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Dashnamoorthy S, Jeyasingh E, Rajamanickam K, Pitchaikannu V, Nachimuthu K. Dosimetric and radiobiological advantages from deep inspiration breath-hold and free breath technique for left-sided breast radiation using 3DCRT, IMRT and Rapid Arc methods-a complete assessment. RADIATION PROTECTION DOSIMETRY 2024; 200:1274-1293. [PMID: 39003236 DOI: 10.1093/rpd/ncae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/16/2024] [Accepted: 03/14/2024] [Indexed: 07/15/2024]
Abstract
The verification and use of the best treatment approach using 3D conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT) and Rapid Arc methods for left breast radiation with dosimetric and radiobiological characteristics. The use of custom-built Python software for the estimation and comparison of volume, mean dose, maximum dose, monitor units and normal tissue integral dose along with radiobiological parameters such as NTCP, tumor control probability, equivalent uniform dose and LKB's effective volume from 3DCRT, IMRT and Rapid Arc planning with deep inspiration with breath holding (DIBH) and free breadth (FB) techniques. Volume growth of three-fourth in DIBH compared with FB causes a decrease in cardiac doses and complications because the left lung expands, pulling the heart away from the chest wall and the treatment area. A tiny area of the left lung was exposed during treatment, which reduced the mean dose. There was little difference in the treatment approaches because the spinal cord was immobile in both techniques. Rapid Arc is the unmatched modality for left-sided breast irradiation with significant patient breath-hold, as shown by the comparison of dosimetric and radiobiological parameters from treatment techniques with a deep inspiration breath-hold approach.
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Affiliation(s)
- Sougoumarane Dashnamoorthy
- Department of Radiotherapy, Thangam Cancer Hospital, Namakkal 637001, Tamil Nadu, India
- PG & Research Department of Physics, Jamal Mohamed College (Autonomous), Affiliated to Bharathidasan University, Tiruchirappalli 620020, Tamil Nadu, India
| | - Ebenezar Jeyasingh
- PG & Research Department of Physics, Jamal Mohamed College (Autonomous), Affiliated to Bharathidasan University, Tiruchirappalli 620020, Tamil Nadu, India
| | - Karthick Rajamanickam
- Department of Radiotherapy, Thangam Cancer Hospital, Namakkal 637001, Tamil Nadu, India
| | | | - Kathiresan Nachimuthu
- Department of Radiotherapy, Thangam Cancer Hospital, Namakkal 637001, Tamil Nadu, India
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Hoeltgen L, Meixner E, Hoegen-Saßmannshausen P, Kim JY, Deng M, Seidensaal K, Held T, Herfarth K, Haberer T, Debus J, Mairani A, Harrabi S, Tessonnier T. Helium Ion Therapy for Advanced Juvenile Nasopharyngeal Angiofibroma. Cancers (Basel) 2024; 16:1993. [PMID: 38893114 PMCID: PMC11171253 DOI: 10.3390/cancers16111993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Helium ion therapy (HRT) is a promising modality for the treatment of pediatric tumors and those located close to critical structures due to the favorable biophysical properties of helium ions. This in silico study aimed to explore the potential benefits of HRT in advanced juvenile nasopharyngeal angiofibroma (JNA) compared to proton therapy (PRT). We assessed 11 consecutive patients previously treated with PRT for JNA in a definitive or postoperative setting with a relative biological effectiveness (RBE) weighted dose of 45 Gy (RBE) in 25 fractions at the Heidelberg Ion-Beam Therapy Center. HRT plans were designed retrospectively for dosimetric comparisons and risk assessments of radiation-induced complications. HRT led to enhanced target coverage in all patients, along with sparing of critical organs at risk, including a reduction in the brain integral dose by approximately 27%. In terms of estimated risks of radiation-induced complications, HRT led to a reduction in ocular toxicity, cataract development, xerostomia, tinnitus, alopecia and delayed recall. Similarly, HRT led to reduced estimated risks of radiation-induced secondary neoplasms, with a mean excess absolute risk reduction of approximately 30% for secondary CNS malignancies. HRT is a promising modality for advanced JNA, with the potential for enhanced sparing of healthy tissue and thus reduced radiation-induced acute and long-term complications.
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Affiliation(s)
- Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Philipp Hoegen-Saßmannshausen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Partner Site, German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Centro Nazionale di Adroterapia Oncologica (CNAO), Medical Physics Department, 27100 Pavia, Italy
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
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Ferrer C, Huertas C, Ocanto A, García D, Plaza R, Mínguez C, de la Monja P, Escribano A, Pérez A, Sáez M. Evolution of dosimetric treatment planning for pediatric total lymphoid irradiation (TLI): a single-institution experience. Rep Pract Oncol Radiother 2024; 28:772-783. [PMID: 38515822 PMCID: PMC10954272 DOI: 10.5603/rpor.98734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/20/2023] [Indexed: 03/23/2024] Open
Abstract
Background Total lymphoid irradiation (TLI) is a conditioning regimen in allogeneic hematopoietic stem cell transplantation (allo-HSCT) which may reduce long-term toxicities attributed to other techniques, such as total body irradiation (TBI). At our institution, TLI treatments were first planned with the three-dimensional conformal radiation therapy (3D-CRT) technique and later with volumetric modulated arc therapy (VMAT). With the recent availability of a basic helical tomotherapy (HT), the possible dosimetric gain of the latter for TLI is studied. Materials and methods 22 pediatric patients were planned for VMAT and HT, prescribed to 8 Gy in 4 fractions. VMAT was planned with template based on a single cost function, using the Monaco treatment planning system (TPS). HT plans were planned using Accuray Precision TPS for a basic HT without the dynamic jaws feature or VOLO-Ultra algorithm. Plan quality was analyzed based on four quality indices, mean and maximum doses to planning target volume (PTV) and organs at risk (OARs), dose gradient and integral doses. Differences were analyzed with Wilcoxon signed-rank test. Results HT plans resulted in improved conformity (CI) and homogeneity indices (HI) (p < 0.05) but less steep dose gradient (p = 0.181). VMAT plans created larger areas with high doses within the PTV, while comparable doses to OARs, except mainly for the spinal marrow, for which a reduction of 37.7% in D2% was obtained (p < 0.05). Integral dose for non-tumor tissue was 11.3% lower with the VMAT template (p < 0.05). Conclusion HT achieves better conformity and homogeneity even without its more advanced features. Nevertheless, the VMAT template achieves dosimetric results close to those of HT, both with similar clinical outcome.
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Affiliation(s)
- Carlos Ferrer
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
| | - Concepción Huertas
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
| | | | - David García
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
| | - Rodrigo Plaza
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
| | - Cristina Mínguez
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
| | | | - Anne Escribano
- Radiation Oncology Department, H.U. La Paz, Madrid, Spain
| | - Antonio Pérez
- Pediatric Hemato-Oncology Department, H.U. La Paz, Madrid, Spain
| | - Moisés Sáez
- Medical Physics and Radiation Protection Department, H.U. La Paz, Madrid, Spain
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Hoeltgen L, Tessonnier T, Meixner E, Hoegen P, Kim JY, Deng M, Seidensaal K, Held T, Herfarth K, Debus J, Harrabi S. Proton Therapy for Advanced Juvenile Nasopharyngeal Angiofibroma. Cancers (Basel) 2023; 15:5022. [PMID: 37894389 PMCID: PMC10605854 DOI: 10.3390/cancers15205022] [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: 09/14/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE To provide the first report on proton radiotherapy (PRT) in the management of advanced nasopharyngeal angiofibroma (JNA) and evaluate potential benefits compared to conformal photon therapy (XRT). METHODS We retrospectively reviewed 10 consecutive patients undergoing PRT for advanced JNA in a definitive or postoperative setting with a relative biological effectiveness weighted dose of 45 Gy in 25 fractions between 2012 and 2022 at the Heidelberg Ion Beam Therapy Center. Furthermore, dosimetric comparisons and risk estimations for short- and long-term radiation-induced complications between PRT plans and helical XRT plans were conducted. RESULTS PRT was well tolerated, with only low-grade acute toxicities (CTCAE I-II) being reported. The local control rate was 100% after a median follow-up of 27.0 (interquartile range 13.3-58.0) months. PRT resulted in considerable tumor shrinkage, leading to complete remission in five patients and bearing the potential to provide partial or complete symptom relief. Favorable dosimetric outcomes in critical brain substructures by the use of PRT translated into reduced estimated risks for neurocognitive impairment and radiation-induced CNS malignancies compared to XRT. CONCLUSIONS PRT is an effective treatment option for advanced JNA with minimal acute morbidity and the potential for reduced radiation-induced long-term complications.
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Affiliation(s)
- Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site, 69120 Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
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Thomas R, Chen H, Gogineni E, Halthore A, Floreza B, Esho-Voltaire T, Weaver A, Alcorn S, Ladra M, Li H, Deville C. Comparing Ultra-hypofractionated Proton versus Photon Therapy in Extremity Soft Tissue Sarcoma. Int J Part Ther 2023; 9:30-39. [PMID: 36721484 PMCID: PMC9875823 DOI: 10.14338/ijpt-22-00022.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/18/2022] [Indexed: 01/19/2023] Open
Abstract
Purpose Recent single institution, phase II evidence has demonstrated the feasibility and efficacy of ultra-hypofractionated, preoperative photon therapy in 5 fractions for the treatment of soft tissue sarcoma (STS). Our purpose was to evaluate the dosimetric benefits of modern scanning beam proton therapy compared with conventional photon radiation therapy (RT) for the neoadjuvant treatment of adult extremity STS. Materials and Methods Existing proton and photon plans for 11 adult patients with STS of the lower extremities previously treated preoperatively with neoadjuvant RT at our center were used to create proton therapy plans using Raystation Treatment Planning System v10.A. Volumes were delineated, and doses reported consistent with International Commission on Radiation Units and Measurements reports 50, 62, and 78. Target volumes were optimized such that 100% clinical target volume (CTV) was covered by 99% of the prescription dose. The prescribed dose was 30 Gy for PT and RT delivered in 5 fractions. For proton therapy, doses are reported in GyRBE = 1.1 Gy. The constraints for adjacent organs at risk (OARs) within 1 cm of the CTV were the following: femur V30Gy ≤ 50%, joint V30Gy < 50%, femoral head V30Gy ≤ 5 cm3, strip V12 ≤ 10%, and skin V12 < 50%. Target coverage goals, OAR constraints, and integral dose were compared by Student t test with P < .05 significance. Results A minimum 99% CTV coverage was achieved for all plans. OAR dose constraints were achieved for all proton and photon plans; however, mean doses to the femur (10.7 ± 8.5 vs 16.1 ± 7.7 GyRBE), femoral head (2.0 ± 4.4 vs 3.6 ± 6.4 GyRBE), and proximal joint (1.8 ± 2.4 vs 3.5 ± 4.4 GyRBE) were all significantly lower with PT vs intensity-modulated radiation therapy (IMRT) (all P < .05). Integral dose was significantly reduced for proton vs photon plans. Conformity and heterogeneity indices were significantly better for proton therapy. Conclusion Proton therapy maintained target coverage while significantly reducing integral and mean doses to the proximal organs at risk compared with RT. Further prospective investigation is warranted to validate these findings and potential benefit in the management of adult STS.
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Affiliation(s)
- Rehema Thomas
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hao Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emile Gogineni
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aditya Halthore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Sara Alcorn
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Matthew Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heng Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wickert R, Tessonnier T, Deng M, Adeberg S, Seidensaal K, Hoeltgen L, Debus J, Herfarth K, Harrabi SB. Radiotherapy with Helium Ions Has the Potential to Improve Both Endocrine and Neurocognitive Outcome in Pediatric Patients with Ependymoma. Cancers (Basel) 2022; 14:cancers14235865. [PMID: 36497348 PMCID: PMC9736041 DOI: 10.3390/cancers14235865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
Ependymomas are the third most-frequent pediatric brain tumors. To prevent local recurrence, the resection site should be irradiated. Compared to photon radiation treatment, proton therapy often achieves even better results regarding target coverage and organ-sparing. Due to their physical properties, helium ions could further reduce side effects, providing better protection of healthy tissue despite similar target coverage. In our in silico study, 15 pediatric ependymoma patients were considered. All patients underwent adjuvant radiotherapeutic treatment with active-scanned protons at Heidelberg Ion Beam Therapy Center (HIT). Both helium ion and highly conformal IMRT plans were calculated to evaluate the potential dosimetric advantage of ion beam therapy compared to the current state-of-the-art photon-based treatments. To estimate the potential clinical benefit of helium ions, normal tissue complication probabilities (NTCP) were calculated. Target coverage was comparable in all three modalities. As expected, the integral dose absorbed by healthy brain tissue could be significantly reduced with protons by up to -48% vs. IMRT. Even compared to actively scanned protons, relative dose reductions for critical neuronal structures of up to another -39% were achieved when using helium ions. The dose distribution of helium ions is significantly superior when compared to proton therapy and IMRT due to the improved sparing of OAR. In fact, previous studies could clearly demonstrate that the dosimetric advantage of protons translates into a measurable clinical benefit for pediatric patients with brain tumors. Given the dose-response relationship of critical organs at risk combined with NTCP calculation, the results of our study provide a strong rationale that the use of helium ions has the potential to even further reduce the risk for treatment related sequelae.
