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Lambri N, Longari G, Loiacono D, Brioso RC, Crespi L, Galdieri C, Lobefalo F, Reggiori G, Rusconi R, Tomatis S, Bellu L, Bramanti S, Clerici E, De Philippis C, Dei D, Navarria P, Carlo-Stella C, Franzese C, Scorsetti M, Mancosu P. Deep learning-based optimization of field geometry for total marrow irradiation delivered with volumetric modulated arc therapy. Med Phys 2024; 51:4402-4412. [PMID: 38634859 DOI: 10.1002/mp.17089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/20/2024] [Accepted: 04/05/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Total marrow (lymphoid) irradiation (TMI/TMLI) is a radiotherapy treatment used to selectively target the bone marrow and lymph nodes in conditioning regimens for allogeneic hematopoietic stem cell transplantation. A complex field geometry is needed to cover the large planning target volume (PTV) of TMI/TMLI with volumetric modulated arc therapy (VMAT). Five isocenters and ten overlapping fields are needed for the upper body, while, for patients with large anatomical conformation, two specific isocenters are placed on the arms. The creation of a field geometry is clinically challenging and is performed by a medical physicist (MP) specialized in TMI/TMLI. PURPOSE To develop convolutional neural networks (CNNs) for automatically generating the field geometry of TMI/TMLI. METHODS The dataset comprised 117 patients treated with TMI/TMLI between 2011 and 2023 at our Institute. The CNN input image consisted of three channels, obtained by projecting along the sagittal plane: (1) average CT pixel intensity within the PTV; (2) PTV mask; (3) brain, lungs, liver, bowel, and bladder masks. This "averaged" frontal view combined the information analyzed by the MP when setting the field geometry in the treatment planning system (TPS). Two CNNs were trained to predict the isocenters coordinates and jaws apertures for patients with (CNN-1) and without (CNN-2) isocenters on the arms. Local optimization methods were used to refine the models output based on the anatomy of the patient. Model evaluation was performed on a test set of 15 patients in two ways: (1) by computing the root mean squared error (RMSE) between the CNN output and ground truth; (2) with a qualitative assessment of manual and generated field geometries-scale: 1 = not adequate, 4 = adequate-carried out in blind mode by three MPs with different expertise in TMI/TMLI. The Wilcoxon signed-rank test was used to evaluate the independence of the given scores between manual and generated configurations (p < 0.05 significant). RESULTS The average and standard deviation values of RMSE for CNN-1 and CNN-2 before/after local optimization were 15 ± 2/13 ± 3 mm and 16 ± 2/18 ± 4 mm, respectively. The CNNs were integrated into a planning automation software for TMI/TMLI such that the MPs could analyze in detail the proposed field geometries directly in the TPS. The selection of the CNN model to create the field geometry was based on the PTV width to approximate the decision process of an experienced MP and provide a single option of field configuration. We found no significant differences between the manual and generated field geometries for any MP, with median values of 4 versus 4 (p = 0.92), 3 versus 3 (p = 0.78), 4 versus 3 (p = 0.48), respectively. Starting from October 2023, the generated field geometry has been introduced in our clinical practice for prospective patients. CONCLUSIONS The generated field geometries were clinically acceptable and adequate, even for an MP with high level of expertise in TMI/TMLI. Incorporating the knowledge of the MPs into the development cycle was crucial for optimizing the models, especially in this scenario with limited data.
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Affiliation(s)
- Nicola Lambri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giorgio Longari
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Daniele Loiacono
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Ricardo Coimbra Brioso
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Leonardo Crespi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
- Health Data Science Centre, Human Technopole, Milan, Italy
| | - Carmela Galdieri
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Roberto Rusconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luisa Bellu
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefania Bramanti
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Chiara De Philippis
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Damiano Dei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carmelo Carlo-Stella
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ciro Franzese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Parsons D, Lim TY, Teruel JR, Galavis P, Agostinelli S, Liang J, Mancosu P, Cherpak A, Stanley DN, Ahn KH, Guo B, Gonzalez Y, Burmeister J, Wong JY, Gu X, Kim GGY. Considerations for intensity modulated total body or total marrow and lymphoid irradiation. Clin Transl Radiat Oncol 2023; 43:100674. [PMID: 37753462 PMCID: PMC10518336 DOI: 10.1016/j.ctro.2023.100674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
We compiled a sampling of the treatment techniques of intensity-modulated total body irradiation, total marrow irradiation and total marrow and lymphoid irradiation utilized by several centers across North America and Europe. This manuscript does not serve as a consensus guideline, but rather is meant to serve as a convenient reference for centers that are considering starting an intensity-modulated program.
