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Elhalawani H, Elgohari B, Lin TA, Mohamed ASR, Fitzgerald TJ, Laurie F, Ulin K, Kalpathy-Cramer J, Guerrero T, Holliday EB, Russo G, Patel A, Jones W, Walker GV, Awan M, Choi M, Dagan R, Mahmoud O, Shapiro A, Kong FMS, Gomez D, Zeng J, Decker R, Spoelstra FOB, Gaspar LE, Kachnic LA, Thomas CR, Okunieff P, Fuller CD. An in-silico quality assurance study of contouring target volumes in thoracic tumors within a cooperative group setting. Clin Transl Radiat Oncol 2019; 15:83-92. [PMID: 30775563 PMCID: PMC6365802 DOI: 10.1016/j.ctro.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 12/25/2022] Open
Abstract
We aimed at quantifying inter-observer Pancoast tumors delineation variability. Experts’ delineations were used to define ground truth. Other observers’ delineations were compared against ground truth. High degree of variability was noted for most target volumes except GTV_P. This unveils potentials for protocol modification for future IMRT studies.
Introduction Target delineation variability is a significant technical impediment in multi-institutional trials which employ intensity modulated radiotherapy (IMRT), as there is a real potential for clinically meaningful variances that can impact the outcomes in clinical trials. The goal of this study is to determine the variability of target delineation among participants from different institutions as part of Southwest Oncology Group (SWOG) Radiotherapy Committee’s multi-institutional in-silico quality assurance study in patients with Pancoast tumors as a “dry run” for trial implementation. Methods CT simulation scans were acquired from four patients with Pancoast tumor. Two patients had simulation 4D-CT and FDG-FDG PET-CT while two patients had 3D-CT and FDG-FDG PET-CT. Seventeen SWOG-affiliated physicians independently delineated target volumes defined as gross primary and nodal tumor volumes (GTV_P & GTV_N), clinical target volume (CTV), and planning target volume (PTV). Six board-certified thoracic radiation oncologists were designated as the ‘Experts’ for this study. Their delineations were used to create a simultaneous truth and performance level estimation (STAPLE) contours using ADMIRE software (Elekta AB, Sweden 2017). Individual participants’ contours were then compared with Experts’ STAPLE contours. Results When compared to the Experts’ STAPLE, GTV_P had the best agreement among all participants, while GTV_N showed the lowest agreement among all participants. There were no statistically significant differences in all studied parameters for all TVs for cases with 4D-CT versus cases with 3D-CT simulation scans. Conclusions High degree of inter-observer variation was noted for all target volume except for GTV_P, unveiling potentials for protocol modification for subsequent clinically meaningful improvement in target definition. Various similarity indices exist that can be used to guide multi-institutional radiotherapy delineation QA credentialing.
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Affiliation(s)
- Hesham Elhalawani
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Baher Elgohari
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Timothy A Lin
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Baylor College of Medicine, TX 77030, USA
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Department of Clinical Oncology and Nuclear Medicine, Alexandria University, Alexandria, Egypt
| | - Thomas J Fitzgerald
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Fran Laurie
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Massachusetts, USA
| | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Emma B Holliday
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Gregory Russo
- Department of Radiation Oncology, Boston Medical Center, Massachusetts, USA
| | - Abhilasha Patel
- Department of Radiation Oncology, University of Texas Health Sciences Center at San Antonio, TX, USA
| | - William Jones
- Department of Radiation Oncology, University of Texas Health Sciences Center at San Antonio, TX, USA
| | - Gary V Walker
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona, USA
| | - Musaddiq Awan
- Department of Radiation Oncology, Case Western Reserve University, OH, USA
| | - Mehee Choi
- Department of Radiation Oncology, Northwestern University, IL, USA
| | - Roi Dagan
- University of Florida Health Proton Therapy Institute, FL, USA
| | - Omar Mahmoud
- Department of Radiation Oncology, University of Miami, FL, USA
| | - Anna Shapiro
- Department of Radiation Oncology, Upstate Cancer Center, SUNY Upstate Medical University, NY, USA
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, OH, USA
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington Medical Center, WA, USA
| | - Roy Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, Connecticut, USA
| | - Femke O B Spoelstra
- Department of Radiation Oncology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurie E Gaspar
- Department of Radiation Oncology, Vanderbilt University, TN, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, Tennessee, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Oregon, USA
| | - Paul Okunieff
- SWOG, Department of Radiation Oncology, University of Florida College of Medicine, Florida, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
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Okunieff P, Casey-Sawicki K, Lockney NA, Hoppe BS, Enderling H, Pinnix C, Welsh J, Krishnan S, Yothers G, Brown M, Knox S, Bristow R, Spellman P, Mitin T, Nabavizadeh N, Jaboin J, Manning HC, Feng F, Galbraith S, Solanki AA, Harkenrider MM, Tuli R, Decker RH, Finkelstein SE, Hsu CC, Ha CS, Jagsi R, Shumway D, Daly M, Wang TJC, Fitzgerald TJ, Laurie F, Marshall DT, Raben D, Constine L, Thomas CR, Kachnic LA. Report from the SWOG Radiation Oncology Committee: Research Objectives Workshop 2017. Clin Cancer Res 2018; 24:3500-3509. [PMID: 29661779 DOI: 10.1158/1078-0432.ccr-17-3202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/12/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022]
