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Oki Y, Uehara K, Mizonobe K, Akasaka H, Shiota Y, Sakamoto R, Harada A, Kitatani K, Yabuuchi T, Miyazaki S, Hattori T, Mayahara H. Plan comparison of prostate stereotactic radiotherapy in spacer implant patients. J Appl Clin Med Phys 2021; 22:280-288. [PMID: 34359100 PMCID: PMC8425928 DOI: 10.1002/acm2.13387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/31/2021] [Accepted: 07/26/2021] [Indexed: 01/26/2023] Open
Abstract
In prostate stereotactic body radiation therapy (SBRT), hydrogel spacers are increasingly used. This study aimed to perform a dosimetry comparison of treatment plans using CyberKnife (CK), commonly used for prostate SBRT, Helical TomoTherapy (HT), and TrueBeam (TB) in patients with hydrogel spacer implantations. The data of 20 patients who received hydrogel spacer implantation for prostate SBRT were retrospectively analyzed. The prescription dose was 36.25 Gy in five fractions to 95% of the planning target volume (PTV; D95). The conformity index (CI), gradient index (GI), homogeneity index (HI), and dose‐volume histogram (DVH) were analyzed for the three modalities, using the same PTV margins. The monitor unit (MU) and the beam‐on‐time (BOT) values were subsequently compared. The CI of TB (0.93 ± 0.02) was significantly superior to those of CK (0.82 ± 0.03, p < 0.01) and HT (0.86 ± 0.03, p < 0.01). Similarly, the GI value of TB (3.59 ± 0.12) was significantly better than those of CK (4.31 ± 0.43, p < 0.01) and HT (4.52 ± 0.24, p < 0.01). The median doses to the bladder did not differ between the CK and TB (V18.1 Gy: 16.5% ± 4.5% vs. 15.8% ± 4.4%, p = 1.00), but were significantly higher for HT (V18.1 Gy: 33.2% ± 7.3%, p < 0.01 vs. CK, p < 0.01 vs. TB). The median rectal dose was significantly lower for TB (V18.1 Gy: 5.6% ± 4.5%) than for CK (V18.1 Gy: 11.2% ± 6.7%, p < 0.01) and HT (20.2% ± 8.3%, p < 0.01). TB had the shortest BOT (2.6 min; CK: 17.4 min, HT: 6.9 min). TB could create treatment plans dosimetrically comparable to those of CK when using the same margins, in patients with hydrogel spacers.
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Affiliation(s)
- Yuya Oki
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Kazuyuki Uehara
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Kazufusa Mizonobe
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Hiroaki Akasaka
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan.,Division of Radiation Oncology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichirou Shiota
- Division of Radiological Technology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Risako Sakamoto
- Division of Radiological Technology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Aya Harada
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Keiji Kitatani
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Tomonori Yabuuchi
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Shuichirou Miyazaki
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Takayuki Hattori
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
| | - Hiroshi Mayahara
- Division of Radiation Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Hyogo, Japan
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Byun DJ, Gorovets DJ, Jacobs LM, Happersett L, Zhang P, Pei X, Burleson S, Zhang Z, Hunt M, McBride S, Kollmeier MA, Zelefsky MJ. Strict bladder filling and rectal emptying during prostate SBRT: Does it make a dosimetric or clinical difference? Radiat Oncol 2020; 15:239. [PMID: 33066781 PMCID: PMC7565753 DOI: 10.1186/s13014-020-01681-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023] Open
Abstract
Background To evaluate inter-fractional variations in bladder and rectum during prostate stereotactic body radiation therapy (SBRT) and determine dosimetric and clinical consequences. Methods Eighty-five patients with 510 computed tomography (CT) images were analyzed. Median prescription dose was 40 Gy in 5 fractions. Patients were instructed to maintain a full bladder and empty rectum prior to simulation and each treatment. A single reviewer delineated organs at risk (OARs) on the simulation (Sim-CT) and Cone Beam CTs (CBCT) for analyses. Results Bladder and rectum volume reductions were observed throughout the course of SBRT, with largest mean reductions of 86.9 mL (19.0%) for bladder and 6.4 mL (8.7%) for rectum noted at fraction #5 compared to Sim-CT (P < 0.01). Higher initial Sim-CT bladder volumes were predictive for greater reduction in absolute bladder volume during treatment (ρ = − 0.69; P < 0.01). Over the course of SBRT, there was a small but significant increase in bladder mean dose (+ 4.5 ± 12.8%; P < 0.01) but no significant change in the D2cc (+ 0.8 ± 4.0%; P = 0.28). The mean bladder trigone displacement was in the anterior direction (+ 4.02 ± 6.59 mm) with a corresponding decrease in mean trigone dose (− 3.6 ± 9.6%; P < 0.01) and D2cc (− 6.2 ± 15.6%; P < 0.01). There was a small but significant increase in mean rectal dose (+ 7.0 ± 12.9%, P < 0.01) but a decrease in rectal D2cc (− 2.2 ± 10.1%; P = 0.04). No significant correlations were found between relative bladder volume changes, bladder trigone displacements, or rectum volume changes with rates of genitourinary or rectal toxicities. Conclusions Despite smaller than expected bladder and rectal volumes at the time of treatment compared to the planning scans, dosimetric impact was minimal and not predictive of detrimental clinical outcomes. These results cast doubt on the need for excessively strict bladder filling and rectal emptying protocols in the context of image guided prostate SBRT and prospective studies are needed to determine its necessity.