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Affiliation(s)
- David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tze Yee Lim
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose R. Teruel
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | - Paulina Galavis
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | | | - Jieming Liang
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Pietro Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Rozzano, Milan, Italy
| | - Amanda Cherpak
- Department of Radiation Oncology and Department of Medical Physics, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kang-Hyun Ahn
- Department of Radiation Oncology, University of Illinois, Chicago, IL and Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Bingqi Guo
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Yesenia Gonzalez
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Center, Detroit, MI, USA
| | - Jeffrey Y.C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Xuejun Gu
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Grace Gwe-Ya Kim
- Radiation Medicine and Applied Science, University of California San Diego, La Jolla, CA, USA
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Kavak AG, Surucu M, Ahn KH, Pearson E, Aydogan B. Impact of respiratory motion on lung dose during total marrow irradiation. Front Oncol 2022; 12:924961. [PMID: 36330489 PMCID: PMC9622752 DOI: 10.3389/fonc.2022.924961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/16/2022] [Indexed: 11/21/2022] Open
Abstract
We evaluated the impact of respiratory motion on the lung dose during linac-based intensity-modulated total marrow irradiation (IMTMI) using two different approaches: (1) measurement of doses within the lungs of an anthropomorphic phantom using thermoluminescent detectors (TLDs) and (2) treatment delivery measurements using ArcCHECK where gamma passing rates (GPRs) and the mean lung doses were calculated and compared with and without motion. In the first approach, respiratory motions were simulated using a programmable motion platform by using typical published peak-to-peak motion amplitudes of 5, 8, and 12 mm in the craniocaudal (CC) direction, denoted here as M1, M2, and M3, respectively, with 2 mm in both anteroposterior (AP) and lateral (LAT) directions. TLDs were placed in five selected locations in the lungs of a RANDO phantom. Average TLD measurements obtained with motion were normalized to those obtained with static phantom delivery. The mean dose ratios were 1.01 (0.98–1.03), 1.04 (1.01–1.09), and 1.08 (1.04–1.12) for respiratory motions M1, M2, and M3, respectively. To determine the impact of directional respiratory motion, we repeated the experiment with 5-, 8-, and 12-mm motion in the CC direction only. The differences in average TLD doses were less than 1% when compared with the M1, M2, and M3 motions indicating a minimal impact from CC motion on lung dose during IMTMI. In the second experimental approach, we evaluated extreme respiratory motion 15 mm excursion in only the CC direction. We placed an ArcCHECK device on a commercial motion platform and delivered the clinical IMTMI plans of five patients. We compared, with and without motion, the dose volume histograms (DVHs) and mean lung dose calculated with the ArcCHECK-3DVH tool as well as GPR with 3%, 5%, and 10% dose agreements and a 3-mm constant distance to agreement (DTA). GPR differed by 11.1 ± 2.1%, 3.8 ± 1.5%, and 0.1 ± 0.2% with dose agreement criteria of 3%, 5%, and 10%, respectively. This indicates that respiratory motion impacts dose distribution in small and isolated parts of the lungs. More importantly, the impact of respiratory motion on the mean lung dose, a critical indicator for toxicity in IMTMI, was not statistically significant (p > 0.05) based on the Student’s t-test. We conclude that most patients treated with IMTMI will have negligible dose uncertainty due to respiratory motion. This is particularly reassuring as lung toxicity is the main concern for future IMTMI dose escalation studies.
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Affiliation(s)
- Ayse Gulbin Kavak
- Department of Radiation Oncology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kang-Hyun Ahn
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago, IL, United States
| | - Erik Pearson
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago, IL, United States
- *Correspondence: Bulent Aydogan, ;
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Ahn KH, Rondelli D, Koshy M, Partouche JA, Hasan Y, Liu H, Yenice K, Aydogan B. Knowledge-based planning for multi-isocenter VMAT total marrow irradiation. Front Oncol 2022; 12:942685. [PMID: 36267964 PMCID: PMC9577613 DOI: 10.3389/fonc.2022.942685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/20/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Total marrow irradiation (TMI) involves optimization of extremely large target volumes and requires extensive clinical experience and time for both treatment planning and delivery. Although volumetric modulated arc therapy (VMAT) achieves substantial reduction in treatment delivery time, planning process still presents a challenge due to use of multiple isocenters and multiple overlapping arcs. We developed and evaluated a knowledge-based planning (KBP) model for VMAT-TMI to address these clinical challenges. Methods Fifty-one patients previously treated in our clinic were selected for the model training, while 22 patients from another clinic were used as a test set. All plans used a 3-isocenter to cover sub-target volumes of head and neck (HN), chest, and pelvis. Chest plan was performed first and then used as the base dose for both the HN and pelvis plans to reduce hot spots around the field junctions. This resulted in a wide range of dose-volume histograms (DVH). To address this, plans without the base-dose plan were optimized and added to the library to train the model. Results KBP achieved our clinical goals (95% of PTV receives 100% of Rx) in a single day, which used to take 4-6 days of effort without KBP. Statistically significant reductions with KBP were observed in the mean dose values to brain, lungs, oral cavity and lenses. KBP substantially improved 105% dose spillage (14.1% ± 2.4% vs 31.8% ± 3.8%), conformity index (1.51 ± 0.06 vs 1.81 ± 0.12) and homogeneity index (1.25 ± 0.02 vs 1.33 ± 0.03). Conclusions KBP improved dosimetric performance with uniform quality. It reduced dependence on planner experience and achieved a factor of 5 reduction in planning time to produce quality plans to allow its wide-spread clinical implementation.
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Affiliation(s)
- Kang-Hyun Ahn
- Department of Radiation Oncology, University of Illinois, Chicago, IL, United States
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Damiano Rondelli
- Division of Hematology/Oncology, University of Illinois, Chicago, IL, United States
| | - Matthew Koshy
- Department of Radiation Oncology, University of Illinois, Chicago, IL, United States
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Julien A. Partouche
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Hongtao Liu
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Kamil Yenice
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
| | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States
- *Correspondence: Bulent Aydogan,
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Total marrow and total lymphoid irradiation in bone marrow transplantation for acute leukaemia. Lancet Oncol 2020; 21:e477-e487. [PMID: 33002443 DOI: 10.1016/s1470-2045(20)30342-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/20/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
The use of total body irradiation as part of conditioning regimens for acute leukaemia is progressively declining because of concerns of late toxic effects and the introduction of radiation-free regimens. Total marrow irradiation and total marrow and lymphoid irradiation represent more targeted forms of radiotherapy compared with total body irradiation that have the potential to decrease toxicity and escalate the dose to the bone marrow for high-risk patients. We review the technological basis and the clinical development of total marrow irradiation and total marrow and lymphoid irradiation, highlighting both the possible advantages as well as the current roadblocks for widespread implementation among transplantation units. The exact role of total marrow irradiation or total marrow and lymphoid irradiation in new conditioning regimens seems dependent on its technological implementation, aiming to make the whole procedure less time consuming, more streamlined, and easier to integrate into the clinical workflow. We also foresee a role for computer-assisted planning, as a way to improve planning and delivery and to incorporate total marrow irradiation and total marrow and lymphoid irradiation in multi-centric phase 2-3 trials.