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Affiliation(s)
- Ricarda Wickert
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Semi B. Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Correspondence:
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7
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Joseph N, Cicchetti A, McWilliam A, Webb A, Seibold P, Fiorino C, Cozzarini C, Veldeman L, Bultijnck R, Fonteyne V, Talbot CJ, Symonds PR, Johnson K, Rattay T, Lambrecht M, Haustermans K, De Meerleer G, Elliott RM, Sperk E, Herskind C, Veldwijk M, Avuzzi B, Giandini T, Valdagni R, Azria D, Jacquet MPF, Charissoux M, Vega A, Aguado-Barrera ME, Gómez-Caamaño A, Franco P, Garibaldi E, Girelli G, Iotti C, Vavassori V, Chang-Claude J, West CML, Rancati T, Choudhury A. High weekly integral dose and larger fraction size increase risk of fatigue and worsening of functional outcomes following radiotherapy for localized prostate cancer. Front Oncol 2022; 12:937934. [PMID: 36387203 PMCID: PMC9645430 DOI: 10.3389/fonc.2022.937934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction We hypothesized that increasing the pelvic integral dose (ID) and a higher dose per fraction correlate with worsening fatigue and functional outcomes in localized prostate cancer (PCa) patients treated with external beam radiotherapy (EBRT). Methods The study design was a retrospective analysis of two prospective observational cohorts, REQUITE (development, n=543) and DUE-01 (validation, n=228). Data were available for comorbidities, medication, androgen deprivation therapy, previous surgeries, smoking, age, and body mass index. The ID was calculated as the product of the mean body dose and body volume. The weekly ID accounted for differences in fractionation. The worsening (end of radiotherapy versus baseline) of European Organisation for Research and Treatment of Cancer EORTC) Quality of Life Questionnaire (QLQ)-C30 scores in physical/role/social functioning and fatigue symptom scales were evaluated, and two outcome measures were defined as worsening in ≥2 (WS2) or ≥3 (WS3) scales, respectively. The weekly ID and clinical risk factors were tested in multivariable logistic regression analysis. Results In REQUITE, WS2 was seen in 28% and WS3 in 16% of patients. The median weekly ID was 13.1 L·Gy/week [interquartile (IQ) range 10.2-19.3]. The weekly ID, diabetes, the use of intensity-modulated radiotherapy, and the dose per fraction were significantly associated with WS2 [AUC (area under the receiver operating characteristics curve) =0.59; 95% CI 0.55-0.63] and WS3 (AUC=0.60; 95% CI 0.55-0.64). The prevalence of WS2 (15.3%) and WS3 (6.1%) was lower in DUE-01, but the median weekly ID was higher (15.8 L·Gy/week; IQ range 13.2-19.3). The model for WS2 was validated with reduced discrimination (AUC=0.52 95% CI 0.47-0.61), The AUC for WS3 was 0.58. Conclusion Increasing the weekly ID and the dose per fraction lead to the worsening of fatigue and functional outcomes in patients with localized PCa treated with EBRT.
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Affiliation(s)
- Nuradh Joseph
- Department of Clinical Oncology, District General Hambantota, Hambantota, Sri Lanka
- Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Maharagama, Sri Lanka
| | - Alessandro Cicchetti
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
| | - Alan McWilliam
- Department of Medical Physics, University of Manchester, Manchester, United Kingdom
| | - Adam Webb
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Claudio Fiorino
- Department of Medical Physics, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | - Cesare Cozzarini
- Department of Radiation Oncology, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Renée Bultijnck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Christopher J. Talbot
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Paul R. Symonds
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Kerstie Johnson
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Tim Rattay
- Leicester Cancer Research Centre, Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Maarten Lambrecht
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Rebecca M. Elliott
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Elena Sperk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Carsten Herskind
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marlon Veldwijk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Barbara Avuzzi
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tommaso Giandini
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - David Azria
- Department of Radiation Oncology, University Federation of Radiation Oncology, Montpellier Cancer Institute, Univ Montpellier MUSE, Grant INCa_Inserm_DGOS_12553, Inserm U1194, Montpellier, France
| | | | - Marie Charissoux
- University Federation of Radiation Oncology of Mediterranean Occitanie, ICM Montpellier, Univ Montpellier, Montpellier, France
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica, Grupo de Medicina Xenómica (USC), Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Biomedical Network on Rare Diseases (CIBERER), Madrid, Spain
| | - Miguel E. Aguado-Barrera
- Fundación Pública Galega de Medicina Xenómica, Grupo de Medicina Xenómica (USC), Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Gómez-Caamaño
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Pierfrancesco Franco
- Department of Radiation Oncology, Ospedale Regionale U. Parini-AUSL Valle d’Aosta, Aosta, Italy
| | - Elisabetta Garibaldi
- Department of Radiation Oncology, Istituto di Candiolo - Fondazione del Piemonte per l’Oncologia IRCCS, Candiolo, Italy
| | | | - Cinzia Iotti
- Department of Radiation Oncology, Azienda USL – IRCCS di Reggio Emilia, Emilia-Romagna, Italy
| | | | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharine M. L. West
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Hambantota, Italy
| | - Ananya Choudhury
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, and The Christie NHS Foundation Trust, Manchester, United Kingdom
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8
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Polan DF, Epelman MA, Wu VW, Sun Y, Varsta M, Owen DR, Jarema D, Matrosic CK, Jolly S, Schonewolf CA, Schipper MJ, Matuszak MM. Direct incorporation of patient-specific efficacy and toxicity estimates in radiation therapy plan optimization. Med Phys 2022; 49:6279-6292. [PMID: 35994026 PMCID: PMC9826508 DOI: 10.1002/mp.15940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Current radiation therapy (RT) treatment planning relies mainly on pre-defined dose-based objectives and constraints to develop plans that aim to control disease while limiting damage to normal tissues during treatment. These objectives and constraints are generally population-based, in that they are developed from the aggregate response of a broad patient population to radiation. However, correlations of new biologic markers and patient-specific factors to treatment efficacy and toxicity provide the opportunity to further stratify patient populations and develop a more individualized approach to RT planning. We introduce a novel intensity-modulated radiation therapy (IMRT) optimization strategy that directly incorporates patient-specific dose response models into the planning process. In this strategy, we integrate the concept of utility-based planning where the optimization objective is to maximize the predicted value of overall treatment utility, defined by the probability of efficacy (e.g., local control) minus the weighted sum of toxicity probabilities. To demonstrate the feasibility of the approach, we apply the strategy to treatment planning for non-small cell lung cancer (NSCLC) patients. METHODS AND MATERIALS We developed a prioritized approach to patient-specific IMRT planning. Using a commercial treatment planning system (TPS), we calculate dose based on an influence matrix of beamlet-dose contributions to regions-of-interest. Then, outside of the TPS, we hierarchically solve two optimization problems to generate optimal beamlet weights that can then be imported back to the TPS. The first optimization problem maximizes a patient's overall plan utility subject to typical clinical dose constraints. In this process, we facilitate direct optimization of efficacy and toxicity trade-off based on individualized dose-response models. After optimal utility is determined, we solve a secondary optimization problem that minimizes a conventional dose-based objective subject to the same clinical dose constraints as the first stage but with the addition of a constraint to maintain the optimal utility from the first optimization solution. We tested this method by retrospectively generating plans for five previously treated NSCLC patients and comparing the prioritized utility plans to conventional plans optimized with only dose metric objectives. To define a plan utility function for each patient, we utilized previously published correlations of dose to local control and grade 3-5 toxicities that include patient age, stage, microRNA levels, and cytokine levels, among other clinical factors. RESULTS The proposed optimization approach successfully generated RT plans for five NSCLC patients that improve overall plan utility based on personalized efficacy and toxicity models while accounting for clinical dose constraints. Prioritized utility plans demonstrated the largest average improvement in local control (16.6%) when compared to plans generated with conventional planning objectives. However, for some patients, the utility-based plans resulted in similar local control estimates with decreased estimated toxicity. CONCLUSION The proposed optimization approach, where the maximization of a patient's RT plan utility is prioritized over the minimization of standardized dose metrics, has the potential to improve treatment outcomes by directly accounting for variability within a patient population. The implementation of the utility-based objective function offers an intuitive, humanized approach to biological optimization in which planning trade-offs are explicitly optimized.
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Affiliation(s)
- Daniel F Polan
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Marina A Epelman
- Department of Industrial and Operations EngineeringUniversity of MichiganAnn ArborMichiganUSA
| | - Victor W Wu
- Department of Industrial and Operations EngineeringUniversity of MichiganAnn ArborMichiganUSA
| | - Yilun Sun
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA,Department of BiostatisticsUniversity of MichiganAnn ArborMichiganUSA
| | | | - Daniel R Owen
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - David Jarema
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Charles K Matrosic
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Shruti Jolly
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - Matthew J Schipper
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA,Department of BiostatisticsUniversity of MichiganAnn ArborMichiganUSA
| | - Martha M Matuszak
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
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9
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Abdelhamid AMH, Jiang L, Zuro D, Liu A, Madabushi SS, Ghimire H, Wong JYC, Saldi S, Fulcheri C, Zucchetti C, Pierini A, Sheng K, Aristei C, Hui SK. Feasibility of a Novel Sparse Orthogonal Collimator-Based Preclinical Total Marrow Irradiation for Enhanced Dosimetric Conformality. Front Oncol 2022; 12:941814. [PMID: 35924145 PMCID: PMC9339640 DOI: 10.3389/fonc.2022.941814] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/23/2022] [Indexed: 12/17/2022] Open
Abstract
Total marrow irradiation (TMI) has significantly improved radiation conditioning for hematopoietic cell transplantation in hematologic diseases by reducing conditioning-induced toxicities and improving survival outcomes in relapsed/refractory patients. Recently, preclinical three-dimensional image-guided TMI has been developed to enhance mechanistic understanding of the role of TMI and to support the development of experimental therapeutics. However, a dosimetric comparison between preclinical and clinical TMI reveals that the preclinical TMI treatment lacks the ability to reduce the dose to some of the vital organs that are very close to the skeletal system and thus limits the ability to evaluate radiobiological relevance. To overcome this limit, we introduce a novel Sparse Orthogonal Collimator (SOC)-based TMI and evaluate its ability to enhance dosimetric conformality. The SOC-TMI-based dose modulation technique significantly improves TMI treatment planning by reducing radiation exposures to critical organs that are close to the skeletal system that leads to reducing the gap between clinical and preclinical TMI.
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Affiliation(s)
- Amr M. H. Abdelhamid
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Lu Jiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States
| | - Darren Zuro
- Department of Radiation Oncology, University of Oklahoma, Norman, OK, United States
| | - An Liu
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States
| | | | - Hemendra Ghimire
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States
| | - Jeffrey Y. C. Wong
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States
| | - Simonetta Saldi
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
| | - Christian Fulcheri
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
| | - Claudio Zucchetti
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
| | - Antonio Pierini
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, Perugia University and General Hospital, Perugia, Italy
| | - Susanta K. Hui
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States
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10
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He DC, Zhu ZJ, Zhang XY, Zhang Y, Hong J, Shi TT, Han JH. Evaluating the influence of 6MV and 10MV photon beams on cervical volumetric-modulated arc therapy plans. Technol Health Care 2022; 30:1515-1523. [PMID: 35661033 DOI: 10.3233/thc-213617] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cervical cancer is a common gynecological cancer among women worldwide. OBJECTIVE To determine the effects of 6 MV and 10 MV volumetric-modulated arc therapy (VMAT) photon beams on the target volume (TV) planning and critical organs in cases of cervical cancer. METHODS Fifty patients with carcinoma of the cervix who underwent radiotherapy were selected. The transverse diameter (T) of the cross section of the upper edge of the sacroiliac joint on computerized tomography images of the patients was measured, and the mean value was calculated as 34 cm. All patients were divided into two groups: Group A (T < 34 cm) and Group B (T > 34 cm). The VMAT plans were generated using 6 MV and 10 MV plans separately. The prescription dose was 47.5 Gy, and the daily dose was 1.9 Gy. RESULTS In Group A, the planned TV (PTV) dose assessment parameters of 6 MV and 10 MV plans and their homogeneity and conformity indices were not statistically significantly different. A significant difference was observed between the 6 MV and 10 MV plans for the PTV dose assessment parameters and the homogeneity index of the plans for Group B. The monitor units of the 10 MV plans were lower than in the 6 MV plans in both Groups A and B, and the difference was statistically significant. The assessment parameter V40 Gy of both the rectum and bladder in the 6 MV plans was smaller than the corresponding parameter in the 10 MV plans in Group A; in Group B, the assessment parameter V50 Gy of the rectum in the 10 MV plans was smaller than in the 6 MV plans. CONCLUSION When T < 34 cm, 6 MV energy is more suitable for the external irradiation of cervical cancer. When T > 34 cm, 10 MV energy is more suitable for cervical cancer radiotherapy. Therefore, 10 MV should be considered for patients with a large abdominal size.
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11
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Menon SV, P R, Bhasi S, Gopalakrishnan Z, B S, K S, Nair RK. Dosimetric comparison and validation of Eclipse Anisotropic Analytical Algorithm (AAA) and AcurosXB (AXB) algorithms in RapidArc-based radiosurgery plans of patients with solitary brain metastasis. Med Dosim 2021; 47:e7-e12. [PMID: 34740518 DOI: 10.1016/j.meddos.2021.09.001] [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: 05/28/2021] [Revised: 08/02/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Stereotactic radiosurgery (SRS) is increasingly being used to manage solitary or multiple brain metastasis. This study aims to compare and validate Anisotropic Analytical Algorithm (AAA) and AcurosXB (AXB) algorithms of Eclipse Treatment Planning System (TPS) in RapidArc-based SRS plans of patients with solitary brain metastasis. Twenty patients with solitary brain metastasis who have been already treated with RapidArc SRS plans calculated using AAA plans were selected for this study. These plans were recalculated using AXB algorithm keeping the same arc orientations, multi-leaf collimator apertures, and monitor units. The two algorithms were compared for target coverage parameters, isodose volumes, plan quality metrics, dose to organs at risk and integral dose. The dose calculated by the TPS using AAA and AXB algorithms was validated against measured dose for all patient plans using an in-house developed cylindrical phantom. An Exradin A14SL ionization chamber was positioned at the center of this phantom to measure the in-field dose. NanoDot Optically Stimulated Luminescent Dosimeters (OSLDs) (Landauer Inc.) were placed at distances 3.0 cm, 4.0 cm, 5.0 cm, and 6.0 cm respectively from the center of the phantom to measure the non-target dose. In addition, the planar dose distribution was measured using amorphous silicon aS1000 Electronic Portal Imaging Device. The measured 2D dose distribution was compared against AAA and AXB estimated 2D distribution using gamma analysis. All results were tested for significance using the paired t-test at 5% level of significance. Significant differences between the AAA and AXB plans were found only for a few parameters analyzed in this study. In the experimental verification using cylindrical phantom, the difference between the AAA calculated dose and the measured dose was found to be highly significant (p < 0.001). However, the difference between the AXB calculated dose and the measured dose was not significant (p = 0.197). The difference between AAA/AXB calculated and measured at non-target locations was statistically insignificant at all four non-target locations and the dose calculated by both AAA and AXB algorithms shows a strong positive correlation with the measured dose. The results of the gamma analysis show that the AXB calculated planar dose is in better agreement with measurements compared to the AAA. Even though the results of the dosimetric comparison show that the differences are mostly not significant, the measurements show that there are differences between the two algorithms within the target volume. The AXB algorithm may be therefore more accurate in the dose calculation of VMAT plans for the treatment of small intracranial targets. For non-target locations either algorithm can be used for the estimation of dose accounting for their limitations in non-target dose estimations.
