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Harris JP, Samson P, Owen D, Siva S, Daly ME, Giuliani M. Adapt or Perish: Adaptive RT for NSCLC. Int J Radiat Oncol Biol Phys 2024; 119:1047-1051. [PMID: 38925759 DOI: 10.1016/j.ijrobp.2024.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Jeremy P Harris
- Department of Radiation Oncology, University of California Irvine, Orange, California.
| | - Pamela Samson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Center, Victoria, Australia
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, California
| | - Meredith Giuliani
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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2
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Chen J, Chen K, OuYang M, Wang G, Bai P, You H. Evaluation of dose delivery based on deformed CT using a commercial software for lung cancer. Sci Rep 2024; 14:14470. [PMID: 38914766 PMCID: PMC11196743 DOI: 10.1038/s41598-024-65381-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024] Open
Abstract
This study employed a commercial software velocity to perform deformable registration and dose calculation on deformed CT images, aiming to assess the accuracy of dose delivery during the radiotherapy for lung cancers. A total of 20 patients with lung cancer were enrolled in this study. Adaptive CT (ACT) was generated by deformed the planning CT (pCT) to the CBCT of initial radiotherapy fraction, followed by contour propagation and dose recalculation. There was not significant difference between volumes of GTV and CTV calculated from the ACT and pCT. However, significant differences in dice similarity coefficient (DSC) and coverage ratio (CR) between GTV and CTV were observed, with lower values for GTV volumes below 15 cc. The mean differences in dose corresponding to 95% of the GTV, GTV-P, CTV, and CTV-P between ACT and pCT were - 0.32%, 4.52%, 2.17%, and 4.71%, respectively. For the dose corresponding to 99%, the discrepancies were - 0.18%, 8.35%, 1.92%, and 24.96%, respectively. These differences in dose primarily appeared at the edges of the target areas. Notably, a significant enhancement of dose corresponding to 1 cc for spinal cord was observed in ACT, compared with pCT. There was no statistical difference in the mean dose of lungs and heart. In general, for lung cancer patients, anatomical motion may result in both CTV and GTV moving outside the original irradiation region. The dose difference within the original target area was small, but the difference in the planning target area was considerable.
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Affiliation(s)
- Jihong Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Kaiqiang Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Min OuYang
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China
| | - Guohua Wang
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China
| | - Penggang Bai
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Hongqiang You
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China.
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3
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Matin HN, Setayeshi S. A computational tumor growth model experience based on molecular dynamics point of view using deep cellular automata. Artif Intell Med 2024; 148:102752. [PMID: 38325930 DOI: 10.1016/j.artmed.2023.102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 11/01/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024]
Abstract
Cancer, as identified by the World Health Organization, stands as the second leading cause of death globally. Its intricate nature makes it challenging to study solely based on biological knowledge, often leading to expensive research endeavors. While tremendous strides have been made in understanding cancer, gaps remain, especially in predicting tumor behavior across various stages. The integration of artificial intelligence in oncology research has accelerated our insights into tumor behavior, right from its genesis to metastasis. Nevertheless, there's a pressing need for a holistic understanding of the interactions between cancer cells, their microenvironment, and their subsequent interplay with the broader body environment. In this landscape, deep learning emerges as a potent tool with its multifaceted applications in diverse scientific challenges. Motivated by this, our study presents a novel approach to modeling cancer tumor growth from a molecular dynamics' perspective, harnessing the capabilities of deep-learning cellular automata. This not only facilitates a microscopic examination of tumor behavior and growth but also delves deeper into its overarching behavioral patterns. Our work primarily focused on evaluating the developed tumor growth model through the proposed network, followed by a rigorous compatibility check with traditional mathematical tumor growth models using R and Matlab software. The outcomes notably aligned with the Gompertz growth model, accentuating the robustness of our approach. Our validated model stands out by offering adaptability to diverse tumor growth datasets, positioning itself as a valuable tool for predictions and further research.
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Affiliation(s)
- Hossein Nikravesh Matin
- Institute for Cognitive Sciences Studies, Tehran, Iran; Medical Radiation Eng. Department, Faculty of Physics and Energy Eng., Amirkabir University of Technology, (Tehran Polytechnics), Tehran, Iran
| | - Saeed Setayeshi
- Institute for Cognitive Sciences Studies, Tehran, Iran; Medical Radiation Eng. Department, Faculty of Physics and Energy Eng., Amirkabir University of Technology, (Tehran Polytechnics), Tehran, Iran.
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Zhou C, Hou L, Tang X, Liu C, Meng Y, Jia H, Yang H, Zhou S. CT-based radiomics nomogram may predict who can benefit from adaptive radiotherapy in patients with local advanced-NSCLC patients. Radiother Oncol 2023; 183:109637. [PMID: 36963440 DOI: 10.1016/j.radonc.2023.109637] [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: 09/21/2022] [Revised: 02/14/2023] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Although adaptive radiotherapy (ART) has many advantages, ART is not universal in the clinical appliance due to the consumption of a lot of labor, and economic burden. It is necessary to explore a CT stimulation-based radiomics model for screening who can get more benefits from ART in locally advanced non-small cell lung cancer (NSCLC) patients. METHOD 183 cases of NSCLC patients receiving concurrent chemoradiotherapy with an adaptive approach were enrolled as a primary cohort, while 28 cases from another hospital served as an independent external validation cohort. Tumor regression assessment was conducted based on GTV reduction (Criteria A) or according to RECIST Version 1.1(Criteria B). The radiomics features were extracted by the "PyRadiomics" package and further screened by the LASSO method. Then, logistic regression was used to establish the model. Bootstrap and external validation were applied to verify the stability of the model. The receiver operating characteristic (ROC) curve was delineated to assess the predictive efficacy of the radiomics model. Dose-volume histograms were quantitatively compared between the initial and composite ART plans. Clinical endpoints included overall survival (OS) and progression-free survival (PFS). RESULT There were no significant differences in clinical features between tumor regression-resistant (RR) and tumor regression-sensitivity (RS) groups. The AUC values of the Criteria A model and Criteria B model were 0.767 and 0.771, respectively. Bootstrapping validation and external validation confirmed the stability of models. In all patients, there was a significant benefit of ART in the lung, heart, cord, and esophagus compared to non-ART, particularly in RS patients. Furthermore, PFS and OS from ART were significantly longer in RS as defined by Criterion B than in RR patients with the same ART application. CONCLUSION CT-based radiomics can screen out the patients who can gain more benefits from ART, which contribute to guiding and popularizing the application of ART strategy in the clinic within economic benefits and feasibility.
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Affiliation(s)
- Chao Zhou
- From Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Zhejiang Province 317000, China
| | - Liqiao Hou
- From Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Zhejiang Province 317000, China
| | - Xingni Tang
- From Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Zhejiang Province 317000, China
| | - Changxing Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China
| | - Yinnan Meng
- From Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Zhejiang Province 317000, China
| | - Haijian Jia
- Department of Radiation Oncology, Enze Hospital Affiliated Hospital of Hangzhou Medical College, Zhejiang Province 317000, China
| | - Haihua Yang
- Department of Radiation Oncology, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shaanxi 710018, P.R. China.
| | - Suna Zhou
- From Department of Radiation Oncology, Taizhou Hospital Affiliated to Wenzhou Medical University, Zhejiang Province 317000, China; Department of Radiation Oncology, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shaanxi 710018, P.R. China.
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5
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But-Hadzic J, Strljic K, Zager Marcius V. The spine and carina as a surrogate for target registration in cone-beam CT imaging verification in locally advanced lung cancer radiotherapy. Radiol Oncol 2023; 57:86-94. [PMID: 36942905 PMCID: PMC10039477 DOI: 10.2478/raon-2022-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 10/19/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND The aim of the study was to evaluate the accuracy of volumetric lung image guidance using the spine or carina as a surrogate to target for image registration, as the best approach is not established. PATIENTS AND METHODS Cone beam computed tomography images from the 1st, 10th, 15th, and 20th fraction in 40 lung cancer patients treated with radical radiotherapy were retrospectively registered to planning CT, using three approaches. The spine and carina alignment set-up deviations from a reference (tumour/lymph nodes) registration in the lateral (LAT), longitudinal (LONG) and vertical (VRT) directions were analysed and compared. Tumour location and nodal stage influence on registration accuracy were explored. RESULTS The spine and carina mean set-up deviation from reference were largest in the LONG, with the best match in the VRT and LAT, respectively. Both strategies were more accurate in central tumours, with the carina being more precise in 50% LAT and 66% LONG mean deviations. For all measurements in all patients a carina vs. spine registration comparison showed improved carina accuracy in LAT and LONG. In comparative subgroup analysis the carina was superior compared to spine in LAT and LONG in centrally located tumours, N2 and N3. Both strategies were comparable for peripheral tumours and N0. CONCLUSIONS Carina registration shows greater accuracy compared to spine in the LAT and LONG directions and is superior in central tumours, N2 and N3. The spine and carina surrogates are equally accurate for peripheral tumours and N0. We propose the carina as a surrogate to target for CBCT image registration in locally advanced lung cancer.
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Affiliation(s)
- Jasna But-Hadzic
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Karmen Strljic
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Valerija Zager Marcius
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Health Sciences, University of Ljubljana, Department of Medical Imaging and Radiotherapy, Ljubljana, Slovenia
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6
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Zhou S, Meng Y, Sun X, Jin Z, Feng W, Yang H. The critical components for effective adaptive radiotherapy in patients with unresectable non-small-cell lung cancer: who, when and how. Future Oncol 2022; 18:3551-3562. [PMID: 36189758 DOI: 10.2217/fon-2022-0291] [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: 12/15/2022] Open
Abstract
Adaptive radiotherapy (ART) is a new radiotherapy technology based on image-guided radiation therapy technology, used to avoid radiation overexposure to residual tumors and the surrounding normal tissues. Tumors undergoing the same radiation doses and modes can occur unequal shrinkage due to the variation of response times to radiation doses in different patients. To perform ART effectively, eligible patients with a high probability of benefits from ART need to be identified. Confirming the precise timetable for ART in every patient is another urgent problem to be resolved. Moreover, the outcomes of ART are different depending on the various image guidance used. This review discusses 'who, when and how' as the three key factors involved in the most effective implementation for the management of ART.