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Hara JH, Ahn KH, Aydogan B, Koshy M. Local Recurrence Following Total Marrow Radiation: Implications for Clinical Target Delineation. Cureus 2020; 12:e10592. [PMID: 33110728 PMCID: PMC7581219 DOI: 10.7759/cureus.10592] [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] [Indexed: 12/03/2022] Open
Abstract
Total marrow radiation is an emerging treatment modality used in patients undergoing stem cell transplantation. We present a rare case of a patient undergoing total marrow irradiation with concurrent ablative stem cell transplantation with local failures in two out-of-field areas that were not included in the clinical target volume A 31-year-old female patient initially presented with abdominal pain secondary to chronic myelogenous leukemia. She underwent dasatinib treatment for years, but subsequently developed recurrence and underwent consolidation systemic chemotherapy followed by allogeneic stem cell transplantation with adjuvant total marrow irradiation. Several months later, she noticed increased left jaw swelling and dysphagia with associated right ankle swelling. Biopsy of the right ankle and left mandible were consistent with recurrent myeloid sarcoma. This case report suggests that inclusion of the mandible and lower extremities may be necessary when performing total marrow radiation.
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Affiliation(s)
- Jared H Hara
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA.,Department of Radiation Oncology, University of Illinois Hospital and Health Sciences System, Chicago, USA
| | - Kang-Hyun Ahn
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA.,Department of Radiation Oncology, University of Illinois Hospital and Health Sciences System, Chicago, USA
| | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA.,Department of Radiation Oncology, University of Illinois Hospital and Health Sciences System, Chicago, USA
| | - Matthew Koshy
- Department of Radiation Oncology, University of Illinois Hospital and Health Sciences System, Chicago, USA.,Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
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Litoborska J, Piotrowski T, Malicki J. Evaluation of three VMAT-TMI planning methods to find an appropriate balance between plan complexity and the resulting dose distribution. Phys Med 2020; 75:26-32. [PMID: 32480353 DOI: 10.1016/j.ejmp.2020.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Evaluation of different planning methods of treatment plan preparation for volumetric modulated arc therapy during total marrow irradiation (VMAT-TMI). METHOD Three different planning methods were evaluated to establish the most appropriate VMAT-TMI technique, based on organ at risk (OAR) dose reduction, conformity and plan simplicity. The methods were: (M1) the sub-plan method, (M2) use of eight arcs optimised simultaneously and (M3) M2 with monitor unit reduction. Friedman ANOVA comparison, with Nemenyi's procedures, was used in the statistical analysis of the results. RESULTS The dosimetric results obtained for the planning target volume and for most OARs do not differ statistically between methods. The M3 method was characterized by the lowest numbers of monitor units (3259 MU vs. 4450 MU for M1 and 4216 MU for M2) and, in general, the lowest complexity. The variability of the monitor units from control points was almost half for M3 than M1 and M2 (i.e. 0.33 MU vs. 0.61 MU for M1 and 0.58 for M2). Analysing the relationship between the dose distributions obtained for the plans and their complexity, the best result was observed for the M3 method. CONCLUSION The use of eight simultaneously optimised arcs with MU reduction allows to obtain VMAT-TMI plans that are characterized by the lowest complexity, with dose distributions comparable to the plans generated by other methods.
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Affiliation(s)
- Joanna Litoborska
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland
| | - Tomasz Piotrowski
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland; Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland.
| | - Julian Malicki
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland; Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland
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Mancosu P, Navarria P, Muren LP, Castagna L, Reggiori G, Clerici E, Sarina B, Bramanti S, De Philippis C, Tomatis S, Santoro A, Scorsetti M. Development of an Immobilization Device for Total Marrow Irradiation. Pract Radiat Oncol 2020; 11:e98-e105. [PMID: 32160952 DOI: 10.1016/j.prro.2020.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/24/2020] [Accepted: 02/15/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE A body frame dedicated to total marrow (lymph node) irradiation (TMI/TMLI) could minimize patient motion during the potentially extended beam-on time with this technique. We present the development of a dedicated immobilization system for TMI/TMLI using volumetric modulated arc therapy. METHODS AND MATERIALS Since 2010, 59 adult patients were treated with TMI/TMLI using a multi-isocenter volumetric modulated arc therapy technique. Two computed tomographies (CTs) were required (1 head-first supine and 1 feet-first supine) to cover the whole volume. For the first 10 patients, 2 standard commercial frames with personalized masks (with/without personalized vacuum cushion for the lower extremities) were used without specific interfixation (frame A). For the next 49 patients a homemade 3-frame immobilization system was adopted (frame B), where each frame was interlocked with the next one and thermoplastic masks used to fix the patient. The effectiveness of the 2 immobilization systems was assessed by offline/online matching between daily cone beam CT of each isocenter and the simulation CTs. RESULTS Mean offline shifts for frame A were 3 to 12 mm in anterior-posterior, 2 to 5 mm in cranilal-caudal, and 2 to 6 mm in left-right directions. Larger shifts were found for feet-first supine series (shifts up to 23 mm). In frame B, mean offline shifts were 1 to 4 mm in anterior-posterior, 1 to 4 mm in cranial-caudal, and 1 to 4 mm in left-right directions. Mean online adjustments were -1 ± 4 mm in anterior-posterior, 0 ± 2 mm in cranial-caudal, and 0 ± 4 mm in left-right directions. CONCLUSIONS The patient positioning shifts for TMI/TMLI irradiation were mitigated by a homemade immobilization system and the use of individualized masks.