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Affiliation(s)
- David J Byun
- Department of Radiation Oncology, NYU Langone Health, 160 East 34th St, New York, NY, USA
| | - Daniel J Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Lauren M Jacobs
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Laura Happersett
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Xin Pei
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sarah Burleson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Margie Hunt
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Marisa A Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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Devlin L, Dodds D, Sadozye A, McLoone P, MacLeod N, Lamb C, Currie S, Thomson S, Duffton A. Dosimetric impact of organ at risk daily variation during prostate stereotactic ablative radiotherapy. Br J Radiol 2020; 93:20190789. [PMID: 31971829 PMCID: PMC7362910 DOI: 10.1259/bjr.20190789] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/19/2019] [Accepted: 01/13/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Prostate stereotactic ablative radiotherapy (SABR) delivers large doses using a fast dose rate. This amplifies the effect geometric uncertainties have on normal tissue dose. The aim of this study was to determine whether the treatment dose-volume histogram (DVH) agrees with the planned dose to organs at risk (OAR). METHODS 41 low-intermediate risk prostate cancer patients were treated with SABR using a linac based technique. Dose prescribed was 35 Gy in five fractions delivered on alternate days, planned using volumetric modulated arc therapy (VMAT) with 10X flattening filter free (FFF). On treatment, prostate was matched to fiducial markers on cone beam CT (CBCT). OAR were retrospectively delineated on 205 pre-treatment CBCT images. Daily CBCT contours were overlaid on the planning CT for dosimetric analysis. Verification plan used to evaluate the daily DVH for each structure. The daily doses received by OAR were recorded using the D%. RESULTS The median rectum and bladder volumes at planning were 67.1 cm3 (interquartile range 56.4-78.2) and 164.4 cm3 (interquartile range 120.3-213.4) respectively. There was no statistically significant difference in median rectal volume at each of the five treatment scans compared to the planning scan (p = 0.99). This was also the case for median bladder volume (p = 0.79). The median dose received by rectum and bladder at each fraction was higher than planned, at the majority of dose levels. For rectum the increase ranged from 0.78-1.64Gy and for bladder 0.14-1.07Gy. The percentage of patients failing for rectum D35% < 18 Gy (p = 0.016), D10% < 28 Gy (p = 0.004), D5% < 32 Gy (p = 0.0001), D1% < 35 Gy (p = 0.0001) and bladder D1% < 35 Gy (p = 0.001) at treatment were all statistically significant. CONCLUSION In this cohort of prostate SABR patients, we estimate the OAR treatment DVH was higher than planned. This was due to rectal and bladder organ variation. ADVANCES IN KNOWLEDGE OAR variation in prostate SABR using a FFF technique, may cause the treatment DVH to be higher than planned.