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Affiliation(s)
- Suna Zhou
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shanxi, 710018, PR China
| | - Yinnan Meng
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Xuefeng Sun
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Zhicheng Jin
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Wei Feng
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, PR China
| | - Haihua Yang
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
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7
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Hattu D, Mannens J, Öllers M, van Loon J, De Ruysscher D, van Elmpt W. A traffic light protocol workflow for image-guided adaptive radiotherapy in lung cancer patients. Radiother Oncol 2022; 175:152-158. [PMID: 36067908 DOI: 10.1016/j.radonc.2022.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and optimized a traffic light protocol (TLP) used in lung cancer patients to identify patients requiring treatment adaptation. MATERIALS AND METHODS First, CBCT review requests of 243 lung cancer patients were retrospectively analyzed and divided into 6 pre-defined categories. Frequencies and follow-up actions were scored. Based on these results, the TLP was optimized and evaluated in the same way on 230 patients treated in 2018. RESULTS In the retrospective study, a total of 543 CBCT review requests were created during treatment in 193/243 patients due to changed anatomy of lung (24%), change of tumor volume (24%), review of match (18%), shift of the mediastinum (15%), shift of tumor (15%) and other (4%). The majority of requests (474, 87%) did not require further action. In 6% an adjustment of the match criteria sufficed; in 7% treatment plan adaptation was required. Plan adaptation was frequently seen in the categories changed anatomy of lung, change of tumor volume and shift of tumor outside the PTV. Shift of mediastinum outside PRV and shift of GTV outside CTV (but inside PTV) never required plan adaptation and were omitted to optimize the TLP, which reduced the CBCT review requests by 23%. CONCLUSIONS The original TLP selected patients that required a treatment adaptation, but with a high false positive rate. The optimized TLP reduced the amount of CBCT review requests, while still correctly identifying patients requiring adaptation.
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Affiliation(s)
- Djoya Hattu
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Jolein Mannens
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michel Öllers
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Judith van Loon
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
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8
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Choi HH, Sung SY, Ko YH. Unexpected Movement of the Esophagus across the Aorta. Diagnostics (Basel) 2022; 12:diagnostics12071758. [PMID: 35885661 PMCID: PMC9317508 DOI: 10.3390/diagnostics12071758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Tumor regression throughout treatment would induce organ movement, but little is known of this in the esophagus. To achieve successful tumor regression, radiation therapy requires several weeks of radiation to be delivered accurately to the tumor. Usually, a 5–10 mm margin is allowed for set-up error and internal organ motion. Our case exhibited an unexpectedly large movement of the esophagus across the aorta with tumor regression that extended outside the margin and thus outside the radiotherapy field. These movements may affect subsequent invasive procedures or treatment during cancer therapy. After the unexpected large movement of the esophagus due to tumor regression, we revised the radiotherapy plan to reflect the new esophageal position. This implied that regular imaging and close monitoring are required during treatment of esophageal cancer.
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Affiliation(s)
- Hyun Ho Choi
- Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 11765, Korea;
| | - Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea
- Correspondence: ; Tel.: +82-2-2030-3077
| | - Yoon Ho Ko
- Division of Oncology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea;
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Pham TT, Whelan B, Oborn BM, Delaney GP, Vinod S, Brighi C, Barton M, Keall P. Magnetic resonance imaging (MRI) guided proton therapy: A review of the clinical challenges, potential benefits and pathway to implementation. Radiother Oncol 2022; 170:37-47. [DOI: 10.1016/j.radonc.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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Mao W, Riess J, Kim J, Vance S, Chetty IJ, Movsas B, Kretzler A. Evaluation of auto-contouring and dose distributions for online adaptive radiation therapy of patients with locally advanced lung cancers. Pract Radiat Oncol 2022; 12:e329-e338. [DOI: 10.1016/j.prro.2021.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/14/2021] [Accepted: 12/26/2021] [Indexed: 11/28/2022]
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Piperdi H, Portal D, Neibart SS, Yue NJ, Jabbour SK, Reyhan M. Adaptive Radiation Therapy in the Treatment of Lung Cancer: An Overview of the Current State of the Field. Front Oncol 2021; 11:770382. [PMID: 34912715 PMCID: PMC8666420 DOI: 10.3389/fonc.2021.770382] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/09/2021] [Indexed: 12/25/2022] Open
Abstract
Lung cancer treatment is constantly evolving due to technological advances in the delivery of radiation therapy. Adaptive radiation therapy (ART) allows for modification of a treatment plan with the goal of improving the dose distribution to the patient due to anatomic or physiologic deviations from the initial simulation. The implementation of ART for lung cancer is widely varied with limited consensus on who to adapt, when to adapt, how to adapt, and what the actual benefits of adaptation are. ART for lung cancer presents significant challenges due to the nature of the moving target, tumor shrinkage, and complex dose accumulation because of plan adaptation. This article presents an overview of the current state of the field in ART for lung cancer, specifically, probing topics of: patient selection for the greatest benefit from adaptation, models which predict who and when to adapt plans, best timing for plan adaptation, optimized workflows for implementing ART including alternatives to re-simulation, the best radiation techniques for ART including magnetic resonance guided treatment, algorithms and quality assurance, and challenges and techniques for dose reconstruction. To date, the clinical workflow burden of ART is one of the major reasons limiting its widespread acceptance. However, the growing body of evidence demonstrates overwhelming support for reduced toxicity while improving tumor dose coverage by adapting plans mid-treatment, but this is offset by the limited knowledge about tumor control. Progress made in predictive modeling of on-treatment tumor shrinkage and toxicity, optimizing the timing of adaptation of the plan during the course of treatment, creating optimal workflows to minimize staffing burden, and utilizing deformable image registration represent ways the field is moving toward a more uniform implementation of ART.
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Affiliation(s)
- Huzaifa Piperdi
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Daniella Portal
- Rutgers Robert Wood Johnson Medical School, Rutgers, The State of New Jersey University, Piscataway, NJ, United States
| | - Shane S. Neibart
- Rutgers Robert Wood Johnson Medical School, Rutgers, The State of New Jersey University, Piscataway, NJ, United States
| | - Ning J. Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Rutgers Robert Wood Johnson Medical School, Rutgers, The State of New Jersey University, Piscataway, NJ, United States
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
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12
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Garcia Schüler HI, Pavic M, Mayinger M, Weitkamp N, Chamberlain M, Reiner C, Linsenmeier C, Balermpas P, Krayenbühl J, Guckenberger M, Baumgartl M, Wilke L, Tanadini-Lang S, Andratschke N. Operating procedures, risk management and challenges during implementation of adaptive and non-adaptive MR-guided radiotherapy: 1-year single-center experience. Radiat Oncol 2021; 16:217. [PMID: 34775998 PMCID: PMC8591958 DOI: 10.1186/s13014-021-01945-9] [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: 06/23/2021] [Accepted: 11/03/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Main purpose was to describe procedures and identify challenges in the implementation process of adaptive and non-adaptive MR-guided radiotherapy (MRgRT), especially new risks in workflow due to the new technique. We herein report the single center experience for the implementation of (MRgRT) and present an overview on our treatment practice. METHODS Descriptive statistics were used to summarize clinical and technical characteristics of treatment and patient characteristics including sites treated between April 2019 and end of March 2020 after ethical approval. A risk analysis was performed to identify risks of the online adaptive workflow. RESULTS A summary of the processes on the MR-Linac including workflows, quality assurance and possible pitfalls is presented. 111 patients with 124 courses were treated during the first year of MR-guided radiotherapy. The most commonly treated site was the abdomen (42% of all treatment courses). 73% of the courses were daily online adapted and a high number of treatment courses (75%) were treated with stereotactic body irradiation. Only 4/382 fractions could not be treated due to a failing online adaptive quality assurance. In the risk analysis for errors, the two risks with the highest risk priority number were both in the contouring category, making it the most critical step in the workflow. CONCLUSION Although challenging, establishment of MRgRT as a routinely used technique at our department was successful for all sites and daily o-ART was feasible from the first day on. However, ongoing research and reports will have to inform us on the optimal indications for MRgRT because careful patient selection is necessary as it continues to be a time-consuming treatment technique with restricted availability. After risk analysis, the most critical workflow category was the contouring process, which resembles the need of experienced staff and safety check paths.
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Affiliation(s)
- Helena Isabel Garcia Schüler
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Matea Pavic
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Nienke Weitkamp
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Madalyne Chamberlain
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Cäcilia Reiner
- University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland.,Department of Diagnostic and Interventional Radiology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Claudia Linsenmeier
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Jerome Krayenbühl
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Michael Baumgartl
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Lotte Wilke
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich and University Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
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Adaptive intensity-modulated radiotherapy with simultaneous integrated boost for stage III non-small cell lung cancer: Is a routine adaptation beneficial? Radiother Oncol 2021; 158:118-124. [PMID: 33636232 DOI: 10.1016/j.radonc.2021.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/31/2021] [Accepted: 02/15/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Tumor and anatomical changes during radiotherapy have been observed in stage III non-small cell lung cancer (NSCLC) from many previous studies. We hypothesized that a routinely scheduled adaptive radiotherapy would have clinical important dose benefits to lower the risk of toxicities, without increasing the tumor recurrences. METHODS We retrospectively reviewed 92 consecutive patients with inoperable stage III NSCLC between November 2017 and March 2019. All eligible patients should received simultaneously integrated boost (SIB) using intensity-modulated radiation therapy (IMRT). A mid-treatment CT simulation and a new adapted plan were routinely given after the first 20 fractions. The organs at risk (OARs) were delineated per RTOG 1106 atlas. Dose-volume histograms were quantitatively compared between the initial and composite adaptive plans. Logistic regression was applied to analyze the dose-response relationship. Clinical endpoints included acute symptomatic radiation pneumonitis (RP2) and esophagitis (RE2), local and regional tumor control, and progression-free survival (PFS). RESULTS Sixty-four eligible patients received adaptive SIB-IMRT were consecutively included. The GTVs reduced by a median of -38.2% after 42 to 44 Gy in 20 fractions of radiotherapy. By adapting to tumor and anatomical changes, dosimetric parameters of OARs decreased significantly. The mean lung dose decreased by an average of -74.8 cGy, and mean esophagus dose was lower by 183.1 cGy. We found grade 2 or higher acute RP in 11 patients (17.2%), and RE2 in 28 patients (43.8%). Commonly used lung and esophagus dose metrics were significantly associated with RP2 and RE2. The adaptation could reduce RP2 probability by 3%, and RE2 risk by 5%. Subgroups with higher OARs dose or larger tumor shrinkage may get more dose and toxicities benefits. The estimated median PFS was 12.5 months from the start of radiotherapy. CONCLUSIONS We demonstrated that the routinely adaptive SIB-IMRT strategy could significantly reduce the dose to surrounding normal tissues, potentially lower the associated acute RP and RE, without increasing the risk of tumor recurrences.