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Affiliation(s)
- Pietro Mancosu
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy.
| | - Pierina Navarria
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | | | - Luca Castagna
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Giacomo Reggiori
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Elena Clerici
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Barbara Sarina
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Stefania Bramanti
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Chiara De Philippis
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Stefano Tomatis
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Armando Santoro
- Medical Oncology Department, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
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Sarigul N, Surucu M, Reft C, Malin M, Yegingil Z, Aydogan B. A practical method for quantifying dose in bone and lung using TLDs when using 6 and 15 MV photon beams. Phys Med Biol 2020; 65:05NT01. [PMID: 32028274 DOI: 10.1088/1361-6560/ab735d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This paper presents a practical method for converting dose measured with thermoluminescent dosimeters (TLD) to dose in lung and bone for 6 MV and 15 MV photon beams. Monte Carlo (MC) simulations and Burlin cavity theory calculations were performed to calculate [Formula: see text], the dose-to-TLD to dose-to-medium conversion factor. A practical method was proposed for converting TLD-measured-dose to dose-in-medium using the TLD dose calibration in water and [Formula: see text] dose-to-medium to dose-to-water conversion factor. Theoretical calculations for [Formula: see text] were performed using photon spectrum weighted parameters and were compared with MC simulations. Verification of the proposed method was done using phantoms having either bone or lung equivalent slabs stacked in between solid water slabs. Percent depth dose (PDD) curves were measured using 0.089 cm thick LiF:Mg,Ti (TLD-100) dosemeters placed at various depths within these phantoms. They were then corrected with [Formula: see text] factors using the proposed dose conversion method, and were compared with the MC simulations. For 6 MV beam, the MC calculated [Formula: see text] factors were 0.942 and 1.002 for bone and lung, and for 15 MV it was 0.927 and 1.005 for bone and lung, respectively. The difference between the MC simulated and spectrum weighted theoretical [Formula: see text] factors were within 3% for both lung and bone. The PDD curves measured with TLD-100 chips that were corrected using the proposed method agreed well within 1.5% of the MC simulated PDD curves for both the water/lung/water and water/bone/water (WBW) phantoms. The dose-to-medium correction using MC simulated [Formula: see text] is convenient, easy, and accurate. Therefore, it can be used instead of Burlin cavity theory, especially in media with high atomic numbers such as bone for accurate dose quantification.
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Affiliation(s)
- Neslihan Sarigul
- Institute of Nuclear Science, Hacettepe University, 06532 Ankara, Turkey. Both authors contributed equally to this manuscript
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Mancosu P, Cozzi L, Muren LP. Total marrow irradiation for hematopoietic malignancies using volumetric modulated arc therapy: A review of treatment planning studies. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 11:47-53. [PMID: 33458277 PMCID: PMC7807866 DOI: 10.1016/j.phro.2019.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/09/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023]
Abstract
Total Marrow Irradiation (TMI) has been introduced in the management of hematopoietic malignancies with the aim of reducing toxicities induced by total body irradiation. TMI is one of the most challenging planning and delivery techniques of radiotherapy, as the whole skeleton should be irradiated, while sparing nearby organs at risk (OARs). Target volumes of 7–10 k cm3 and healthy tissue volumes of 50–90 k cm3 should be considered and inverse treatment planning is needed. This review focused on aspects of TMI delivery using volumetric modulated arc therapy (VMAT). In particular, multiple arcs from isocenters with different positions are required for VMAT-TMI as the cranial-caudal lengths of patients are much larger than the jaw aperture. Therefore, many field junctions between arcs with different isocenters should be managed. This review covered, in particular, feasibility studies for managing multiple isocenters, optimization of plan parameters, plan optimization of the lower extremities, robustness of field junctions and dosimetric plan verification of VMAT-TMI. This review demonstrated the possibility of VMAT in delivering TMI with multi-arcs and multi-isocenters. Care should be paid in the patient repositioning, with particular attention to the cranial-caudal direction.
