bortfeld
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching, Germany
| | - Joost Verburg
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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10
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Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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Borderías-Villarroel E, Taasti V, Van Elmpt W, Teruel-Rivas S, Geets X, Sterpin E. Evaluation of the clinical value of automatic online dose restoration for adaptive proton therapy of head and neck cancer. Radiother Oncol 2022; 170:190-197. [PMID: 35346754 DOI: 10.1016/j.radonc.2022.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Intensity modulated proton therapy (IMPT) is highly sensitive to anatomical variations which can cause inadequate target coverage during treatment. This study compares not-adapted (NA) robust plans to two adaptive IMPT methods - a fully-offline adaptive (FOA) and a simplified automatic online adaptive strategy (dose restoration (DR)) to determine the benefit of DR, in head and neck cancer (HNC). MATERIAL/METHODS Robustly optimized clinical IMPT doses in planning-CTs (pCTs) were available for a cohort of 10 HNC patients. During robust re-optimization, DR used isodose contours, generated from the clinical dose on pCTs, and patient specific objectives to reproduce the clinical dose in every repeated-CT(rCT). For each rCT(n=50), NA, DR and FOA plans were robustly evaluated. RESULTS An improvement in DVH-metrics and robustness was seen for DR and FOA plans compared to NA plans. For NA plans, 74%(37/50) of rCTs did not fulfill the CTV coverage criteria (D98%>95%Dprescription). DR improved target coverage, target homogeneity and variability on critical risk organs such as the spinal cord. After DR, 52%(26/50) of rCTs met all clinical goals. Because of large anatomical changes and/or inaccurate patient repositioning, 48%(24/50) of rCTs still needed full offline adaptation to ensure an optimal treatment since dose restoration was not able to re-establish the initial plan quality. CONCLUSION Robust optimization together with fully-automatized DR avoided offline adaptation in 52% of the cases. Implementation of dose restoration in clinical routine could ensure treatment plan optimality while saving valuable human and material resources to radiotherapy departments.
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Affiliation(s)
- Elena Borderías-Villarroel
- Molecular Imaging, Radiotherapy and Oncology (MIRO), UCLouvain, Brussels, Belgium. Avenue Hippocrate 54, Bte B1.54.07, 1200 Brussels, (Belgium).
| | - Vicki Taasti
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229 ET Maastricht, (Netherlands).
| | - Wouter Van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229 ET Maastricht, (Netherlands).
| | - S Teruel-Rivas
- Molecular Imaging, Radiotherapy and Oncology (MIRO), UCLouvain, Brussels, Belgium. Avenue Hippocrate 54, Bte B1.54.07, 1200 Brussels, (Belgium)
| | - X Geets
- Molecular Imaging, Radiotherapy and Oncology (MIRO), UCLouvain, Brussels, Belgium. Avenue Hippocrate 54, Bte B1.54.07, 1200 Brussels, (Belgium); Department of Radiation Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium. Avenue Hippocrate 10, 1200 Brussels, (Belgium).
| | - E Sterpin
- Molecular Imaging, Radiotherapy and Oncology (MIRO), UCLouvain, Brussels, Belgium. Avenue Hippocrate 54, Bte B1.54.07, 1200 Brussels, (Belgium); Department of Oncology, Laboratory of Experimental Radiotherapy, KULeuven, Herestraat 49, 3000 Leuven, (Belgium).
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12
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Scandurra D, Meijer T, Free J, van den Hoek J, Kelder L, Oldehinkel E, Steenbakkers R, Both S, Langendijk J. Evaluation of robustly optimised intensity modulated proton therapy for nasopharyngeal carcinoma. Radiother Oncol 2022; 168:221-228. [DOI: 10.1016/j.radonc.2022.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
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13
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Paganetti H, Botas P, Sharp GC, Winey B. Adaptive proton therapy. Phys Med Biol 2021; 66:10.1088/1361-6560/ac344f. [PMID: 34710858 PMCID: PMC8628198 DOI: 10.1088/1361-6560/ac344f] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy treatments are typically planned based on a single image set, assuming that the patient's anatomy and its position relative to the delivery system remains constant during the course of treatment. Similarly, the prescription dose assumes constant biological dose-response over the treatment course. However, variations can and do occur on multiple time scales. For treatment sites with significant intra-fractional motion, geometric changes happen over seconds or minutes, while biological considerations change over days or weeks. At an intermediate timescale, geometric changes occur between daily treatment fractions. Adaptive radiation therapy is applied to consider changes in patient anatomy during the course of fractionated treatment delivery. While traditionally adaptation has been done off-line with replanning based on new CT images, online treatment adaptation based on on-board imaging has gained momentum in recent years due to advanced imaging techniques combined with treatment delivery systems. Adaptation is particularly important in proton therapy where small changes in patient anatomy can lead to significant dose perturbations due to the dose conformality and finite range of proton beams. This review summarizes the current state-of-the-art of on-line adaptive proton therapy and identifies areas requiring further research.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pablo Botas
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Foundation 29 of February, Pozuelo de Alarcón, Madrid, Spain
| | - Gregory C Sharp
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian Winey
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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14
