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Li H, Dong L, Bert C, Chang J, Flampouri S, Jee KW, Lin L, Moyers M, Mori S, Rottmann J, Tryggestad E, Vedam S. Report of AAPM Task Group 290: Respiratory motion management for particle therapy. Med Phys 2022; 49:e50-e81. [PMID: 35066871 PMCID: PMC9306777 DOI: 10.1002/mp.15470] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 12/28/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
Dose uncertainty induced by respiratory motion remains a major concern for treating thoracic and abdominal lesions using particle beams. This Task Group report reviews the impact of tumor motion and dosimetric considerations in particle radiotherapy, current motion‐management techniques, and limitations for different particle‐beam delivery modes (i.e., passive scattering, uniform scanning, and pencil‐beam scanning). Furthermore, the report provides guidance and risk analysis for quality assurance of the motion‐management procedures to ensure consistency and accuracy, and discusses future development and emerging motion‐management strategies. This report supplements previously published AAPM report TG76, and considers aspects of motion management that are crucial to the accurate and safe delivery of particle‐beam therapy. To that end, this report produces general recommendations for commissioning and facility‐specific dosimetric characterization, motion assessment, treatment planning, active and passive motion‐management techniques, image guidance and related decision‐making, monitoring throughout therapy, and recommendations for vendors. Key among these recommendations are that: (1) facilities should perform thorough planning studies (using retrospective data) and develop standard operating procedures that address all aspects of therapy for any treatment site involving respiratory motion; (2) a risk‐based methodology should be adopted for quality management and ongoing process improvement.
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Affiliation(s)
- Heng Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christoph Bert
- Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Joe Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Kyung-Wook Jee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Michael Moyers
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Shinichiro Mori
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan
| | - Joerg Rottmann
- Center for Proton Therapy, Proton Therapy Singapore, Proton Therapy Pte Ltd, Singapore
| | - Erik Tryggestad
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sastry Vedam
- Department of Radiation Oncology, University of Maryland, Baltimore, USA
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2
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Lis M, Newhauser W, Donetti M, Wolf M, Steinsberger T, Paz A, Graeff C. Preliminary tests of dosimetric quality and projected therapeutic outcomes of multi-phase 4D radiotherapy with proton and carbon ion beams. Phys Med Biol 2021; 66. [PMID: 34740202 DOI: 10.1088/1361-6560/ac36e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/05/2021] [Indexed: 12/25/2022]
Abstract
Objective. The purpose of this study was to perform preliminary pre-clinical tests to compare the dosimetric quality of two approaches to treating moving tumors with ion beams: synchronously delivering the beam with the motion of a moving planning target volume (PTV) using the recently developed multi-phase 4D dose delivery (MP4D) approach, and asynchronously delivering the ion beam to a motion-encompassing internal tumor volume (ITV) combined with rescanning.Approach. We created 4D optimized treatment plans with proton and carbon ion beams for two patients who had previously received treatment for non-small cell lung cancer. For each patient, we created several treatment plans, using approaches with and without motion mitigation: MP4D, ITV with rescanning, static deliveries to a stationary PTV, and deliveries to a moving tumor without motion compensation. Two sets of plans were optimized with margins or robust uncertainty scenarios. Each treatment plan was delivered using a recently-developed motion-synchronized dose delivery system (M-DDS); dose distributions in water were compared to measurements using gamma index analysis to confirm the accuracy of the calculations. Reconstructed dose distributions on the patient CT were analyzed to assess the dosimetric quality of the deliveries (conformity, uniformity, tumor coverage, and extent of hotspots).Main results. Gamma index analysis pass rates confirmed the accuracy of dose calculations. Dose coverage was >95% for all static and MP4D treatments. The best conformity and the lowest lung doses were achieved with MP4D deliveries. Robust optimization led to higher lung doses compared to conventional optimization for ITV deliveries, but not for MP4D deliveries.Significance. We compared dosimetric quality for two approaches to treating moving tumors with ion beams. Our findings suggest that the MP4D approach, using an M-DDS, provides conformal motion mitigation, with full target coverage and lower OAR doses.