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14
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Hoegen P, Lang C, Akbaba S, Häring P, Splinter M, Miltner A, Bachmann M, Stahl-Arnsberger C, Brechter T, El Shafie RA, Weykamp F, König L, Debus J, Hörner-Rieber J. Cone-Beam-CT Guided Adaptive Radiotherapy for Locally Advanced Non-small Cell Lung Cancer Enables Quality Assurance and Superior Sparing of Healthy Lung. Front Oncol 2020; 10:564857. [PMID: 33363005 PMCID: PMC7756078 DOI: 10.3389/fonc.2020.564857] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/04/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate the potential of cone-beam-CT (CB-CT) guided adaptive radiotherapy (ART) for locally advanced non-small cell lung cancer (NSCLC) for sparing of surrounding organs-at-risk (OAR). Materials and Methods In 10 patients with locally advanced NSCLC, daily CB-CT imaging was acquired during radio- (n = 4) or radiochemotherapy (n = 6) for simulation of ART. Patients were treated with conventionally fractionated intensity-modulated radiotherapy (IMRT) with total doses of 60–66 Gy (pPlan) (311 fraction CB-CTs). OAR were segmented on every daily CB-CT and the tumor volumes were modified weekly depending on tumor changes. Doses actually delivered were recalculated on daily images (dPlan), and voxel-wise dose accumulation was performed using a deformable registration algorithm. For simulation of ART, treatment plans were adapted using the new contours and re-optimized weekly (aPlan). Results CB-CT showed continuous tumor regression of 1.1 ± 0.4% per day, leading to a residual gross tumor volume (GTV) of 65.3 ± 13.4% after 6 weeks of radiotherapy (p = 0.005). Corresponding PTVs decreased to 83.7 ± 7.8% (p = 0.005). In the actually delivered plans (dPlan), both conformity (p = 0.005) and homogeneity (p = 0.059) indices were impaired compared to the initial plans (pPlan). This resulted in higher actual lung doses than planned: V20Gy was 34.6 ± 6.8% instead of 32.8 ± 4.9% (p = 0.066), mean lung dose was 19.0 ± 3.1 Gy instead of 17.9 ± 2.5 Gy (p = 0.013). The generalized equivalent uniform dose (gEUD) of the lung was 18.9 ± 3.1 Gy instead of 17.8 ± 2.5 Gy (p = 0.013), leading to an increased lung normal tissue complication probability (NTCP) of 15.2 ± 13.9% instead of 9.6 ± 7.3% (p = 0.017). Weekly plan adaptation enabled decreased lung V20Gy of 31.6 ± 6.2% (−3.0%, p = 0.007), decreased mean lung dose of 17.7 ± 2.9 Gy (−1.3 Gy, p = 0.005), and decreased lung gEUD of 17.6 ± 2.9 Gy (−1.3 Gy, p = 0.005). Thus, resulting lung NTCP was reduced to 10.0 ± 9.5% (−5.2%, p = 0.005). Target volume coverage represented by conformity and homogeneity indices could be improved by weekly plan adaptation (CI: p = 0.007, HI: p = 0.114) and reached levels of the initial plan (CI: p = 0.721, HI: p = 0.333). Conclusion IGRT with CB-CT detects continuous GTV and PTV changes. CB-CT-guided ART for locally advanced NSCLC is feasible and enables superior sparing of healthy lung at high levels of plan conformity.
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Affiliation(s)
- Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Clemens Lang
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Mainz University Hospital, Mainz, Germany
| | - Peter Häring
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mona Splinter
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Medical Physics in Radiotherapy, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annette Miltner
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marion Bachmann
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Thomas Brechter
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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15
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Wang B, Wang DQ, Lin MS, Lu SP, Zhang J, Chen L, Li QW, Cheng ZK, Liu FJ, Guo JY, Liu H, Qiu B. Accumulation of the delivered dose based on cone-beam CT and deformable image registration for non-small cell lung cancer treated with hypofractionated radiotherapy. BMC Cancer 2020; 20:1112. [PMID: 33198676 PMCID: PMC7670776 DOI: 10.1186/s12885-020-07617-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background This study aimed to quantify the dosimetric differences between the planned and delivered dose to tumor and normal organs in locally advanced non-small cell lung cancer (LANSCLC) treated with hypofractionated radiotherapy (HRT), and to explore the necessity and identify optimal candidates for adaptive radiotherapy (ART). Methods Twenty-seven patients with stage III NSCLC were enrolled. Planned radiation dose was 51Gy in 17 fractions with cone-beam CT (CBCT) acquired at each fraction. Virtual CT was generated by deformable image registration (DIR) of the planning CT to CBCT for dose calculation and accumulation. Dosimetric parameters were compared between original and accumulated plans using Wilcoxon signed rank test. Correlations between dosimetric differences and clinical variables were analyzed using Mann-Whitney U test or Chi-square test. Results Patients had varied gross tumor volume (GTV) reduction by HRT (median reduction rate 11.1%, range − 2.9-44.0%). The V51 of planning target volume for GTV (PTV-GTV) was similar between original and accumulated plans (mean, 88.2% vs. 87.6%, p = 0.452). Only 11.1% of patients had above 5% relative decrease in V51 of PTV-GTV in accumulated plans. Compared to the original plan, limited increase (median relative increase < 5%) was observed in doses of total lung (mean dose, V20 and V30), esophagus (mean dose, maximum dose) and heart (mean dose, V30 and V40) in accumulated plans. Less than 30% of patients had above 5% relative increase of lung or heart doses. Patients with quick tumor regression or baseline obstructive pneumonitis showed more notable increase in doses to normal structures. Patients with baseline obstructive atelectasis showed notable decrease (10.3%) in dose coverage of PTV-GTV. Conclusions LANSCLC patients treated with HRT had sufficient tumor dose coverage and acceptable normal tissue dose deviation. ART should be applied in patients with quick tumor regression and baseline obstructive pneumonitis/atelectasis to spare more normal structures. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12885-020-07617-3.
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Affiliation(s)
- Bin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Da Quan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Mao Sheng Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shi Pei Lu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jun Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Qi Wen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Zhang Kai Cheng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Fang Jie Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jin Yu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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16
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Giaj-Levra N, Borghetti P, Bruni A, Ciammella P, Cuccia F, Fozza A, Franceschini D, Scotti V, Vagge S, Alongi F. Current radiotherapy techniques in NSCLC: challenges and potential solutions. Expert Rev Anticancer Ther 2020; 20:387-402. [PMID: 32321330 DOI: 10.1080/14737140.2020.1760094] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Radiotherapy is an important therapeutic strategy in the management of non-small cell lung cancer (NSCLC). In recent decades, technological implementations and the introduction of image guided radiotherapy (IGRT) have significantly increased the accuracy and tolerability of radiation therapy.Area covered: In this review, we provide an overview of technological opportunities and future prospects in NSCLC management.Expert opinion: Stereotactic body radiotherapy (SBRT) is now considered the standard approach in patients ineligible for surgery, while in operable cases, it is still under debate. Additionally, in combination with systemic treatment, SBRT is an innovative option for managing oligometastatic patients and features encouraging initial results in clinical outcomes. To date, in inoperable locally advanced NSCLC, the radical dose prescription has not changed (60 Gy in 30 fractions), despite the median overall survival progressively increasing. These results arise from technological improvements in precisely hitting target treatment volumes and organ at risk sparing, which are associated with better treatment qualities. Finally, for the management of NSCLC, proton and carbon ion therapies and the recent development of MR-Linac are new, intriguing technological approaches under investigation.
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Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Paolo Borghetti
- Dipartimento di Radioterapia Oncologica, Università e ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessio Bruni
- Radiotherapy Unit, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, AUSL-IRCCS, Reggio, Emilia, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Alessandra Fozza
- Department of Radiation Oncology, SS.Antonio e Biagio e C.Arrigo Hospital Alessandria, Alessandria, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Center- IRCCS - Rozzano (MI), Milano, Italy
| | - Vieri Scotti
- Radiation Therapy Unit, Department of Oncology, Careggi University Hospital, Firenze, Italy
| | - Stefano Vagge
- Radiation oncology Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Italy
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17
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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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18
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Corradini S, Alongi F, Andratschke N, Belka C, Boldrini L, Cellini F, Debus J, Guckenberger M, Hörner-Rieber J, Lagerwaard FJ, Mazzola R, Palacios MA, Philippens MEP, Raaijmakers CPJ, Terhaard CHJ, Valentini V, Niyazi M. MR-guidance in clinical reality: current treatment challenges and future perspectives. Radiat Oncol 2019; 14:92. [PMID: 31167658 PMCID: PMC6551911 DOI: 10.1186/s13014-019-1308-y] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022] Open
Abstract
Magnetic Resonance-guided radiotherapy (MRgRT) marks the beginning of a new era. MR is a versatile and suitable imaging modality for radiotherapy, as it enables direct visualization of the tumor and the surrounding organs at risk. Moreover, MRgRT provides real-time imaging to characterize and eventually track anatomical motion. Nevertheless, the successful translation of new technologies into clinical practice remains challenging. To date, the initial availability of next-generation hybrid MR-linac (MRL) systems is still limited and therefore, the focus of the present preview was on the initial applicability in current clinical practice and on future perspectives of this new technology for different treatment sites.MRgRT can be considered a groundbreaking new technology that is capable of creating new perspectives towards an individualized, patient-oriented planning and treatment approach, especially due to the ability to use daily online adaptation strategies. Furthermore, MRL systems overcome the limitations of conventional image-guided radiotherapy, especially in soft tissue, where target and organs at risk need accurate definition. Nevertheless, some concerns remain regarding the additional time needed to re-optimize dose distributions online, the reliability of the gating and tracking procedures and the interpretation of functional MR imaging markers and their potential changes during the course of treatment. Due to its continuous technological improvement and rapid clinical large-scale application in several anatomical settings, further studies may confirm the potential disruptive role of MRgRT in the evolving oncological environment.