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Affiliation(s)
- Sharika Venugopal Menon
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India; Centre for Research and Evaluation, Bharathiar University, Coimbatore, Tamil Nadu, India
| | - Raghukumar P
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India.
| | - Saju Bhasi
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Zhenia Gopalakrishnan
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Sarin B
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Shilpa K
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Raghuram K Nair
- SUT Royal Hospital, Ulloor, Thiruvananthapuram, Kerala, India
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12
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He DC, Zhu ZJ, Zhang XY, Zhang Y, Hong J, Shi TT, Han JH. Dosimetric analysis of postoperative radiotherapy for thymoma. Cancer Radiother 2021; 26:537-541. [PMID: 34728117 DOI: 10.1016/j.canrad.2021.07.037] [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: 05/24/2021] [Revised: 07/11/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the dosimetric differences between intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) in the treatment of male and female thymoma. MATERIAL AND METHODS This single-institutional analysis included 20 patients with thymoma treated with RT between January 2017 and December 2020. Twenty patients were retrospectively planned for IMRT (IMRT1 with an average field angle of 216°, 288°, 0°, 72°,and 144°; IMRT2 with fan-shaped field angles of 280°, 320°, 0°, 40°, and 80°) and VMAT (VMAT1 with two arcs ranging form 280° to 80°,clockwise and then counterclockwise; VMAT2 with two 360° arcs). The plans for all investigated RT modalities were optimized for a prescriptional dose of 50Gy and fractional dose of 2.0Gy. Planning target volume (PTV) and organs-at-risk (OARs: heart, breasts, lungs, spinal cord, and esophagus) dosimetric parameters were compared. RESULTS All plans met the preparation aims for all the included metrics. There was little difference in the median values of PTV parameters (D2%, D98%, Dmean, homogeneity index[HI], and conformity index [CI]). The CI of the VMAT2 plan was the closest to 1 in both therapy groups. The monitor unit (MU) of IMRT2 and the estimated total delivery time of VMAT1 were the lowest in both therapy groups and were statistically significant. In the male group, the lung parameters (Dmean, V5Gy, V10Gy, and V20Gy) for VMAT1 were the lowest and showed statistical significance. In the female group, the lung parameters (Dmean, V5Gy, V10Gy, and V20Gy) and bilateral breast parameters (Dmean, V5Gy, V10Gy, and V20Gy) of IMRT2 were the lowest and showed statistical significance. CONCLUSIONS In male thymoma patients undergoing postoperative RT (PORT) treatment, the choice of fan-shaped VMAT may be a better option for protecting the lungs. For female thymoma patients receiving PORT, fan-shaped IMRT can better protect the lungs and breasts. The fan-shaped field performed better than the average and the full arc fields in PORT for thymoma.
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Affiliation(s)
- D-C He
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - Z-J Zhu
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - X-Y Zhang
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - Y Zhang
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - J Hong
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - T-T Shi
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China
| | - J-H Han
- Department of Radiation Oncology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, No. 1 Huanghe Road West, Huaiyin District, Huai'an ,Jiangsu 223300,People's Republic of China.
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13
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Khalladi N, Dejean C, Bosset M, Pointreau Y, Kinj R, Racadot S, Castelli J, Huguet F, Renard S, Guihard S, Tao Y, Rouvier JM, Johnson A, Bourhis J, Xu Shan S, Thariat J. A priori quality assurance using a benchmark case of the randomized phase 2 GORTEC 2014-14 in oligometastatic head and neck cancer patients. Cancer Radiother 2021; 25:755-762. [PMID: 34565664 DOI: 10.1016/j.canrad.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE A Benchmark Case (BC) was performed as part of the quality assurance process of the randomized phase 2 GORTEC 2014-14 OMET study, testing the possibility of multisite stereotactic radiation therapy (SBRT) alone in oligometastatic head and neck squamous cell carcinoma (HNSCC) as an alternative to systemic treatment and SBRT. MATERIAL AND METHODS Compliance of the investigating centers with the prescription, delineation, planning and evaluation recommendations available in the research protocol was assessed. In addition, classical dosimetric analysis was supplemented by quantitative geometric analysis using conformation indices. RESULTS Twenty centers participated in the BC analysis. Among them, four major deviations (MaD) were reported in two centers. Two (10%) centers in MaD had omitted the satellite tumor nodule and secondarily validated after revision. Their respective DICE indexes were 0.37 and 0 and use of extracranial SBRT devices suboptimal There were significant residual heterogeneities between participating centers, including those with a similar SBRT equipment, with impact of plan quality using standard indicators and geometric indices. CONCLUSION A priori QA using a BC conditioning the participation of the clinical investigation centers showed deviations from good SBRT practice and led to the exclusion of one out of the twenty participating centers. The majority of centers have demonstrated rigorous compliance with the research protocol. The use of quality indexes adds a complementary approach to improve assessment of plan quality.
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Affiliation(s)
- N Khalladi
- Centre François Baclesse, 3, avenue General Harris, 14076 Caen, France
| | - C Dejean
- Centre Antoine Lacassagne, Nice, France
| | - M Bosset
- Centre Marie Curie, Valence, France
| | | | - R Kinj
- Centre Antoine Lacassagne, Nice, France
| | | | | | - F Huguet
- Centre hospitalier et universitaire Tenon, Paris, France
| | - S Renard
- Institut de Cancérologie de Lorraine, Nancy, France
| | - S Guihard
- Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Y Tao
- Institut Gustave Roussy, Villejuif, France
| | - J M Rouvier
- Centre hospitalier régional et universitaire, Besançon-Montbéliard, France
| | - A Johnson
- Centre François Baclesse, 3, avenue General Harris, 14076 Caen, France
| | - J Bourhis
- Centre hospitalier universitaire vaudois, Lausanne, Switzerland
| | - S Xu Shan
- Centre hospitalier universitaire vaudois, Lausanne, Switzerland
| | - J Thariat
- Centre François Baclesse, 3, avenue General Harris, 14076 Caen, France; Corpuscular Physics Laboratory-Normandy University, Caen, France.
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14
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Giovanetti A, Marconi R, Awad N, Abuzied H, Agamy N, Barakat M, Bartoleschi C, Bossi G, Canfora M, Elsaid AA, Ioannilli L, Ismail HM, Issa YA, Novelli F, Pardini MC, Pioli C, Pinnarò P, Sanguineti G, Tahoun MM, Turchi R, Strigari L. Validation of a biomarker tool capable of measuring the absorbed dose soon after exposure to ionizing radiation. Sci Rep 2021; 11:8118. [PMID: 33854097 PMCID: PMC8047015 DOI: 10.1038/s41598-021-87173-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 03/19/2021] [Indexed: 01/17/2023] Open
Abstract
A radiological or nuclear attack could involve such a large number of subjects as to overwhelm the emergency facilities in charge. Resources should therefore be focused on those subjects needing immediate medical attention and care. In such a scenario, for the triage management by first responders, it is necessary to count on efficient biological dosimetry tools capable of early detection of the absorbed dose. At present the validated assays for measuring the absorbed dose are dicentric chromosomes and micronuclei counts, which require more than 2–3 days to obtain results. To overcome this limitation the NATO SPS Programme funded an Italian–Egyptian collaborative project aimed at validating a fast, accurate and feasible tool for assessing the absorbed dose early after radiation exposure. Biomarkers as complete blood cell counts, DNA breaks and radio-inducible proteins were investigated on blood samples collected before and 3 h after the first fraction of radiotherapy in patients treated in specific target areas with doses/fraction of about: 2, 3.5 or > 5 Gy and compared with the reference micronuclei count. Based on univariate and multivariate multiple linear regression correlation, our results identify five early biomarkers potentially useful for detecting the extent of the absorbed dose 3 h after the exposure.
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Affiliation(s)
- Anna Giovanetti
- Division of Health Protection Technologies, ENEA-Italian National Agency for New Technologies, Energy and Sustainable Economic Development, 00123, Rome, Italy.
| | - Raffaella Marconi
- Scientific Direction, National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149, Rome, Italy
| | - Noha Awad
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, 21561, Egypt
| | - Hala Abuzied
- Alexandria University Cancer Research Cluster, Alexandria, 21561, Egypt
| | - Neveen Agamy
- Nutrition Department, High Institute of Public Health, Alexandria University, Alexandria, 21561, Egypt
| | - Mohamed Barakat
- Alexandria University Cancer Research Cluster, Alexandria, 21561, Egypt
| | - Cecilia Bartoleschi
- Division of Health Protection Technologies, ENEA-Italian National Agency for New Technologies, Energy and Sustainable Economic Development, 00123, Rome, Italy
| | - Gianluca Bossi
- Oncogenomic and Epigenetic Unit, Department of Diagnostic Research and Technological Innovation, IRCCS - Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Marco Canfora
- Clinical Trial Center, Biostatistics and Bioinformatics, IRCCS Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Amr A Elsaid
- Oncology Department, Faculty of Medicine, Alexandria University, Alexandria, 21561, Egypt
| | - Laura Ioannilli
- Department of Biology, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Horeya M Ismail
- Alexandria University Cancer Research Cluster, Alexandria, 21561, Egypt
| | - Yasmine Amr Issa
- Medical Biochemistry Department, Faculty of Medicine, University of Alexandria, Alexandria, 21561, Egypt
| | - Flavia Novelli
- Division of Health Protection Technologies, ENEA-Italian National Agency for New Technologies, Energy and Sustainable Economic Development, 00123, Rome, Italy
| | - Maria Chiara Pardini
- Division of Health Protection Technologies, ENEA-Italian National Agency for New Technologies, Energy and Sustainable Economic Development, 00123, Rome, Italy
| | - Claudio Pioli
- Division of Health Protection Technologies, ENEA-Italian National Agency for New Technologies, Energy and Sustainable Economic Development, 00123, Rome, Italy
| | - Paola Pinnarò
- Departments of Radiation Oncology, IRCCS - Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Giuseppe Sanguineti
- Departments of Radiation Oncology, IRCCS - Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Mohamed M Tahoun
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, 21561, Egypt
| | - Riccardo Turchi
- Department of Biology, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Lidia Strigari
- IRCCS Azienda Ospedaliera Universitaria di Bologna, 40138, Bologna, Italy
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Dosimetric comparison of intensity-modulated radiotherapy (IMRT) and RapidArc in low grade mucoepidermoid carcinoma of the salivary gland: a single institutional experience. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose:To report a single-institution experience of intensity-modulated radiotherapy (IMRT) and RapidArc treatment plans for the patients treated with low grade mucoepidermoid carcinoma (MEC) of the salivary gland while sparing the organs at risk (OARs) within tolerance limits.Material and Methods:Twenty-five patients with MEC were selected to develop and analyse the treatment plans using both of the techniques. Dose distributions were calculated using Eclipse treatment planning system (Varian Medical Systems, Palo Alto, CA). Plans were generated to deliver the dose of 6000 cGy in 30 fractions. For IMRT, seven angle plans were used and for RapidArc, two half arcs were used with the same 6 MV photon beam. Quality of treatment plans was evaluated by using parameters such as, coverage, conformity index (CI), homogeneity index (HI), gradient index (GI), unified dosimetry index (UDI), dose volume histogram, delivery time and OARs sparing for IMRT and RapidArc plans.Results:The analysis revealed that IMRT and RapidArc coverages are 0·90 and 0·94, respectively; CIs are 1·15 and 1·10, respectively; HIs are 1·12 and 1·07, respectively; GIs are 0·94 and 0·98, respectively. Average UDI values for RapidArc and IMRT are 1·09 and 1·11, respectively. Integral dose comparison shows better OAR sparing for RapidArc. RapidArc plans have the shorter beam on time (45%) in comparison with IMRT plans.Conclusion:Planning constraints were achieved in both techniques. However, RapidArc showed better quality treatment plan, OARs sparing and shorter delivery time as compared to IMRT.
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Dosimetric comparison of volumetric-modulated arc therapy and helical tomotherapy for adjuvant treatment of bilateral breast cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractPurpose:Dosimetric comparison between volumetric-modulated arc therapy (VMAT) and helical tomotherapy (HT) in the treatment of bilateral breast cancer (BBC).Materials and methods:Ten patients treated on HT were selected retrospectively. Dose prescription was 50 Gy in 25 fractions to breast/chest wall and supraclavicular fossa (SCF) while tumour bed was simultaneously boosted to 61 Gy in 25 fractions. VMAT plans were made with four mono-isocentric partial arcs. The monitoring unit (MU) and treatment time were used to quantify the treatment efficiency. Target volumes were compared for homogeneity index (HI), conformity index (CI) while organs at risk (OARs) were compared for relevant dose volumes and integral doses (IDs).Result:For targets, no significant difference is observed between VMAT and HT in CI but VMAT could give better HI. The mean lung dose, V20 and V5 is 10·6 Gy versus 8·4 Gy (p-value 0·03), 12% versus 11·5% (p-value 0·5) and 78·1% versus 43·4% (p-value 0·005), respectively. The mean heart dose, V30 and V5 is 4·9 Gy versus 4·7 Gy (p-value 0·88), 0·5% versus 1·5% (p-value 0·18) and 26·2% versus 22·8% (p-value 0·4). Integral dose (ID) for the whole body and heart are comparable: 289 Gy kg versus 299 Gy kg (p-value 0·24) and 2·9 Gy kg versus 2·8 Gy kg (p-value 0·80). ID for lungs was significantly higher with VMAT: 7·9 Gy kg versus 6·3 Gy kg (p-value 0·03). There is a 53% reduction in treatment time and 78% in MU with VMAT against HT.Conclusion:VMAT can generate clinically acceptable plans comparable to HT for BBC. HT shows better control over low dose spillage in lungs compared to VMAT thereby increasing ID to lungs. VMAT shows better homogeneity and efficient treatment delivery than HT.