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Affiliation(s)
- Michelle Lis
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America.,Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Department of Electrical Engineering and Information Technology, Technical University of Darmstadt, German
| | - Wayne Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America.,Department of Radiation Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, United States of America
| | - Marco Donetti
- Research and Development Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Moritz Wolf
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Timo Steinsberger
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technical University of Darmstadt, Germany
| | - Athena Paz
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Christian Graeff
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
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3
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Zhou Y, Li Y, Kubota Y, Sakai M, Ohno T. Robust Angle Selection in Particle Therapy. Front Oncol 2021; 11:715025. [PMID: 34621672 PMCID: PMC8490826 DOI: 10.3389/fonc.2021.715025] [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: 05/26/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
The popularity of particle radiotherapy has grown exponentially over recent years owing to the marked advantage of the depth–dose curve and its unique biological property. However, particle therapy is sensitive to changes in anatomical structure, and the dose distribution may deteriorate. In particle therapy, robust beam angle selection plays a crucial role in mitigating inter- and intrafractional variation, including daily patient setup uncertainties and tumor motion. With the development of a rotating gantry, angle optimization has gained increasing attention. Currently, several studies use the variation in the water equivalent thickness to quantify anatomical changes during treatment. This method seems helpful in determining better beam angles and improving the robustness of planning. Therefore, this review will discuss and summarize the robust beam angles at different tumor sites in particle radiotherapy.
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Affiliation(s)
- Yuan Zhou
- Department of Radiation Oncology, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Yang Li
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Japan.,Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yoshiki Kubota
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Japan
| | - Makoto Sakai
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Graduate School of Medicine, Gunma University, Maebashi, Japan.,Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Japan
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4
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Patel NV, Yu NY, Koroulakis A, Diwanji T, Sawant A, Sio TT, Mohindra P. Proton therapy for thoracic malignancies: a review of oncologic outcomes. Expert Rev Anticancer Ther 2021; 21:177-191. [PMID: 33118427 DOI: 10.1080/14737140.2021.1844567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Radiotherapy is an integral component in the treatment of the majority of thoracic malignancies. By taking advantage of the steep dose fall-off characteristic of protons combined with modern optimization and delivery techniques, proton beam therapy (PBT) has emerged as a potential tool to improve oncologic outcomes while reducing toxicities from treatment.Areas covered: We review the physical properties and treatment techniques that form the basis of PBT as applicable for thoracic malignancies, including a brief discussion on the recent advances that show promise to enhance treatment planning and delivery. The dosimetric advantages and clinical outcomes of PBT are critically reviewed for each of the major thoracic malignancies, including lung cancer, esophageal cancer, mesothelioma, thymic cancer, and primary mediastinal lymphoma.Expert opinion: Despite clear dosimetric benefits with PBT in thoracic radiotherapy, the improvement in clinical outcomes remains to be seen. Nevertheless, with the incorporation of newer techniques, PBT remains a promising modality and ongoing randomized studies will clarify its role to determine which patients with thoracic malignancies receive the most benefit. Re-irradiation, advanced disease requiring high cardio-pulmonary irradiation volume and younger patients will likely derive maximum benefit with modern PBT.
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Affiliation(s)
- Nirav V Patel
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Antony Koroulakis
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Amit Sawant
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
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Jie AW, Marignol L. Pro-con of proton: Dosimetric advantages of intensity-modulation over passive scatter for thoracic malignancies. Tech Innov Patient Support Radiat Oncol 2020; 15:37-46. [PMID: 32954018 PMCID: PMC7486544 DOI: 10.1016/j.tipsro.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/18/2019] [Accepted: 11/11/2019] [Indexed: 12/25/2022] Open
Abstract
Intensity Modulated Proton Therapy (IMPT) results in significant reduction of dose to organ at risk. Improving plan robustness mitigates interplay effects. Blanket use of small spots on a group of patients may severely worsen interplay in selected patients. Hypofractionated regimes have fewer interplay effects in both fractional and overall simulations. Randomised control trials are required before any clinical benefit of IMPT can be confirmed.
The use of passively scattered proton therapy (PSPT) or intensity modulated proton therapy (IMPT) opens the potential for dose escalation or critical structure sparing in thoracic malignancies. While the latter offers greater dose conformality, dose distributions are subjected to greater uncertainties, especially due to interplay effects. Exploration in this area is warranted to determine if there is any dosimetric advantages in using IMPT for thoracic malignancies. This review aims to both compare organs-at-risk sparing and plan robustness between PSPT and IMPT and examine the mitigation strategies for the reduction of interplay effects currently available. Early evidence suggests that IMPT is dosimetrically superior to PSPT in thoracic malignancies. Randomised control trials are required before any clinical benefit of IMPT can be confirmed.