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Affiliation(s)
- S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - F. Alongi
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - C. Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - L. Boldrini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - F. Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - J. Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zürich, Switzerland
| | - J. Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - F. J. Lagerwaard
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - R. Mazzola
- Department of Radiation Oncology, IRCSS Sacro Cuore don Calabria Hospital, Negrar-Verona, Italy
- University of Brescia, Brescia, Italy
| | - M. A. Palacios
- Department of Radiation Oncology, VU medical center, Amsterdam, The Netherlands
| | - M. E. P. Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. P. J. Raaijmakers
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C. H. J. Terhaard
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - V. Valentini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Rome, Italy
| | - M. Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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D'Amico NC, Sicilia R, Cordelli E, Valbusa G, Grossi E, Zanetti IB, Fazzini D, Scotti G, Beltramo G, Iannello G, Soda P. Early radiomics experiences in predicting CyberKnife response in acoustic neuroma. ACTA ACUST UNITED AC 2019. [DOI: 10.1145/3307616.3307620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Natascha Claudia D'Amico
- Imaging Department Centro Diagnostico Italiano S.p.A., Milan, Italy and Unit of Computer Systems and Bioinformatics Università Campus Bio-Medico di Roma, Rome, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | - Rosa Sicilia
- Unit of Computer Systems and Bioinformatics Università Campus Bio-Medico di Roma, Rome, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | - Ermanno Cordelli
- Unit of Computer Systems and Bioinformatics Università Campus Bio-Medico di Roma, Rome, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | - Giovanni Valbusa
- Imaging Department Centro Diagnostico Italiano S.p.A., Milan, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | | | - Isa Bossi Zanetti
- CyberKnife Department Centro Diagnostico Italiano S.p.A., Milan, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | - Deborah Fazzini
- Imaging Department Centro Diagnostico Italiano S.p.A., Milan, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | - Giuseppe Scotti
- Imaging Department Centro Diagnostico Italiano S.p.A., Milan, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
| | | | - Giulio Iannello
- Unit of Computer Systems and Bioinformatics Università Campus Bio-Medico di Roma, Rome, Italy
| | - Paolo Soda
- Unit of Computer Systems and Bioinformatics Università Campus Bio-Medico di Roma, Rome, Italy and Università Campus Bio-Medico di Roma - Centro, Diagnostico Italiano S.p.A., Italy
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20
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Phantom Verification of AAA and Acuros Dose Calculations for Lung Cancer: Do Tumor Size and Regression Matter? Pract Radiat Oncol 2019; 9:29-37. [DOI: 10.1016/j.prro.2018.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/22/2018] [Accepted: 06/10/2018] [Indexed: 12/14/2022]
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21
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Ramella S, Fiore M, Greco C, Cordelli E, Sicilia R, Merone M, Molfese E, Miele M, Cornacchione P, Ippolito E, Iannello G, D’Angelillo RM, Soda P. A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients. PLoS One 2018; 13:e0207455. [PMID: 30462705 PMCID: PMC6248970 DOI: 10.1371/journal.pone.0207455] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 10/29/2018] [Indexed: 01/26/2023] Open
Abstract
The primary goal of precision medicine is to minimize side effects and optimize efficacy of treatments. Recent advances in medical imaging technology allow the use of more advanced image analysis methods beyond simple measurements of tumor size or radiotracer uptake metrics. The extraction of quantitative features from medical images to characterize tumor pathology or heterogeneity is an interesting process to investigate, in order to provide information that may be useful to guide the therapies and predict survival. This paper discusses the rationale supporting the concept of radiomics and the feasibility of its application to Non-Small Cell Lung Cancer in the field of radiation oncology research. We studied 91 stage III patients treated with concurrent chemoradiation and adaptive approach in case of tumor reduction during treatment. We considered 12 statistics features and 230 textural features extracted from the CT images. In our study, we used an ensemble learning method to classify patients' data into either the adaptive or non-adaptive group during chemoradiation on the basis of the starting CT simulation. Our data supports the hypothesis that a specific signature can be identified (AUC 0.82). In our experience, a radiomic signature mixing semantic and image-based features has shown promising results for personalized adaptive radiotherapy in non-small cell lung cancer.
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Affiliation(s)
- Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
- * E-mail:
| | - Ermanno Cordelli
- Computer Science and Bioinformatics Laboratory, Integrated Research Centre, Campus Bio-Medico University, Rome, Italy
| | - Rosa Sicilia
- Computer Science and Bioinformatics Laboratory, Integrated Research Centre, Campus Bio-Medico University, Rome, Italy
| | - Mario Merone
- Computer Science and Bioinformatics Laboratory, Integrated Research Centre, Campus Bio-Medico University, Rome, Italy
| | | | - Marianna Miele
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Edy Ippolito
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Giulio Iannello
- Computer Science and Bioinformatics Laboratory, Integrated Research Centre, Campus Bio-Medico University, Rome, Italy
| | | | - Paolo Soda
- Computer Science and Bioinformatics Laboratory, Integrated Research Centre, Campus Bio-Medico University, Rome, Italy
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22
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Molitoris JK, Diwanji T, Snider JW, Mossahebi S, Samanta S, Badiyan SN, Simone CB, Mohindra P. Advances in the use of motion management and image guidance in radiation therapy treatment for lung cancer. J Thorac Dis 2018; 10:S2437-S2450. [PMID: 30206490 PMCID: PMC6123191 DOI: 10.21037/jtd.2018.01.155] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 01/26/2018] [Indexed: 12/22/2022]
Abstract
The development of advanced radiation technologies, including intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and proton therapy, has resulted in increasingly conformal radiation treatments. Recent evidence for the importance of minimizing dose to normal critical structures including the heart and lungs has led to incorporation of these advanced treatment modalities into radiation therapy (RT) for non-small cell lung cancer (NSCLC). While such technologies have allowed for improved dose delivery, implementation requires improved target accuracy with treatments, placing increasing importance on evaluating tumor motion at the time of planning and verifying tumor position at the time of treatment. In this review article, we describe issues and updates related both to motion management and image guidance in the treatment of NSCLC.
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Affiliation(s)
- Jason K. Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James W. Snider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
| | - Santanu Samanta
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
| | - Shahed N. Badiyan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Maryland Proton Treatment Center, University of Maryland, Baltimore, MD, USA
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Guy CL, Weiss E, Christensen GE, Jan N, Hugo GD. CALIPER: A deformable image registration algorithm for large geometric changes during radiotherapy for locally advanced non-small cell lung cancer. Med Phys 2018; 45:2498-2508. [PMID: 29603277 DOI: 10.1002/mp.12891] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/06/2018] [Accepted: 03/19/2018] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Locally advanced non-small cell lung cancer (NSCLC) patients may experience dramatic changes in anatomy during radiotherapy and could benefit from adaptive radiotherapy (ART). Deformable image registration (DIR) is necessary to accurately accumulate dose during plan adaptation, but current algorithms perform poorly in the presence of large geometric changes, namely atelectasis resolution. The goal of this work was to develop a DIR framework, named Consistent Anatomy in Lung Parametric imagE Registration (CALIPER), to handle large geometric changes in the thorax. METHODS Registrations were performed on pairs of baseline and mid-treatment CT datasets of NSCLC patients presenting with atelectasis at the start of treatment. Pairs were classified based on atelectasis volume change as either full, partial, or no resolution. The evaluated registration algorithms consisted of several combinations of a hybrid intensity- and feature-based similarity cost function to investigate the ability to simultaneously match healthy lung parenchyma and adjacent atelectasis. These components of the cost function included a mass-preserving intensity cost in the lung parenchyma, use of filters to enhance vascular structures in the lung parenchyma, manually delineated lung lobes as labels, and several intensity cost functions to model atelectasis change. Registration error was quantified with landmark-based target registration error and post-registration alignment of atelectatic lobes. RESULTS The registrations using both lobe labels and vasculature enhancement in addition to intensity of the CT images were found to have the highest accuracy. Of these registrations, the mean (SD) of mean landmark error across patients was 2.50 (1.16) mm, 2.80 (0.70) mm, and 2.04 (0.13) mm for no change, partial resolution, and full atelectasis resolution, respectively. The mean (SD) atelectatic lobe Dice similarity coefficient was 0.91 (0.08), 0.90 (0.08), and 0.89 (0.04), respectively, for the same groups. Registration accuracy was comparable to healthy lung registrations of current state-of-the-art algorithms reported in literature. CONCLUSIONS The CALIPER algorithm developed in this work achieves accurate image registration for challenging cases involving large geometric and topological changes in NSCLC patients, a requirement for enabling ART in this patient group.