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Ricotti R, Pella A, Mirandola A, Fiore MR, Chalaszczyk A, Paganelli C, Antonioli L, Vai A, Tagaste B, Belotti G, Rossi M, Ciocca M, Orlandi E, Baroni G. Dosimetric effect of variable rectum and sigmoid colon filling during carbon ion radiotherapy to sacral chordoma. Phys Med 2021; 90:123-133. [PMID: 34628271 DOI: 10.1016/j.ejmp.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/13/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Carbon ion radiotherapy (CIRT) is sensitive to anatomical density variations. We examined the dosimetric effect of variable intestinal filling condition during CIRT to ten sacral chordoma patients. METHODS For each patient, eight virtual computed tomography scans (vCTs) were generated by varying the density distribution within the rectum and the sigmoid in the planning computed tomography (pCT) with a density override approach mimicking a heterogeneous combination of gas and feces. Totally full and empty intestinal preparations were modelled. In addition, five different intestinal filling conditions were modelled by a mixed density pattern derived from two combined and weighted Gaussian distributions simulating gas and feces respectively. Finally, a patient-specific mixing proportion was estimated by evaluating the daily amount of gas detected in the cone beam computed tomography (CBCT). Dose distribution was recalculated on each vCT and dose volume histograms (DVHs) were examined. RESULTS No target coverage degradation was observed at different vCTs. Rectum and sigma dose degradation ranged respectively between: [-6.7; 21.6]GyE and [-0.7; 15.4]GyE for D50%; [-377.4; 1197.9] and [-95.2; 1027.5] for AUC; [-1.2; 10.7]GyE and [-2.6; 21.5]GyE for D1%. CONCLUSIONS Variation of intestinal density can greatly influence the penetration depth of charged particle and might compromise dose distribution. In particular cases, with large clinical target volume in very close proximity to rectum and sigmoid colon, it is appropriate to evaluate the amount of gas present in the daily CBCT images even if it is totally included in the reference planning structures.
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Affiliation(s)
- R Ricotti
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy.
| | - A Pella
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - M R Fiore
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Chalaszczyk
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - C Paganelli
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - L Antonioli
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Vai
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - B Tagaste
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - G Belotti
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - M Rossi
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - M Ciocca
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - E Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - G Baroni
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy; Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
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15
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Tattenberg S, Madden TM, Gorissen BL, Bortfeld T, Parodi K, Verburg J. Proton range uncertainty reduction benefits for skull base tumors in terms of normal tissue complication probability (NTCP) and healthy tissue doses. Med Phys 2021; 48:5356-5366. [PMID: 34260085 DOI: 10.1002/mp.15097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/04/2021] [Accepted: 07/07/2021] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Proton therapy allows for more conformal dose distributions and lower organ at risk and healthy tissue doses than conventional photon-based radiotherapy, but uncertainties in the proton range currently prevent proton therapy from making full use of these advantages. Numerous developments therefore aim to reduce such range uncertainties. In this work, we quantify the benefits of reductions in range uncertainty for treatments of skull base tumors. METHODS The study encompassed 10 skull base patients with clival tumors. For every patient, six treatment plans robust to setup errors of 2 mm and range errors from 0% to 5% were created. The determined metrics included the brainstem and optic chiasm normal tissue complication probability (NTCP) with the endpoints of necrosis and blindness, respectively, as well as the healthy tissue volume receiving at least 70% of the prescription dose. RESULTS A range uncertainty reduction from the current level of 4% to a potentially achievable level of 1% reduced the probability of brainstem necrosis by up to 1.3 percentage points in the nominal scenario in which neither setup nor range errors occur and by up to 2.9 percentage points in the worst-case scenario. Such a range uncertainty reduction also reduced the optic chiasm NTCP with the endpoint of blindness by up to 0.9 percentage points in the nominal scenario and by up to 2.2 percentage points in the worst-case scenario. The decrease in the healthy tissue volume receiving at least 70% of the prescription dose ranged from -7.8 to 24.1 cc in the nominal scenario and from -3.4 to 38.4 cc in the worst-case scenario. CONCLUSION The benefits quantified as part of this study serve as a guideline of the OAR and healthy tissue dose benefits that range monitoring techniques may be able to achieve. Benefits were observed between all levels of range uncertainty. Even smaller range uncertainty reductions may therefore be beneficial.
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Affiliation(s)
- Sebastian Tattenberg
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching, Germany
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas M Madden
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bram L Gorissen
- Stanley Center for Psychiatric Research, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Thomas Bortfeld
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching, Germany
| | - Joost Verburg
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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16
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Zhang X. A Review of the Robust Optimization Process and Advances with Monte Carlo in the Proton Therapy Management of Head and Neck Tumors. Int J Part Ther 2021; 8:14-24. [PMID: 34285932 PMCID: PMC8270090 DOI: 10.14338/ijpt-20-00078.1] [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: 10/19/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
Abstract
In intensity-modulated proton therapy, robust optimization processes have been developed to manage uncertainties associated with (1) range, (2) setup, (3) anatomic changes, (4) dose calculation, and (5) biological effects. Here we review our experience using a robust optimization technique that directly incorporates range and setup uncertainties into the optimization process to manage those sources of uncertainty. We also review procedures for implementing adaptive planning to manage the anatomic uncertainties. Finally, we share some early experiences regarding the impact of uncertainties in dose calculation and biological effects, along with techniques to manage and potentially reduce these uncertainties.