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Key Words
- BSPTV, Beam Specific Planning Target Volume
- CT, Computed Tomography
- DIBH, Deep Inspiration Breath-Hold
- Dosimetry
- EUD, Equivalent Uniform Dose
- HI, Homogeneity Index
- IMPT, Intensity Modulated Proton Therapy
- IMRT, Intensity Modulated Radiation Therapy
- ITV, Internal Target Volume
- Intensity modulated proton therapy (IMPT)
- Interplay
- MFO, Multi Field Optimisation
- MU, Monitor Unit
- NSCLC, Non-Small-Cell Lung cancer
- OAR, Organ-At-Risk
- Organ at risks
- PSPT, Passively Scattered Proton Therapy
- PTV, Planning Target Volume
- Passively scattered proton therapy (PSPT)
- RT, Radiation Therapy
- SFO, Single Field Optimisation
- SFUD, Single Field Uniform Dose
- Thoracic malignancies
- iCTV, Internal Clinical Target Volume
- iGTV/HU, Internal Gross Tumour Volume/Hounsfield Unit
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Affiliation(s)
- Ang Wei Jie
- Singapore Institute of Technology, Singapore
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland
| | - Laure Marignol
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland
- Corresponding author.
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Miyamoto N, Yokokawa K, Takao S, Matsuura T, Tanaka S, Shimizu S, Shirato H, Umegaki K. Dynamic gating window technique for the reduction of dosimetric error in respiratory-gated spot-scanning particle therapy: An initial phantom study using patient tumor trajectory data. J Appl Clin Med Phys 2020; 21:13-21. [PMID: 32068347 PMCID: PMC7170289 DOI: 10.1002/acm2.12832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/06/2020] [Accepted: 01/14/2020] [Indexed: 11/22/2022] Open
Abstract
Spot-scanning particle therapy possesses advantages, such as high conformity to the target and efficient energy utilization compared with those of the passive scattering irradiation technique. However, this irradiation technique is sensitive to target motion. In the current clinical situation, some motion management techniques, such as respiratory-gated irradiation, which uses an external or internal surrogate, have been clinically applied. In surrogate-based gating, the size of the gating window is fixed during the treatment in the current treatment system. In this study, we propose a dynamic gating window technique, which optimizes the size of gating window for each spot by considering a possible dosimetric error. The effectiveness of the dynamic gating window technique was evaluated by simulating irradiation using a moving target in a water phantom. In dosimetric characteristics comparison, the dynamic gating window technique exhibited better performance in all evaluation volumes with different effective depths compared with that of the fixed gate approach. The variation of dosimetric characteristics according to the target depth was small in dynamic gate compared to fixed gate. These results suggest that the dynamic gating window technique can maintain an acceptable dose distribution regardless of the target depth. The overall gating efficiency of the dynamic gate was approximately equal or greater than that of the fixed gating window. In dynamic gate, as the target depth becomes shallower, the gating efficiency will be reduced, although dosimetric characteristics will be maintained regardless of the target depth. The results of this study suggest that the proposed gating technique may potentially improve the dose distribution. However, additional evaluations should be undertaken in the future to determine clinical applicability by assuming the specifications of the treatment system and clinical situation.
