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Tham BZ, Aleman DM, Nordström H, Nygren N, Coolens C. Treatment Planning Methods for Dose Painting by Numbers Treatment in Gamma Knife Radiosurgery. Adv Radiat Oncol 2024; 9:101534. [PMID: 39104874 PMCID: PMC11298584 DOI: 10.1016/j.adro.2024.101534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/16/2024] [Indexed: 08/07/2024] Open
Abstract
Purpose Dose painting radiation therapy delivers a nonuniform dose to tumors to account for heterogeneous radiosensitivity. With recent and ongoing development of Gamma Knife machines making large-volume brain tumor treatments more practical, it is increasingly feasible to deliver dose painting treatments. The increased prescription complexity means automated treatment planning is greatly beneficial, and the impact of dose painting on stereotactic radiosurgery (SRS) plan quality has not yet been studied. This research investigates the plan quality achievable for Gamma Knife SRS dose painting treatments when using optimization techniques and automated isocenter placement in treatment planning. Methods and Materials Dose painting prescription functions with varying parameters were applied to convert voxel image intensities to prescriptions for 10 sample cases. To study achievable plan quality and optimization, clinically placed isocenters were used with each dose painting prescription and optimized using a semi-infinite linear programming formulation. To study automated isocenter placement, a grassfire sphere-packing algorithm and a clinically available Leksell gamma plan isocenter fill algorithm were used. Plan quality for each optimized treatment plan was measured with dose painting SRS metrics. Results Optimization can be used to find high quality dose painting plans, and plan quality is affected by the dose painting prescription method. Polynomial function prescriptions show more achievable plan quality than sigmoid function prescriptions even with high mean dose boost. Automated isocenter placement is shown as a feasible method for dose painting SRS treatment, and increasing the number of isocenters improves plan quality. The computational solve time for optimization is within 5 minutes in most cases, which is suitable for clinical planning. Conclusions The impact of dose painting prescription method on achievable plan quality is quantified in this study. Optimization and automated isocenter placement are shown as possible treatment planning methods to obtain high quality plans.
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Affiliation(s)
- Benjamin Z. Tham
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Dionne M. Aleman
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Catherine Coolens
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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2
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Garrido-Hernandez G, Henjum H, Winter RM, Alsaker MD, Danielsen S, Boer CG, Ytre-Hauge KS, Redalen KR. Interim 18F-FDG-PET based response-adaptive dose escalation of proton therapy for head and neck cancer: a treatment planning feasibility study. Phys Med 2024; 123:103404. [PMID: 38852365 DOI: 10.1016/j.ejmp.2024.103404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 05/06/2024] [Accepted: 06/05/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Image-driven dose escalation to tumor subvolumes has been proposed to improve treatment outcome in head and neck cancer (HNC). We used 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) acquired at baseline and into treatment (interim) to identify biologic target volumes (BTVs). We assessed the feasibility of interim dose escalation to the BTV with proton therapy by simulating the effects to organs at risk (OARs). METHODS We used the semiautomated just-enough-interaction (JEI) method to identify BTVs in 18F-FDG-PET images from nine HNC patients. Between baseline and interim FDG-PET, patients received photon radiotherapy. BTV was identified assuming that high standardized uptake value (SUV) at interim reflected tumor radioresistance. Using Eclipse (Varian Medical Systems), we simulated a 10% (6.8 Gy(RBE1.1)) and 20% (13.6 Gy(RBE1.1)) dose escalation to the BTV with protons and compared results with proton plans without dose escalation. RESULTS At interim 18F-FDG-PET, radiotherapy resulted in reduced SUV compared to baseline. However, spatial overlap between high-SUV regions at baseline and interim allowed for BTV identification. Proton therapy planning demonstrated that dose escalation to the BTV was feasible, and except for some 20% dose escalation plans, OAR doses did not significantly increase. CONCLUSION Our in silico analysis demonstrated the potential for interim 18F-FDG-PET response-adaptive dose escalation to the BTV with proton therapy. This approach may give more efficient treatment to HNC with radioresistant tumor subvolumes without increasing normal tissue toxicity. Studies in larger cohorts are required to determine the full potential for interim 18F-FDG-PET-guided dose escalation of proton therapy in HNC.