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Affiliation(s)
- Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Vidal M, Moignier C, Patriarca A, Sotiropoulos M, Schneider T, De Marzi L. Future technological developments in proton therapy - A predicted technological breakthrough. Cancer Radiother 2021; 25:554-564. [PMID: 34272182 DOI: 10.1016/j.canrad.2021.06.017] [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: 06/07/2021] [Accepted: 06/18/2021] [Indexed: 12/13/2022]
Abstract
In the current spectrum of cancer treatments, despite high costs, a lack of robust evidence based on clinical outcomes or technical and radiobiological uncertainties, particle therapy and in particular proton therapy (PT) is rapidly growing. Despite proton therapy being more than fifty years old (first proposed by Wilson in 1946) and more than 220,000 patients having been treated with in 2020, many technological challenges remain and numerous new technical developments that must be integrated into existing systems. This article presents an overview of on-going technical developments and innovations that we felt were most important today, as well as those that have the potential to significantly shape the future of proton therapy. Indeed, efforts have been done continuously to improve the efficiency of a PT system, in terms of cost, technology and delivery technics, and a number of different developments pursued in the accelerator field will first be presented. Significant developments are also underway in terms of transport and spatial resolution achievable with pencil beam scanning, or conformation of the dose to the target: we will therefore discuss beam focusing and collimation issues which are important parameters for the development of these techniques, as well as proton arc therapy. State of the art and alternative approaches to adaptive PT and the future of adaptive PT will finally be reviewed. Through these overviews, we will finally see how advances in these different areas will allow the potential for robust dose shaping in proton therapy to be maximised, probably foreshadowing a future era of maturity for the PT technique.
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Affiliation(s)
- M Vidal
- Centre Antoine-Lacassagne, Fédération Claude Lalanne, 227, avenue de la Lanterne, 06200 Nice, France
| | - C Moignier
- Centre François Baclesse, Department of Medical Physics, Centre de protonthérapie de Normandie, 14000 Caen, France
| | - A Patriarca
- Institut Curie, PSL Research University, Radiation oncology department, Centre de protonthérapie d'Orsay, Campus universitaire, bâtiment 101, 91898 Orsay, France
| | - M Sotiropoulos
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, 91400 Orsay, France
| | - T Schneider
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, 91400 Orsay, France
| | - L De Marzi
- Institut Curie, PSL Research University, Radiation oncology department, Centre de protonthérapie d'Orsay, Campus universitaire, bâtiment 101, 91898 Orsay, France; Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Campus universitaire, 91898 Orsay, France.
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18
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Lalonde A, Bobić M, Winey B, Verburg J, Sharp GC, Paganetti H. Anatomic changes in head and neck intensity-modulated proton therapy: Comparison between robust optimization and online adaptation. Radiother Oncol 2021; 159:39-47. [PMID: 33741469 PMCID: PMC8205952 DOI: 10.1016/j.radonc.2021.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Setup variations and anatomical changes can severely affect the quality of head and neck intensity-modulated proton therapy (IMPT) treatments. The impact of these changes can be alleviated by increasing the plan's robustness a priori, or by adapting the plan online. This work compares these approaches in the context of head and neck IMPT. MATERIALS/METHODS A representative cohort of 10 head and neck squamous cell carcinoma (HNSCC) patients with daily cone-beam computed tomography (CBCT) was evaluated. For each patient, three IMPT plans were created: 1- a classical robust optimization (cRO) plan optimized on the planning CT, 2- an anatomical robust optimization (aRO) plan additionally including the two first daily CBCTs and 3- a plan optimized without robustness constraints, but online-adapted (OA) daily, using a constrained spot intensity re-optimization technique only. RESULTS The cumulative dose following OA fulfilled the clinical objective of both the high-risk and low-risk clinical target volumes (CTV) coverage in all 10 patients, compared to 8 for aRO and 4 for cRO. aRO did not significantly increase the dose to most organs at risk compared to cRO, although the integral dose was higher. OA significantly reduced the integral dose to healthy tissues compared to both robust methods, while providing equivalent or superior target coverage. CONCLUSION Using a simple spot intensity re-optimization, daily OA can achieve superior target coverage and lower dose to organs at risk than robust optimization methods.
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Affiliation(s)
- Arthur Lalonde
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA.
| | - Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA; ETH Zürich, Zürich, Switzerland
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Joost Verburg
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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19
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Busch K, Dahl B, Petersen SE, Rønde HS, Bentzen L, Pilskog S, Muren LP. Anatomically robust proton therapy using multiple planning computed tomography scans for locally advanced prostate cancer. Acta Oncol 2021; 60:598-604. [PMID: 33646069 DOI: 10.1080/0284186x.2021.1892181] [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: 10/22/2022]
Abstract
BACKGROUND Proton therapy (PT) is sensitive towards anatomical changes that may occur during a treatment course. The aim of this study was to investigate if anatomically robust PT (ARPT) plans incorporating patient-specific target motion improved target coverage while still sparing normal tissues, when applied on locally advanced prostate cancer patients where pelvic irradiation is indicated. MATERIAL AND METHODS A planning computed tomography (CT) scan used for dose calculation and two additional CTs (acquired on different days) were used to make patient-specific targets for the ARPT plans on the eight included patients. The plans were compared to a conventional robust PT plan and a volumetric modulated arc therapy (VMAT) photon plan, which were derived from the planning CT (pCT). Worst-case robust optimisation was used for all proton plans with a setup uncertainty of 5 mm and a range uncertainty of 3.5%. Target coverage (V95% and D95%) and normal tissue doses (V5-75 Gy) were evaluated on 6-8 rCTs per patient. RESULTS The ARPT plans improved the prostate target coverage for the most challenging patient compared to conventional robust PT plans (20% point increase for V95% and 31 Gy increase for D95%). Across the whole cohort the estimated mean value for V95% was 97% for the ARPT plans and 95% for the conventional robust PT plans. The ARPT plans had a slight, statistically insignificant increase in normal tissue doses compared to the conventional robust proton plans. Compared to VMAT, the ARPT plans significantly reduced the normal tissue doses in the low-to-intermediate dose range. CONCLUSIONS While both proton plans reduced the low-to-intermediate normal tissue doses compared to VMAT, ARPT plans improved the target coverage for the most challenging patient without significantly increasing the normal tissue doses compared to conventional robust PT plans.
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Affiliation(s)
- Kia Busch
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Benjamin Dahl
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Stine E. Petersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Heidi S. Rønde
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Bentzen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Pilskog
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Ludvig P. Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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20
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De Ornelas M, Xu Y, Padgett K, Schmidt RM, Butkus M, Diwanji T, Luciani G, Lambiase J, Samuels S, Samuels M, Dogan N. CBCT-Based Adaptive Assessment Workflow for Intensity Modulated Proton Therapy for Head and Neck Cancer. Int J Part Ther 2021; 7:29-41. [PMID: 33829071 PMCID: PMC8019579 DOI: 10.14338/ijpt-d-20-00056.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/23/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Anatomical changes and patient setup uncertainties during intensity modulated proton therapy (IMPT) of head and neck (HN) cancers demand frequent evaluation of delivered dose. This work investigated a cone-beam computed tomography (CBCT) and deformable image registration based therapy workflow to demonstrate the feasibility of proton dose calculation on synthetic computed tomography (sCT) for adaptive IMPT treatment of HN cancer. Materials and Methods Twenty-one patients with HN cancer were enrolled in this study, a retrospective institutional review board protocol. They had previously been treated with volumetric modulated arc therapy and had daily iterative CBCT. For each patient, robust optimization (RO) IMPT plans were generated using ±3 mm patient setup and ±3% proton range uncertainties. The sCTs were created and the weekly delivered dose was recalculated using an adaptive dose accumulation workflow in which the planning computed tomography (CT) was deformably registered to CBCTs and Hounsfield units transferred from the planning CT. Accumulated doses from ±3 mm/±3% RO-IMPT plans were evaluated using clinical dose-volume constraints for targets (clinical target volume, or CTV) and organs at risk. Results Evaluation of weekly recalculated dose on sCTs showed that most of the patient plans maintained target dose coverage. The primary CTV remained covered by the V95 > 95% (95% of the volume receiving more than 95% of the prescription dose) worst-case scenario for 84.5% of the weekly fractions. The oral cavity accumulated mean dose remained lower than the worst-case scenario for all patients. Parotid accumulated mean dose remained within the uncertainty bands for 18 of the 21 patients, and all were kept lower than RO-IMPT worst-case scenario for 88.7% and 84.5% for left and right parotids, respectively. Conclusion This study demonstrated that RO-IMPT plans account for most setup and anatomical uncertainties, except for large weight-loss changes that need to be tracked throughout the treatment course. We showed that sCTs could be a powerful decision tool for adaptation of these cases in order to reduce workload when using repeat CTs.
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Affiliation(s)
- Mariluz De Ornelas
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yihang Xu
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kyle Padgett
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ryder M Schmidt
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael Butkus
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gus Luciani
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jason Lambiase
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stuart Samuels
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael Samuels
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
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Sharma M, Argota Perez R, Holm A, Korreman S, Jensen K, Elstrøm U, Grau C. Air variability in maxillary sinus during radiotherapy for sinonasal carcinoma. Clin Transl Radiat Oncol 2021; 27:36-43. [PMID: 33490653 PMCID: PMC7809099 DOI: 10.1016/j.ctro.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The aim was to characterise patterns and predictability of aeration changes in the ipsilateral maxillary sinus during intensity-modulated radiotherapy (IMRT) for sinonasal cancer (SNC), and in a sample evaluate the dosimetric effects of aeration changes for both photon and proton therapy. MATERIALS AND METHODS The study included patients treated with IMRT for SNC in a single institution in 2009-2017. The volume of air in the ipsilateral maxillary sinus was recorded in 1578 daily cone beam computer tomography (CBCT) from 53 patients. Patterns of changing air volumes were categorised as 'stable', increasing', 'decreasing', or 'erratic'. For the prediction analysis, categorisation was performed based both on the entire treatment course and the first five fractions (F1-5). Photon and proton therapy plans were generated for four patients, the one from each category with the largest aeration variation. Synthetic CT images were generated for each CBCT and all plans were recalculated on the daily synthetic CTs. RESULTS The absolute volume of air varied considerably during the treatment course, ranging from 0 to 25.9 cm3. Changes within a single participant varied in the range of 0-18.7 cm3. In the categorisation of patterns, most patients had increasing aeration of the sinus. Generally, patterns of aeration could not be predicted from F1-5. Patients categorised as increasing in F1-5 had the best prediction, with 78% predicted correctly as increasing for the entire treatment course. The numeric correlation coefficients for target coverage and air volume were low for 3/4 scenarios (photons 0.03-0.23, protons 0.26-0.48). No straightforward correlation between the dosimetric effect and the volume changes could be detected in the sample test of four patients for neither photon nor proton therapy. CONCLUSION The variation of aeration was large and unpredictable. No clear dosimetric consequences of the aeration variation were evident for neither IMRT nor proton therapy for the patients investigated.