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Noufal MP, Widesott L, Sharma SD, Righetto R, Cianchetti M, Schwarz M. The Role of Plan Robustness Evaluation in Comparing Protons and Photons Plans - An Application on IMPT and IMRT Plans in Skull Base Chordomas. J Med Phys 2020; 45:206-214. [PMID: 33953495 PMCID: PMC8074721 DOI: 10.4103/jmp.jmp_45_20] [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: 06/04/2020] [Revised: 10/17/2020] [Accepted: 10/30/2020] [Indexed: 12/03/2022] Open
Abstract
PURPOSE To analyze robustness of treatment plans optimized using different approaches in intensity modulated proton therapy (IMPT) and investigate the necessity of robust optimization and evaluation in intensity modulated radiotherapy (IMRT) plans for skull base chordomas. MATERIALS AND METHODS Two photon plans, standard IMRT and robustly optimized IMRT (RB-IMRT), and two IMPT plans, robustly optimized multi field optimization (MFO) and hybrid-MFO (HB-MFO), were created in RayStation TPS for five patients previously treated using single field uniform optimization (SFO). Both set-up and range uncertainties were incorporated during robust optimization of IMPT plans whereas only set-up uncertainty was used in RB-IMRT. The dosimetric outcomes from the five planning techniques were compared for every patient using standard dose volume indices and integral dose (ID) estimated for target and organs at risk (OARs). Robustness of each treatment plan was assessed by introducing set-up uncertainties of ±3 mm along the three translational axes and, only in protons, an additional range uncertainty of ±3.5%. RESULTS All the five nominal plans provided comparable and clinically acceptable target coverage. In comparison to nominal plans, worst case decrease in D95% of clinical target volume-high risk (CTV-HR) were 11.1%, 13.5%, and 13.6% for SFO, MFO, and HB-MFO plans respectively. The corresponding values were 13.7% for standard IMRT which improved to 11.5% for RB-IMRT. The worst case increased in high dose (D1%) to CTV-HR was highest in IMRT (2.1%) and lowest in SFO (0.7%) plans. Moreover, IMRT showed worst case increases in D1% for all neurological OARs and were lowest for SFO plans. The worst case D1% for brainstem, chiasm, spinal cord, optic nerves, and temporal lobes were increased by 29%, 41%, 30%, 41% and 14% for IMRT and 18%, 21%, 21%, 24%, and 7% for SFO plans, respectively. In comparison to IMRT, RB-IMRT improved D1% of all neurological OARs ranging from 5% to 14% in worst case scenarios. CONCLUSION Based on the five cases presented in the current study, all proton planning techniques (SFO, MFO and HB-MFO) were robust both for target coverage and OARs sparing. Standard IMRT plans were less robust than proton plans in regards to high doses to neurological OARs. However, robust optimization applied to IMRT resulted in improved robustness in both target coverage and high doses to OARs. Robustness evaluation may be considered as a part of plan evaluation procedure even in IMRT.
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Affiliation(s)
| | - Lamberto Widesott
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | | | - Roberto Righetto
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | - Marco Cianchetti
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | - Marco Schwarz
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
- TIFPA - INFN, Trento, Italy
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18
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Barkousaraie AS, Ogunmolu O, Jiang S, Nguyen D. A fast deep learning approach for beam orientation optimization for prostate cancer treated with intensity-modulated radiation therapy. Med Phys 2020; 47:880-897. [PMID: 31868927 PMCID: PMC7849631 DOI: 10.1002/mp.13986] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 12/10/2019] [Accepted: 12/10/2019] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Beam orientation selection, whether manual or protocol-based, is the current clinical standard in radiation therapy treatment planning, but it is tedious and can yield suboptimal results. Many algorithms have been designed to optimize beam orientation selection because of its impact on treatment plan quality, but these algorithms suffer from slow calculation of the dose influence matrices of all candidate beams. We propose a fast beam orientation selection method, based on deep learning neural networks (DNN), capable of developing a plan comparable to those developed by the state-of-the-art column generation (CG) method. Our model's novelty lies in its supervised learning structure (using CG to teach the network), DNN architecture, and ability to learn from anatomical features to predict dosimetrically suitable beam orientations without using dosimetric information from the candidate beams. This may save hours of computation. METHODS A supervised DNN is trained to mimic the CG algorithm, which iteratively chooses beam orientations one-by-one by calculating beam fitness values based on Karush-Kush-Tucker optimality conditions at each iteration. The DNN learns to predict these values. The dataset contains 70 prostate cancer patients - 50 training, 7 validation, and 13 test patients - to develop and test the model. Each patient's data contains 6 contours: PTV, body, bladder, rectum, and left and right femoral heads. Column generation was implemented with a GPU-based Chambolle-Pock algorithm, a first-order primal-dual proximal-class algorithm, to create 6270 plans. The DNN trained over 400 epochs, each with 2500 steps and a batch size of 1, using the Adam optimizer at a learning rate of 1 × 10-5 and a sixfold cross-validation technique. RESULTS The average and standard deviation of training, validation, and testing loss functions among the six folds were 0.62 ± 0.09%, 1.04 ± 0.06%, and 1.44 ± 0.11%, respectively. Using CG and supervised DNN, we generated two sets of plans for each scenario in the test set. The proposed method took at most 1.5 s to select a set of five beam orientations and 300 s to calculate the dose influence matrices for 5 beams and finally 20 s to solve the fluence map optimization (FMO). However, CG needed around 15 h to calculate the dose influence matrices of all beams and at least 400 s to solve both the beam orientation selection and FMO problems. The differences in the dose coverage of PTV between plans generated by CG and by DNN were 0.2%. The average dose differences received by organs at risk were between 1 and 6 percent: Bladder had the smallest average difference in dose received (0.956 ± 1.184%), then Rectum (2.44 ± 2.11%), Left Femoral Head (6.03 ± 5.86%), and Right Femoral Head (5.885 ± 5.515%). The dose received by Body had an average difference of 0.10 ± 0.1% between the generated treatment plans. CONCLUSIONS We developed a fast beam orientation selection method based on a DNN that selects beam orientations in seconds and is therefore suitable for clinical routines. In the training phase of the proposed method, the model learns the suitable beam orientations based on patients' anatomical features and omits time intensive calculations of dose influence matrices for all possible candidate beams. Solving the FMO to get the final treatment plan requires calculating dose influence matrices only for the selected beams.
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Affiliation(s)
- Azar Sadeghnejad Barkousaraie
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Olalekan Ogunmolu
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Steve Jiang
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Dan Nguyen
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
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Nguyen D, McBeth R, Sadeghnejad Barkousaraie A, Bohara G, Shen C, Jia X, Jiang S. Incorporating human and learned domain knowledge into training deep neural networks: A differentiable dose-volume histogram and adversarial inspired framework for generating Pareto optimal dose distributions in radiation therapy. Med Phys 2020; 47:837-849. [PMID: 31821577 PMCID: PMC7819274 DOI: 10.1002/mp.13955] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 11/12/2022] Open
Abstract
PURPOSE We propose a novel domain-specific loss, which is a differentiable loss function based on the dose-volume histogram (DVH), and combine it with an adversarial loss for the training of deep neural networks. In this study, we trained a neural network for generating Pareto optimal dose distributions, and evaluate the effects of the domain-specific loss on the model performance. METHODS In this study, three loss functions - mean squared error (MSE) loss, DVH loss, and adversarial (ADV) loss - were used to train and compare four instances of the neural network model: (a) MSE, (b) MSE + ADV, (c) MSE + DVH, and (d) MSE + DVH+ADV. The data for 70 prostate patients, including the planning target volume (PTV), and the organs at risk (OAR) were acquired as 96 × 96 × 24 dimension arrays at 5 mm3 voxel size. The dose influence arrays were calculated for 70 prostate patients, using a 7 equidistant coplanar beam setup. Using a scalarized multicriteria optimization for intensity-modulated radiation therapy, 1200 Pareto surface plans per patient were generated by pseudo-randomizing the PTV and OAR tradeoff weights. With 70 patients, the total number of plans generated was 84 000 plans. We divided the data into 54 training, 6 validation, and 10 testing patients. Each model was trained for a total of 100,000 iterations, with a batch size of 2. All models used the Adam optimizer, with a learning rate of 1 × 10-3 . RESULTS Training for 100 000 iterations took 1.5 days (MSE), 3.5 days (MSE+ADV), 2.3 days (MSE+DVH), and 3.8 days (MSE+DVH+ADV). After training, the prediction time of each model is 0.052 s. Quantitatively, the MSE+DVH+ADV model had the lowest prediction error of 0.038 (conformation), 0.026 (homogeneity), 0.298 (R50), 1.65% (D95), 2.14% (D98), and 2.43% (D99). The MSE model had the worst prediction error of 0.134 (conformation), 0.041 (homogeneity), 0.520 (R50), 3.91% (D95), 4.33% (D98), and 4.60% (D99). For both the mean dose PTV error and the max dose PTV, Body, Bladder and rectum error, the MSE+DVH+ADV outperformed all other models. Regardless of model, all predictions have an average mean and max dose error <2.8% and 4.2%, respectively. CONCLUSION The MSE+DVH+ADV model performed the best in these categories, illustrating the importance of both human and learned domain knowledge. Expert human domain-specific knowledge can be the largest driver in the performance improvement, and adversarial learning can be used to further capture nuanced attributes in the data. The real-time prediction capabilities allow for a physician to quickly navigate the tradeoff space for a patient, and produce a dose distribution as a tangible endpoint for the dosimetrist to use for planning. This is expected to considerably reduce the treatment planning time, allowing for clinicians to focus their efforts on the difficult and demanding cases.
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Affiliation(s)
- Dan Nguyen
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Rafe McBeth
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Azar Sadeghnejad Barkousaraie
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Gyanendra Bohara
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Chenyang Shen
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Xun Jia
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Steve Jiang
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, 75390, USA
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Menon SV, Paramu R, Bhasi S, Gopalakrishnan Z, Bhaskaran S, Nair RK. Dosimetric comparison of iPlan Ⓡ Pencil Beam (PB) and Monte Carlo (MC) algorithms in stereotactic radiosurgery/radiotherapy (SRS/SRT) plans of intracranial arteriovenous malformations. Med Dosim 2020; 45:225-234. [PMID: 32001069 DOI: 10.1016/j.meddos.2019.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/11/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
Abstract
Stereotactic radiosurgery/radiotherapy (SRS/SRT) is a hypofractionated treatment where accurate dose calculation is of prime importance. The accuracy of the dose calculation depends on the treatment planning algorithm. This study is a retrospective dosimetric comparison of iPlanⓇ Monte Carlo (MC) and Pencil Beam (PB) algorithms in SRS/SRT plans of cranial arteriovenous malformations (AVMs). PB plans of 60 AVM patients who were already treated using 6 MV photons from a linear accelerator were selected and divided into 2 groups. Group-I consists of 30 patients who have undergone embolization procedure with high density OnyxⓇ prior to radiosurgery whereas Group-II had 30 patients who did not have embolization. These plans were recalculated with MC algorithm while keeping parameters like beam orientation, multileaf collimator (MLC) positions, MLC margin, prescription dose, and monitor units constant. Several treatment coverage parameters, isodose volumes, plan quality metrics, dose to organs at risk, and integral dose were used for comparing the 2 algorithms. The isodose distribution generated by the 2 algorithms was also compared with gamma analysis using 1%/1 mm criterion. The difference between the 2 groups as well as the differences in dose calculation by PB and MC algorithms were tested for significance using independent t-test and paired t-test respectively at 5% level of significance. The results of the independent t-test showed that there is no significant difference between the Group-I and Group-II patients for PB as well as MC algorithm due to the presence of high density embolization material. However, results of the paired t-test showed that the differences between the PB and MC algorithms were significant for several parameters analyzed in both groups of patients. The gamma analysis results also showed differences in the dose calculated by the 2 algorithms especially in the low dose regions. The significant differences between the 2 algorithms are probably due to the incorrect representation of the loss of lateral charged particle equilibrium and lateral broadening of small photon beams by PB algorithm. MC algorithms are generally considered not essential for dose calculations for target volumes located in the brain. This study demonstrates PB algorithm may not be sufficiently accurate to predict dose distributions for small fields where there is loss of LCPE. The lateral broadening due to the loss of LCPE as predicted by the MC algorithm could be the main reason for significant differences in the parameters compared. Hence, an accurate MC algorithm if available may prove valuable for intracranial SRS treatment planning of such benign lesions where the long life expectancy of patients makes accurate dosimetry critical.
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Affiliation(s)
- Sharika Venugopal Menon
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India.
| | - Raghukumar Paramu
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
| | - Saju Bhasi
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
| | - Zhenia Gopalakrishnan
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
| | - Sarin Bhaskaran
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
| | - Raghuram Kesavan Nair
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
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Guerreiro F, Seravalli E, Janssens GO, van den Heuvel-Eibrink MM, Lagendijk JJW, Raaymakers BW. Potential benefit of MRI-guided IMRT for flank irradiation in pediatric patients with Wilms' tumor. Acta Oncol 2019; 58:243-250. [PMID: 30523729 DOI: 10.1080/0284186x.2018.1537507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE/OBJECTIVE Flank irradiation for Wilms' tumor (WT) is currently performed at our institute using a cone-beam computed tomography-guided volumetric modulated arc (VMATCBCT) workflow. By adding real-time magnetic resonance imaging (MRI) guidance to the treatment, safety margins could be reduced. The study purpose was to quantify the potential reduction of the planning target volume (PTV) margin and its dosimetric impact when using an MRI-guided intensity modulated radiation therapy (IMRTMRI) workflow compared to the VMATCBCT workflow. MATERIAL/METHODS 4D-CT, MRI and CBCT scans acquired during preparation and treatment of 15 patients, were used to estimate both geometric, motion and patient set-up systematic (∑) and random (σ) errors for VMATCBCT and IMRTMRI workflows. The mean PTV (PTVmean) expansion was calculated using the van Herk formula. Treatment plans were generated using five margin scenarios (PTVmean ± 0, 1 and 2 mm). Furthermore, the IMRTMRI plans were optimized with a 1.5T transverse magnetic field turned-on to realistically model an MRI-guided treatment. Plans were evaluated using dose-volume statistics (p<.01, Wilcoxon). RESULTS Analysis of ∑ and σ errors resulted in a PTVmean of 5 mm for the VMATCBCT and 3 mm for the IMRTMRI workflows in each orthogonal direction. Target coverage was unaffected by the margin decrease with a mean V95%=100% for all margin scenarios. For the PTVmean, an average reduction of the mean dose to the organs at risk (OARs) was achieved with IMRTMRI compared to VMATCBCT: 3.4 ± 2.4% (p<.01) for the kidney, 3.4 ± 2.1% (p<.01) for the liver, 2.8 ± 3.0% (p<.01) for the spleen and 4.9 ± 3.8% (p<.01) for the pancreas, respectively. CONCLUSIONS Imaging data in children with WT demonstrated that the PTV margin could be reduced isotropically down to 2 mm when using the IMRTMRI compared to the VMATCBCT workflow. The former results in a dose reduction to the OARs while maintaining target coverage.
