How rapid advances in imaging are defining the future of precision radiation oncology

Imaging has an essential role in the planning and delivery of radiotherapy. Recent advances in imaging have led to the development of advanced radiotherapy techniques—including image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy and proton beam therapy. The optimal use of imaging might enable higher doses of radiation to be delivered to the tumour, while sparing normal surrounding tissues. In this article, we review how the integration of existing and novel forms of computed tomography, magnetic resonance imaging and positron emission tomography have transformed tumour delineation in the radiotherapy planning process, and how these advances have the potential to allow a more individualised approach to the cancer therapy. Recent data suggest that imaging biomarkers that assess underlying tumour heterogeneity can identify areas within a tumour that are at higher risk of radio-resistance, and therefore potentially allow for biologically focussed dose escalation. The rapidly evolving concept of adaptive radiotherapy, including artificial intelligence, requires imaging during treatment to be used to modify radiotherapy on a daily basis. These advances have the potential to improve clinical outcomes and reduce radiation-related long-term toxicities. We outline how recent technological advances in both imaging and radiotherapy delivery can be combined to shape the future of precision radiation oncology.

A practical method of modeling a treatment couch using cone-beam computed tomography for intensity-modulated radiation therapy and RapidArc treatment delivery

The effect of a treatment couch on dose perturbation is not always fully considered in intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). In the course of inverse planning radiotherapy techniques, beam parameter optimization may change in the absence of the couch, causing errors in the calculated dose distributions. Although modern treatment planning systems (TPS) include data for the treatment couch components, they are not manufactured identically. Thus, variations in their Hounsfield unit (HU) values may exist. Moreover, a radiotherapy facility may wish to have a third-party custom tabletop installed that is not included by the TPS vendor. This study demonstrates a practical and simple method of acquiring reliable computed tomography (CT) data for the treatment couch and shows how the absorbed dose calculated with the modeled treatment couch can differ from that with the default treatment couch found in the TPS. We also experimentally verified that neglecting to incorporate the treatment couch completely in the treatment planning process might result in dose differences of up to 9.5% and 7.3% for 4-MV and 10-MV photon beams, respectively. Furthermore, 20 RapidArc and IMRT cases were used to quantify the change in calculated dose distributions caused by using either the default or modeled couch. From 2-dimensional (2D) ionization chamber array measurements, we observed large dose distribution differences between the measurements and calculations when the couch was omitted that varied according to the planning technique and anatomic site. Thus, incorporating the treatment couch in the dose calculation phase of treatment planning significantly decreases dose calculation errors.