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Affiliation(s)
- M.B. Sharma
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R. Argota Perez
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - A.I.S. Holm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - S.S. Korreman
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - K. Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - U.V. Elstrøm
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - C. Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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22
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Paganetti H, Beltran C, Both S, Dong L, Flanz J, Furutani K, Grassberger C, Grosshans DR, Knopf AC, Langendijk JA, Nystrom H, Parodi K, Raaymakers BW, Richter C, Sawakuchi GO, Schippers M, Shaitelman SF, Teo BKK, Unkelbach J, Wohlfahrt P, Lomax T. Roadmap: proton therapy physics and biology. Phys Med Biol 2021; 66. [DOI: 10.1088/1361-6560/abcd16] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
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23
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Bobić M, Lalonde A, Sharp GC, Grassberger C, Verburg JM, Winey BA, Lomax AJ, Paganetti H. Comparison of weekly and daily online adaptation for head and neck intensity-modulated proton therapy. Phys Med Biol 2021; 66. [PMID: 33503592 DOI: 10.1088/1361-6560/abe050] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/27/2021] [Indexed: 12/11/2022]
Abstract
The high conformality of intensity-modulated proton therapy (IMPT) dose distributions causes treatment plans to be sensitive to geometrical changes during the course of a fractionated treatment. This can be addressed using adaptive proton therapy (APT). One important question in APT is the frequency of adaptations performed during a fractionated treatment, which is related to the question whether plan adaptation has to be done online or offline. The purpose of this work is to investigate the impact of weekly and daily online IMPT plan adaptation on the treatment quality for head and neck patients. A cohort of ten head and neck patients with daily acquired cone-beam CT (CBCT) images was evaluated retrospectively. Dose tracking of the IMPT treatment was performed for three scenarios: base plan with no adaptation (BP), weekly online adaptation (OAW), and daily online adaptation (OAD). Both adaptation schemes used an in-house developed online APT workflow, performing Monte Carlo (MC) dose calculations on scatter-corrected CBCTs. IMPT plan adaptation was achieved by only tuning the weights of a subset of beamlets, based on deformable image registration from the planning CT to each CBCT. Although OADmitigated random delivery errors more effectively than OAWon a fraction per fraction basis, both OAWand OADachieved the clinical goals for all ten patients, while BP failed for six cases. In the high-risk CTV, accumulated values of D98%ranged between 97.15% and 99.73% of the prescription dose for OAD, with a median of 98.07%. For OAW, values between 95.02% and 99.26% were obtained, with a median of 97.61% of the prescription dose. Otherwise, the dose to most organs at risk was similar for all three scenarios. Globally, our results suggest that OAWcould be used as an alternative approach to OADfor most patients in order to reduce the clinical workload.
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Affiliation(s)
- Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, UNITED STATES
| | - Arthur Lalonde
- Radiation-Oncology, Massachusetts General Hospital, Boston, Massachusetts, 02114-2696, UNITED STATES
| | - Gregory C Sharp
- Dept of Radiation Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox Building, 302, Boston, MA 02114, USA, Boston, UNITED STATES
| | | | - Joost M Verburg
- Department of Radiation Oncology, Harvard Medical School, Massachussets General Hospital, Francis H Burr Proton Therapy Center, 30 Fruit Street, Boston, 02114, UNITED STATES
| | - Brian A Winey
- Department of Radiation Oncology, Harvard Medical School, FH Burr Proton Therapy Center, 55 Fruit St, Boston, Massachusetts, 02114, UNITED STATES
| | - Antony John Lomax
- Department of Radiation Medicine, Paul Scherrer Institute, CH-5232 Villigen PSI, Villigen, SWITZERLAND
| | - Harald Paganetti
- Northeast Proton Therapy Centre, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA, Boston, Massachusetts, 02114, UNITED STATES
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Zhu M, Kaiser A, Mishra MV, Kwok Y, Remick J, DeCesaris C, Langen KM. Multiple Computed Tomography Robust Optimization to Account for Random Anatomic Density Variations During Intensity Modulated Proton Therapy. Adv Radiat Oncol 2020; 5:1022-1031. [PMID: 33083665 PMCID: PMC7557143 DOI: 10.1016/j.adro.2019.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 11/27/2022] Open
Abstract