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Affiliation(s)
- F. Guerreiro
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E. Seravalli
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G. O. Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | | | - J. J. W Lagendijk
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B. W. Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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22
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Correia D, Terribilini D, Zepter S, Pica A, Bizzocchi N, Volken W, Stieb S, Ahlhelm F, Herrmann E, Fix MK, Manser P, Aebersold DM, Weber DC. Whole-ventricular irradiation for intracranial germ cell tumors: Dosimetric comparison of pencil beam scanned protons, intensity-modulated radiotherapy and volumetric-modulated arc therapy. Clin Transl Radiat Oncol 2019; 15:53-61. [PMID: 30734001 PMCID: PMC6357692 DOI: 10.1016/j.ctro.2019.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/04/2019] [Accepted: 01/06/2019] [Indexed: 10/29/2022] Open
Abstract
Background Whole-ventricular radiotherapy (WV-RT) followed by a boost to the tumor bed (WV-RT/TB) is recommended for intracranial germ cell tumors (IGCT). As the critical brain areas are mainly in the target volume vicinity, it is unclear if protons indeed substantially spare neurofunctional organs at risk (NOAR). Therefore, a dosimetric comparison study of WV-RT/TB was conducted to assess whether proton or photon radiotherapy achieves better NOAR sparing. Methods Eleven children with GCT received 24 Gy(RBE) WV-RT and a boost up to 40 Gy(RBE) in 25 fractions of 1.6 Gy(RBE) with pencil beam scanning proton therapy (PBS-PT). Intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans were generated for these patients. NOAR were delineated and treatment plans were compared for target volume coverage (TVC), homogeneity index (HI), inhomogeneity coefficient (IC) and (N)OAR sparing. Results TVC was comparable for all three modalities. Compared to IMRT and VMAT, PBS-PT showed statistically significant optimized IC, as well as dose reduction, among others, in mean and integral dose to the: normal brain (-35.2%, -32.7%; -35.2%, -33.0%, respectively), cerebellum (-53.7%, -33.1%; -53.6%, -32.7%) and right temporal lobe (-14.5%, -31.9%; -14.7%, -29.9%). The Willis' circle was better protected with PBS-PT than IMRT (-7.1%; -7.8%). The left hippocampus sparing was higher with IMRT. Compared to VMAT, the dose to the hippocampi, amygdalae and temporal lobes was significantly decreased in the IMRT plans. Conclusions Dosimetric comparison of WV-RT/TB in IGCT suggests PBS-PT's advantage over photons in conformality and NOAR sparing, whereas IMRT's superiority over VMAT, thus potentially minimizing long-term sequelae.
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Affiliation(s)
- Dora Correia
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Aargau, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Dario Terribilini
- Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stefan Zepter
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Aargau, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Aargau, Switzerland
| | - Nicola Bizzocchi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Aargau, Switzerland
| | - Werner Volken
- Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Sonja Stieb
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Frank Ahlhelm
- Department of Radiology, Cantonal Hospital Baden, Baden, Aargau, Switzerland
| | - Evelyn Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Michael K Fix
- Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Aargau, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Cosset JM, Nassef M, Saïdi R, Pugnaire J, Ben Abdennebi A, Noël A. [Which photon energy for intensity-modulated radiotherapy and volumetric-modulated arctherapy in 2019?]. Cancer Radiother 2018; 23:58-61. [PMID: 30551930 DOI: 10.1016/j.canrad.2018.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 01/02/2023]
Abstract
For more than a decade, the majority of radiation oncology centres have been delivering intensity-modulated radiotherapy (then volumetric-modulated arctherapy) with 6 MV photons as their standard of care. This « dogma » had been supported by the usual absence of dosimetric advantages with high-energy photons (15 to 18 MV or more), at least for the planning target volume and the dose received by the adjacent organs at risk, and by the neutron component as soon as the photon energy exceeds 10 MV. Recent data could question such a dogma. First, in 2019, one cannot avoid taking into account the integral dose, delivered outside the treated volume. Actually, most available data show that integral dose is higher with low energy photons (as 6 MV) than with higher energies. Moreover, recent studies have shown that the neutron component at high energies may have been overestimated in the past; in fact, the neutron dose appears to be lower, and sometimes much lower, than the dose we accept for imaging. Finally, a few cohort studies did not show any increase in second cancers incidence after high-energy photon radiotherapy. In such a context, the American Association of Physicists in Medicine (AAPM) TG 158 document, released a few months ago, clearly states that there is a trade-off between high- and low-energy treatments. High-energy therapy is associated with neutron production, while low-energy therapy results in higher stray photon dose. According to the AAPM, « the optimal energy is likely an intermediate such as 10 MV ».
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Affiliation(s)
- J-M Cosset
- GIE Charlebourg, Amethyst group, 65, avenue Foch, 92250 La Garenne-Colombes, France.
| | - M Nassef
- GIE Charlebourg, Amethyst group, 65, avenue Foch, 92250 La Garenne-Colombes, France
| | - R Saïdi
- GIE Charlebourg, Amethyst group, 65, avenue Foch, 92250 La Garenne-Colombes, France
| | - J Pugnaire
- GIE Charlebourg, Amethyst group, 65, avenue Foch, 92250 La Garenne-Colombes, France
| | - A Ben Abdennebi
- CNS CROM Compiègne, Amethyst group, 3, rue Jean-Jacques-Bernard, 60200 Compiègne, France
| | - A Noël
- Campus Sciences, centre de recherche en automatique de Nancy (Cran), BP 70239, 54506 Vandœuvre-lès-Nancy cedex, France; Campus Sciences, université de Lorraine, UMR 7039, BP 70239, 54506 Vandœuvre-lès-Nancy cedex, France; CNRS, UMR7039, Campus Sciences, BP 70239, 54506 Vandœuvre-lès-Nancy cedex, France
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24
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Haefner MF, Verma V, Bougatf N, Mielke T, Tonndorf-Martini E, König L, Rwigema JCM, Simone 2nd CB, Uhlmann L, Eichhorn F, Winter H, Grosch H, Haberer T, Herfarth K, Debus J, Rieken S. Dosimetric comparison of advanced radiotherapy approaches using photon techniques and particle therapy in the postoperative management of thymoma. Acta Oncol 2018; 57:1713-1720. [PMID: 30264630 DOI: 10.1080/0284186x.2018.1502467] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The purpose of this study was to compare dosimetric differences related to target volume and organs-at-risk (OAR) using 3D-conformal radiotherapy (3DCRT), volumetric modulated arc therapy (VMAT), TomoTherapy (Tomo), proton radiotherapy (PRT), and carbon ion radiotherapy (CIRT) as part of postoperative thymoma irradiation. MATERIAL AND METHODS This single-institutional analysis included 10 consecutive patients treated with adjuvant radiotherapy between December 2013 and September 2016. CT-datasets and respective RT-structures were anonymized and plans for all investigated RT modalities (3DCRT, VMAT, Tomo, PRT, CIRT) were optimized for a total dose of 50 Gy in 25 fractions. Comparisons between target volume and OAR dosimetric parameters were performed using the Wilcoxon rank-sum test. RESULTS The best target volume coverage (mean PTV V95% for all patients) was observed for Tomo (97.9%), PRT (97.6%), and CIRT (96.6%) followed by VMAT (85.4%) and 3DCRT (74.7%). PRT and CIRT both significantly reduced mean doses to the lungs, breasts, heart, and esophagus, as well as the spinal cord maximum dose compared with photon modalities. Among photon-based techniques, VMAT showed improved OAR sparing over 3DCRT. Tomo was associated with considerable low-dose exposure to the lungs, breasts, and heart. CONCLUSIONS Particle radiotherapy (PRT, CIRT) showed superior OAR sparing and optimal target volume coverage. The observed dosimetric advantages are expected to reduce toxicity rates. However, their clinical impact must be investigated prospectively.
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Affiliation(s)
- Matthias Felix Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Nina Bougatf
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Thomas Mielke
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Eric Tonndorf-Martini
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | | | - Charles B. Simone 2nd
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg, Germany
| | - Florian Eichhorn
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Heidrun Grosch
- Department of Thoracic Oncology, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
- National Center of Radiation Research in Oncology (NCRO) Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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Atiq A, Atiq M, Iqbal K, Sial MA, Altaf S, Shamsi QA, Buzdar SA. A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment. Indian J Cancer 2018; 55:74-79. [PMID: 30147098 DOI: 10.4103/ijc.ijc_609_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. Aims This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. Materials and Methods Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. Results and Conclusion RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.
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Affiliation(s)
- Atia Atiq
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Maria Atiq
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Khalid Iqbal
- Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan
| | - Manzar A Sial
- Department of Bioscience, King Abdullah University of Science and Technology, Thuwal, Kingdom of Saudi Arabia
| | - Saima Altaf
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Quratul Ain Shamsi
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Saeed A Buzdar
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
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Wong KK, Ragab O, Tran HN, Pham A, All S, Waxer J, Olch AJ. Acute toxicity of craniospinal irradiation with volumetric-modulated arc therapy in children with solid tumors. Pediatr Blood Cancer 2018; 65:e27050. [PMID: 29630782 DOI: 10.1002/pbc.27050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/30/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is an important part of curative radiation therapy (RT) for many types of pediatric brain or solid tumors. After conventional CSI, long term survivors may experience sequelae due to unintended dose to normal tissue. Volumetric modulated arc therapy (VMAT) CSI reduces off-target doses at the cost of greater complexity and error risk, and we describe our initial experience in a group of pediatric patients with solid tumors presenting with disseminated or recurrent disease. PROCEDURE Pediatric patients with brain tumors were identified at Children's Hospital Los Angeles from 2013 to 2015. Clinical characteristics, acute toxicity, and radiotherapy data were abstracted from their medical records. We identified 19 patients who received VMAT CSI. Quality assurance was performed with a cylindrical detector array and ion chamber measurements at the arc junctions. RESULTS Patients had medulloblastoma or supratentorial primitive neuro-ectodermal tumor (n = 14, 11 high risk), germ cell tumors (two), relapsed neuroblastoma (two), and atypical teratoid/rhabdoid tumor (one). The most common acute toxicity was hematologic, including leukopenia (11% grade [Gr] 2, 26% Gr 3, and 63% Gr 4), anemia (89% Gr 2), and thrombocytopenia (16% Gr 1-2, 26% Gr 3, and 37% Gr 4). Despite leukopenia, we encountered only two Gr 3 infections (urinary tract and lung). The majority required blood products (89% red blood cells and 68% platelets). Weight loss was also common (47% Gr 1 and 26% Gr 2). CONCLUSIONS VMAT CSI, along with chemotherapy and anesthesia, is feasible with supportive care. Daily image-guided RT improves accuracy and reduces the risk of spinal cord overdose without increasing treatment time. Further research is needed to determine whether reducing doses to organs, such as thyroid, heart, or hippocampus, offsets the risk of increased volume of low-dose irradiation.
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Affiliation(s)
- Kenneth K Wong
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Omar Ragab
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Hung N Tran
- Pediatric Neuro-Oncology, Department of Pediatrics, Kaiser Permanente, Los Angeles, California
| | - Anthony Pham
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- College of Medicine, University of Central Florida, Orlando, Florida
| | - Jonathan Waxer
- School of Medicine, Tulane University, New Orleans, Louisiana
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
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27
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Tamilarasu S, Saminathan M, Sharma SK, Pahuja A, Dewan A. Comparative Evaluation of a 6MV Flattened Beam and a Flattening Filter Free Beam for Carcinoma of Cervix – IMRT
Planning Study. Asian Pac J Cancer Prev 2018; 19:639-643. [PMID: 29580032 PMCID: PMC5980834 DOI: 10.22034/apjcp.2018.19.3.639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose: Intensity modulated radiotherapy (IMRT) plan quality, beam on time and integral dose were compared using 6MV FB (Flattened Beam) and FFFB (Flattening filter free beam) for carcinoma of cervix. Materials and Methods: Ten patients with stage II–IIIB cervix cancer (Ca.Cx) were retrospectively identified from the department database. Target volume (TV) and organ at risk (OAR) were delineated as per Radiation Therapy Oncology Group (RTOG) cancer guidelines. Dose prescribed to planning target volume (PTV) was 50.4Gy in 28 fractions. Two plans (6MV FB IMRT and 6MV FFFB IMRT) were generated to achieve 95% of prescription dose to PTV and sparing OAR as per normal tissue guidelines. Numbers of beams and their orientations were the same for all plans. The homogeneity index (HI), conformity index (CI), treatment monitor unit (MU), beam on time (BOT) and non-tumor integral dose (NTID) were chosen for comparison. Results: FFFB generated plans were clinically acceptable. There was a statistically significant difference among the FB IMRT and FFFB IMRT plans with respect to CI, HI, D50%, D2% in PTV coverage, bladder V50Gy, MU, mean NTID and non-tumor low dose volume. Conclusions: 6MV flattened and flattening filter free photon beams produce comparable plans by IMRT. FFF beams allow time efficient treatment delivery and may help reduce the risk of secondary malignances in carcinoma cervix cases.
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Affiliation(s)
- Suresh Tamilarasu
- Department of Radiotherapy, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India.
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28
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Mascarin M, Drigo A, Dassie A, Gigante M, Franchin G, Sartor G, Trovò MG. Optimizing Craniospinal Radiotherapy Delivery in a Pediatric Patient Affected by Supratentorial PNET: A Case Report. TUMORI JOURNAL 2018; 96:316-21. [DOI: 10.1177/030089161009600221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
New advances in radiation therapy for children allow increased conformability and reduced doses to non-target tissues. We report our experience in treating a 4-year-old child with craniospinal tomotherapy after surgery of the primary tumor, a supratentorial primitive neuroectodermal tumor. The tomotherapy plan was compared with conventional craniospinal irradiation, 3D conformal radiation therapy, and intensity-modulated radiation therapy plans. The possible disadvantages of tomotherapy related to the radiation dose to organs at risk, treatment planning, and anesthesia should be carefully considered as the use of the technique is not suggested in a general manner, but selectively, in critical pediatric radiotherapy cases.