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Affiliation(s)
- Pietro Mancosu
- Medical Physics, Radiotherapy Department, Humanitas Clinical and Research Hospital, Rozzano-Milano, Italy
| | - Luca Cozzi
- Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Ludvig Paul Muren
- Dept of Medical Physics, Aarhus University/Aarhus University Hospital, Aarhus, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Feasibility of a novel dose fractionation strategy in TMI/TMLI. Radiat Oncol 2018; 13:248. [PMID: 30558631 PMCID: PMC6296054 DOI: 10.1186/s13014-018-1201-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022] Open
Abstract
Background To report our experience in planning and delivering total marrow irradiation (TMI) and total marrow and lymphatic irradiation (TMLI) in patients with hematologic malignancies. Methods Twenty-seven patients undergoing bone marrow transplantation were treated with TMI/TMLI using Helical Tomotherapy (HT). All skeletal bones exclusion of the mandible comprised the treatment target volume and, for TMLI, lymph node chains, liver, spleen and/or brain were also included according to the clinical indication. Planned dose of 8Gy in 2 fractions was delivered over 1 day for TMI while 10Gy in 2 fractions BID was used for TMLI. Organs at risk (OAR) contoured included the brain, brainstem, lens, eyes, optic nerves, parotids, oral cavity, lungs, heart, liver, kidneys, stomach, small bowel, bladder and rectum. In particular, a simple method to avoid hot or cold doses in the overlapping region was implemented and the plan sum was adopted to evaluate dose inhomogeneity. Furthermore, setup errors from 54 treatments were summarized to gauge the effectiveness of immobilization. Results During the TMI/TMLI treatment, no acute adverse effects occurred during the radiation treatment. Two patients suffered nausea or vomiting right after radiation course. For the 9 patients treated with TMI, the median dose reduction of major organs varied 30–65% of the prescribed dose, substantially lower than the traditional total body irradiation (TBI). Meanwhile, average biological equivalent doses to OARs with 8Gy/2F TMI approach were not different from the conventional 12Gy/6F TMI approach. In the dose junction region, the 93% of PTV was covered by the prescribed dose without obvious hotspots. For the 27 patients, the overall setup corrections were lower than 3 mm except those in the SI direction for abdomen-pelvis region, demonstrating excellent immobilization. Conclusion The present study confirmed the technical feasibility of HT-based TMI/TMLI delivering 8-10Gy in 2 fractions over 1 day. For patients undergoing hematopoietic cell transplantation the proposed 8Gy/2F TMI (or 10Gy/2F TMLI) strategy may be a novel approach to improve delivery efficiency, increase effective radiation dose to target while maintaining low risk of severe organ toxicities.
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12
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Tas B, Durmus IF, Okumus A, Uzel OE, Gokce M, Goksoy HS, Ozsahin EM. Total-body irradiation using linac-based volumetric modulated arc therapy: Its clinical accuracy, feasibility and reliability. Radiother Oncol 2018; 129:527-533. [DOI: 10.1016/j.radonc.2018.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
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A dosimetric phantom study of thoracic radiotherapy based on three-dimensional modeling of mediastinal lymph nodes. Oncol Lett 2018; 15:5634-5642. [PMID: 29556300 PMCID: PMC5844048 DOI: 10.3892/ol.2018.8084] [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: 06/12/2017] [Accepted: 11/16/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the optimal strategy and dosimetric measurement of thoracic radiotherapy based on three-dimensional (3D) modeling of mediastinal lymph nodes (MLNs). A 3D model of MLNs was constructed from a Chinese Visible Human female dataset. Image registration and fusion between reconstructed MLNs and original chest computed tomography (CT) images was conducted in the Eclipse™ treatment planning system (TPS). There were three plans, including 3D conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT), which were designed based on 10 cases of simulated lung lesions (SLLs) and MLNs. The quality of these plans was evaluated via examining indexes, including conformity index (CI), homogeneity index and clinical target volume (CTV) coverage. Dose-volume histogram analysis was performed on SLL, MLNs and organs at risk (OARs). A Chengdu Dosimetric Phantom (CDP) was then drilled at specific MLNs according to 20 patients with thoracic tumors and of a medium-build. These plans were repeated on fused MLNs and CDP CT images in the Eclipse™ TPS. Radiation doses at the SLLs and MLNs of the CDP were measured and compared with calculated doses. The established 3D MLN model demonstrated the spatial location of MLNs and adjacent structures. Precise image registration and fusion were conducted between reconstructed MLNs and the original chest CT or CDP CT images. IMRT demonstrated greater values in CI, CTV coverage and OAR (lungs and spinal cord) protection, compared with 3D-CRT and VMAT (P<0.05). The deviation between the measured and calculated doses was within ± 10% at SLL, and at the 2R and 7th MLN stations. In conclusion, the 3D MLN model can benefit plan optimization and dosimetric measurement of thoracic radiotherapy, and when combined with CDP, it may provide a tool for clinical dosimetric monitoring.
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Morrison CT, Symons KL, Woodings SJ, House MJ. Verification of junction dose between VMAT arcs of total body irradiation using a Sun Nuclear ArcCHECK phantom. J Appl Clin Med Phys 2017; 18:177-182. [PMID: 29082594 PMCID: PMC5689932 DOI: 10.1002/acm2.12208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/09/2017] [Accepted: 09/11/2017] [Indexed: 11/06/2022] Open
Abstract
A volumetric modulated arc therapy (VMAT) approach to total body irradiation (TBI) has recently been introduced at our institution. The planning target volume (PTV) is divided into separate sub-volumes, each being treated with 2 arcs with their own isocentre. Pre-treatment quality assurance of beams is performed on a Sun Nuclear ArcCHECK diode array. Measurement of junction regions between VMAT arcs with separate isocentres has previously been performed with point dose ionization chamber measurements, or with films. Translations of the ArcCHECK with respect to a known distance between the adjacent isocentres of two arcs, which are repeated with the ArcCHECK in an inverted position, allows the recording of a junction dose map. A 3%/3 mm global gamma analysis (10% threshold) pass rate for arc junctions were comparable to their component arcs. Dose maps of junction regions between adjacent arcs with different isocentres can be readily measured on a Sun Nuclear ArcCHECK diode array.