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Affiliation(s)
- Lynsey Devlin
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - David Dodds
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Azmat Sadozye
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Philip McLoone
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Nicholas MacLeod
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Carolynn Lamb
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Suzanne Currie
- Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Stefanie Thomson
- Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Aileen Duffton
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
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Gensanne D, Hadj Henni A, Lauzin Y, Clarisse P, Thureau S. [Inter- and intrafraction imaging during stereotactic body radiation therapy: Which solutions for which tumours?]. Cancer Radiother 2019; 23:891-895. [PMID: 31615729 DOI: 10.1016/j.canrad.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/29/2019] [Accepted: 09/02/2019] [Indexed: 10/25/2022]
Abstract
Due to high dose gradients, stereotactic body radiation therapy requires high precision in the location of the tumour. Uncertainties in the positioning can introduce serious damage on organs at risk and consequently can reduce tumour local control. A better tumour location can be achieved by controlling its position with an efficient inter and intrafraction imaging procedure. The various imaging techniques available on treatment systems are presented and performances are discussed. Finally, propositions are given in terms of imaging system according to the location treated by stereotactic body radiation therapy.
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Affiliation(s)
- D Gensanne
- Centre Henri-Becquerel, département de radiothérapie et de physique médicale, rue d'Amiens, CS 11516, 76038 Rouen cedex 1, France.
| | - A Hadj Henni
- Centre Henri-Becquerel, département de radiothérapie et de physique médicale, rue d'Amiens, CS 11516, 76038 Rouen cedex 1, France
| | - Y Lauzin
- Centre Henri-Becquerel, département de radiothérapie et de physique médicale, rue d'Amiens, CS 11516, 76038 Rouen cedex 1, France
| | - P Clarisse
- Centre Henri-Becquerel, département de radiothérapie et de physique médicale, rue d'Amiens, CS 11516, 76038 Rouen cedex 1, France
| | - S Thureau
- Centre Henri-Becquerel, département de radiothérapie et de physique médicale, rue d'Amiens, CS 11516, 76038 Rouen cedex 1, France; Quantif-Litis EA 4108, université de Rouen, 76000 Rouen, France
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Ma X, Yan H, Nath R, Chen Z, Li H, Liu W. Adaptive Imaging Versus Periodic Surveillance for Intrafraction Motion Management During Prostate Cancer Radiotherapy. Technol Cancer Res Treat 2019; 18:1533033819844489. [PMID: 31177934 PMCID: PMC6558533 DOI: 10.1177/1533033819844489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the benefits of adaptive imaging with automatic correction compared to
periodic surveillance strategies with either manual or automatic correction. Methods: Using Calypso trajectories from 54 patients with prostate cancer at 2 institutions, we
simulated 5-field intensity-modulated radiation therapy and dual-arc
volumetric-modulated arc therapy with periodic imaging at various frequencies and with
continuous adaptive imaging, respectively. With manual/automatic correction, we assumed
there was a 30/1 second delay after imaging to determine and apply couch shift. For
adaptive imaging, real-time “dose-free” cine-MV images during beam delivery are used in
conjunction with online-updated motion pattern information to estimate 3D displacement.
Simultaneous MV-kV imaging is only used to confirm the estimated overthreshold motion
and calculate couch shift, hence very low additional patient dose from kV imaging. Results: Without intrafraction intervention, the prostates could on average have moved out of a
3-mm margin for ∼20% of the beam-on time after setup imaging in current clinical
situation. If the time interval from the setup imaging to beam-on can be reduced to only
30 seconds, the mean over-3 mm percentage can be reduced to ∼7%. For intensity-modulated
radiation therapy simulation, with manual correction, 110 and 70 seconds imaging periods
both reduced the mean over-3 mm time to ∼4%. Automatic correction could give another 1%
to 2% improvement. However, with either manual or automatic correction, the maximum
patient-specific over-3 mm time was still relatively high (from 6.4% to 12.6%) and those
patients are actually clinically most important. In contrast, adaptive imaging with
automatic intervention significantly reduced the mean percentage to 0.6% and the maximum
to 2.7% and averagely only ∼1 kV image and ∼1 couch shift were needed per fraction. The
results of volumetric-modulated arc therapy simulation show a similar trend to that of
intensity-modulated radiation therapy. Conclusions: Adaptive continuous monitoring with automatic motion compensation is more beneficial
than periodic imaging surveillance at similar or even less imaging dose.