Purpose To propose a method of optimizing intensity modulated proton therapy (IMPT) plans robust against dosimetric degradation caused by random anatomic variations during treatment. Methods and Materials Fifteen patients with prostate cancer treated with IMPT to the pelvic targets were nonrandomly selected. On the repeated quality assurance computed tomography (QACTs) for some patients, bowel density changes were observed and caused dose degradation because the treated plans were not robustly optimized (non-RO). To mitigate this effect, we developed a robust planning method based on 3 CT images, including the native planning CT and its 2 copies, with the bowel structures being assigned to air and tissue, respectively. The RO settings included 5 mm setup uncertainty and 3.5% range uncertainty on 3 CTs. This method is called pseudomultiple-CT RO (pMCT-RO). Plans were also generated using RO on the native CT only, with the same setup and range uncertainties. This method is referred to as single-CT RO (SCT-RO). Doses on the QACTs and the nominal planning CT were compared for the 3 planning methods. Results All 3 plan methods provided sufficient clinical target volumes D95% and V95% on the QACTs. For pMCT-RO plans, the normal tissue Dmax on QACTs of all patients was at maximum 109.1%, compared with 144.4% and 116.9% for non-RO and SCT-RO plans, respectively. On the nominal plans, the rectum and bladder doses were similar among all 3 plans; however, the volume of normal tissue (excluding the rectum and bladder) receiving the prescription dose or higher is substantially reduced in either pMCT-RO plans or SCT-RO plans, compared with the non-RO plans. Conclusions We developed a robust optimization method to further mitigate undesired dose heterogeneity caused by random anatomic changes in pelvic IMPT treatment. This method does not require additional patient CT scans. The pMCT-RO planning method has been implemented clinically since 2017 in our center.
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25
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Nenoff L, Matter M, Jarhall AG, Winterhalter C, Gorgisyan J, Josipovic M, Persson GF, Munck af Rosenschold P, Weber DC, Lomax AJ, Albertini F. Daily Adaptive Proton Therapy: Is it Appropriate to Use Analytical Dose Calculations for Plan Adaption? Int J Radiat Oncol Biol Phys 2020; 107:747-755. [DOI: 10.1016/j.ijrobp.2020.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/26/2020] [Accepted: 03/27/2020] [Indexed: 12/25/2022]
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26
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Nenoff L, Ribeiro CO, Matter M, Hafner L, Josipovic M, Langendijk JA, Persson GF, Walser M, Weber DC, Lomax AJ, Knopf AC, Albertini F, Zhang Y. Deformable image registration uncertainty for inter-fractional dose accumulation of lung cancer proton therapy. Radiother Oncol 2020; 147:178-185. [DOI: 10.1016/j.radonc.2020.04.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 12/25/2022]
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27
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Grau C, Durante M, Georg D, Langendijk JA, Weber DC. Particle therapy in Europe. Mol Oncol 2020; 14:1492-1499. [PMID: 32223048 PMCID: PMC7332216 DOI: 10.1002/1878-0261.12677] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/17/2019] [Accepted: 03/22/2020] [Indexed: 12/16/2022] Open
Abstract
Particle therapy using protons or heavier ions is currently the most advanced form of radiotherapy and offers new opportunities for improving cancer care and research. Ions deposit the dose with a sharp maximum – the Bragg peak – and normal tissue receives a much lower dose than what is delivered by X‐ray therapy. Particle therapy has also biological advantages due to the high linear energy transfer of the charged particles around the Bragg peak. The introduction of particle therapy has been slow in Europe, but within the last decade, more than 20 clinical facilities have opened and facilitated access to this frontline therapy. In this review article, the basic concepts of particle therapy are reviewed along with a presentation of the current clinical indications, the European clinical research, and the established networks.
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Affiliation(s)
- Cai Grau
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany.,Institut für Festkörperphysik, Technische Universität Darmstadt, Germany
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna/AKH Wien, Vienna, Austria
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Centrum Groningen, Groningen, The Netherlands
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28
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Albertini F, Matter M, Nenoff L, Zhang Y, Lomax A. Online daily adaptive proton therapy. Br J Radiol 2020; 93:20190594. [PMID: 31647313 PMCID: PMC7066958 DOI: 10.1259/bjr.20190594] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
It is recognized that the use of a single plan calculated on an image acquired some time before the treatment is generally insufficient to accurately represent the daily dose to the target and to the organs at risk. This is particularly true for protons, due to the physical finite range. Although this characteristic enables the generation of steep dose gradients, which is essential for highly conformal radiotherapy, it also tightens the dependency of the delivered dose to the range accuracy. In particular, the use of an outdated patient anatomy is one of the most significant sources of range inaccuracy, thus affecting the quality of the planned dose distribution. A plan should be ideally adapted as soon as anatomical variations occur, ideally online. In this review, we describe in detail the different steps of the adaptive workflow and discuss the challenges and corresponding state-of-the art developments in particular for an online adaptive strategy.