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Affiliation(s)
- Christopher L Guy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Gary E Christensen
- Department of Electrical and Computer Engineering and Department of Radiation Oncology, University of Iowa, Iowa City, IA, 52242, USA
| | - Nuzhat Jan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University, St. Louis, MO, 63110, USA
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Sharifi H, Zhang H, Bagher-Ebadian H, Lu W, Ajlouni MI, Jin JY, Kong FMS, Chetty IJ, Zhong H. Utilization of a hybrid finite-element based registration method to quantify heterogeneous tumor response for adaptive treatment for lung cancer patients. Phys Med Biol 2018; 63:065017. [PMID: 29480158 DOI: 10.1088/1361-6560/aab235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Tumor response to radiation treatment (RT) can be evaluated from changes in metabolic activity between two positron emission tomography (PET) images. Activity changes at individual voxels in pre-treatment PET images (PET1), however, cannot be derived until their associated PET-CT (CT1) images are appropriately registered to during-treatment PET-CT (CT2) images. This study aimed to investigate the feasibility of using deformable image registration (DIR) techniques to quantify radiation-induced metabolic changes on PET images. Five patients with non-small-cell lung cancer (NSCLC) treated with adaptive radiotherapy were considered. PET-CTs were acquired two weeks before RT and 18 fractions after the start of RT. DIR was performed from CT1 to CT2 using B-Spline and diffeomorphic Demons algorithms. The resultant displacements in the tumor region were then corrected using a hybrid finite element method (FEM). Bitmap masks generated from gross tumor volumes (GTVs) in PET1 were deformed using the four different displacement vector fields (DVFs). The conservation of total lesion glycolysis (TLG) in GTVs was used as a criterion to evaluate the quality of these registrations. The deformed masks were united to form a large mask which was then partitioned into multiple layers from center to border. The averages of SUV changes over all the layers were 1.0 ± 1.3, 1.0 ± 1.2, 0.8 ± 1.3, 1.1 ± 1.5 for the B-Spline, B-Spline + FEM, Demons and Demons + FEM algorithms, respectively. TLG changes before and after mapping using B-Spline, Demons, hybrid-B-Spline, and hybrid-Demons registrations were 20.2%, 28.3%, 8.7%, and 2.2% on average, respectively. Compared to image intensity-based DIR algorithms, the hybrid FEM modeling technique is better in preserving TLG and could be useful for evaluation of tumor response for patients with regressing tumors.
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Affiliation(s)
- Hoda Sharifi
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States of America. Department of Physics, Oakland University, Rochester, MI, United States of America
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Bissonnette JP, Yap ML, Clarke K, Shessel A, Higgins J, Vines D, Atenafu EG, Becker N, Leavens C, Bezjak A, Jaffray DA, Sun A. Serial 4DCT/4DPET imaging to predict and monitor response for locally-advanced non-small cell lung cancer chemo-radiotherapy. Radiother Oncol 2018; 126:347-354. [DOI: 10.1016/j.radonc.2017.11.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/07/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
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MacManus M, Everitt S, Schimek-Jasch T, Li XA, Nestle U, Kong FMS. Anatomic, functional and molecular imaging in lung cancer precision radiation therapy: treatment response assessment and radiation therapy personalization. Transl Lung Cancer Res 2017; 6:670-688. [PMID: 29218270 DOI: 10.21037/tlcr.2017.09.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article reviews key imaging modalities for lung cancer patients treated with radiation therapy (RT) and considers their actual or potential contributions to critical decision-making. An international group of researchers with expertise in imaging in lung cancer patients treated with RT considered the relevant literature on modalities, including computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). These perspectives were coordinated to summarize the current status of imaging in lung cancer and flag developments with future implications. Although there are no useful randomized trials of different imaging modalities in lung cancer, multiple prospective studies indicate that management decisions are frequently impacted by the use of complementary imaging modalities, leading both to more appropriate treatments and better outcomes. This is especially true of 18F-fluoro-deoxyglucose (FDG)-PET/CT which is widely accepted to be the standard imaging modality for staging of lung cancer patients, for selection for potentially curative RT and for treatment planning. PET is also more accurate than CT for predicting survival after RT. PET imaging during RT is also correlated with survival and makes response-adapted therapies possible. PET tracers other than FDG have potential for imaging important biological process in tumors, including hypoxia and proliferation. MRI has superior accuracy in soft tissue imaging and the MRI Linac is a rapidly developing technology with great potential for online monitoring and modification of treatment. The role of imaging in RT-treated lung cancer patients is evolving rapidly and will allow increasing personalization of therapy according to the biology of both the tumor and dose limiting normal tissues.
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Affiliation(s)
- Michael MacManus
- Department of Radiation Oncology, Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Sarah Everitt
- Department of Radiation Oncology, Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI, USA
| | - Ursula Nestle
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Feng-Ming Spring Kong
- Indiana University Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
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Zhong H, Chetty IJ. Adaptive radiotherapy for NSCLC patients: utilizing the principle of energy conservation to evaluate dose mapping operations. Phys Med Biol 2017; 62:4333-4345. [PMID: 28475493 DOI: 10.1088/1361-6560/aa54a5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tumor regression during the course of fractionated radiotherapy confounds the ability to accurately estimate the total dose delivered to tumor targets. Here we present a new criterion to improve the accuracy of image intensity-based dose mapping operations for adaptive radiotherapy for patients with non-small cell lung cancer (NSCLC). Six NSCLC patients were retrospectively investigated in this study. An image intensity-based B-spline registration algorithm was used for deformable image registration (DIR) of weekly CBCT images to a reference image. The resultant displacement vector fields were employed to map the doses calculated on weekly images to the reference image. The concept of energy conservation was introduced as a criterion to evaluate the accuracy of the dose mapping operations. A finite element method (FEM)-based mechanical model was implemented to improve the performance of the B-Spline-based registration algorithm in regions involving tumor regression. For the six patients, deformed tumor volumes changed by 21.2 ± 15.0% and 4.1 ± 3.7% on average for the B-Spline and the FEM-based registrations performed from fraction 1 to fraction 21, respectively. The energy deposited in the gross tumor volume (GTV) was 0.66 Joules (J) per fraction on average. The energy derived from the fractional dose reconstructed by the B-spline and FEM-based DIR algorithms in the deformed GTV's was 0.51 J and 0.64 J, respectively. Based on landmark comparisons for the 6 patients, mean error for the FEM-based DIR algorithm was 2.5 ± 1.9 mm. The cross-correlation coefficient between the landmark-measured displacement error and the loss of radiation energy was -0.16 for the FEM-based algorithm. To avoid uncertainties in measuring distorted landmarks, the B-Spline-based registrations were compared to the FEM registrations, and their displacement differences equal 4.2 ± 4.7 mm on average. The displacement differences were correlated to their relative loss of radiation energy with a cross-correlation coefficient equal to 0.68. Based on the principle of energy conservation, the FEM-based mechanical model has a better performance than the B-Spline-based DIR algorithm. It is recommended that the principle of energy conservation be incorporated into a comprehensive QA protocol for adaptive radiotherapy.
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Local Control and Toxicity of Adaptive Radiotherapy Using Weekly CT Imaging: Results from the LARTIA Trial in Stage III NSCLC. J Thorac Oncol 2017; 12:1122-1130. [PMID: 28428149 DOI: 10.1016/j.jtho.2017.03.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/14/2017] [Accepted: 03/30/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Anatomical change of tumor during radiotherapy contributes to target missing. However, in the case of tumor shrinkage, adaptation of volume could result in an increased incidence of recurrence in the area of target reduction. This study aims to investigate the incidence of failure of the adaptive approach and, in particular, the risk for local recurrence in the area excluded after replanning. METHODS In this prospective study, patients with locally advanced NSCLC treated with concomitant chemoradiation underwent weekly chest computed tomography simulation during treatment. In the case of tumor shrinkage, a new tumor volume was delineated and a new treatment plan outlined (replanning). Toxicity was evaluated with the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer scale. Patterns of failures were classified as in field (dimensional and/or metabolic progression within the replanning planning target volume [PTV]), marginal (recurrence in initial the PTV excluded from the replanning PTV), and out of field (recurrence outside the initial PTV). RESULTS Replanning was outlined in 50 patients selected from a total of 217 patients subjected to weekly simulation computed tomography in our center from 2012 to 2014. With a median follow-up of 20.5 months, acute grade 3 or higher pulmonary and esophageal toxicity were reported in 2% and 4% of cases and late toxicity in 4% and 2%, respectively. Marginal relapse was recorded in 6% of patients, and 20% and 4% of patients experienced in-field and out-of-field local failure, respectively. CONCLUSIONS The reduced toxicity and the documented low rate of marginal failures make the adaptive approach a modern option for future randomized studies. The best scenario to confirm its application is probably in neoadjuvant chemoradiation trials.
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Late-Course Adaptive Adjustment Based on Metabolic Tumor Volume Changes during Radiotherapy May Reduce Radiation Toxicity in Patients with Non-Small Cell Lung Cancer. PLoS One 2017; 12:e0170901. [PMID: 28125698 PMCID: PMC5268643 DOI: 10.1371/journal.pone.0170901] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/12/2017] [Indexed: 12/19/2022] Open
Abstract
To reduce the high risk of radiation toxicity and enhance the quality of life of patients with non-small cell lung cancer (NSCLC), we quantified the metabolic tumor volumes (MTVs) from baseline to the late-course of radiotherapy (RT) by fluorodeoxyglucose positron emission tomography computerized tomography (FDG PET-CT) and discussed the potential benefit of late-course adaptive plans rather than original plans by dose volume histogram (DVH) comparisons. Seventeen patients with stage II-III NSCLC who were treated with definitive conventionally fractionated RT were eligible for this prospective study. FDG PET-CT scans were acquired within 1 week before RT (pre-RT) and at approximately two-thirds of the total dose during-RT (approximately 40 Gy). MTVs were taken as gross tumor volumes (GTVs) that included the primary tumor and any involved hilar or mediastinal lymph nodes. An original plan based on the baseline MTVs and adaptive plans based on observations during-RT MTVs were generated for each patient. The DVHs for lung, heart, esophagus and spinal cord were compared between the original plans and composite plans at 66 Gy. At the time of approximately 40 Gy during-RT, MTVs were significantly reduced in patients with NSCLC (pre-RT 136.2±82.3 ml vs. during-RT 64.7±68.0 ml, p = 0.001). The composite plan of the original plan at 40 Gy plus the adaptive plan at 26 Gy resulted in better DVHs for all the organs at risk that were evaluated compared to the original plan at 66 Gy (p<0.05), including V5, V10, V15, V20, V25, V30 and the mean dose of total lung, V10, V20, V30, V40, V50, V60 and the mean dose of heart, V35, V40, V50, V55, V60, the maximum dose and mean dose of the esophagus, and the maximum dose of the spinal-cord. PET-MTVs were reduced significantly at the time of approximately 40 Gy during-RT. Late course adaptive radiotherapy may be an effective way to reduce the dose volume to the organs at risk, thus reducing radiation toxicity in patients with NSCLC.