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Affiliation(s)
- Xiangyu Ma
- 1 School of Biomedical Engineering, Capital Medical University, Beijing, China.,2 Department of Therapeutic Radiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA.,3 Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Huagang Yan
- 1 School of Biomedical Engineering, Capital Medical University, Beijing, China.,2 Department of Therapeutic Radiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA
| | - Ravinder Nath
- 2 Department of Therapeutic Radiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA
| | - Zhe Chen
- 2 Department of Therapeutic Radiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA
| | - Haiyun Li
- 1 School of Biomedical Engineering, Capital Medical University, Beijing, China.,3 Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Wu Liu
- 2 Department of Therapeutic Radiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA
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Li T, Wu QJ, Matzen T, Yin FF, O'Daniel JC. Diode-based transmission detector for IMRT delivery monitoring: a validation study. J Appl Clin Med Phys 2016; 17:235-244. [PMID: 27685115 PMCID: PMC5874094 DOI: 10.1120/jacmp.v17i5.6204] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 06/02/2016] [Accepted: 05/02/2016] [Indexed: 11/23/2022] Open
Abstract
The purpose of this work was to evaluate the potential of a new transmission detector for real‐time quality assurance of dynamic‐MLC‐based radiotherapy. The accuracy of detecting dose variation and static/dynamic MLC position deviations was measured, as well as the impact of the device on the radiation field (surface dose, transmission). Measured dose variations agreed with the known variations within 0.3%. The measurement of static and dynamic MLC position deviations matched the known deviations with high accuracy (0.7–1.2 mm). The absorption of the device was minimal (∼ 1%). The increased surface dose was small (1%–9%) but, when added to existing collimator scatter effects could become significant at large field sizes (≥30×30 cm2). Overall the accuracy and speed of the device show good potential for real‐time quality assurance. PACS number(s): 87.55.Qr
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Abstract
The past decade has brought an improved ability to precisely target and deliver radiation as well as other focal prostate-directed therapy. Stereotactic body radiotherapy (SBRT), proton beam radiation, high-dose-rate (HDR) brachytherapy, as well as nonradiotherapy treatments such as cryoablation and high-intensity focused ultrasound are several therapeutic modalities that have been investigated for the treatment of prostate cancer in an attempt to reduce toxicity while improving cancer control. However, high-risk prostate cancer requires a comprehensive treatment of the prostate as well as areas at risk for cancer spread. Therefore, most new radiation treatment (SBRT, HDR, and proton beam radiation) modalities have been largely investigated in combination with regional radiation therapy. Though the evidence is evolving, the use of SBRT, HDR, and proton beam radiation is promising. Nonradiation focal therapy has been proposed mainly for partial gland treatment in men with low-risk disease, and its use in high-risk prostate cancer patients remains experimental.
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Affiliation(s)
- William J Magnuson
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Amandeep Mahal
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT.
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Li W, Vassil A, Godley A, Mossolly LM, Shang Q, Xia P. Using daily diagnostic quality images to validate planning margins for prostate interfractional variations. J Appl Clin Med Phys 2016; 17:61-74. [PMID: 27167262 PMCID: PMC5690910 DOI: 10.1120/jacmp.v17i3.5923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/18/2015] [Accepted: 12/15/2015] [Indexed: 12/31/2022] Open
Abstract
The purpose of this study is to use the same diagnostic-quality verification and planning CTs to validate planning margin account for residual interfractional variations with image-guided soft tissue alignment of the prostate. For nine pros-tate cancer patients treated with IMRT to 78 Gy in 39 fractions, daily verification CT-on-rails images of the first seven and last seven fractions (n = 126) were retrospectively selected for this study. On these images, prostate, bladder, and rectum were delineated by the same attending physician. Clinical plans were cre-ated with a margin of 8 mm except for 5 mm posteriorly, referred to as 8/5mm. Three additional plans were created for each patient with the margins of 6/4 mm, 4/2mm, and 2 mm uniform. These plans were subsequently applied to daily images and radiation doses were recalculated. The isocenters of these plans were placed according to clinical online shifts, which were based on soft tissue alignment to the prostate. Retrospective offline shifts by aligning prostate contours were com-pared to online shifts. The resultant daily target dose was analyzed using D99, the percentage of the prescription dose received by 99% of CTV. The percent of blad-der volume receiving 65 Gy (V65Gy) and rectum V70Gy were also analyzed. After interfractional correction, using CTV D99 > 97% criteria, 8/5 mm, 6/4 mm, 4/2 mm, and 2 mm planning margins met the CTV dose coverage in 95%, 91%, 65%, and 53% of the 126 fractions with online shifts, and 99%, 98%, 85%, and 68% with offline shifts. The rectum V70Gy and bladder V65Gy were significantly decreased at each level of margin reduction (p < 0.05). With daily diagnostic quality imaging-guidance, the interfractional planning margin may be reduced from 8/5mm to 6/4 mm. The residual interfractional uncertainties most likely stem from prostate rotation anddeformation.