Abstract
The Radiation Therapy Committee of SWOG periodically evaluates its strategic plan in an effort to maintain a current and relevant scientific focus, and to provide a standard platform for future development of protocol concepts. Participants in the 2017 Strategic Planning Workshop included leaders in cancer basic sciences, molecular theragnostics, pharmaceutical and technology industries, clinical trial design, oncology practice, and statistical analysis. The committee discussed high-priority research areas, such as optimization of combined modality therapy, radiation oncology-specific drug design, identification of molecular profiles predictive of radiation-induced local or distant tumor responses, and methods for normal tissue-specific mitigation of radiation toxicity. The following concepts emerged as dominant questions ready for national testing: (i) what is the role of radiotherapy in the treatment of oligometastatic, oligorecurrent, and oligoprogressive disease? (ii) How can combined modality therapy be used to enhance systemic and local response? (iii) Can we validate and optimize liquid biopsy and other biomarkers (such as novel imaging) to supplement current response criteria to guide therapy and clinical trial design endpoints? (iv) How can we overcome deficiencies of randomized survival endpoint trials in an era of increasing molecular stratification factors? And (v) how can we mitigate treatment-related side effects and maximize quality of life in cancer survivors? The committee concluded that many aspects of these questions are ready for clinical evaluation and example protocol concepts are provided that could improve rates of cancer cure and quality of survival. Clin Cancer Res; 24(15); 3500-9. ©2018 AACR.
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Affiliation(s)
- Paul Okunieff
- Department of Radiation Oncology, University of Florida Health Cancer Center, Gainesville, Florida.
| | - Katherine Casey-Sawicki
- Department of Radiation Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - Natalie A Lockney
- Department of Radiation Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - Heiko Enderling
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Chelsea Pinnix
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - James Welsh
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Greg Yothers
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Martin Brown
- Departments of Radiation Oncology and Neurology, Stanford University, Palo Alto, California
| | - Susan Knox
- Departments of Radiation Oncology and Neurology, Stanford University, Palo Alto, California
| | - Robert Bristow
- Manchester Cancer Research Centre, University of Manchester, Manchester, United Kingdom
| | - Paul Spellman
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Timur Mitin
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon
| | - Jerry Jaboin
- Department of Radiation Medicine, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon
| | - H Charles Manning
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Felix Feng
- Department of Urology, University of California, San Francisco, California
| | | | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | | | - Charles C Hsu
- Department of Radiation Oncology, University of Arizona Cancer Center, Tucson, Arizona
| | - Chul S Ha
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, Texas
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Dean Shumway
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Megan Daly
- Department of Radiation Oncology, University of California, San Diego, California
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
| | - Thomas J Fitzgerald
- Department of Radiation Oncology, University of Massachusetts Medical School, North Worcester, Massachusetts
| | - Fran Laurie
- Department of Radiation Oncology, University of Massachusetts Medical School, North Worcester, Massachusetts
| | - David T Marshall
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - David Raben
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Louis Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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Targeting the epigenetics of the DNA damage response in breast cancer. Cell Death Dis 2016; 7:e2180. [PMID: 27054335 PMCID: PMC4855664 DOI: 10.1038/cddis.2016.85] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/25/2016] [Accepted: 03/14/2016] [Indexed: 12/15/2022]
Abstract
Cancer is as much an epigenetic disease as it is a genetic disease, and epigenetic alterations in cancer often serve as potent surrogates for genetic mutations. Because the epigenetic factors involved in the DNA damage response are regulated by multiple elements, therapies to target specific components of the epigenetic machinery can be inefficient. In contrast, therapies aimed at inhibiting the methionine cycle can indirectly inhibit both DNA and protein methylation, and the wide variety of genes and pathways that are affected by these methylations make this global strategy very attractive. In the present study, we propose an adjuvant therapy that targets the epigenetics of the DNA damage response in breast cancer cells and that results in efficient apoptosis and a reduction in distant metastases in vivo. We observed that a combined therapy designed to uncouple adenosine metabolism using dipyridamole in the presence of a new synthetic antifolate, 3-O-(3,4,5-trimethoxybenzoyl)-(-)-catechin, simultaneously and efficiently blocked both the folic cycle and the methionine cycle in breast cancer cells and sensitized these cells to radiotherapy. The treatment impeded the recruitment of 53BP1 and BRCA1 to the chromatin regions flanking DNA double-strand breaks and thereby avoided the DNA damage responses in breast cancer cells that were exposed to ionizing radiation. In addition, this hypomethylating therapy was also efficient in reducing the self-renewal capability of breast cancer-initiating cells and induced reversion of mesenchymal phenotypes in breast cancer cells.