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Affiliation(s)
- Maurizio Mascarin
- Pediatric Radiotherapy Unit and Divisions of Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Annalisa Drigo
- Medical Physics, Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Andrea Dassie
- Medical Physics, Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Marco Gigante
- Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Giovanni Franchin
- Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Giovanna Sartor
- Medical Physics, Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
| | - Mauro G Trovò
- Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano (PN), Italy
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29
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Daniela Falco M, Giancaterino S, D'Andrea M, Gimenez De Lorenzo R, Trignani M, Caravatta L, Di Carlo C, Di Biase S, Allajbej A, Genovesi D. Hippocampal sparing approach in fractionated stereotactic brain VMAT radio therapy: A retrospective feasibility analysis. J Appl Clin Med Phys 2017; 19:86-93. [PMID: 29125239 PMCID: PMC5768008 DOI: 10.1002/acm2.12216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/13/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022] Open
Abstract
Volumetric Modulated Arc Therapy (VMAT) techniques for fractioned stereotactic brain radiotherapy (FSBRT) can achieve highly conformal dose distribution to intracranial lesions. However, they can potentially increase the dose to hippocampus (H) causing neurocognitive toxicity during the first four months after irradiation. The purpose of this study was to assess the feasibility of hippocampal‐sparing (HS) treatment plans in 22 patients with brain metastasis treated with VMAT technique. Firstly, we retrospectively analyzed hippocampal doses in all 22 VMAT original (not hippocampal‐sparing, NHS) plans. Plans with hippocampal dose exceeding constraints (9 out of 22) were re‐planned considering dose constraints on the hippocampus (H) and on hippocampal avoidance zone (HAZ) generated using 5 mm isotropic margin to the hippocampus. Conformity (CI) and homogeneity indexes (HI) on the target and MUs, were maintained as close as possible to the original plans. Mean CINHS and CIHS obtained were: 0.79 ± 0.11 and 0.81 ± 0.10, respectively (P = 0.75); mean HINHS and HIHS were 1.05 ± 0.02 and 1.04 ± 0.01 respectively (P = 0.72). In both sets of plans, the mean MU values were similar: 1033 ± 275 and 1022 ± 234 for NHS and HS respectively. In HS plans, the mean hippocampal dose was decreased by an average of 35%. After replanning, the Dmax (21.3 Gy) for HAZ and H was met by 45% (4/9) and 78% (7/9) of the NHS plans, respectively. The worst results were obtained for cases with target volumes extention closer than 12 mm to H, because of the difficulty to spare hippocampus without compromising target coverage. After replanning D40% constraint value (7.3 Gy) was met by all the 9 NHS plans. In conclusion, this study suggests that an hippocampal‐sparing approach to FSBRT is feasible resulting in a decrease in the dose to the hippocampus without any loss in conformity or increase in treatment time.
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Affiliation(s)
- Maria Daniela Falco
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Stefano Giancaterino
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Marco D'Andrea
- Laboratory of Medical Physics and Expert Systems, National Cancer Center Institute Regina Elena, Rome, Italy
| | - Ramon Gimenez De Lorenzo
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Marianna Trignani
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Clelia Di Carlo
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Saide Di Biase
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Albina Allajbej
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, "G. D'Annunzio" University of Chieti, SS. Annunziata Hospital, Chieti, Italy
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Zaleska A, Bogaczyk K, Piotrowski T. Influence of optimizing protocol choice on the integral dose value in prostate radiotherapy planning by dynamic techniques - Pilot study. Rep Pract Oncol Radiother 2017; 22:415-419. [PMID: 28855852 DOI: 10.1016/j.rpor.2017.04.003] [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: 09/17/2016] [Revised: 12/27/2016] [Accepted: 04/19/2017] [Indexed: 11/16/2022] Open
Abstract
AIM The purpose of this study was to compare the values of integral dose, calculated for treatment plans of dynamic radiotherapy techniques prepared with two different optimization protocols. BACKGROUND Delivering radiation by IMRT, VMAT and also HT techniques has an influence on the low dose deposition of large areas of the patient body. Delivery of low dose can induce injury of healthy cells. In this situation, a good solution would be to reduce the area, which receives a low dose, but with appropriate dose level for the target volume. MATERIALS AND METHODS To calculate integral dose values of plans structures, we used 90 external beam radiotherapy plans prepared for three techniques (intensity modulated radiotherapy, volumetric modulated arc therapy and helical tomotherapy). One technique includes three different geometry combinations. 45 plans were prepared with classic optimization protocol and 45 with rings optimization protocol which should reduce the low doses in the normal tissue. RESULTS Differences in values of the integral dose depend on the geometry and technique of irradiation, as well as optimization protocol used in preparing treatment plans. The application of the rings optimization caused the value of normal tissue integral dose (NTID) to decrease. CONCLUSION It is possible to limit the area of low dose irradiation and reduce NTID in dynamic techniques with the same clinical constraints for OAR and PTV volumes by using an optimization protocol other than the classic one.
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Affiliation(s)
- Anna Zaleska
- Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
- Faculty of Physics, University of Warsaw, Warsaw, Poland
| | | | - Tomasz Piotrowski
- Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
- Department of Electroradiology, University of Medical Sciences, Poznan, Poland
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31
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Dosimetric comparison of helical tomotherapy using different techniques, simultaneous integrated boost and sequential boost for craniospinal irradiation: a single institution experience. JOURNAL OF RADIOTHERAPY IN PRACTICE 2017. [DOI: 10.1017/s1460396917000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeCraniospinal irradiation (CSI) has become an important and challenging radiation technique for radiation oncologists. Helical tomotherapy (HT) seems to have dosimetric advantage for CSI compared with other radiation modalities. The purpose of this study was to compare dosimetric data between two different HT plans; simultaneous integrated boost (SIB) and sequential boost (Sq).MethodTwelve previously treated CSI contoured datasets by SIB technique were replanned. Dosimetric comparative parameters of targets were conformity index (CI) and homogeneity index (HI). For organ at risk (OARs), the mean dose of parallel organs, D2% of serial organs and whole body integral dose (ID) were also investigated.ResultSIB plan significantly provided more conformed dose to CSI and tumour boost while resulting in a similar CI in spinal boost region compared with Sq plan. The HI showed no differences between two plans. Radiation exposure to serial organs and ID were also significantly lower in SIB plan.ConclusionCSI treatment using HT, SIB technique was feasible and had more target coverage while minimising the radiation dose to healthy tissues.
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32
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Kontaxis C, Bol GH, Kerkmeijer LGW, Lagendijk JJW, Raaymakers BW. Fast online replanning for interfraction rotation correction in prostate radiotherapy. Med Phys 2017; 44:5034-5042. [DOI: 10.1002/mp.12467] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/05/2017] [Accepted: 07/06/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
- Charis Kontaxis
- Department of Radiotherapy; University Medical Center Utrecht; Heidelberglaan 100 Utrecht 3584 CX The Netherlands
| | - Gijsbert H. Bol
- Department of Radiotherapy; University Medical Center Utrecht; Heidelberglaan 100 Utrecht 3584 CX The Netherlands
| | - Linda G. W. Kerkmeijer
- Department of Radiotherapy; University Medical Center Utrecht; Heidelberglaan 100 Utrecht 3584 CX The Netherlands
| | - Jan J. W. Lagendijk
- Department of Radiotherapy; University Medical Center Utrecht; Heidelberglaan 100 Utrecht 3584 CX The Netherlands
| | - Bas W. Raaymakers
- Department of Radiotherapy; University Medical Center Utrecht; Heidelberglaan 100 Utrecht 3584 CX The Netherlands
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33
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Tamilarasu S, Saminathan M, Sharma SK, P A, Dewan A. Treatment Planning With Unflattened as Compared to Flattened
Beams for Bilateral Carcinoma of the Breast. Asian Pac J Cancer Prev 2017; 18:1377-1381. [PMID: 28612590 PMCID: PMC5555550 DOI: 10.22034/apjcp.2017.18.5.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aim: To evaluate the plan quality of 6MV unflattened (UFB) and flattened beam (FB) photon energy using AAA dose calculation algorithms for volumetric arc therapy. Materials and Methods: Plans were generated for bilateral carcinoma of breast and the dose prescribed was 50.4Gy in 28 fractions. Two different plans were made for each patient using 6MV FB and 6MV UFB. Dose calculations were performed on an AAA dose calculation algorithm. Plans were generated on Eclipse TPS and were capable of being delivered with a true beam STx linear accelerator. The homogeneity index (HI), conformity index (CI), normal tissue integral dose (NTID), and effect of low dose volume on normal tissue and monitor units (MU) were noted. Results: All the plans were clinically acceptable. The HI and CI of 6MV UF rapid arc (RA) plans were higher than with the 6MV FB plan (1.16±0.05 and 0.12±0.00 respectively). There was no appreciable difference observed in Organ at risk (OAR) doses. The mean NTID and low dose volume were significantly low with 6MV RA UFB as compared to FB. 6MV RA UFB required a 35% higher MU than with the 6MV RA plan (p<0.05). Conclusion: RA plans generated with UFB on Eclipse TPS achieved target volume coverage and preserved OAR’s essentially similar to 6MV RA FB plans. However RA plans generated in Varian Eclipse of UFB were superior with respect to mean NTID and low dose volumes in normal tissue.
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Affiliation(s)
- Suresh Tamilarasu
- Department of Radiotherapy, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
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Mihaylov IB. Integral Dose-Based Inverse Optimization May Reduce Side Effects in Radiotherapy of Prostate Carcinoma. Front Oncol 2017; 7:27. [PMID: 28299284 PMCID: PMC5331038 DOI: 10.3389/fonc.2017.00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/15/2017] [Indexed: 12/01/2022] Open
Abstract
PURPOSE The purpose of this work is to apply a novel inverse optimization approach, based on utilization of quantitative imaging information in the optimization function, to prostate carcinoma. MATERIALS AND METHODS This new inverse optimization algorithm relies upon quantitative information derived from computed tomography (CT) imaging studies. The Hounsfield numbers of the CT voxels are converted to physical density, which in turn is used to calculate voxel mass and the corresponding integral dose, by summation over the product of dose and mass in each dose voxel. This integral dose is used for plan optimization through its global minimization. The optimization results are compared to the optimization results derived from most commonly used dose-volume-based inverse optimization, where objective functions are formed as summation over all dose voxels of the squared differences between voxel doses and user specified doses. The data from 25 prostate plans were optimized with dose-volume histogram (DVH) and integral dose (energy) minimization objective functions. The results obtained with the energy- and DVH-based optimization schemes were studied through commonly used dosimetric indices (DIs). Statistical equivalence tests were further performed to establish population-based significance results. RESULTS Both DVH- and energy-based plans for each case were normalized so that 95% of the planning target volume receives the prescription dose. The average differences for the rectum and bladder DIs ranged from 1.6 to 25%, where the energy-based quantities were lower. For both femoral heads, the energy-based optimization-derived doses were lower on average by 32%. The statistical tests demonstrated that the significant differences in the tallied dose indices range from 2.7% to more than 50% for rectum, bladder, and femoral heads. CONCLUSION For majority of the clinically relevant dosimetric quantities, energy-based inverse optimization performs better than the standard of care DVH-based optimization in prostate carcinoma. The population averaged statistically significant differences range from ~3 to ~50%. Therefore, this newly proposed optimization approach, incorporating explicitly quantitative imaging information in the inverse optimization function, holds potential for further reduction of complication rates in prostate cancer.
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Jouglar E, Wagner A, Delpon G, Campion L, Meingan P, Bernier V, Demoor-Goldschmidt C, Mahé MA, Lacornerie T, Supiot S. Can We Spare the Pancreas and Other Abdominal Organs at Risk? A Comparison of Conformal Radiotherapy, Helical Tomotherapy and Proton Beam Therapy in Pediatric Irradiation. PLoS One 2016; 11:e0164643. [PMID: 27764132 PMCID: PMC5072698 DOI: 10.1371/journal.pone.0164643] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/28/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Late abdominal irradiation toxicity during childhood included renal damage, hepatic toxicity and secondary diabetes mellitus. We compared the potential of conformal radiotherapy (CRT), helical tomotherapy (HT) and proton beam therapy (PBT) to spare the abdominal organs at risk (pancreas, kidneys and liver- OAR) in children undergoing abdominal irradiation. METHODS We selected children with abdominal tumors who received more than 10 Gy to the abdomen. Treatment plans were calculated in order to keep the dose to abdominal OAR as low as possible while maintaining the same planned target volume (PTV) coverage. Dosimetric values were compared using the Wilcoxon signed-rank test. RESULTS The dose distribution of 20 clinical cases with a median age of 8 years (range 1-14) were calculated with different doses to the PTV: 5 medulloblastomas (36 Gy), 3 left-sided and 2 right-sided nephroblastomas (14.4 Gy to the tumor + 10.8 Gy boost to para-aortic lymphnodes), 1 left-sided and 4 right-sided or midline neuroblastomas (21 Gy) and 5 Hodgkin lymphomas (19.8 Gy to the para-aortic lymphnodes and spleen). HT significantly reduced the mean dose to the whole pancreas (WP), the pancreatic tail (PT) and to the ipsilateral kidney compared to CRT. PBT reduced the mean dose to the WP and PT compared to both CRT and HT especially in midline and right-sided tumors. PBT decreased the mean dose to the ispilateral kidney but also to the contralateral kidney and the liver compared to CRT. Low dose to normal tissue was similar or increased with HT whereas integral dose and the volume of normal tissue receiving at least 5 and 10 Gy were reduced with PBT compared to CRT and HT. CONCLUSION In children undergoing abdominal irradiation therapy, proton beam therapy reduces the dose to abdominal OAR while sparing normal tissue by limiting low dose irradiation.