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Hunt MA, Sonnick M, Pham H, Regmi R, Xiong JP, Morf D, Mageras GS, Zelefsky M, Zhang P. Simultaneous MV-kV imaging for intrafractional motion management during volumetric-modulated arc therapy delivery. J Appl Clin Med Phys 2016; 17:473-486. [PMID: 27074467 PMCID: PMC4831078 DOI: 10.1120/jacmp.v17i2.5836] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 12/06/2015] [Accepted: 11/20/2015] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the accuracy and clinical feasibility of a motion monitoring method employing simultaneously acquired MV and kV images during volumetric-modulated arc therapy (VMAT). Short-arc digital tomosynthesis (SA-DTS) is used to improve the quality of the MV images that are then combined with orthogonally acquired kV images to assess 3D motion. An anthropomorphic phantom with implanted gold seeds was used to assess accuracy of the method under static, typical prostatic, and respiratory motion scenarios. Automatic registra-tion of kV images and single MV frames or MV SA-DTS reconstructed with arc lengths from 2° to 7° with the appropriate reference fiducial template images was performed using special purpose-built software. Clinical feasibility was evaluated by retrospectively analyzing images acquired over four or five sessions for each of three patients undergoing hypofractionated prostate radiotherapy. The standard deviation of the registration error in phantom using MV SA-DTS was similar to single MV images for the static and prostate motion scenarios (σ = 0.25 mm). Under respiratory motion conditions, the standard deviation of the registration error increased to 0.7mm and 1.7 mm for single MV and MV SA-DTS, respectively. Registration failures were observed with the respiratory scenario only and were due to motion-induced fiducial blurring. For the three patients studied, the mean and standard deviation of the difference between automatic registration using 4° MV SA-DTS and manual registration using single MV images results was 0.07±0.52mm. The MV SA-DTS results in patients were, on average, superior to single-frame MV by nearly 1 mm - significantly more than what was observed in phantom. The best MV SA-DTS results were observed with arc lengths of 3° to 4°. Registration failures in patients using MV SA-DTS were primarily due to blockage of the gold seeds by the MLC. The failure rate varied from 2% to 16%. Combined MV SA-DTS and kV imaging is feasible for intratreatment motion monitoring during VMAT of anatomic sites where limited motion is expected, and improves registration accuracy compared to single MV/kV frames. To create a clinically robust technique, further improvements to ensure visualization of fiducials at the desired control points without degradation of the treatment plan are needed.
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Ruggieri R, Naccarato S, Stavrev P, Stavreva N, Fersino S, Giaj Levra N, Mazzola R, Mancosu P, Scorsetti M, Alongi F. Volumetric-modulated arc stereotactic body radiotherapy for prostate cancer: dosimetric impact of an increased near-maximum target dose and of a rectal spacer. Br J Radiol 2015; 88:20140736. [PMID: 26235142 DOI: 10.1259/bjr.20140736] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE In volumetric-modulated arc therapy (VMAT) prostate stereotactic body radiotherapy (SBRT), dose coverage of the planning target volume (PTV) becomes challenging when the sparing of rectum, bladder and urethra is strictly pursued. Our current 35-Gy-in-five-fraction plans only assure 33.2 Gy to ≥95% PTV ([Formula: see text] ≥ 95%). Looking for an improved [Formula: see text], increased near-maximum target dose (D2%) and prostate-rectum spacer insertion were tested. METHODS For 11 patients, two VMAT plans, with D2% ≤ 37.5 Gy (Hom) or D2% ≤ 40.2 Gy (Het), on each of two CT studies, before or after spacer insertion, were computed. All plans assured [Formula: see text] ≥95%, and <1 cm(3) of rectum, bladder and urethra receiving ≥35 Gy. By hypothesis testing, several dose-volume metrics for target coverage and rectal sparing were compared across the four groups of plans. The impact of spacer insertion on the fractions of rectum receiving more than 18, 28 and 32 Gy ([Formula: see text]) was further tested by linear correlation analysis. RESULTS By hypothesis testing, the increased D2% was associated with improvements in target coverage, whereas spacer insertion was associated with improvements in both target coverage and rectal [Formula: see text]. By linear correlation analysis, spacer insertion was related to the reductions in rectal [Formula: see text] for X ≥ 28 Gy. CONCLUSION A slightly increased D2% or the use of spacer insertion was each able to improve [Formula: see text]. Their combined use assured [Formula: see text] ≥ 98% to all our patients. Spacer insertion was further causative for improvements in rectal sparing. ADVANCES IN KNOWLEDGE For VMAT plans in prostate SBRT, the distinct dosimetric usefulness of increased D2% and of the use of spacer insertion were validated in terms of target coverage and rectal sparing.