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Affiliation(s)
- Naoki Miyamoto
- Division of Quantum Science and EngineeringFaculty of EngineeringHokkaido UniversitySapporoJapan
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
- Department of Medical PhysicsHokkaido University HospitalSapporoJapan
| | - Kouhei Yokokawa
- Division of Quantum Science and EngineeringFaculty of EngineeringHokkaido UniversitySapporoJapan
| | - Seishin Takao
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
- Department of Medical PhysicsHokkaido University HospitalSapporoJapan
| | - Taeko Matsuura
- Division of Quantum Science and EngineeringFaculty of EngineeringHokkaido UniversitySapporoJapan
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
- Department of Medical PhysicsHokkaido University HospitalSapporoJapan
| | - Sodai Tanaka
- Division of Quantum Science and EngineeringFaculty of EngineeringHokkaido UniversitySapporoJapan
- Department of Medical PhysicsHokkaido University HospitalSapporoJapan
| | - Shinichi Shimizu
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
- Department of Medical PhysicsHokkaido University HospitalSapporoJapan
- Department of Radiation Medical Science and EngineeringFaculty of MedicineHokkaido UniversitySapporoJapan
| | - Hiroki Shirato
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
- Department of Radiation MedicineFaculty of MedicineHokkaido UniversitySapporoJapan
| | - Kikuo Umegaki
- Division of Quantum Science and EngineeringFaculty of EngineeringHokkaido UniversitySapporoJapan
- Global Station for Quantum Medical Science and EngineeringGlobal Institution for Collaborative Research and Education (GI‐CoRE)Hokkaido UniversitySapporoJapan
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7
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Dias MF, Collins-Fekete CA, Baroni G, Riboldi M, Seco J. Theoretical tumor edge detection technique using multiple Bragg peak decomposition in carbon ion therapy. Biomed Phys Eng Express 2019. [DOI: 10.1088/2057-1976/ab18e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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8
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Vyfhuis MA, Onyeuku N, Diwanji T, Mossahebi S, Amin NP, Badiyan SN, Mohindra P, Simone CB. Advances in proton therapy in lung cancer. Ther Adv Respir Dis 2018; 12:1753466618783878. [PMID: 30014783 PMCID: PMC6050808 DOI: 10.1177/1753466618783878] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022] Open
Abstract
Lung cancer remains the leading cause of cancer deaths in the United States (US) and worldwide. Radiation therapy is a mainstay in the treatment of locally advanced non-small cell lung cancer (NSCLC) and serves as an excellent alternative for early stage patients who are medically inoperable or who decline surgery. Proton therapy has been shown to offer a significant dosimetric advantage in NSCLC patients over photon therapy, with a decrease in dose to vital organs at risk (OARs) including the heart, lungs and esophagus. This in turn, can lead to a decrease in acute and late toxicities in a population already predisposed to lung and cardiac injury. Here, we present a review on proton treatment techniques, studies, clinical outcomes and toxicities associated with treating both early stage and locally advanced NSCLC.
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Affiliation(s)
- Melissa A.L. Vyfhuis
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Nasarachi Onyeuku
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Sina Mossahebi
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Neha P. Amin
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Shahed N. Badiyan
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Charles B. Simone
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, 850 West Baltimore Street, Baltimore, MD 21201,
USA
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9
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Consensus Guidelines for Implementing Pencil-Beam Scanning Proton Therapy for Thoracic Malignancies on Behalf of the PTCOG Thoracic and Lymphoma Subcommittee. Int J Radiat Oncol Biol Phys 2017; 99:41-50. [DOI: 10.1016/j.ijrobp.2017.05.014] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/05/2017] [Accepted: 05/09/2017] [Indexed: 12/25/2022]
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10
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Remick JS, Schonewolf C, Gabriel P, Doucette A, Levin WP, Kucharczuk JC, Singhal S, Pechet TT, Rengan R, Simone CB, Berman AT. First Clinical Report of Proton Beam Therapy for Postoperative Radiotherapy for Non–Small-Cell Lung Cancer. Clin Lung Cancer 2017; 18:364-371. [DOI: 10.1016/j.cllc.2016.12.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 12/11/2016] [Accepted: 12/13/2016] [Indexed: 12/25/2022]
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11