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Affiliation(s)
- Colm T Morrison
- Department of Radiation Oncology, Genesis Cancer Care WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, 6150, Western Australia.,School of Physics, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia
| | - Kirsty L Symons
- Department of Radiation Oncology, Genesis Cancer Care WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, 6150, Western Australia
| | - Simon J Woodings
- Department of Radiation Oncology, Genesis Cancer Care WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, 6150, Western Australia.,School of Physics, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia
| | - Michael J House
- School of Physics, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia
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Springer A, Hammer J, Winkler E, Track C, Huppert R, Böhm A, Kasparu H, Weltermann A, Aschauer G, Petzer AL, Putz E, Altenburger A, Gruber R, Moser K, Wiesauer K, Geinitz H. Total body irradiation with volumetric modulated arc therapy: Dosimetric data and first clinical experience. Radiat Oncol 2016; 11:46. [PMID: 27000180 PMCID: PMC4802832 DOI: 10.1186/s13014-016-0625-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/18/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To implement total body irradiation (TBI) using volumetric modulated arc therapy (VMAT). We applied the Varian RapidArc™ software to calculate and optimize the dose distribution. Emphasis was placed on applying a homogenous dose to the PTV and on reducing the dose to the lungs. METHODS From July 2013 to July 2014 seven patients with leukaemia were planned and treated with a VMAT-based TBI-technique with photon energy of 6 MV. The overall planning target volume (PTV), comprising the whole body, had to be split into 8 segments with a subsequent multi-isocentric planning. In a first step a dose optimization of each single segment was performed. In a second step all these elements were calculated in one overall dose-plan, considering particular constraints and weighting factors, to achieve the final total body dose distribution. The quality assurance comprised the verification of the irradiation plans via ArcCheck™ (Sun Nuclear), followed by in vivo dosimetry via dosimeters (MOSFETs) on the patient. RESULTS The time requirements for treatment planning were high: contouring took 5-6 h, optimization and dose calculation 25-30 h and quality assurance 6-8 h. The couch-time per fraction was 2 h on day one, decreasing to around 1.5 h for the following fractions, including patient information, time for arc positioning, patient positioning verification, mounting of the MOSFETs and irradiation. The mean lung dose was decreased to at least 80 % of the planned total body dose and in the central parts to 50 %. In two cases we additionally pursued a dose reduction of 30 to 50 % in a pre-irradiated brain and in renal insufficiency. All high dose areas were outside the lungs and other OARs. The planned dose was in line with the measured dose via MOSFETs: in the axilla the mean difference between calculated and measured dose was 3.6 % (range 1.1-6.8 %), and for the wrist/hip-inguinal region it was 4.3 % (range 1.1-8.1 %). CONCLUSION TBI with VMAT provides the benefit of satisfactory dose distribution within the PTV, while selectively reducing the dose to the lungs and, if necessary, in other organs. Planning time, however, is extensive.
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Affiliation(s)
- Andreas Springer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Josef Hammer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Erwin Winkler
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Christine Track
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Roswitha Huppert
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Alexandra Böhm
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
- />Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Hedwig Kasparu
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
| | - Ansgar Weltermann
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Gregor Aschauer
- />Internal Medicine I - Medical Oncology, Hematology and Gastroenterology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
| | - Andreas L. Petzer
- />Internal Medicine I - Medical Oncology, Hematology and Gastroenterology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Ernst Putz
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Alexander Altenburger
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Rainer Gruber
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Karin Moser
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Karin Wiesauer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Hans Geinitz
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
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Abstract
RapidArc™ is a radiation technique that delivers highly conformal dose distributions through the complete rotation (360°) and speed variation of the linear accelerator gantry. This technique, called volumetric modulated arc therapy (VMAT), compared with conventional radiotherapy techniques, can achieve high-target volume coverage and sparing damage to normal tissues. RapidArc delivers precise dose distribution and conformity similar to or greater than intensity-modulated radiation therapy in a short time, generally a few minutes, to which image-guided radiation therapy is added. RapidArc has become a currently used technology in many centers, which use RapidArc technology to treat a large number of patients. Large and small hospitals use it to treat the most challenging cases, but more and more frequently for the most common cancers. The clinical use of RapidArc and VMAT technology is constantly growing. At present, a limited number of clinical data are published, mostly concerning planning and feasibility studies. Clinical outcome data are increasing for a few tumor sites, even if only a little. The purpose of this work is to discuss the current status of VMAT techniques in clinical use through a review of the published data of planning systems and clinical outcomes in several tumor sites. The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, BioMed Central, and Scopus databases by searching for the keywords “RapidArc”, “Volumetric modulated arc radiotherapy”, and “Intensity-modulated radiotherapy”.
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Affiliation(s)
- Erminia Infusino
- Department of Radiotherapy, Campus Bio-Medico University Hospital, Rome, Italy
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17
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Plan robustness in field junction region from arcs with different patient orientation in total marrow irradiation with VMAT. Phys Med 2015; 31:677-82. [DOI: 10.1016/j.ejmp.2015.05.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/19/2015] [Accepted: 05/18/2015] [Indexed: 11/21/2022] Open
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Polednik M, Lohr F, Ehmann M, Wenz F. Accelerating total body irradiation with large field modulated arc therapy in standard treatment rooms without additional equipment. Strahlenther Onkol 2015; 191:869-74. [PMID: 26276407 DOI: 10.1007/s00066-015-0883-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/25/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to develop a generic and ultra-efficient modulated arc technique for treatment with total body irradiation (TBI) without additional equipment in standard treatment rooms. METHODS A continuous gantry arc between 300° and 70° composed of 26 subarcs (5° per subarc) using a field size of 40 × 40 cm(2) was used to perform the initial beam data measurements. The profile was measured parallel to the direction of gantry rotation at a constant depth of 9 cm (phantom thickness 18 cm). Beam data were measured for single 5° subarcs, dissecting the individual contribution of each subarc to a certain measurement point. The phantom was moved to 20 measurement positions along the profile. Then profile optimization was performed manually by varying the weighting factors of all segments until calculated doses at all points were within ± 1 %. Finally, the dose distribution of the modulated arc was verified in phantom thicknesses of 18 and 28 cm. RESULTS The measured profile showed a relative mean dose of 99.7 % [standard deviation (SD) 0.7 %)] over the length of 200 cm at a depth of 9 cm. The measured mean effective surface dose (at a depth of 2 cm) was 102.7 % (SD 2.1 %). The measurements in the 28 cm slab phantom revealed a mean dose of 95.9 % (SD 2.9 %) at a depth of 14 cm. The mean dose at a depth of 2 cm was 111.9 % (SD 4.1 %). Net beam-on-time for a 2 Gy fraction is approximately 8 min. CONCLUSION This highly efficient modulated arc technique for TBI can replace conventional treatment techniques, providing a homogeneous dose distribution, dosimetric robustness, extremely fast delivery, and applicability in small treatment rooms, with no need for additional equipment.