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Affiliation(s)
- Ruggero Ruggieri
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | | | - Pavel Stavrev
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | - Nadejda Stavreva
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | - Sergio Fersino
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | | | - Rosario Mazzola
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | - Pietro Mancosu
- 2 Radiotherapy and Radiosurgery Department, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Marta Scorsetti
- 2 Radiotherapy and Radiosurgery Department, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Filippo Alongi
- 1 Radiation Oncology, Ospedale Sacro Cuore Don Calabria, Verona, Italy
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Ballhausen H, Ballhausen BD, Lachaine M, Li M, Parodi K, Belka C, Reiner M. Surface refraction of sound waves affects calibration of three-dimensional ultrasound. Radiat Oncol 2015; 10:119. [PMID: 26014494 PMCID: PMC4450514 DOI: 10.1186/s13014-015-0424-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Three-dimensional ultrasound (3D-US) is used in planning and treatment during external beam radiotherapy. The accuracy of the technique depends not only on the achievable image quality in clinical routine, but also on technical limitations of achievable precision during calibration. Refraction of ultrasound waves is a known source for geometric distortion, but such an effect was not expected in homogenous calibration phantoms. However, in this paper we demonstrate that the discontinuity of the refraction index at the phantom surface may affect the calibration unless the ultrasound probe is perfectly perpendicular to the phantom. METHODS A calibration phantom was repeatedly scanned with a 3D-US system (Elekta Clarity) by three independent observers. The ultrasound probe was moved horizontally at a fixed angle in the sagittal plane. The resulting wedge shaped volume between probe and phantom was filled with water to couple in the ultrasound waves. Because the speed of sound in water was smaller than the speed of sound in Zerdine, the main component of the phantom, the angle of the ultrasound waves inside the phantom increased. This caused an apparent shift in the calibration features which was recorded as a function of the impeding angle. To confirm the magnitude and temperature dependence, the experiment was repeated by two of the observers with a mixture of ice and water at 0 °C and with thermalized tap water at 21 °C room temperature. RESULTS During the first series of measurements, a linear dependency of the displacements dx of the calibration features on the angle α of the ultrasound probe was observed. The three observers recorded significantly nonzero (p < 0.0001) and very consistent slopes of dx/dα of 0.12, 0.12, and 0.13 mm/°, respectively.. At 0 °C water temperature, the slope increased to 0.18 ± 0.04 mm/°. This matched the prediction of Snell's law of 0.185 mm/° for a speed of sound of 1,402 m/s at the melting point of ice. At 21 °C, slopes of 0.11 and 0.12 mm/° were recorded in agreement with the first experiment at about room temperature. The difference to the theoretical expectation of 0.07 mm/° was not significant (p = 0.09). CONCLUSIONS The surface refraction of sound waves my affect the calibration of three-dimensional ultrasound. The temperature dependence of the effect rules out alternative explanations for the observed shifts in calibration. At room temperature and for a structure that is 10 cm below the water-phantom interface, a tilt of the ultrasound probe of 10° may result in a position reading that is off by more than half a millimeter. Such errors are of the order of other relevant errors typically encountered during the calibration of a 3D-US system. Hence, care must be taken not to tilt the ultrasound probe during calibration.