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Kang M, Huang S, Solberg TD, Mayer R, Thomas A, Teo BKK, McDonough JE, Simone CB, Lin L. A study of the beam-specific interplay effect in proton pencil beam scanning delivery in lung cancer. Acta Oncol 2017; 56:531-540. [PMID: 28358666 DOI: 10.1080/0284186x.2017.1293287] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND For lung tumors with large motion amplitudes, the use of proton pencil beam scanning (PBS) can produce large dose errors. In this study, we assess under what circumstances PBS can be used to treat lung cancer patients who exhibit large tumor motion, based on the quantification of tumor motion and the dose interplay. MATERIAL AND METHODS PBS plans were optimized on average 4DCT datasets using a beam-specific PTV method for 10 consecutive patients with locally advanced non-small-cell-lung-cancer (NSCLC) treated with proton therapy to 6660/180 cGy. End inhalation (CT0) and end exhalation (CT50) were selected as the two extreme scenarios to acquire the relative stopping power ratio difference (Δrsp) for a respiration cycle. The water equivalent difference (ΔWET) per radiological path was calculated from the surface of patient to the iCTV by integrating the Δrsp of each voxel. The magnitude of motion of voxels within the target follows a quasi-Gaussian distribution. A motion index (MI (>5mm WET)), defined as the percentage of target voxels with an absolute integral ΔWET larger than 5 mm, was adopted as a metric to characterize interplay. To simulate the treatment process, 4D dose was calculated by accumulating the spot dose on the corresponding respiration phase to the reference phase CT50 by deformable image registration based on spot timing and patient breathing phase. RESULTS The study indicated that the magnitude of target underdose in a single fraction plan is proportional to the MI (p < .001), with larger motion equating to greater dose degradation and standard deviations. The target homogeneity, minimum, maximum and mean dose in the 4D dose accumulations of 37 fractions varied as a function of MI. CONCLUSIONS This study demonstrated that MI can predict the level of dose degradation, which potentially serves as a clinical decision tool to assess whether lung cancer patients are potentially suitable to receive PBS treatment.
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Affiliation(s)
- Minglei Kang
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sheng Huang
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy D. Solberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Rulon Mayer
- Department of Radiation Oncology, Walter Reed Military Hospital, Bethesda, MD, USA
| | - Andy Thomas
- Department of Radiation Oncology, Walter Reed Military Hospital, Bethesda, MD, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - James E. McDonough
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Liyong Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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12
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Diwanji TP, Mohindra P, Vyfhuis M, Snider JW, Kalavagunta C, Mossahebi S, Yu J, Feigenberg S, Badiyan SN. Advances in radiotherapy techniques and delivery for non-small cell lung cancer: benefits of intensity-modulated radiation therapy, proton therapy, and stereotactic body radiation therapy. Transl Lung Cancer Res 2017; 6:131-147. [PMID: 28529896 DOI: 10.21037/tlcr.2017.04.04] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The 21st century has seen several paradigm shifts in the treatment of non-small cell lung cancer (NSCLC) in early-stage inoperable disease, definitive locally advanced disease, and the postoperative setting. A key driver in improvement of local disease control has been the significant evolution of radiation therapy techniques in the last three decades, allowing for delivery of definitive radiation doses while limiting exposure of normal tissues. For patients with locally-advanced NSCLC, the advent of volumetric imaging techniques has allowed a shift from 2-dimensional approaches to 3-dimensional conformal radiation therapy (3DCRT). The next generation of 3DCRT, intensity-modulated radiation therapy and volumetric-modulated arc therapy (VMAT), have enabled even more conformal radiation delivery. Clinical evidence has shown that this can improve the quality of life for patients undergoing definitive management of lung cancer. In the early-stage setting, conventional fractionation led to poor outcomes. Evaluation of altered dose fractionation with the previously noted technology advances led to advent of stereotactic body radiation therapy (SBRT). This technique has dramatically improved local control and expanded treatment options for inoperable, early-stage patients. The recent development of proton therapy has opened new avenues for improving conformity and the therapeutic ratio. Evolution of newer proton therapy techniques, such as pencil-beam scanning (PBS), could improve tolerability and possibly allow reexamination of dose escalation. These new progresses, along with significant advances in systemic therapies, have improved survival for lung cancer patients across the spectrum of non-metastatic disease. They have also brought to light new challenges and avenues for further research and improvement.