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Zhong H, Siddiqui SM, Movsas B, Chetty IJ. Evaluation of adaptive treatment planning for patients with non-small cell lung cancer. Phys Med Biol 2017; 62:4346-4360. [PMID: 28072395 DOI: 10.1088/1361-6560/aa586f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of this study was to develop metrics to evaluate uncertainties in deformable dose accumulation for patients with non-small cell lung cancer (NSCLC). Initial treatment plans (primary) and cone-beam CT (CBCT) images were retrospectively processed for seven NSCLC patients, who showed significant tumor regression during the course of treatment. Each plan was developed with IMRT for 2 Gy × 33 fractions. A B-spline-based DIR algorithm was used to register weekly CBCT images to a reference image acquired at fraction 21 and the resultant displacement vector fields (DVFs) were then modified using a finite element method (FEM). The doses were calculated on each of these CBCT images and mapped to the reference image using a tri-linear dose interpolation method, based on the B-spline and FEM-generated DVFs. Contours propagated from the planning image were adjusted to the residual tumor and OARs on the reference image to develop a secondary plan. For iso-prescription adaptive plans (relative to initial plans), mean lung dose (MLD) was reduced, on average from 17.3 Gy (initial plan) to 15.2, 14.5 and 14.8 Gy for the plans adapted using the rigid, B-Spline and FEM-based registrations. Similarly, for iso-toxic adaptive plans (considering MLD relative to initial plans) using the rigid, B-Spline and FEM-based registrations, the average doses were 69.9 ± 6.8, 65.7 ± 5.1 and 67.2 ± 5.6 Gy in the initial volume (PTV1), and 81.5 ± 25.8, 77.7 ± 21.6, and 78.9 ± 22.5 Gy in the residual volume (PTV21), respectively. Tumor volume reduction was correlated with dose escalation (for isotoxic plans, correlation coefficient = 0.92), and with MLD reduction (for iso-fractional plans, correlation coefficient = 0.85). For the case of the iso-toxic dose escalation, plans adapted with the B-Spline and FEM DVFs differed from the primary plan adapted with rigid registration by 2.8 ± 1.0 Gy and 1.8 ± 0.9 Gy in PTV1, and the mean difference between doses accumulated using the B-spline and FEM DVF's was 1.1 ± 0.6 Gy. As a dose mapping-induced energy change, energy defect in the tumor volume was 20.8 ± 13.4% and 4.5 ± 2.4% for the B-spline and FEM-based dose accumulations, respectively. The energy defect of the B-Spline-based dose accumulation is significant in the tumor volume and highly correlated to the difference between the B-Spline and FEM-accumulated doses with their correlation coefficient equal to 0.79. Adaptive planning helps escalate target dose and spare normal tissue for patients with NSCLC, but deformable dose accumulation may have a significant loss of energy in regressed tumor volumes when using image intensity-based DIR algorithms. The metric of energy defect is a useful tool for evaluation of adaptive planning accuracy for lung cancer patients.
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Michienzi A, Kron T, Callahan J, Plumridge N, Ball D, Everitt S. Cone-beam computed tomography for lung cancer - validation with CT and monitoring tumour response during chemo-radiation therapy. J Med Imaging Radiat Oncol 2016; 61:263-270. [DOI: 10.1111/1754-9485.12551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Alissa Michienzi
- Faculty of Medicine, Dentistry and Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - Tomas Kron
- Department of Physical Sciences; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Medical Imaging and Radiation Sciences; Monash University; Clayton Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Jason Callahan
- Department of Medical Imaging and Radiation Sciences; Monash University; Clayton Victoria Australia
- Centre for Cancer Imaging; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Nikki Plumridge
- Division of Radiation Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - David Ball
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
- Division of Radiation Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Sarah Everitt
- Department of Medical Imaging and Radiation Sciences; Monash University; Clayton Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
- Radiation Therapy Services; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
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Duffton A, Harrow S, Lamb C, McJury M. An assessment of cone beam CT in the adaptive radiotherapy planning process for non-small-cell lung cancer patients. Br J Radiol 2016; 89:20150492. [PMID: 27052681 DOI: 10.1259/bjr.20150492] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the potential use of cone beam CT (CBCT) in adaptive radiotherapy (ART) planning process for non-small-cell lung cancer (NSCLC). METHODS 17 retrospective patients with NSCLC Stage T1-T4, who had completed a course of radiotherapy with weekly CBCT imaging were selected for the study. The patients had been delineated and planned for three-dimensional (3D) conformal treatment (prescription: 55 Gy in 20 fractions) based on free-breathing four-dimensional CT data. Of these initial 17 patients, 12 had full quantitative data on gross tumour volume (GTV) position and volume throughout treatment. GTV delineation was carried out on weekly CBCT by a clinical oncologist. For each patient, mean percentage change in GTV and centre of mass (COM) displacement (based on 3D vectors) were calculated throughout treatment. Volume overlap between GTVs was calculated. Correlation of the COM displacement and planning GTV (pGTV) was assessed. A linear mixed model with patients as random effects was fitted to the data to assess potential benefit from using ART for these patients. RESULTS Comparison of CBCT-based GTV acquired prior to Fraction 1 (cbctGTV1) to pGTV showed mean 20 ± 19% volume increase using a related sample Wilcoxon signed rank test p = 0.04. Correlation was identified between volume reductions and dose delivered (beta = -0.003, p < 0.001)-a highly statistically significant association. Compared with cbctGTV1, the mean ratios ± standard deviation were cbctGTV2, 0.93 ± 0.08; cbctGTV3, 0.84 ± 0.12; and cbctGTV4, 0.75 ± 0.14. The dice similarity coefficient was 0.81 ± 0.14, 0.78 ± 0.17, 0.73 ± 0.19, respectively. The COM was consistent throughout treatment (mean 0.35 ± 0.24 cm). A fitted model predicts that a mean change of 30% volume relative to cbctGTV1 occurs at a dose of approximately 50 Gy. CONCLUSION Using a 30% reduction in volume, ART would not be of benefit for all radiotherapy-alone-treated patients with NSCLC assessed in this study. For individual patients and patients with atelectasis, CBCT imaging was able to identify volume change. ADVANCES IN KNOWLEDGE For patients treated with 55 Gy in 20 fractions, target volume changes throughout treatment have been demonstrated using CBCT and can be used to highlight patients who may benefit from ART.
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Affiliation(s)
- Aileen Duffton
- 1 Department of Radiotherapy, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Stephen Harrow
- 1 Department of Radiotherapy, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Carolynn Lamb
- 1 Department of Radiotherapy, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Mark McJury
- 2 Department of Clinical Physics and Bio-Engineering, Beatson West of Scotland Cancer Centre, Glasgow, UK
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De Tollenaere C, Lievens Y, Vandecasteele K, Vermaelen K, Surmont V. Unresectable stage III non-small-cell lung cancer: Have we made any progress? World J Respirol 2015; 5:140-151. [DOI: 10.5320/wjr.v5.i2.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 03/27/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Lung cancer is responsible for the most cancer deaths worldwide with an incidence that is still rising. One third of patients have unresectable stage IIIA or stage IIIB disease. The standard of care for locally advanced disease in patients with good performance status consists of combined modality therapy in particular concurrent chemoradiotherapy. But despite a lot of efforts done in the past, local control and survival of patients with unresectable stage III non-small-cell lung cancer (NSCLC) remains poor. Improving outcomes for patients with unresectable stage III NSCLC has therefore been an area of ongoing research. Research has focused on improving systemic therapy, improving radiation therapy or adding a maintenance therapy to consolidate the initial therapy. Also implementation of newer targeted therapies and immunotherapy has been investigated as well as the option of prophylactic cranial irradiation. This article reviews the latest literature on improving local control and preventing distant metastases. It seems that we have reached a plateau with conventional chemotherapy. Radiotherapy dose escalation did not improve outcome although increasing radiation dose-intensity with new radiotherapy techniques and the use of newer agents, e.g., immunotherapy might be promising. In the future well-designed clinical trials are necessary to prove those promising results.
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Lee YH, Kim YS, Lee HC, Lee SW, Kang YN, Kang JH, Hong SH, Kim YK, Kim SJ, Ahn MI, Han DH, Yoo IR, Park JG, Sung SW, Lee KY. Tumour volume changes assessed with high-quality KVCT in lung cancer patients undergoing concurrent chemoradiotherapy. Br J Radiol 2015; 88:20150156. [PMID: 26055505 DOI: 10.1259/bjr.20150156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We evaluated tumour volume changes in patients with lung cancer undergoing concurrent chemoradiotherapy using image-guided radiotherapy (RT). METHODS The kilovoltage image was obtained using CT on rail at every five fractions. The gross tumour volumes (GTVs), including the primary tumour and lymph nodes (LNs), were contoured to analyse the time and degree of tumour regression. RESULTS 46 patients [32, non-small-cell lung cancer (NSCLC), and 14, small-cell lung cancer (SCLC)] were included in this study. In total, 281 CT scans and 82 sites of GTVs were evaluated. Significant volume changes occurred in both the NSCLC and SCLC groups (p < 0.001 and 0.002), and the average GTV change compared with baseline was 49.85 ± 3.65 [standard error (SE)]% and 65.95 ± 4.60 (SE)% for the NSCLC and SCLC groups, respectively. A significant difference in the degree of volume reduction between the primary tumour and LNs was observed in only the NSCLC group (p < 0.0001) but not in the SCLC group (p = 0.735). The greatest volume regression compared with the volume before the five fractions occurred between the 15 and 20 fractions in the NSCLC group and between the 5 and 10 fractions in the SCLC group. CONCLUSION Both primary tumour and LNs were well defined using CT on rail. Significant volume changes occurred during RT, and there was a difference in volume reduction between the NSCLC and SCLC groups, regarding the degree and timing of the tumour reduction in the primary tumour and LNs. ADVANCES IN KNOWLEDGE NSCLC and SCLC groups showed differences in the degree and timing of volume reduction. The primary tumour and LNs in NSCLC regressed differently.