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Affiliation(s)
- Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilians-University, Marchioninistraße 15, 81377, Munich, Germany.
| | | | | | - Minglun Li
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilians-University, Marchioninistraße 15, 81377, Munich, Germany.
| | - Katia Parodi
- Department of Experimental Physics, Medical Physics, Ludwig-Maximilians-University, Am Coulombwall 1, 85748, Garching, Germany.
| | - Claus Belka
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilians-University, Marchioninistraße 15, 81377, Munich, Germany.
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilians-University, Marchioninistraße 15, 81377, Munich, Germany.
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Li M, Ballhausen H, Hegemann NS, Ganswindt U, Manapov F, Tritschler S, Roosen A, Gratzke C, Reiner M, Belka C. A comparative assessment of prostate positioning guided by three-dimensional ultrasound and cone beam CT. Radiat Oncol 2015; 10:82. [PMID: 25890013 PMCID: PMC4465303 DOI: 10.1186/s13014-015-0380-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/16/2015] [Indexed: 12/25/2022] Open
Abstract
Background The accuracy of the Elekta Clarity™ three-dimensional ultrasound system (3DUS) was assessed for prostate positioning and compared to seed- and bone-based positioning in kilo-voltage cone-beam computed tomography (CBCT) during a definitive radiotherapy. Methods The prostate positioning of 6 patients, with fiducial markers implanted into the prostate, was controlled by 3DUS and CBCT. In total, 78 ultrasound scans were performed trans-abdominally and compared to bone-matches and seed-matches in CBCT scans. Setup errors detected by the different modalities were compared. Systematic and random errors were analysed, and optimal setup margins were calculated. Results The discrepancy between 3DUS and seed-match in CBCT was −0.2 ± 2.7 mm laterally, −1.9 ± 2.3 mm longitudinally and 0.0 ± 3.0 mm vertically and significant only in longitudinal direction. Using seed-match as reference, systematic errors of 3DUS were 1.3 mm laterally, 0.8 mm longitudinally and 1.4 mm vertically, and random errors were 2.5 mm laterally, 2.3 mm longitudinally, and 2.7 mm vertically. No significant difference could be detected for 3DUS in comparison to bone-match in CBCT. Conclusions 3DUS is feasible for image guidance for patients with prostate cancer and appears comparable to CBCT based image guidance in the retrospective study. While 3DUS offers some distinct advantages such as no need of invasive fiducial implantation and avoidance of extra radiation, its disadvantages include the operator dependence of the technique and dependence on sufficient bladder filling. Further study of 3DUS for image guidance in a large patient cohort is warranted.
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Affiliation(s)
- Minglun Li
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Nina-Sophie Hegemann
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Stefan Tritschler
- Department of Urology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Alexander Roosen
- Department of Urology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Christian Gratzke
- Department of Urology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Claus Belka
- Department of Radiation Oncology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
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13
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Lee HJ, Yoon C, Park DJ, Kim YJ, Schmidt B, Lee YJ, Tap WD, Eisinger-Mathason TSK, Choy E, Kirsch DG, Simon MC, Yoon SS. Inhibition of vascular endothelial growth factor A and hypoxia-inducible factor 1α maximizes the effects of radiation in sarcoma mouse models through destruction of tumor vasculature. Int J Radiat Oncol Biol Phys 2015; 91:621-30. [PMID: 25544668 PMCID: PMC4559849 DOI: 10.1016/j.ijrobp.2014.10.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE To examine the addition of genetic or pharmacologic inhibition of hypoxia-inducible factor 1α (HIF-1α) to radiation therapy (RT) and vascular endothelial growth factor A (VEGF-A) inhibition (ie trimodality therapy) for soft-tissue sarcoma. METHODS AND MATERIALS Hypoxia-inducible factor 1α was inhibited using short hairpin RNA or low metronomic doses of doxorubicin, which blocks HIF-1α binding to DNA. Trimodality therapy was examined in a mouse xenograft model and a genetically engineered mouse model of sarcoma, as well as in vitro in tumor endothelial cells (ECs) and 4 sarcoma cell lines. RESULTS In both mouse models, any monotherapy or bimodality therapy resulted in tumor growth beyond 250 mm(3) within the 12-day treatment period, but trimodality therapy with RT, VEGF-A inhibition, and HIF-1α inhibition kept tumors at <250 mm(3) for up to 30 days. Trimodality therapy on tumors reduced HIF-1α activity as measured by expression of nuclear HIF-1α by 87% to 95% compared with RT alone, and cytoplasmic carbonic anhydrase 9 by 79% to 82%. Trimodality therapy also increased EC-specific apoptosis 2- to 4-fold more than RT alone and reduced microvessel density by 75% to 82%. When tumor ECs were treated in vitro with trimodality therapy under hypoxia, there were significant decreases in proliferation and colony formation and increases in DNA damage (as measured by Comet assay and γH2AX expression) and apoptosis (as measured by cleaved caspase 3 expression). Trimodality therapy had much less pronounced effects when 4 sarcoma cell lines were examined in these same assays. CONCLUSIONS Inhibition of HIF-1α is highly effective when combined with RT and VEGF-A inhibition in blocking sarcoma growth by maximizing DNA damage and apoptosis in tumor ECs, leading to loss of tumor vasculature.