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Affiliation(s)
- Martin Polednik
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Frank Lohr
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Mancosu P, Navarria P, Reggiori G, Cozzi L, Fogliata A, Gaudino A, Lobefalo F, Paganini L, Palumbo V, Sarina B, Stravato A, Castagna L, Tomatis S, Scorsetti M. In-vivo dosimetry with Gafchromic films for multi-isocentric VMAT irradiation of total marrow lymph-nodes: a feasibility study. Radiat Oncol 2015; 10:86. [PMID: 25881084 PMCID: PMC4397694 DOI: 10.1186/s13014-015-0391-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/17/2015] [Indexed: 12/03/2022] Open
Abstract
Background Total marrow (lymph-nodes) irradiation (TMI-TMLI) by volumetric modulated arc therapy (VMAT) was shown to be feasible by dosimetric feasibility studies. It was demonstrated that several partially overlapping arcs with different isocenters are required to achieve the desired coverage of the hematopoietic or lymphoid tissues targets and to spare the neighbouring healthy tissues. The effect of isocenter shifts was investigated with the treatment planning system but an in- vivo verification of the procedure was not carried out. The objective of this study was the in-vivo verification of the consistency between the delivered and planned doses using bi-dimensional GafChromic EBT3 films. Methods In a first phase a phantom study was carried out to quantify the uncertainties under controlled conditions. In a second phase three patients treated with TMLI were enrolled for in-vivo dosimetry. The dose prescription was 2Gy in single fraction. Ten arcs paired on 4-6 isocenters were used to cover the target. Cone Beam Computed Tomography (CBCT) was used to verify the patient positioning at each isocenter. GafChromic EBT3 films were placed below the patient on the top of a dedicated immobilization system specifically designed. The dose maps measured with the EBT3 films were compared with the corresponding calculations along the patient support couch. Gamma Agreement Index (GAI) with dose difference of 5% and distance to agreement of 5 mm was computed. Results In the phantom study, optimal target coverage and healthy tissue sparing was observed. GAI(5%,5 mm) was 99.4%. For the patient-specific measurements, GAI(5%,5 mm) was greater than 95% and GAI (5%,3 mm) > 90% for all patients. Conclusions In vivo measurements demonstrated the delivered dose to be in good agreement with the planned one for the TMI-TMLI protocol where partially overlapping arcs with different isocenters are required.
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Affiliation(s)
- Pietro Mancosu
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Pierina Navarria
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Giacomo Reggiori
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Luca Cozzi
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Antonella Fogliata
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Anna Gaudino
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Francesca Lobefalo
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Lucia Paganini
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Valentina Palumbo
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Barbara Sarina
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Antonella Stravato
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Luca Castagna
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Stefano Tomatis
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - Marta Scorsetti
- Radiation Oncology Department, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
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Chakraborty S, Cheruliyil S, Bharathan R, Muttath G. Total Body Irradiation using VMAT (RapidArc): A Planning Study of a novel treatment delivery method. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2015. [DOI: 10.14319/ijcto.0302.8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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21
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Patel P, Aydogan B, Koshy M, Mahmud D, Oh A, Saraf SL, Quigley JG, Khan I, Sweiss K, Mahmud N, Peace DJ, DeMasi V, Awan AM, Weichselbaum RR, Rondelli D. Combination of Linear Accelerator–Based Intensity-Modulated Total Marrow Irradiation and Myeloablative Fludarabine/Busulfan: A Phase I Study. Biol Blood Marrow Transplant 2014; 20:2034-41. [DOI: 10.1016/j.bbmt.2014.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 09/09/2014] [Indexed: 12/31/2022]
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Jahnke A, Jahnke L, Molina-Duran F, Ehmann M, Kantz S, Steil V, Wenz F, Glatting G, Lohr F, Polednik M. Arc therapy for total body irradiation – A robust novel treatment technique for standard treatment rooms. Radiother Oncol 2014; 110:553-7. [DOI: 10.1016/j.radonc.2013.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/05/2013] [Accepted: 12/15/2013] [Indexed: 12/20/2022]
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Takahashi Y, Hui SK. Fast, simple, and informative patient-specific dose verification method for intensity modulated total marrow irradiation with helical tomotherapy. Radiat Oncol 2014; 9:34. [PMID: 24461048 PMCID: PMC3922911 DOI: 10.1186/1748-717x-9-34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 01/23/2014] [Indexed: 11/20/2022] Open
Abstract
Background Patient-specific dose verification for treatment planning in helical tomotherapy is routinely performed using a homogeneous virtual water cylindrical phantom of 30 cm diameter and 18 cm length (Cheese phantom). Because of this small length, treatment with total marrow irradiation (TMI) requires multiple deliveries of the dose verification procedures to cover a wide range of the target volumes, which significantly prolongs the dose verification process. We propose a fast, simple, and informative patient-specific dose verification method which reduce dose verification time for TMI with helical tomotherapy. Methods We constructed a two-step solid water slab phantom (length 110 cm, height 8 cm, and two-step width of 30 cm and 15 cm), termed the Whole Body Phantom (WB phantom). Three ionization chambers and three EDR-2 films can be inserted to cover extended field TMI treatment delivery. Three TMI treatment plans were conducted with a TomoTherapy HiArt Planning Station and verified using the WB phantom with ion chambers and films. Three regions simulating the head and neck, thorax, and pelvis were covered in a single treatment delivery. The results were compared to those with the cheese phantom supplied by Accuray, Inc. following three treatment deliveries to cover the body from head to pelvis. Results Use of the WB phantom provided point doses or dose distributions from head and neck to femur in a single treatment delivery of TMI. Patient-specific dose verification with the WB phantom was 62% faster than with the cheese phantom. The average pass rate in gamma analysis with the criteria of a 3-mm distance-to-agreement and 3% dose differences was 94% ± 2% for the three TMI treatment plans. The differences in pass rates between the WB and cheese phantoms at the upper thorax to abdomen regions were within 2%. The calculated dose agreed with the measured dose within 3% for all points in all five cases in both the WB and cheese phantoms. Conclusions Our dose verification method with the WB phantom provides simple and rapid quality assurance without limiting dose verification information in total marrow irradiation with helical tomotherapy.