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Kalpathy-Cramer J, Awan M, Bedrick S, Rasch CRN, Rosenthal DI, Fuller CD. Development of a software for quantitative evaluation radiotherapy target and organ-at-risk segmentation comparison. J Digit Imaging 2014; 27:108-19. [PMID: 24043593 DOI: 10.1007/s10278-013-9633-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Modern radiotherapy requires accurate region of interest (ROI) inputs for plan optimization and delivery. Target delineation, however, remains operator-dependent and potentially serves as a major source of treatment delivery error. In order to optimize this critical, yet observer-driven process, a flexible web-based platform for individual and cooperative target delineation analysis and instruction was developed in order to meet the following unmet needs: (1) an open-source/open-access platform for automated/semiautomated quantitative interobserver and intraobserver ROI analysis and comparison, (2) a real-time interface for radiation oncology trainee online self-education in ROI definition, and (3) a source for pilot data to develop and validate quality metrics for institutional and cooperative group quality assurance efforts. The resultant software, Target Contour Testing/Instructional Computer Software (TaCTICS), developed using Ruby on Rails, has since been implemented and proven flexible, feasible, and useful in several distinct analytical and research applications.
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Affiliation(s)
- Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Harvard Medical School, Department of Radiology and Neuroscience, Massachusetts General Hospital, Charlestown, MA, USA
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Awan M, Kalpathy-Cramer J, Gunn GB, Beadle BM, Garden AS, Phan J, Holliday E, Jones WE, Maani E, Patel A, Choi J, Clyburn V, Tantiwongkosi B, Rosenthal DI, Fuller CD. Prospective assessment of an atlas-based intervention combined with real-time software feedback in contouring lymph node levels and organs-at-risk in the head and neck: Quantitative assessment of conformance to expert delineation. Pract Radiat Oncol 2012; 3:186-193. [PMID: 24674363 DOI: 10.1016/j.prro.2012.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 11/06/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE A number of studies have previously assessed the role of teaching interventions to improve organ-at-risk (OAR) delineation. We present a preliminary study demonstrating the benefit of a combined atlas and real time software-based feedback intervention to aid in contouring of OARs in the head and neck. METHODS AND MATERIALS The study consisted of a baseline evaluation, a real-time feedback intervention, atlas presentation, and a follow-up evaluation. At baseline evaluation, 8 resident observers contoured 26 OARs on a computed tomography scan without intervention or aid. They then received feedback comparing their contours both statistically and graphically to a set of atlas-based expert contours. Additionally, they received access to an atlas to contour these structures. The resident observers were then asked to contour the same 26 OARs on a separate computed tomography scan with atlas access. In addition, 6 experts (5 radiation oncologists specializing in the head and neck, and 1 neuroradiologist) contoured the 26 OARs on both scans. A simultaneous truth and performance level estimation (STAPLE) composite of the expert contours was used as a gold-standard set for analysis of OAR contouring. RESULTS Of the 8 resident observers who initially participated in the study, 7 completed both phases of the study. Dice similarity coefficients were calculated for each user-drawn structure relative to the expert STAPLE composite for each structure. Mean dice similarity coefficients across all structures increased between phase 1 and phase 2 for each resident observer, demonstrating a statistically significant improvement in overall OAR-contouring ability (P < .01). Additionally, intervention improved contouring in 16/26 delineated organs-at-risk across resident observers at a statistically significant level (P ≤ .05) including all otic structures and suprahyoid lymph node levels of the head and neck. CONCLUSIONS Our data suggest that a combined atlas and real-time feedback-based educational intervention detectably improves contouring of OARs in the head and neck.
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Affiliation(s)
- Musaddiq Awan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Harvard Medical School, Charlestown, Massachusetts; Department of Radiology and Neuroscience, Massachusetts General Hospital, Charlestown, Massachusetts; Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beth M Beadle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emma Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William E Jones
- South Texas Veterans Affairs Health Care System, San Antonio, Texas; Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Elizabeth Maani
- South Texas Veterans Affairs Health Care System, San Antonio, Texas; Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Abhilasha Patel
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jehee Choi
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Virginia Clyburn
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Bundhit Tantiwongkosi
- Department of Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon.
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Kalpathy-Cramer J, Bedrick SD, Boccia K, Fuller CD. A pilot prospective feasibility study of organ-at-risk definition using Target Contour Testing/Instructional Computer Software (TaCTICS), a training and evaluation platform for radiotherapy target delineation. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2011; 2011:654-663. [PMID: 22195121 PMCID: PMC3243186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Target volume delineation is a critical, but time-consuming step in the creation of radiation therapy plans used in the treatment of many types of cancer. However, variability in target volume definitions can introduce substantial differences in resulting doses to tumors and critical structures. We developed TaCTICS, a web-based educational training software application targeted towards non-expert users. We report on a small, prospective study to evaluate the utility of this online tool in improving conformance of regions-of-interest (ROIs) with a reference set. Eight residents contoured a set of structures for a head-and-neck cancer case. Subsequently, they were provided access to TaCTICS as well as contouring atlases to allow evaluation of their contours in reference to other users as well as reference ROIs. The residents then contoured a second case using these resources. Volume overlap metrics between the users showed a substantial improvement following the intervention. Additionally, 66% of users reported that they found TaCTICS to be a useful educational tool and all participants reported they would like to use TaCTICS to track their contouring skills over the course of their residency.
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