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Affiliation(s)
- Y H Lee
- 1 Department of Radiation Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Y S Kim
- 1 Department of Radiation Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - H C Lee
- 1 Department of Radiation Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S W Lee
- 1 Department of Radiation Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Y N Kang
- 1 Department of Radiation Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - J H Kang
- 2 Department of Medical Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S H Hong
- 2 Department of Medical Oncology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Y K Kim
- 3 Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S J Kim
- 3 Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - M I Ahn
- 4 Department of Radiology, Seoul St Mary's Hospital, Seoul, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - D H Han
- 4 Department of Radiology, Seoul St Mary's Hospital, Seoul, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - I R Yoo
- 5 Department of Nuclear Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - J G Park
- 6 Department of Thoracic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S W Sung
- 6 Department of Thoracic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - K Y Lee
- 7 Department of Pathology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Correlation of 18F-FDG PET avid volumes on pre-radiation therapy and post-radiation therapy FDG PET scans in recurrent lung cancer. In regard to Shusharina et al. Int J Radiat Oncol Biol Phys 2014; 90:968-9. [PMID: 25585790 DOI: 10.1016/j.ijrobp.2014.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 06/25/2014] [Accepted: 07/13/2014] [Indexed: 11/21/2022]
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36
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Separating the dosimetric consequences of changing tumor anatomy from positional uncertainty for conventionally fractionated lung cancer patients. Pract Radiat Oncol 2014; 4:455-65. [DOI: 10.1016/j.prro.2014.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/23/2022]
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van Rijssel MJ, Dahele M, Verbakel WF, Rosario TS. A critical approach to the clinical use of deformable image registration software. In response to Meijneke et al. Radiother Oncol 2014; 112:447-8. [DOI: 10.1016/j.radonc.2014.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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Analysis of automatic match results for cone-beam computed tomography localization of conventionally fractionated lung tumors. Pract Radiat Oncol 2014; 4:35-42. [DOI: 10.1016/j.prro.2013.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/06/2013] [Accepted: 02/18/2013] [Indexed: 11/21/2022]
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Christodoulou M, Bayman N, McCloskey P, Rowbottom C, Faivre-Finn C. New radiotherapy approaches in locally advanced non-small cell lung cancer. Eur J Cancer 2013; 50:525-34. [PMID: 24333095 DOI: 10.1016/j.ejca.2013.11.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/25/2013] [Accepted: 11/24/2013] [Indexed: 12/25/2022]
Abstract
Radiotherapy plays a major role in the treatment of patients with locally advanced non-small cell lung cancer (NSCLC), particularly since most patients are not suitable for surgery due to the extent of their disease, advanced age and multiple co-morbidities. Despite advances in local and systemic therapies local control and survival remain poor and there is a sense that a therapeutic plateau has been reached with conventional approaches. Strategies for the intensification of radiotherapy such as dose escalation have shown encouraging results in phase I-II trials, but the outcome of the phase III Radiation Therapy Oncology Group 0617 trial was surprisingly disappointing. Hyperfractionated and/or accelerated fractionating schedules have demonstrated superior survival compared to conventional fractionation at the expense of greater oesophageal toxicity. Modern radiotherapy techniques such as the integration of 4-dimensional computed tomography for planning, intensity modulated radiotherapy and image-guided radiotherapy have substantially enhanced the accuracy of the radiotherapy delivery through improved target conformality and incorporation of tumour respiratory motion. A number of studies are evaluating personalised radiation treatment including the concept of isotoxic radiotherapy and the boosting of the primary tumour based on functional imaging. Proton beam therapy is currently under investigation in locally advanced NSCLC. These approaches, either alone or in combination could potentially allow for further dose escalation and improvement of the therapeutic ratio and survival for patients with NSCLC.
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Affiliation(s)
| | - Neil Bayman
- Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Paula McCloskey
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Carl Rowbottom
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- The University of Manchester, Oxford Road, Greater Manchester, United Kingdom; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.
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40
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Jan N, Balik S, Hugo GD, Mukhopadhyay N, Weiss E. Interfraction displacement of primary tumor and involved lymph nodes relative to anatomic landmarks in image guided radiation therapy of locally advanced lung cancer. Int J Radiat Oncol Biol Phys 2013; 88:210-5. [PMID: 24239387 DOI: 10.1016/j.ijrobp.2013.09.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 09/25/2013] [Accepted: 09/27/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE To analyze primary tumor (PT) and lymph node (LN) position changes relative to each other and relative to anatomic landmarks during conventionally fractionated radiation therapy for patients with locally advanced lung cancer. METHODS AND MATERIALS In 12 patients with locally advanced non-small cell lung cancer PT, LN, carina, and 1 thoracic vertebra were manually contoured on weekly 4-dimensional fan-beam CT scans. Systematic and random interfraction displacements of all contoured structures were identified in the 3 cardinal directions, and resulting setup margins were calculated. Time trends and the effect of volume changes on displacements were analyzed. RESULTS Three-dimensional displacement vectors and systematic/random interfraction displacements were smaller for carina than for vertebra both for PT and LN. For PT, mean (SD) 3-dimensional displacement vectors with carina-based alignment were 7 (4) mm versus 9 (5) mm with bony anatomy (P<.0001). For LN, smaller displacements were found with carina- (5 [3] mm, P<.0001) and vertebra-based (6 [3] mm, P=.002) alignment compared with using PT for setup (8 [5] mm). Primary tumor and LN displacements relative to bone and carina were independent (P>.05). Displacements between PT and bone (P=.04) and between PT and LN (P=.01) were significantly correlated with PT volume regression. Displacements between LN and carina were correlated with LN volume change (P=.03). CONCLUSIONS Carina-based setup results in a more reproducible PT and LN alignment than bony anatomy setup. Considering the independence of PT and LN displacement and the impact of volume regression on displacements over time, repeated CT imaging even with PT-based alignment is recommended in locally advanced disease.
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Affiliation(s)
- Nuzhat Jan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Salim Balik
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Nitai Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia.
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Robertson S, Weiss E, Hugo GD. Deformable mesh registration for the validation of automatic target localization algorithms. Med Phys 2013; 40:071721. [PMID: 23822425 DOI: 10.1118/1.4811105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To evaluate deformable mesh registration (DMR) as a tool for validating automatic target registration algorithms used during image-guided radiation therapy. METHODS DMR was implemented in a hierarchical model, with rigid, affine, and B-spline transforms optimized in succession to register a pair of surface meshes. The gross tumor volumes (primary tumor and involved lymph nodes) were contoured by a physician on weekly CT scans in a cohort of lung cancer patients and converted to surface meshes. The meshes from weekly CT images were registered to the mesh from the planning CT, and the resulting registered meshes were compared with the delineated surfaces. Known deformations were also applied to the meshes, followed by mesh registration to recover the known deformation. Mesh registration accuracy was assessed at the mesh surface by computing the symmetric surface distance (SSD) between vertices of each registered mesh pair. Mesh registration quality in regions within 5 mm of the mesh surface was evaluated with respect to a high quality deformable image registration. RESULTS For 18 patients presenting with a total of 19 primary lung tumors and 24 lymph node targets, the SSD averaged 1.3 ± 0.5 and 0.8 ± 0.2 mm, respectively. Vertex registration errors (VRE) relative to the applied known deformation were 0.8 ± 0.7 and 0.2 ± 0.3 mm for the primary tumor and lymph nodes, respectively. Inside the mesh surface, corresponding average VRE ranged from 0.6 to 0.9 and 0.2 to 0.9 mm, respectively. Outside the mesh surface, average VRE ranged from 0.7 to 1.8 and 0.2 to 1.4 mm. The magnitude of errors generally increased with increasing distance away from the mesh. CONCLUSIONS Provided that delineated surfaces are available, deformable mesh registration is an accurate and reliable method for obtaining a reference registration to validate automatic target registration algorithms for image-guided radiation therapy, specifically in regions on or near the target surfaces.
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Affiliation(s)
- Scott Robertson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298, USA
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43
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Mishra S, Hammond A, Read N, Venkatesan V, Winquist E, Nichols A, Warner A, Palma D. Can radiological changes in lymph node volume during treatment predict success of radiation therapy in patients with locally advanced head and neck squamous cell carcinoma? J Med Imaging Radiat Oncol 2013; 57:603-9. [PMID: 24119277 DOI: 10.1111/1754-9485.12067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 04/06/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Assessment of nodal response after radiotherapy (RT) for head and neck squamous cell carcinoma is difficult, as both CT and positron emission tomography scanning have limited predictive value for residual disease. We sought to measure changes in nodal volume during RT to determine whether such changes are predictive of nodal disease control. METHODS Patients with locally advanced head and neck squamous cell carcinoma treated with 70 Gy of radical RT (±chemotherapy or anti-epidermal growth factor receptor (EGFR) antibodies) were eligible. Baseline pre-RT scans and cone-beam CT scans done at the outset of treatment and at weeks 3, 5 and 7 (cone-beam CTs # 1, 2, 3 and 4, respectively) were deformably coregistered, and 3D nodal volumes were measured. RESULTS Thirty-eight eligible patients were identified. The main primary tumour site was oropharyngeal; most patients had stage IVa disease. Twenty-seven patients received concurrent platinum-based chemotherapy, 10 received only an EGFR inhibitor with RT and one received RT alone. Twelve patients had a failure in the neck. After week 1 of treatment, a 4% mean decrease in nodal volume was observed, increasing to 40% at week 7. Platinum-based chemotherapy achieved significantly greater decreases in nodal volume than EGFR inhibitors (44 vs. 25%; P = 0.026). Advanced tumour stage predicted neck failure (P = 0.002), but nodal volumes did not correlate with neck control. CONCLUSIONS Changes in nodal volume are minimal initially during RT but accelerate during the latter weeks of therapy. This study suggests that chemotherapy achieves a greater decrease in nodal volume than EGFR inhibitors and that nodal changes do not predict disease control in the neck.