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Affiliation(s)
- Emmanuel Jouglar
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Antoine Wagner
- Department of Medical Physics, Centre Oscar Lambret, 3 rue Frédéric Combemale, Lille, 59000 France
| | - Grégory Delpon
- Department of Medical Physics, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Loïc Campion
- Department of Statistics, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint-Herblain, 44800 France
| | - Philippe Meingan
- Department of Radiology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint-Herblain, 44800 France
| | - Valérie Bernier
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, Vandœuvre-lès-Nancy, 54519 France
| | - Charlotte Demoor-Goldschmidt
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Marc-André Mahé
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Thomas Lacornerie
- Department of Medical Physics, Centre Oscar Lambret, 3 rue Frédéric Combemale, Lille, 59000 France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
- * E-mail:
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Kumar L, Yadav G, Samuvel KR, Bhushan M, Kumar P, Suhail M, Pal M. Dosimetric influence of filtered and flattening filter free photon beam on rapid arc (RA) radiotherapy planning in case of cervix carcinoma. Rep Pract Oncol Radiother 2016; 22:10-18. [PMID: 27790073 DOI: 10.1016/j.rpor.2016.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 04/09/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
AIM To investigate the dosimetric influence of filtered and flattening filter free (FFF) photon beam of 6 and 10 MV energies on cervix RA radiotherapy planning and to find possibilities to develop the clinically acceptable RA plans with FFFB photon beam and explore their potential benefits to cervix cancer patients. BACKGROUND FFF photon beams enhances the treatment delivery by increased dose rate which results in shorter treatment time, this shorter treatment time reduces intrafraction motion and enhance comfort to the patients. MATERIALS AND METHODS RA plans were generated for filtered and flattening filter free photon beams of 6 and 10 MV energies using same dose-volumes constraints. RA plans were generated to deliver a dose of 50.4 Gy in 28 fractions, for a cohort of eleven patients reported with cervix carcinoma. RA plans were evaluated in terms of PTV coverage, dose to OAR's, CI, HI, total no. of monitor units (MUs) and NTID and low dose volume of normal tissues. RESULTS Clinically acceptable and similar plans were generated for filtered and flattening filter free photon beams. FFFB delivered slightly higher mean target dose (52.28 Gy vs. 52.0 Gy, p = 0.000 for 6 MV and 52.42 Gy vs. 52.0 Gy, p = 0.000 for 10 MV) less homogeneous (1.062 vs. 1.052, p = 0.000 for 6 MV and 1.066 vs. 1.051, p = 0.000 for 10 MV) and less conformal (1.007 vs. 1.004, p = 0.104 for 6 MV and 1.012 vs. 1.003, p = 0.010 for 10 MV) RA plans compared to FB. FFFB delivered more doses to the bladder and rectum, also required more numbers of MUs in comparison to FB. CONCLUSIONS This study concludes that FB is more beneficial for cervix RA planning in comparison to FFFB, as FB generates more conformal and homogenous rapid arc plans and offers better OAR's sparing.
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Affiliation(s)
- Lalit Kumar
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Girigesh Yadav
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Kothanda Raman Samuvel
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Manindra Bhushan
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Pawan Kumar
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Mahammood Suhail
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
| | - Manoj Pal
- Medical Physics Division & Radiotherapy Department, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi 110085, India
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Mihaylov IB. New approach in lung cancer radiotherapy offers better normal tissue sparing. Radiother Oncol 2016; 121:316-321. [PMID: 27692398 DOI: 10.1016/j.radonc.2016.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/27/2016] [Accepted: 09/04/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Medical images are more than pictures. They contain additional quantitative information which can be interrogated, quantified, and utilized. Besides anatomical information computed tomography (CT) imaging data provide electron density information. Radiotherapy use of this density information is limited to its application only in dose calculations. The direct product of dose, density, and volume forms a quantity called integral dose. The integral dose delivered to a volume of interest is the total energy deposited in that volume. Here it is hypothesized that minimization of the integral dose is advantageous in radiotherapy planning. The purpose of this work is to study the incorporation of quantitative imaging information in radiotherapy inverse optimization through total energy minimization (Energy hereafter). DESIGN Twenty lung patient plans were studied. For each patient density was quantified on voxel-by-voxel basis through image gray value-to-density conversion curves. Energy-based objective function was used for inverse radiotherapy plan optimization. The obtained plans were evaluated in the light of current standard of care, based on dose-volume (DVH) optimization approach. RESULTS The statistical significance analyses of the results indicated that the doses to normal tissue were between 14% and 45% lower, when Energy-based optimization was used instead of DVH-based optimization. CONCLUSION Incorporation of quantitative imaging information, through CT derived density, in the optimization cost function allows reduction of dose to normal tissue for NSCLC cases. Energy-based radiotherapy plans result in lower normal tissue dose and potentially lower complication rates compared to standard of care.
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Affiliation(s)
- Ivaylo B Mihaylov
- Department of Radiation Oncology, University of Miami, United States.
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Harrabi SB, Bougatf N, Mohr A, Haberer T, Herfarth K, Combs SE, Debus J, Adeberg S. Dosimetric advantages of proton therapy over conventional radiotherapy with photons in young patients and adults with low-grade glioma. Strahlenther Onkol 2016; 192:759-769. [PMID: 27363701 PMCID: PMC5080304 DOI: 10.1007/s00066-016-1005-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/20/2016] [Indexed: 12/26/2022]
Abstract
Background and purpose Low-grade glioma (LGG) is a very common brain tumor in pediatric patients typically associated with a very good prognosis. This prognosis makes it imperative that the risk of long-term treatment-related side effects be kept at an absolute minimum. Proton therapy (PRT) provides a radiation technique that has the potential to further reduce the genesis of radiogenic impairment. Materials and methods We retrospectively assessed 74 patients with LGG who underwent PRT. Conventional three-dimensional photon and PRT plans were generated after contouring structures of neurogenesis, crucial neuronal structures, and areas susceptible to secondary malignancies. Target volume coverage was evaluated using the homogeneity index (HI) and inhomogeneity coefficient (IC). Results were compared using the Wilcoxon-signed rank test, with p < 0.05 being statistically significant. Results Target volume coverage was comparable for the photon and proton plans. Overall, we could show an essential reduction in maximal, mean, and integral doses in critical neurologic structures, areas of neurogenesis, and structures of neurocognitive function. The study indicated specifically how contralaterally located structures could be spared with PRT. Conclusion PRT is a highly conformal radiation technique offering superior dosimetric advantages over conventional radiotherapy by allowing significant dose reduction for organs at risk (OAR) that are essential for neurologic function, neurocognition, and quality of life, thus demonstrating the potential of this technique for minimizing long-term sequelae.
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Affiliation(s)
- S B Harrabi
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - N Bougatf
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - A Mohr
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - T Haberer
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - K Herfarth
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - S E Combs
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany.,Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (dktk), Munich, Germany
| | - J Debus
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - S Adeberg
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany. .,Dept. of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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Comparison of dosimetric parameters and acute toxicity of intensity-modulated and three-dimensional radiotherapy in patients with cervix carcinoma: A randomized prospective study. Cancer Radiother 2016; 20:370-6. [PMID: 27368915 DOI: 10.1016/j.canrad.2016.05.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/05/2016] [Accepted: 05/13/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE The use of intensity-modulated radiotherapy (IMRT) to treat cervix carcinoma has increased, however prospective randomized trials are still lacking. AIM To compare the dosimetric parameters and associated acute toxicity in patients with cervix carcinoma treated with three-dimensional (3D) conformal radiotherapy and IMRT. PATIENTS AND METHODS Forty patients were randomized in two arms each consisting of 20 patients. Patients in both arms received concurrent chemoradiation (cisplatin 40mg/m(2) weekly; 50Gy/25 fractions). Patients were treated with 3D conformal radiotherapy in one arm and with IMRT in another arm. After external beam radiotherapy, all patients received brachytherapy (21Gy/3 fractions at weekly interval). For dosimetric comparison, both kinds of the plans were done for all the patients. All patients were assessed throughout and until 90 days after completion of treatment for acute gastrointestinal, genitourinary and hematologic toxicities. RESULTS Both plans achieved adequate planning target volume coverage, while mean conformity index was found significantly better in IMRT plans (P-value=0.001). D35 (dose to 35% volume) and D50 for bladder was reduced by 14.62 and 32.57% and for rectum by 23.82 and 43.68% in IMRT. For IMRT, V45 (volume receiving 45Gy) of bowel were found significantly lesser (P-value=0.0001), non-tumour integral dose was found significantly higher (P-value=0.0240) and V20 of bone marrow was found significantly reduced (P-value=0.019) in comparison to that in 3D conformal radiotherapy. Significant reduction of grade 2 or more (20 vs 45%; P-value=0.058) and grade≥3 (5 vs 15%, P-value=0.004) acute genitourinary toxicity and grade 2 or more (20 vs 45%, P-value=0.003) and grade 3 or more (5 vs. 20%, P-value=0.004) acute gastrointestinal toxicity while no significant difference for grade 2 and 3 or more haematological toxicity was noted in patients treated with IMRT compared to 3D conformal radiotherapy. CONCLUSION IMRT provide a good alternative for treatment of cervix carcinoma with lower acute gastrointestinal and acute genitourinary toxicity with similar target coverage compared to 3D conformal radiotherapy.
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Peñagarícano JA, Shi C, Ratanatharathorn V. Evaluation of Integral Dose in Cranio-spinal Axis (CSA) Irradiation with Conventional and Helical Delivery. Technol Cancer Res Treat 2016; 4:683-9. [PMID: 16292889 DOI: 10.1177/153303460500400613] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In cranio-spinal axis (CSA) irradiation, patients are usually treated in the prone position with junctions between cranial and spinal fields. Collimator angle and pedestal rotations are introduced to obtain coplanar alignment of the matched junction. Furthermore, daily moving junctions are commonly used to feather out the junctional dose as additional safe-guards to avoid radiation myelopathy. Helical tomotherapy integrates linear accelerator and CT technology capable of delivering CSA treatment without geometric matches or feathering of junctions. The patient is treated with helical beams in the supine position. Since CSA is used mainly in the pediatric population, the potential increase in integral dose to structures or the whole body from linac- or tomotherapy-based IMRT raises concerns of increased rates of secondary malignancies. In this study, we will present an integral dose comparison between conventional CSA (3D) and helical delivery to the CSA (TOMO) utilizing the Tomotherapy Hi-ART system for three pediatric patients. Integral dose was calculated for organ at risk (OAR), two targets (PTV-BRAIN and PTV-SPINE), entire planning CT data set and to the healthy tissue (entire CT-DATA SET minus the PTV). Overall integral dose was 8% higher in the TOMO plans for Patients #1 and #3, but 2% lower in Patient #2. DVH analysis shows that TOMO plans give lower doses to larger volumes and higher doses to smaller volumes of tissue in all three cases. The advantages of the TOMO plans are minimization of matched junctions and better sparing of most OARs. With increased computational and memory power in the tomotherapy planning station, the excess integral dose to the healthy tissue can be re-distributed within the patient and in turn the total integral dose can be same or lower than in conventional delivery. The impact of a small increase in overall integral dose and the associated risks of secondary malignancies are unknown. Long-term follow-up is needed to answer this question.
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Affiliation(s)
- José A Peñagarícano
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, 72205, USA.
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Intensity-modulated proton therapy, volumetric-modulated arc therapy, and 3D conformal radiotherapy in anaplastic astrocytoma and glioblastoma : A dosimetric comparison. Strahlenther Onkol 2016; 192:770-779. [PMID: 27334276 DOI: 10.1007/s00066-016-1007-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/20/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE The prognosis for high-grade glioma (HGG) patients is poor; thus, treatment-related side effects need to be minimized to conserve quality of life and functionality. Advanced techniques such as proton radiation therapy (PRT) and volumetric-modulated arc therapy (VMAT) may potentially further reduce the frequency and severity of radiogenic impairment. MATERIALS AND METHODS We retrospectively assessed 12 HGG patients who had undergone postoperative intensity-modulated proton therapy (IMPT). VMAT and 3D conformal radiotherapy (3D-CRT) plans were generated and optimized for comparison after contouring crucial neuronal structures important for neurogenesis and neurocognitive function. Integral dose (ID), homogeneity index (HI), and inhomogeneity coefficient (IC) were calculated from dose statistics. Toxicity data were evaluated. RESULTS Target volume coverage was comparable for all three modalities. Compared to 3D-CRT and VMAT, PRT showed statistically significant reductions (p < 0.05) in mean dose to whole brain (-20.2 %, -22.7 %); supratentorial (-14.2 %, -20,8 %) and infratentorial (-91.0 %, -77.0 %) regions; brainstem (-67.6 %, -28.1 %); pituitary gland (-52.9 %, -52.5 %); contralateral hippocampus (-98.9 %, -98.7 %); and contralateral subventricular zone (-62.7 %, -66.7 %, respectively). Fatigue (91.7 %), radiation dermatitis (75.0 %), focal alopecia (100.0 %), nausea (41.7 %), cephalgia (58.3 %), and transient cerebral edema (16.7 %) were the most common acute toxicities. CONCLUSION Essential dose reduction while maintaining equal target volume coverage was observed using PRT, particularly in contralaterally located critical neuronal structures, areas of neurogenesis, and structures of neurocognitive functions. These findings were supported by preliminary clinical results confirming the safety and feasibility of PRT in HGG.
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Pediatric craniospinal irradiation with conventional technique or helical tomotherapy: impact of age and body volume on integral dose. TUMORI JOURNAL 2016; 102:387-92. [PMID: 27056336 DOI: 10.5301/tj.5000512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE The use of helical tomotherapy (HT) for craniospinal irradiation (CSI) in pediatric patients remains an issue of discussion. In this study, we evaluated the integral dose (ID) to organs at risk (OARs) and to the whole body delivered with conventional 3-dimensional conformal radiotherapy (3D-CRT) and HT for pediatric patients and made a comparison according to different whole body volumes. METHODS We selected 10 pediatric patients with different body volumes and of different ages undergoing CSI. Plans for 3D-CRT and HT were developed for each patient. The ID to OARs and to the whole body were compared and statistical analyses were performed to determine differences. RESULTS We noticed that variations of ID depend on the different anatomical location of the organs relatively to the target, with lower ID to OARs opposed to the target and increased ID to lateral organs: ID tomotherapy/3D-CRT ratio was higher in lungs, kidneys, and mammary region, while it was lower in heart, liver, thyroid, and esophagus. The ID of the body increased with large volumes both in HT and in 3D-CRT plans, but in tomotherapy plans ID increased significantly more with large volumes than with small ones. CONCLUSIONS While there are no differences in using tomotherapy or 3D-CRT with small body volumes, we found a difference with large volumes (≥20,000 mL vs ≤20,000 mL). Therefore, for very small patients, the use of intensity-modulated radiotherapy provided with tomotherapy to reduce the dose to OARs can be reconsidered.