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Affiliation(s)
- Tejan P Diwanji
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Pranshu Mohindra
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
| | - Melissa Vyfhuis
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - James W Snider
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Chaitanya Kalavagunta
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Jen Yu
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Steven Feigenberg
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
| | - Shahed N Badiyan
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
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13
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Graeff C. Robustness of 4D-optimized scanned carbon ion beam therapy against interfractional changes in lung cancer. Radiother Oncol 2017; 122:387-392. [PMID: 28073579 DOI: 10.1016/j.radonc.2016.12.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/16/2016] [Accepted: 12/02/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Moving targets could be conformally treated with actively scanned carbon ion beams using 4D-optimization. As this heavily exploits 4D-CTs, an important question is whether the conformity also upholds in the context of interfractional changes, i.e. variable positioning, anatomy and breathing patterns. MATERIALS AND METHODS In 4 lung cancer patients, 6 weekly 4D-CTs were available. 4D-CTs and their phases were non-rigidly registered to propagate contours and 4D-doses. On the first 4D-CT, a 4D-optimized plan delivering a uniform dose to each motion phase (total dose 9.4Gy(RBE)) was simulated, as well as an ITV plan for comparison. On the five following 4D-CTs, 4D-dose was forward calculated and evaluated for target coverage and conformity. Variable uniform (3-7mm) and range margins (2mm/%) were investigated. RESULTS For all patients, target coverage (V95>95% accumulated over 5 fractions) could be achieved, but with variable margin size weakly depending on motion amplitude and range changes. The same margins were also necessary for ITV plans, which lead to lower conformity and higher integral doses. CONCLUSION 4D-optimization appears feasible also under interfractional changes and maintains a dosimetric advantage over less conformal ITV irradiations. Further studies are needed to identify patients benefiting most from the technically more complex 4D-optimization.
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Affiliation(s)
- Christian Graeff
- GSI Helmholzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.
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Santiago A, Fritz P, Mühlnickel W, Engenhart-Cabillic R, Wittig A. Changes in the radiological depth correlate with dosimetric deterioration in particle therapy for stage I NSCLC patients under high frequency jet ventilation. Acta Oncol 2015; 54:1631-7. [PMID: 26228661 DOI: 10.3109/0284186x.2015.1067716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Particle dose distributions are highly sensitive to anatomy changes in the beam path, which may lead to substantial dosimetric deviations. Robust planning and dedicated image guidance together with strategies for online decision making to counteract dosimetric deterioration are thus mandatory. We aimed to develop methods to quantify anatomical discrepancies as depicted by repeated computed tomography (CT) imaging and to test whether they can predict deviations in target coverage. MATERIAL AND METHODS Dedicated software tools allowed for voxel-based calculations of changes in the water equivalent path length (WEPL) in beam directions. We prepared proton and carbon ion plans with different coplanar beam angle settings on a series of lung cancer patients, for which planning and localization CT scans under high frequency jet ventilation (HFJV) for tumor fixation were performed. We investigated the reproducibility of target coverage between the optimized and recalculated treatment plans. We then studied how different raster scan and planning settings influence the robustness. Finally, we carried out a systematic analysis of the variations in the WEPL along different coplanar beam angles to find beam directions, which could minimize such variations. RESULTS The Spearman's correlations for the GTV ΔV95 and ΔV98 with the ΔWEPL for the proton plans with a 0° and -45° two-field configuration were 0.701 (p = 0.02) and 0.719 (p = 0.08), respectively. For beam configurations 0° and -90°, or 0° and + 45°, with lower ΔWEPL, the correlations were no significant. The same trends were observed for the carbon ion plans. Increased beam spot overlap reduced dosimetric deterioration in case of large ΔWEPL. CONCLUSION Software tools for fast online analysis of WEPL changes might help supporting clinical decision making of image guidance. Raster scan and treatment planning settings can help to compensate for anatomical deviations.