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Affiliation(s)
- Sanju Mishra
- Division of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
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Edmunds K, Bedford J. Assessment of the robustness of volumetric-modulated arc therapy for lung radiotherapy. Br J Radiol 2013; 86:20120498. [PMID: 23392190 PMCID: PMC3608059 DOI: 10.1259/bjr.20120498] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 11/30/2012] [Accepted: 12/19/2012] [Indexed: 01/31/2023] Open
Abstract
Volumetric-modulated arc therapy (VMAT) is increasingly popular as a treatment method in radiotherapy owing to the speed with which treatments can be delivered. However, there has been little investigation into the effect of increased modulation in lung plans with regard to interfraction organ motion. This is most likely to occur where the planning target volume (PTV) lies within areas of low density. This paper aims to investigate the effect of modulation on the dose distribution using simulated patient movement and to propose a method that is less susceptible to such movement. Simulated interfraction motion is achieved by moving the plan isocentre in steps of 0.5 cm and 1.0 cm in six directions for five clinical VMAT patients. The proposed planning method involves optimisation using a density override of 1 g cm(-3), within the PTV in lung, to reduce segment boosting in the periphery of the PTV. This investigation shows that modulation can result in an increase in the maximum dose of >25%, an increase in PTV near-maximum dose of 17% and a reduction in near-minimum dose by 46%. Unacceptable organ at risk (OAR) doses are also seen. The proposed method reduces modulation, resulting in a maximum dose increase of 10%. Although safeguards are in place to prevent the increased dose to OARs from patient movement, there is nothing to prevent the increased dose as a result of modulation in lung. A simple planning method is proposed to safeguard against this effect. Investigation suggests that, where modulation exists in a plan, this method reduces it and is clinically viable.
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Affiliation(s)
- K Edmunds
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
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Zhang F, Hu J, Kelsey CR, Yoo D, Yin FF, Cai J. Reproducibility of Tumor Motion Probability Distribution Function in Stereotactic Body Radiation Therapy of Lung Cancer. Int J Radiat Oncol Biol Phys 2012; 84:861-6. [DOI: 10.1016/j.ijrobp.2012.01.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 01/10/2012] [Accepted: 01/11/2012] [Indexed: 12/25/2022]
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Louvel G, Cazoulat G, Chajon E, Le Maître A, Simon A, Henry O, Bensadoun RJ, de Crevoisier R. [Image-guided and adaptive radiotherapy]. Cancer Radiother 2012; 16:423-9. [PMID: 22920086 DOI: 10.1016/j.canrad.2012.07.177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 06/28/2012] [Accepted: 07/09/2012] [Indexed: 11/18/2022]
Abstract
Image-guided radiotherapy (IGRT) aims to take into account anatomical variations occurring during irradiation by visualization of anatomical structures. It may consist of a rigid registration of the tumour by moving the patient, in case of prostatic irradiation for example. IGRT associated with intensity-modulated radiotherapy (IMRT) is strongly recommended when high-dose is delivered in the prostate, where it seems to reduce rectal and bladder toxicity. In case of significant anatomical deformations, as in head and neck tumours (tumour shrinking and decrease in volume of the salivary glands), replanning appears to be necessary, corresponding to the adaptive radiotherapy. This should ideally be "monitored" and possibly triggered based on a calculation of cumulative dose, session after session, compared to the initial planning dose, corresponding to the concept of dose-guided adaptive radiotherapy. The creation of "planning libraries" based on predictable organ positions (as in cervical cancer) is another way of adaptive radiotherapy. All of these strategies still appear very complex and expensive and therefore require stringent validation before being routinely applied.
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Affiliation(s)
- G Louvel
- Département de radiothérapie, centre Eugène-Marquis, Rennes, France
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47
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Robertson SP, Weiss E, Hugo GD. Localization accuracy from automatic and semi-automatic rigid registration of locally-advanced lung cancer targets during image-guided radiation therapy. Med Phys 2012; 39:330-41. [PMID: 22225303 DOI: 10.1118/1.3671929] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate localization accuracy resulting from rigid registration of locally-advanced lung cancer targets using fully automatic and semi-automatic protocols for image-guided radiation therapy. METHODS Seventeen lung cancer patients, fourteen also presenting with involved lymph nodes, received computed tomography (CT) scans once per week throughout treatment under active breathing control. A physician contoured both lung and lymph node targets for all weekly scans. Various automatic and semi-automatic rigid registration techniques were then performed for both individual and simultaneous alignments of the primary gross tumor volume (GTV(P)) and involved lymph nodes (GTV(LN)) to simulate the localization process in image-guided radiation therapy. Techniques included "standard" (direct registration of weekly images to a planning CT), "seeded" (manual prealignment of targets to guide standard registration), "transitive-based" (alignment of pretreatment and planning CTs through one or more intermediate images), and "rereferenced" (designation of a new reference image for registration). Localization error (LE) was assessed as the residual centroid and border distances between targets from planning and weekly CTs after registration. RESULTS Initial bony alignment resulted in centroid LE of 7.3 ± 5.4 mm and 5.4 ± 3.4 mm for the GTV(P) and GTV(LN), respectively. Compared to bony alignment, transitive-based and seeded registrations significantly reduced GTV(P) centroid LE to 4.7 ± 3.7 mm (p = 0.011) and 4.3 ± 2.5 mm (p < 1 × 10(-3)), respectively, but the smallest GTV(P) LE of 2.4 ± 2.1 mm was provided by rereferenced registration (p < 1 × 10(-6)). Standard registration significantly reduced GTV(LN) centroid LE to 3.2 ± 2.5 mm (p < 1 × 10(-3)) compared to bony alignment, with little additional gain offered by the other registration techniques. For simultaneous target alignment, centroid LE as low as 3.9 ± 2.7 mm and 3.8 ± 2.3 mm were achieved for the GTV(P) and GTV(LN), respectively, using rereferenced registration. CONCLUSIONS Target shape, volume, and configuration changes during radiation therapy limited the accuracy of standard rigid registration for image-guided localization in locally-advanced lung cancer. Significant error reductions were possible using other rigid registration techniques, with LE approaching the lower limit imposed by interfraction target variability throughout treatment.
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Affiliation(s)
- Scott P Robertson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298, USA
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Lavoie C, Higgins J, Bissonnette JP, Le LW, Sun A, Brade A, Hope A, Cho J, Bezjak A. Volumetric image guidance using carina vs spine as registration landmarks for conventionally fractionated lung radiotherapy. Int J Radiat Oncol Biol Phys 2012; 84:1086-92. [PMID: 22494582 DOI: 10.1016/j.ijrobp.2012.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 01/30/2012] [Accepted: 02/06/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare the relative accuracy of 2 image guided radiation therapy methods using carina vs spine as landmarks and then to identify which landmark is superior relative to tumor coverage. METHODS AND MATERIALS For 98 lung patients, 2596 daily image-guidance cone-beam computed tomography scans were analyzed. Tattoos were used for initial patient alignment; then, spine and carina registrations were performed independently. A separate analysis assessed the adequacy of gross tumor volume, internal target volume, and planning target volume coverage on cone-beam computed tomography using the initial, middle, and final fractions of radiation therapy. Coverage was recorded for primary tumor (T), nodes (N), and combined target (T+N). Three scenarios were compared: tattoos alignment, spine registration, and carina registration. RESULTS Spine and carina registrations identified setup errors ≥ 5 mm in 35% and 46% of fractions, respectively. The mean vector difference between spine and carina matching had a magnitude of 3.3 mm. Spine and carina improved combined target coverage, compared with tattoos, in 50% and 34% (spine) to 54% and 46% (carina) of the first and final fractions, respectively. Carina matching showed greater combined target coverage in 17% and 23% of fractions for the first and final fractions, respectively; with spine matching, this was only observed in 4% (first) and 6% (final) of fractions. Carina matching provided superior nodes coverage at the end of radiation compared with spine matching (P=.0006), without compromising primary tumor coverage. CONCLUSION Frequent patient setup errors occur in locally advanced lung cancer patients. Spine and carina registrations improved combined target coverage throughout the treatment course, but carina matching provided superior combined target coverage.
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Affiliation(s)
- Caroline Lavoie
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada M5G 2M9
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Weiss E, Robertson SP, Mukhopadhyay N, Hugo GD. Tumor, lymph node, and lymph node-to-tumor displacements over a radiotherapy series: analysis of interfraction and intrafraction variations using active breathing control (ABC) in lung cancer. Int J Radiat Oncol Biol Phys 2011; 82:e639-45. [PMID: 22197237 DOI: 10.1016/j.ijrobp.2011.08.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 06/12/2011] [Accepted: 08/26/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE To estimate errors in soft tissue-based image guidance due to relative changes between primary tumor (PT) and affected lymph node (LN) position and volume, and to compare the results with bony anatomy-based displacements of PTs and LNs during radiotherapy of lung cancer. METHODS AND MATERIALS Weekly repeated breath-hold computed tomography scans were acquired in 17 lung cancer patients undergoing radiotherapy. PTs and affected LNs were manually contoured on all scans after rigid registration. Interfraction and intrafraction displacements in the centers of mass of PTs and LNs relative to bone, as well as LNs relative to PTs (LN-PT), were calculated. RESULTS The mean volume after 5 weeks was 65% for PTs and 63% for LNs. Systematic and random interfraction displacements were 2.6 to 4.6 mm and 2.7 to 2.9 mm, respectively, for PTs; 2.4 to 3.8 mm and 1.4 to 2.7 mm, respectively, for LNs; and 2.3 to 3.9 mm and 1.9 to 2.8 mm, respectively, for LN-PT. Systematic and random intrafraction displacements were less than 1 mm except in the superoinferior direction. Interfraction LN-PT displacements greater than 3 mm were observed in 67% of fractions and require a safety margin of 12 mm in the lateral direction, 11 mm in the anteroposterior direction, and 9 mm in the superoinferior direction. LN-PT displacements displayed significant time trends (p < 0.0001) and depended on the presence of pathoanatomic conditions of the ipsilateral lung, such as atelectasis. CONCLUSION Interfraction LN-PT displacements were mostly systematic and comparable to bony anatomy-based displacements of PTs or LNs alone. Time trends, large volume changes, and the influence of pathoanatomic conditions underline the importance of soft tissue-based image guidance and the potential of plan adaptation.
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Affiliation(s)
- Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA 23298, USA.
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