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Affiliation(s)
| | | | | | - Ye Zhang
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
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29
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Cubillos-Mesías M, Troost EGC, Lohaus F, Agolli L, Rehm M, Richter C, Stützer K. Quantification of plan robustness against different uncertainty sources for classical and anatomical robust optimized treatment plans in head and neck cancer proton therapy. Br J Radiol 2020; 93:20190573. [PMID: 31778315 PMCID: PMC7066968 DOI: 10.1259/bjr.20190573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Classical robust optimization (cRO) in intensity-modulated proton therapy (IMPT) considers isocenter position and particle range uncertainties; anatomical robust optimization (aRO) aims to consider additional non-rigid positioning variations. This work compares the influence of different uncertainty sources on the robustness of cRO and aRO IMPT plans for head and neck squamous cell carcinoma (HNSCC). METHODS Two IMPT plans were optimized for 20 HNSCC patients who received weekly control CTs (cCT): cRO, using solely the planning CT, and aRO, including 2 additional cCTs. The robustness of the plans in terms of clinical target volume (CTV) coverage and organ at risk (OAR) sparing was analyzed considering stepwise the influence of (1) non-rigid anatomical variations given by the weekly cCT, (2) with fraction-wise added rigid random setup errors and (3) additional systematic proton range uncertainties. RESULTS cRO plans presented significantly higher nominal CTV coverage but are outperformed by aRO plans when considering non-rigid anatomical variations only, as cRO and aRO plans presented a median target coverage (D98%) decrease for the low-risk/high-risk CTV of 1.8/1.1 percentage points (pp) and -0.2 pp/-0.3 pp, respectively. Setup and range uncertainties had larger influence on cRO CTV coverage, but led to similar OAR dose changes in both plans. Considering all error sources, 10/2 cRO/aRO patients missed the CTV coverage and a limited number exceeded some OAR constraints in both plans. CONCLUSION Non-rigid anatomical variations are mainly responsible for critical target coverage loss of cRO plans, whereas the aRO approach was robust against such variations. Both plans provide similar robustness of OAR parameters. ADVANCES IN KNOWLEDGE The influence of different uncertainty sources was quantified for robust IMPT HNSCC plans.
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Affiliation(s)
- Macarena Cubillos-Mesías
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | | | | | - Linda Agolli
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maximilian Rehm
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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30
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Burigo LN, Oborn BM. MRI-guided proton therapy planning: accounting for an inline MRI fringe field. Phys Med Biol 2019; 64:215015. [PMID: 31509819 DOI: 10.1088/1361-6560/ab436a] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
MRI-guided proton therapy is being pursued for its promise to provide a more conformal, accurate proton therapy. However, the presence of the magnetic field imposes a challenge for the beam delivery as protons are deflected due to the Lorenz force. In this study, the impact of realistic inline MRI fringe field on IMPT plan delivery is investigated for a water phantom, liver tumor and prostate cancer differing in target volume, shape, and field configuration using Monte Carlo simulations. A method to correct for the shift of the beam spot positions in the presence of the inline magnetic field is presented. Results show that when not accounting for the effect of the magnetic field on the pencil beam delivery, the spot positions are substantially shifted and the quality of delivered plans is significantly deteriorated leading to dose inhomogeneities and creation of hot and cold spots. However, by correcting the pencil beam delivery, the dose quality of the IMPT plans is restored to a high degree. Nevertheless, adaptation of beam delivery alone is not robust regarding different treatment sites. By fully accounting during plan optimization for the dose distortions caused by the fringe and imaging fields, highly conformal IMPT plans are achieved. These results demonstrate proton pencil beam scanning and treatment planning can be adapted for precise delivery of state-of-the-art IMPT plans in MR-guided proton therapy in the presence of an inline MRI fringe field.
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Affiliation(s)
- Lucas N Burigo
- German Cancer Research Center (DKFZ), Heidelberg, Germany. National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO) Heidelberg, Germany
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31
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Nenoff L, Matter M, Hedlund Lindmar J, Weber DC, Lomax AJ, Albertini F. Daily adaptive proton therapy - the key to innovative planning approaches for paranasal cancer treatments. Acta Oncol 2019; 58:1423-1428. [PMID: 31364904 DOI: 10.1080/0284186x.2019.1641217] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: For proton therapy of paranasal tumors, field directions avoiding volumes that might change during therapy are typically used. If the plan is optimized on the daily anatomy using daily adapted proton therapy (DAPT) however, field directions crossing the nasal cavities might be feasible. In this study, we investigated the effectiveness of DAPT for enabling narrow-field treatment approaches. Material and methods: For five paranasal tumor patients, representing a wide patient spectrum, anatomically robust 4-field-star and narrow-field plans were calculated and their robustness to anatomical and setup uncertainties was compared with and without DAPT. Based on the nominal planning CTs, per patient up to 125 simulated CTs (simCTs) with different nasal cavity fillings were created and random translations and rotations due to patient setup uncertainties were further simulated. Plans were recalculated or re-optimized on all error scenarios, representing non-adapted and DAPT fractions, respectively. From these, 100 possible treatments (60 GyRBE, 30 fx) were simulated and changes in integral dose, target and organs at risk (OARs) doses evaluated. Results: In comparison to the 4-field-star approach, the use of narrow-fields reduced integral dose between 29% and 56%. If OARs did not overlap with the target, OAR doses were also reduced. Finally, the significantly reduced target coverage in non-adapted treatments (mean V95 reductions of up to 34%) could be almost fully restored with DAPT in all cases (differences <1%). Conclusions: DAPT was found to be not only an effective way to increase plan robustness to anatomical and positional uncertainties, but also opened the possibility to use improved and more conformal field arrangements.