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Affiliation(s)
- Alina Santiago
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
| | - Peter Fritz
- b St Marien-Krankenhaus , Department of Radiotherapy , Siegen , Germany
| | - Werner Mühlnickel
- b St Marien-Krankenhaus , Department of Radiotherapy , Siegen , Germany
| | - Rita Engenhart-Cabillic
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
| | - Andrea Wittig
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
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15
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Chang JY, Li H, Zhu XR, Liao Z, Zhao L, Liu A, Li Y, Sahoo N, Poenisch F, Gomez DR, Wu R, Gillin M, Zhang X. Clinical implementation of intensity modulated proton therapy for thoracic malignancies. Int J Radiat Oncol Biol Phys 2014; 90:809-18. [PMID: 25260491 DOI: 10.1016/j.ijrobp.2014.07.045] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Intensity modulated proton therapy (IMPT) can improve dose conformality and better spare normal tissue over passive scattering techniques, but range uncertainties complicate its use, particularly for moving targets. We report our early experience with IMPT for thoracic malignancies in terms of motion analysis and management, plan optimization and robustness, and quality assurance. METHODS AND MATERIALS Thirty-four consecutive patients with lung/mediastinal cancers received IMPT to a median 66 Gy(relative biological equivalence [RBE]). All patients were able to undergo definitive radiation therapy. IMPT was used when the treating physician judged that IMPT conferred a dosimetric advantage; all patients had minimal tumor motion (<5 mm) and underwent individualized tumor-motion dose-uncertainty analysis and 4-dimensional (4D) computed tomographic (CT)-based treatment simulation and motion analysis. Plan robustness was optimized by using a worst-case scenario method. All patients had 4D CT repeated simulation during treatment. RESULTS IMPT produced lower mean lung dose (MLD), lung V5 and V20, heart V40, and esophageal V60 than did IMRT (P<.05) and lower MLD, lung V20, and esophageal V60 than did passive scattering proton therapy (PSPT) (P<.05). D5 to the gross tumor volume and clinical target volume was higher with IMPT than with intensity modulated radiation therapy or PSPT (P<.05). All cases were analyzed for beam-angle-specific motion, water-equivalent thickness, and robustness. Beam angles were chosen to minimize the effect of respiratory motion and avoid previously treated regions, and the maximum deviation from the nominal dose-volume histogram values was kept at <5% for the target dose and met the normal tissue constraints under a worst-case scenario. Patient-specific quality assurance measurements showed that a median 99% (range, 95% to 100%) of the pixels met the 3% dose/3 mm distance criteria for the γ index. Adaptive replanning was used for 9 patients (26.5%). CONCLUSIONS IMPT using 4D CT-based planning, motion management, and optimization was implemented successfully and met our quality assurance parameters for treating challenging thoracic cancers.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Heng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lina Zhao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yupeng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; Applied Research, Varian Medical Systems, Palo Alto, California
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Falk Poenisch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Wu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Gillin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Casares-Magaz O, Toftegaard J, Muren LP, Kallehauge JF, Bassler N, Poulsen PR, Petersen JBB. A method for selection of beam angles robust to intra-fractional motion in proton therapy of lung cancer. Acta Oncol 2014; 53:1058-63. [PMID: 24975371 DOI: 10.3109/0284186x.2014.927586] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Proton therapy offers the potential for sparing the normal tissue surrounding the target. However, due to well-defined proton ranges around the Bragg peak, dose deposition is more sensitive to changes in the water equivalent path length (WEPL) than with photons. In this study, we assess WEPL variations caused by breathing-induced motion for all possible beam angles in a series of lung cancer patients. By studying the association between measures for WEPL variation and breathing-induced target dose degradation we aimed to develop and explore a tool to identify beam angles that are robust to patient-specific patterns of intra-fractional motion. MATERIAL AND METHODS Using four-dimensional computed tomography (4DCT) images of three lung cancer patients we evaluated the impact of the WEPL changes on target dose coverage for a series of coplanar single-beam plans. The plans were optimised for the internal target volume (ITV) at the maximum intensity projection (MIP) CT for every 3° gantry interval. The plans were transferred to the ten 4DCT phases and the average reduction in ITV V₉₅ over the ten phases, relative to the original MIP CT calculation, was quantified. The target dose reduction was associated with the mean difference between the WEPL and the phase-averaged WEPL computed for all beam rays across all possible gantry-couch angle combinations. RESULTS The gantry-couch angle maps showed areas of both high and low WEPL variation, with overall quite similar patterns yet with individual differences reflecting differences in tumour position and breathing-induced motion. The coplanar plans showed a strong association between WEPL changes and ITV V₉₅ reduction, with a correlation coefficient ranging between 0.92 and 0.98 for the three patients (p < 0.01). CONCLUSION We have presented a 4DCT-based method to quantify WEPL changes during the breathing cycle. The method identified proton field gantry-couch angle combinations that were either sensitive or robust to WEPL changes. WEPL variations along the beam path were associated with target under-dosage.
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Affiliation(s)
- Oscar Casares-Magaz
- Department of Medical Physics, Aarhus University/Aarhus University Hospital , Aarhus , Denmark
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