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Sengupta C, Nguyen DT, Moodie T, Mason D, Luo J, Causer T, Liu SF, Brown E, Inskip L, Hazem M, Chao M, Wang T, Lee YY, van Gysen K, Sullivan E, Cosgriff E, Ramachandran P, Poulsen P, Booth J, O'Brien R, Greer P, Keall P. The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients. Radiother Oncol 2024; 190:110031. [PMID: 38008417 DOI: 10.1016/j.radonc.2023.110031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients. METHODS/MATERIALS The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone. RESULTS The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone. CONCLUSIONS This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.
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Affiliation(s)
| | | | | | - Daniel Mason
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Jianjie Luo
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Trent Causer
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Sau Fan Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | - Elizabeth Brown
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | - Maryam Hazem
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Menglei Chao
- Nepean Cancer & Wellness Centre, Nepean Hospital, Australia
| | - Tim Wang
- Crown Princess Mary Cancer Centre, Australia
| | - Yoo Y Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Australia
| | | | | | | | | | - Per Poulsen
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Australia; Institute of Medical Physics, The University of Sydney, Australia
| | - Ricky O'Brien
- Image X Institute, The University of Sydney, Australia; RMIT University, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Australia
| | - Paul Keall
- Image X Institute, The University of Sydney, Australia
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Hardcastle N, Gaudreault M, Yeo AU, Ungureanu E, Markham C, Barnes R, Chander S, Chu J. Selection of motion management in liver stereotactic body radiotherapy and its impact on treatment time. Phys Imaging Radiat Oncol 2023; 25:100407. [PMID: 36655214 PMCID: PMC9841271 DOI: 10.1016/j.phro.2022.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/30/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background and purpose Reduction of respiratory tumour motion is important in liver stereotactic body radiation therapy (SBRT) to reduce side effects and improve tumour control probability. We have assessed the distribution of use of voluntary exhale breath hold (EBH), abdominal compression (AC), free breathing gating (gating) and free breathing (FB), and the impact of these on treatment time. Materials and Methods We assessed all patients treated in a single institution with liver SBRT between September 2017 and September 2021. Data from pre-simulation motion management assessment using fluoroscopic assessment of liver dome position in repeat breath holds, and motion with and without AC, was reviewed to determine liver dome position consistency in EBH and the impact of AC on motion. Treatment time was assessed for all fractions as time from first image acquisition to last treatment beam off. Results Of 136 patients treated with 145 courses of liver SBRT, 68 % were treated in EBH, 20 % with AC, 7 % in gating and 5 % in FB. AC resulted in motion reduction < 1 mm in 9/26 patients assessed. Median treatment time was higher using EBH (39 min) or gating (42 min) compared with AC (30 min) or FB (24 min) treatments. Conclusions Motion management in liver SBRT needs to be assessed per-patient to ensure appropriate techniques are applied. Motion management significantly impacts treatment time therefore patient comfort must also be taken into account when selecting the technique for each patient.
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Key Words
- AC, Abdominal Compression
- Abdominal compression
- BED, Biologically Effective Dose
- CBCT, Cone Beam Computed Tomography
- EBH, Exhale Breath Hold
- FB, Free Breathing
- FFF, Flattening Filter Free
- GTV, Gross Tumor Volume
- IMRT, Intensity Modulated Radiation Therapy
- ITV, Internal Target Volume
- Liver
- Motion management
- PTV, Planning Target Volume
- SBRT, Stereotactic body radiation thearpy
- Stereotactic body radiation therapy
- VMAT, Volumetric Modulated Arc Therapy
- exhale breath hold. Stereotactic ablative body radiotherapy
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Affiliation(s)
- Nicholas Hardcastle
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
- Corresponding author.