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Affiliation(s)
| | - Susanta K Hui
- Masonic Cancer Center, University of Minnesota, 424 Harvard Street SE, Minneapolis 55455, MN, USA.
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Mancosu P, Navarria P, Castagna L, Reggiori G, Sarina B, Tomatis S, Alongi F, Nicolini G, Fogliata A, Cozzi L, Scorsetti M. Interplay effects between dose distribution quality and positioning accuracy in total marrow irradiation with volumetric modulated arc therapy. Med Phys 2013; 40:111713. [DOI: 10.1118/1.4823767] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Langner UW, Molloy JA, Gleason JF, Feddock JM. A feasibility study using TomoDirect for craniospinal irradiation. J Appl Clin Med Phys 2013; 14:104-14. [PMID: 24036863 PMCID: PMC5714580 DOI: 10.1120/jacmp.v14i5.4304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 05/09/2013] [Accepted: 05/07/2013] [Indexed: 11/28/2022] Open
Abstract
The feasibility of delivering craniospinal irradiation (CSI) with TomoDirect is investigated. A method is proposed to generate TomoDirect plans using standard three‐dimensional (3D) beam arrangements on Tomotherapy with junctioning of these fields to minimize hot or cold spots at the cranial/spinal junction. These plans are evaluated and compared to a helical Tomotherapy and a three‐dimensional conformal therapy (3D CRT) plan delivered on a conventional linear accelerator (linac) for CSI. The comparison shows that a TomoDirect plan with an overlap between the cranial and spinal fields might be preferable over Tomotherapy plans because of decreased low dose to large volumes of normal tissues outside of the planning target volume (PTV). Although the TomoDirect plans were not dosimetrically superior to a 3D CRT linac plan, the patient can be easily treated in the supine position, which is often more comfortable and efficient from an anesthesia standpoint. TomoDirect plans also have only one setup position which obviates the need for matching of fields and feathering of junctions, two issues encountered with conventional 3D CRT plans. TomoDirect plans can be delivered with comparable treatment times to conventional 3D plans and in shorter times than a Tomotherapy plan. In this paper, a method is proposed for creating TomoDirect craniospinal plans, and the dosimetric consequences for choosing different planning parameters are discussed. PACS number: 87.55.D‐
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Nalichowski A, Burmeister J. Dosimetric comparison of helical tomotherapy treatment plans for total marrow irradiation created using GPU and CPU dose calculation engines. Med Phys 2013; 40:071716. [DOI: 10.1118/1.4810936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Liang Y, Kim GY, Pawlicki T, Mundt AJ, Mell LK. Feasibility study on dosimetry verification of volumetric-modulated arc therapy-based total marrow irradiation. J Appl Clin Med Phys 2013; 14:3852. [PMID: 23470926 PMCID: PMC5714362 DOI: 10.1120/jacmp.v14i2.3852] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 11/15/2012] [Accepted: 11/27/2012] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to develop dosimetry verification procedures for volumetric‐modulated arc therapy (VMAT)‐based total marrow irradiation (TMI). The VMAT based TMI plans were generated for three patients: one child and two adults. The planning target volume (PTV) was defined as bony skeleton, from head to mid‐femur, with a 3 mm margin. The plan strategy similar to published studies was adopted. The PTV was divided into head and neck, chest, and pelvic regions, with separate plans each of which is composed of 2–3 arcs/fields. Multiple isocenters were evenly distributed along the patient's axial direction. The focus of this study is to establish a dosimetry quality assurance procedure involving both two‐dimensional (2D) and three‐dimensional (3D) volumetric verifications, which is desirable for a large PTV treated with multiple isocenters. The 2D dose verification was performed with film for gamma evaluation and absolute point dose was measured with ion chamber, with attention to the junction between neighboring plans regarding hot/cold spots. The 3D volumetric dose verification used commercial dose reconstruction software to reconstruct dose from electronic portal imaging devices (EPID) images. The gamma evaluation criteria in both 2D and 3D verification were 5% absolute point dose difference and 3 mm of distance to agreement. With film dosimetry, the overall average gamma passing rate was 98.2% and absolute dose difference was 3.9% in junction areas among the test patients; with volumetric portal dosimetry, the corresponding numbers were 90.7% and 2.4%. A dosimetry verification procedure involving both 2D and 3D was developed for VMAT‐based TMI. The initial results are encouraging and warrant further investigation in clinical trials. PACS number: 87.55.Qr
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Affiliation(s)
- Yun Liang
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA, USA.
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