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MESH Headings
- Animals
- Antibiotics, Antineoplastic/therapeutic use
- Cell Line, Tumor
- Combined Modality Therapy/methods
- DNA Damage
- Doxorubicin/therapeutic use
- Hypoxia-Inducible Factor 1, alpha Subunit/antagonists & inhibitors
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Mice
- Mice, Transgenic/genetics
- Neovascularization, Pathologic/therapy
- RNA, Small Interfering/therapeutic use
- Radiation Tolerance
- Radiotherapy
- Sarcoma, Experimental/blood supply
- Sarcoma, Experimental/genetics
- Sarcoma, Experimental/metabolism
- Sarcoma, Experimental/pathology
- Sarcoma, Experimental/therapy
- Treatment Outcome
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Hae-June Lee
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Radiation Effects, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Changhwan Yoon
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Do Joong Park
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York; Department of Surgery, Seoul National University Bundang Hospital, Sungnam, Korea
| | - Yeo-Jung Kim
- Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Schmidt
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yoon-Jin Lee
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Radiation Effects, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - William D Tap
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - T S Karin Eisinger-Mathason
- Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edwin Choy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David G Kirsch
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, North Carolina; Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - M Celeste Simon
- Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Howard Hughes Medical Institute
| | - Sam S Yoon
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
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14
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Lovelock DM, Messineo AP, Cox BW, Kollmeier MA, Zelefsky MJ. Continuous monitoring and intrafraction target position correction during treatment improves target coverage for patients undergoing SBRT prostate therapy. Int J Radiat Oncol Biol Phys 2015; 91:588-94. [PMID: 25680601 DOI: 10.1016/j.ijrobp.2014.10.049] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/21/2014] [Accepted: 10/24/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the potential benefits of continuous monitoring of prostate position and intervention (CMI) using 2-mm displacement thresholds during stereotactic body radiation therapy (SBRT) treatment to those of a conventional image-guided procedure involving single localization prior to treatment. METHODS AND MATERIALS Eighty-nine patients accrued to a prostate SBRT dose escalation protocol were implanted with radiofrequency transponder beacons. The planning target volume (PTV) margin was 5 mm in all directions, except for 3 mm in the posterior direction. The prostate was kept within 2 mm of its planned position by the therapists halting dose delivery and, if necessary, correcting the couch position. We computed the number, type, and time required for interventions and where the prostate would have been during dose delivery had there been, instead, a single image-guided setup procedure prior to each treatment. Distributions of prostate displacements were computed as a function of time. RESULTS After the initial setup, 1.7 interventions per fraction were required, with a concomitant increase in time for dose delivery of approximately 65 seconds. Small systematic drifts in prostate position in the posterior and inferior directions were observed in the study patients. Without CMI, intrafractional motion would have resulted in approximately 10% of patients having a delivered dose that did not meet our clinical coverage requirement, that is, a PTV D95 of >90%. The posterior PTV margin required for 95% of the dose to be delivered with the target positioned within the PTV was computed as a function of time. The margin necessary was found to increase by 2 mm every 5 minutes, starting from the time of the imaging procedure. CONCLUSIONS CMI using a tight 2-mm displacement threshold was not only feasible but was found to deliver superior PTV coverage compared with the conventional image-guided procedure in the SBRT setting.
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Affiliation(s)
| | | | - Brett W Cox
- North Shore-Long Island Jewish Health System, New Hyde Park, New York
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