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Ph Kamerling C, Ziegenhein P, Sterzing F, Oelfke U. Interactive dose shaping part 2: proof of concept study for six prostate patients. Phys Med Biol 2016; 61:2471-84. [PMID: 26948274 PMCID: PMC5390954 DOI: 10.1088/0031-9155/61/6/2471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 02/09/2016] [Indexed: 11/11/2022]
Abstract
Recently we introduced interactive dose shaping (IDS) as a new IMRT planning strategy. This planning concept is based on a hierarchical sequence of local dose modification and recovery operations. The purpose of this work is to provide a feasibility study for the IDS planning strategy based on a small set of six prostate patients. The IDS planning paradigm aims to perform interactive local dose adaptations of an IMRT plan without compromising already established valuable dose features in real-time. Various IDS tools were developed in our in-house treatment planning software Dynaplan and were utilized to create IMRT treatment plans for six patients with an adeno-carcinoma of the prostate. The sequenced IDS treatment plans were compared to conventionally optimized clinically approved plans (9 beams, co-planar). For each patient, several IDS plans were created, with different trade-offs between organ sparing and target coverage. The reference dose distributions were imported into Dynaplan. For each patient, the IDS treatment plan with a similar or better trade-off between target coverage and OAR sparing was selected for plan evaluation, guided by a physician. For this initial study we were able to generate treatment plans for prostate geometries in 15-45 min. Individual local dose adaptations could be performed in less than one second. The average differences compared to the reference plans were for the mean dose: 0.0 Gy (boost) and 1.2 Gy (PTV), for D98% : -1.1 Gy and for D2% : 1.1 Gy (both target volumes). The dose-volume quality indicators were well below the Quantec constraints. However, we also observed limitations of our currently implemented approach. Most prominent was an increase of the non-tumor integral dose by 16.4% on average, demonstrating that further developments of our planning strategy are required.
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Affiliation(s)
- Cornelis Ph Kamerling
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, SM2 5NG, UK
| | - Peter Ziegenhein
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, SM2 5NG, UK
| | - Florian Sterzing
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, SM2 5NG, UK
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Fast MF, Kamerling CP, Ziegenhein P, Menten MJ, Bedford JL, Nill S, Oelfke U. Assessment of MLC tracking performance during hypofractionated prostate radiotherapy using real-time dose reconstruction. Phys Med Biol 2016; 61:1546-62. [PMID: 26816273 PMCID: PMC5390952 DOI: 10.1088/0031-9155/61/4/1546] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/25/2015] [Accepted: 12/16/2015] [Indexed: 11/16/2022]
Abstract
By adapting to the actual patient anatomy during treatment, tracked multi-leaf collimator (MLC) treatment deliveries offer an opportunity for margin reduction and healthy tissue sparing. This is assumed to be especially relevant for hypofractionated protocols in which intrafractional motion does not easily average out. In order to confidently deliver tracked treatments with potentially reduced margins, it is necessary to monitor not only the patient anatomy but also the actually delivered dose during irradiation. In this study, we present a novel real-time online dose reconstruction tool which calculates actually delivered dose based on pre-calculated dose influence data in less than 10 ms at a rate of 25 Hz. Using this tool we investigate the impact of clinical target volume (CTV) to planning target volume (PTV) margins on CTV coverage and organ-at-risk dose. On our research linear accelerator, a set of four different CTV-to-PTV margins were tested for three patient cases subject to four different motion conditions. Based on this data, we can conclude that tracking eliminates dose cold spots which can occur in the CTV during conventional deliveries even for the smallest CTV-to-PTV margin of 1 mm. Changes of organ-at-risk dose do occur frequently during MLC tracking and are not negligible in some cases. Intrafractional dose reconstruction is expected to become an important element in any attempt of re-planning the treatment plan during the delivery based on the observed anatomy of the day.
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Affiliation(s)
- M F Fast
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - C P Kamerling
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - P Ziegenhein
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - M J Menten
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - J L Bedford
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - S Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - U Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
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45
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Kumar L, Yadav G, Raman K, Bhushan M, Pal M. The dosimetric impact of different photon beam energy on RapidArc radiotherapy planning for cervix carcinoma. J Med Phys 2015; 40:207-13. [PMID: 26865756 PMCID: PMC4728891 DOI: 10.4103/0971-6203.170787] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 07/29/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022] Open
Abstract
The main purpose of this study is to know the effect of three different photon energies viz., 6, 10, and 15 mega voltage (MV) on RapidArc (RA) planning for deep-seated cervix tumor and to develop clinically acceptable RA plans with suitable photon energy. RA plans were generated for 6, 10, and 15 MV photon energies for twenty patients reported with cervix carcinoma. RA plans were evaluated in terms of planning target volume (PTV) coverage, dose to organs at risk (OARs), conformity index (CI), homogeneity index (HI), gradient measure, external volume index of dose distribution produced, total number of monitor units (MUs), nontumor integral dose (ID), and low dose volume of normal tissue. A two-sample paired t-test was performed to compare the dosimetric parameters of RA plans. Irrespective of photon energy used for RA planning, plans were dosimetrically similar in terms of PTV coverage, OARs sparing, CI and HI. The numbers of MUs were 13.4 ± 1.4% and 18.2 ± 1.5% higher and IDs were 2.7 ± 0.8% and 3.7 ± 0.9% higher in 6 MV plans in comparison to that in the 10 and 15 MV plans, respectively. V1Gy, V2Gy, V3Gy, and V4Gy were higher in 6 MV plans in comparison to that in 10 and 15 MV plans. Based on this study, 6 MV photon beam is a good choice for RA planning in case of cervix carcinoma, as it does not deliver additional exposure to patients caused by photoneutrons produced in high energy beams.
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Affiliation(s)
- Lalit Kumar
- Department of Radiotherapy, Medical Physics Division, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Girigesh Yadav
- Department of Radiotherapy, Medical Physics Division, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Kothanda Raman
- Department of Radiotherapy, Medical Physics Division, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Manindra Bhushan
- Department of Radiotherapy, Medical Physics Division, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Manoj Pal
- Department of Radiotherapy, Medical Physics Division, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
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Khalifa J, Vieillevigne L, Boyrie S, Ouali M, Filleron T, Rives M, Laprie A. Dosimetric comparison between helical tomotherapy and volumetric modulated arc-therapy for non-anaplastic thyroid cancer treatment. Radiat Oncol 2014; 9:247. [PMID: 25424320 PMCID: PMC4251932 DOI: 10.1186/s13014-014-0247-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 11/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate and compare dosimetric parameters of volumetric modulated arctherapy (VMAT) and helical tomotherapy (HT) for non-anaplastic thyroid cancer adjuvant radiotherapy. METHODS Twelve patients with non-anaplastic thyroid cancer at high risk of local relapse received adjuvant external beam radiotherapy with curative intent in our institution, using a two-dose level prescription with a simultaneous integrated boost approach. Each patient was re-planned by the same physicist twice using both VMAT and HT. Several dosimetric quality indexes were used: target coverage index (proportion of the target volume covered by the reference isodose), healthy tissue conformity index (proportion of the reference isodose volume including the target volume), conformation number (combining both previous indexes), Dice Similarity Coefficient (DSC), and homogeneity index ((D2%-D98%)/prescribed dose). Dose-volume histogram statistics were also compared. RESULTS HT provided statistically better target coverage index and homogeneity index for low risk PTV in comparison with VMAT (respectively 0.99 vs. 0.97 (p=0.008) and 0.22 vs. 0.25 (p=0.016)). However, HT provided poorer results for healthy tissue conformity index, conformation number and DSC with low risk and high risk PTV. As regards organs at risk sparing, by comparison with VMAT, HT statistically decreased the D2% to medullary canal (25.3 Gy vs. 32.6 Gy (p=0.003)). Besides, HT allowed a slight sparing dose for the controlateral parotid (Dmean: 4.3 Gy vs. 6.6 Gy (p=0.032)) and for the controlateral sub-maxillary gland (Dmean: 29.1 Gy vs. 33.1 Gy (p=0.041)). CONCLUSIONS Both VMAT and HT techniques for adjuvant treatment of non-anaplastic thyroid cancer provide globally attractive treatment plans with slight dosimetric differences. However, helical tomotherapy clearly provides a benefit in term of medullary canal sparing.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Laure Vieillevigne
- Department of Medical Physics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Sabrina Boyrie
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Monia Ouali
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Michel Rives
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France.
| | - Anne Laprie
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, Oncopôle - 1, avenue Irène Joliot Curie, 31059, Toulouse, France. .,Université Toulouse III Paul Sabatier, Toulouse, F-31000, France. .,INSERM, UMR825, Toulouse, 24 F-31059, France.
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Garnica-Garza HM. Influence of the electron energy and number of beams on the absorbed dose distributions in radiotherapy of deep seated targets. Appl Radiat Isot 2014; 94:101-108. [PMID: 25151497 DOI: 10.1016/j.apradiso.2014.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/17/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Abstract
With the advent of compact laser-based electron accelerators, there has been some renewed interest on the use of such charged particles for radiotherapy purposes. Traditionally, electrons have been used for the treatment of fairly superficial lesions located at depths of no more than 4cm inside the patient, but lately it has been proposed that by using very high energy electrons, i.e. those with an energy in the order of 200-250MeV it should be possible to safely reach deeper targets. In this paper, we used a realistic patient model coupled with detailed Monte Carlo simulations of the electron transport in such a patient model to examine the characteristics of the resultant absorbed dose distributions as a function of both the electron beam energy as well as the number of beams for a particular type of treatment, namely, a prostate radiotherapy treatment. Each treatment is modeled as consisting of nine, five or three beam ports isocentrically distributed around the patient. An optimization algorithm is then applied to obtain the beam weights in each treatment plan. It is shown that for this particularly challenging case, both excellent target coverage and critical structure sparing can be obtained for energies in the order of 150MeV and for as few as three treatment ports, while significantly reducing the total energy absorbed by the patient with respect to a conventional megavoltage x-ray treatment.
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Affiliation(s)
- H M Garnica-Garza
- Centro de Investigación y de Estudios Avanzados del IPN Unidad Monterrey, Vía del Conocimiento 201 Parque PIIT, Apodaca, Nuevo León C.P. 66600, Mexico.
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Mihaylov IB. Mathematical formulation of energy minimization - based inverse optimization. Front Oncol 2014; 4:181. [PMID: 25101243 PMCID: PMC4102877 DOI: 10.3389/fonc.2014.00181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 06/27/2014] [Indexed: 01/01/2023] Open
Abstract
Purpose: To introduce the concept of energy minimization-based inverse optimization for external beam radiotherapy. Materials and Methods: Mathematical formulation of energy minimization-based inverse optimization is presented. This mathematical representation is compared to the most commonly used dose–volume based formulation used in inverse optimization. A simple example on digitally created phantom is demonstrated. The phantom consists of three sections: a target surrounded by high and low density regions. The target is irradiated with two beams passing through those regions. Inverse optimization with dose–volume and energy minimization-based objective functions is performed. The dosimetric properties of the two optimization results are evaluated. Results: Dose–volume histograms for all the volumes of interest used for dose optimization are compared. Energy-based optimization results in higher maximum dose to the volumes that are used as dose-limiting structures. However, the average and the integral doses delivered for the volumes outside of the target are larger with dose–volume optimization. Conclusion: Mathematical formulation of energy minimization-based inverse optimization is derived. The optimization applied on the digital phantom shows that energy minimization-based approach tends to deliver somewhat higher maximum doses compared to standard of care, realized with dose–volume based optimization. At the same time, however, the energy minimization-based optimization reduces much more significantly the average and the integral doses.
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Affiliation(s)
- Ivaylo B Mihaylov
- Department of Radiation Oncology, University of Miami , Miami, FL , USA
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Peters S, Schiefer H, Plasswilm L. A treatment planning study comparing Elekta VMAT and fixed field IMRT using the varian treatment planning system eclipse. Radiat Oncol 2014; 9:153. [PMID: 25011529 PMCID: PMC4107584 DOI: 10.1186/1748-717x-9-153] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/21/2014] [Indexed: 12/16/2022] Open
Abstract
Background The newest release of the Eclipse (Varian) treatment planning system (TPS) includes an optimizing engine for Elekta volumetric-modulated arc therapy (VMAT) planning. The purpose of this study was to evaluate this new algorithm and to compare it to intensity-modulated radiation therapy (IMRT) for various disease sites by creating single- and double-arc VMAT plans. Methods A total of 162 plans were evaluated in this study, including 38 endometrial, 57 head and neck, 12 brain, 10 breast and 45 prostate cancer cases. The real-life IMRT plans were developed during routine clinical cases using the TPS Eclipse. VMAT plans were generated using a preclinical version of Eclipse with tumor-region-specific optimizing templates without interference of the operator: with one full arc (1A) and with two full arcs (2A), and with partial arcs for breast and prostate with hip implant cases. All plans were evaluated based on target coverage, homogeneity and conformity. The organs at risk (OARs) were analyzed according to plan objectives, such as the mean and maximum doses. If one or more objectives were exceeded, the plan was considered clinically unacceptable, and a second VMAT plan was created by adapting the optimization penalties once. Results Compared to IMRT, single- and double-arc VMAT plans showed comparable or better results concerning the target coverage: the maximum dose in the target for 1A is the same as that for IMRT; for 2A, an average reduction of 1.3% over all plans was observed. The conformity showed a statistically significant improvement for both 1A (+3%) and 2A (+6%). The mean total body dose was statistically significant lower for the considered arc techniques (IMRT: 16.0 Gy, VMAT: 15.3 Gy, p < 0.001). However, the sparing of OARs shows individual behavior that depends strongly on the different tumor regions. A clear difference is found in the number of monitor units (MUs) per plan: VMAT shows a reduction of 31%. Conclusion These findings demonstrate that based on optimizing templates with minimal interaction of the operator, the Eclipse TPS is able to achieve a plan quality for the Elekta VMAT delivery technique that is comparable to that of fixed-field IMRT. Plans with two arcs show better dose distributions than plans with one arc.
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Affiliation(s)
- Samuel Peters
- Department of Radiation Oncology, Kantonsspital St, Gallen, Rorschacherstrasse 95, 9007 St, Gallen, Switzerland.
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Vernat SS, Ali D, Messina C, Pommier P, Dussart S, Puyraveau M, Viard R, Lacornerie T, Lisbona A, Fenoglietto P, Mazurier J, Garcia R, Hangard G, Zefkili S, Makovicka L, Giraud P. Intensity Modulated Arc Therapy in Bilaterally Irradiated Head and Neck Cancer: A Comparative and Prospective Multicenter Planning Study. Cancer Invest 2014; 32:159-67. [DOI: 10.3109/07357907.2014.889705] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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