| | - Mathieu Gaudreault
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Adam U. Yeo
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elena Ungureanu
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Cathy Markham
- Department of Radiation Therapy, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Rebecca Barnes
- Department of Radiation Therapy, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Sarat Chander
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Julie Chu
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Tadimalla S, Wang W, Haworth A. Role of Functional MRI in Liver SBRT: Current Use and Future Directions. Cancers (Basel) 2022; 14:cancers14235860. [PMID: 36497342 PMCID: PMC9739660 DOI: 10.3390/cancers14235860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is an emerging treatment for liver cancers whereby large doses of radiation can be delivered precisely to target lesions in 3-5 fractions. The target dose is limited by the dose that can be safely delivered to the non-tumour liver, which depends on the baseline liver functional reserve. Current liver SBRT guidelines assume uniform liver function in the non-tumour liver. However, the assumption of uniform liver function is false in liver disease due to the presence of cirrhosis, damage due to previous chemo- or ablative therapies or irradiation, and fatty liver disease. Anatomical information from magnetic resonance imaging (MRI) is increasingly being used for SBRT planning. While its current use is limited to the identification of target location and size, functional MRI techniques also offer the ability to quantify and spatially map liver tissue microstructure and function. This review summarises and discusses the advantages offered by functional MRI methods for SBRT treatment planning and the potential for adaptive SBRT workflows.
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Affiliation(s)
- Sirisha Tadimalla
- Institute of Medical Physics, School of Physics, Faculty of Science, The University of Sydney, Camperdown, NSW 2006, Australia
- Correspondence:
| | - Wei Wang
- Crown Princess Mary Cancer Centre, Sydney West Radiation Oncology Network, Western Sydney Local Health District, Sydney, NSW 2145, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, Faculty of Science, The University of Sydney, Camperdown, NSW 2006, Australia
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Shanker MD, Moodaley P, Soon W, Liu HY, Lee YY, Pryor DI. Stereotactic ablative radiotherapy for hepatocellular carcinoma: A systematic review and meta-analysis of local control, survival and toxicity outcomes. J Med Imaging Radiat Oncol 2021; 65:956-968. [PMID: 34396706 DOI: 10.1111/1754-9485.13309] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
There is a growing body of literature supporting the use of stereotactic ablative body radiotherapy (SABR) in the management of primary hepatocellular carcinoma (HCC). This systematic review and meta-analysis of the current published evidence for SABR for HCC assessed the impact of treatment dose, fractionation and tumour size on the outcomes of local control (LC), overall survival (OS) and toxicity. A systematic search was independently performed by two authors for articles published in peer-reviewed journals between January 2005 and December 2019. A DerSimonian and Laird random effects model was used to assess pooled results. A multivariate meta-regression analysis incorporated the effect of explanatory variables (radiation dose in EQD2[10], fractionation and tumour size) on outcomes of OS, LC and toxicity. Forty-nine cohorts involving 2846 HCC patients with 3088 lesions treated with SABR were included. Pooled 1-, 2- and 3-year LC rates were 91.1% (95% confidence interval [CI] 88.3-93.2), 86.7% (95% CI 82.7-89.8) and 84.2% (95% CI 77.9-88.9) respectively. Pooled 1-, 2- and 3-year OS rates were 78.4% (95% CI 73.4-82.6), 61.3% (55.2-66.9) and 48.3% (95% CI 39.0-57). Population-weighted median grade 3 toxicity rates were 6.5% (IQR 3.2-16) and mean grade 4/5 rates were 1.4% (IQR 0-2.1). Within EQD2[10] ranges of 40 to 83.33 Gy corresponding to common dose-fractionation regimens of 30-50 Gy in 5 fractions, there was a multivariate association between superior LC and OS with increasing EQD2[10] , with a proportionately smaller increase in grade 3 toxicity and no association with grade 4/5 toxicity. Stereotactic ablative body radiotherapy is a viable treatment option for HCC with high LC rates and low rates of reported grade 3/4 toxicity. Increasing EQD2[10] was associated with improvements in LC and OS with a comparatively smaller increase in toxicity. Prospective randomised trials are warranted to define optimal patient selection and dose-fractionation regimens.
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Affiliation(s)
- Mihir D Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Pereshin Moodaley
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Wei Soon
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Howard Y Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Yoo Young Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David I Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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