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Affiliation(s)
- Lena Nenoff
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Michael Matter
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Johanna Hedlund Lindmar
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Antony John Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
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32
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Winterhalter C, Zepter S, Shim S, Meier G, Bolsi A, Fredh A, Hrbacek J, Oxley D, Zhang Y, Weber DC, Lomax A, Safai S. Evaluation of the ray-casting analytical algorithm for pencil beam scanning proton therapy. Phys Med Biol 2019; 64:065021. [PMID: 30641496 DOI: 10.1088/1361-6560/aafe58] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
For pencil beam scanned (PBS) proton therapy, analytical dose calculation engines are still typically used for the optimisation process, and often for the final evaluation of the plan. Recently however, the suitability of analytical calculations for planning PBS treatments has been questioned. Conceptually, the two main approaches for these analytical dose calculations are the ray-casting (RC) and the pencil-beam (PB) method. In this study, we compare dose distributions and dosimetric indices, calculated on both the clinical dose calculation grid and as a function of dose grid resolution, to Monte Carlo (MC) calculations. The analysis is done using a comprehensive set of clinical plans which represent a wide choice of treatment sites. When analysing dose difference histograms for relative treatment plans, pencil beam calculations with double grid resolution perform best, with on average 97.7%/91.9% (RC), 97.9%/92.7% (RC, double grid resolution), 97.6%/91.0% (PB) and 98.6%/94.0% (PB, double grid resolution) of voxels agreeing within ±5%/± 3% between the analytical and the MC calculations. Even though these point-to-point dose comparison shows differences between analytical and MC calculations, for all algorithms, clinically relevant dosimetric indices agree within ±4% for the PTV and within ±5% for critical organs. While the clinical agreement depends on the treatment site, there is no substantial difference of indices between the different algorithms. The pencil-beam approach however comes at a higher computational cost than the ray-casting calculation. In conclusion, we would recommend using the ray-casting algorithm for fast dose optimization and subsequently combine it with one MC calculation to scale the absolute dose and assure the quality of the treatment plan.
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Affiliation(s)
- Carla Winterhalter
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland. Department of Physics, ETH Zurich, Zurich, Switzerland
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Frederic-Moreau T, Piram L, Bellini R, Martin F, Miroir J, Saroul N, Pham Dang N, Lapeyre M, Biau J. Postoperative volumetric modulated arc therapy for sinonasal cancer: Improved survival compared with 3D conformal radiation therapy. Head Neck 2018; 41:448-455. [PMID: 30549346 DOI: 10.1002/hed.25410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/11/2018] [Accepted: 09/12/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Prospective evaluation of the results of volumetric modulated arc therapy (VMAT) for sinonasal cancer compared to 3D conformal radiation therapy (3DCRT). MATERIALS AND METHODS We prospectively evaluated 34 patients (pts) treated with postoperative VMAT with simultaneous integrated boost (SIB; RapidArc) from 2011 to 2015. These pts were retrospectively compared with 24 pts treated with 3DCRT from 2003 to 2011. The two sets were not significantly different on sex, mean age, tumor site, stage, histology. Efficacy and toxicity were evaluated. RESULTS Median follow-up was 45 months (range: 6-143 months). Three-year overall survival was 85.2% in VMAT-SIB versus 65.2% in 3DCRT (P = .02). Three-year local control was 81.2% in VMAT-SIB versus 62.5% in 3DCRT (P = .04). There was a reduction of acute (<0.09) and late (0.03) ocular toxicity of grade ≥ 2 for pts with VMAT-SIB. CONCLUSION VMAT significantly improved local control and overall survival in sinonasal cancer with lower rate of toxicity.
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Affiliation(s)
| | - Lucie Piram
- Department of Radiation Therapy, Centre Jean Perrin, Clermont-Ferrand, France
| | - Romain Bellini
- Department of Radiology, Centre Jean Perrin, Clermont-Ferrand, France
| | - Fanny Martin
- Department of Radiation Therapy, Centre Jean Perrin, Clermont-Ferrand, France
| | - Jessica Miroir
- Department of Radiation Therapy, Centre Jean Perrin, Clermont-Ferrand, France
| | - Nicolas Saroul
- Department of Head and Neck Surgery, CHU, Clermont-Ferrand, France
| | | | - Michel Lapeyre
- Department of Radiation Therapy, Centre Jean Perrin, Clermont-Ferrand, France
| | - Julian Biau
- Department of Radiation Therapy, Centre Jean Perrin, Clermont-Ferrand, France.,University Clermont Auvergne, INSERM, U1240 IMoST, Clermont-Ferrand, France
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Langen K, Zhu M. Concepts of PTV and Robustness in Passively Scattered and Pencil Beam Scanning Proton Therapy. Semin Radiat Oncol 2018; 28:248-255. [PMID: 29933884 DOI: 10.1016/j.semradonc.2018.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Concepts of planning target volume and plan robustness in proton therapy are described. Implementation of these concepts into treatment planning is described. Proton plan sensitivity and interfractional and intrafractional anatomical variation are also discussed.
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Affiliation(s)
- Katja Langen
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, MD.
| | - Mingyao Zhu
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, MD
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35
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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