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Affiliation(s)
| | - Helge Henjum
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - René Mario Winter
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mirjam Delange Alsaker
- Department of Radiotherapy, Cancer Clinic, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Signe Danielsen
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | | | - Kathrine Røe Redalen
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
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3
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Pang Y, Kosmin M, Li Z, Deng X, Li Z, Li X, Zhang Y, Royle G, Manolopoulos S. Isotoxic dose escalated radiotherapy for glioblastoma based on diffusion-weighted MRI and tumor control probability-an in-silico study. Br J Radiol 2023; 96:20220384. [PMID: 37102792 PMCID: PMC10230387 DOI: 10.1259/bjr.20220384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 02/19/2023] [Accepted: 03/03/2023] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVES Glioblastoma (GBM) is the most common malignant primary brain tumor with local recurrence after radiotherapy (RT), the most common mode of failure. Standard RT practice applies the prescription dose uniformly across tumor volume disregarding radiological tumor heterogeneity. We present a novel strategy using diffusion-weighted (DW-) MRI to calculate the cellular density within the gross tumor volume (GTV) in order to facilitate dose escalation to a biological target volume (BTV) to improve tumor control probability (TCP). METHODS The pre-treatment apparent diffusion coefficient (ADC) maps derived from DW-MRI of ten GBM patients treated with radical chemoradiotherapy were used to calculate the local cellular density based on published data. Then, a TCP model was used to calculate TCP maps from the derived cell density values. The dose was escalated using a simultaneous integrated boost (SIB) to the BTV, defined as the voxels for which the expected pre-boost TCP was in the lowest quartile of the TCP range for each patient. The SIB dose was chosen so that the TCP in the BTV increased to match the average TCP of the whole tumor. RESULTS By applying a SIB of between 3.60 Gy and 16.80 Gy isotoxically to the BTV, the cohort's calculated TCP increased by a mean of 8.44% (ranging from 7.19 to 16.84%). The radiation dose to organ at risk is still under their tolerance. CONCLUSIONS Our findings indicate that TCPs of GBM patients could be increased by escalating radiation doses to intratumoral locations guided by the patient's biology (i.e., cellularity), moreover offering the possibility for personalized RT GBM treatments. ADVANCES IN KNOWLEDGE A personalized and voxel level SIB radiotherapy method for GBM is proposed using DW-MRI, which can increase the tumor control probability and maintain organ at risk dose constraints.
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Affiliation(s)
- Yaru Pang
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, United Kingdom
| | | | - Zhuangling Li
- Department of Radiation Oncology, Shenzhen People's Hospital, Shenzhen, China
| | - Xiaonian Deng
- Department of Radiation Oncology, Shenzhen People's Hospital, Shenzhen, China
| | - Zihuang Li
- Department of Radiation Oncology, Shenzhen People's Hospital, Shenzhen, China
| | - Xianming Li
- Department of Radiation Oncology, Shenzhen People's Hospital, Shenzhen, China
| | - Ying Zhang
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, United Kingdom
| | - Gary Royle
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, United Kingdom
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Pang Y, Wang H, Li H. Medical Imaging Biomarker Discovery and Integration Towards AI-Based Personalized Radiotherapy. Front Oncol 2022; 11:764665. [PMID: 35111666 PMCID: PMC8801459 DOI: 10.3389/fonc.2021.764665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022] Open
Abstract
Intensity-modulated radiation therapy (IMRT) has been used for high-accurate physical dose distribution sculpture and employed to modulate different dose levels into Gross Tumor Volume (GTV), Clinical Target Volume (CTV) and Planning Target Volume (PTV). GTV, CTV and PTV can be prescribed at different dose levels, however, there is an emphasis that their dose distributions need to be uniform, despite the fact that most types of tumour are heterogeneous. With traditional radiomics and artificial intelligence (AI) techniques, we can identify biological target volume from functional images against conventional GTV derived from anatomical imaging. Functional imaging, such as multi parameter MRI and PET can be used to implement dose painting, which allows us to achieve dose escalation by increasing doses in certain areas that are therapy-resistant in the GTV and reducing doses in less aggressive areas. In this review, we firstly discuss several quantitative functional imaging techniques including PET-CT and multi-parameter MRI. Furthermore, theoretical and experimental comparisons for dose painting by contours (DPBC) and dose painting by numbers (DPBN), along with outcome analysis after dose painting are provided. The state-of-the-art AI-based biomarker diagnosis techniques is reviewed. Finally, we conclude major challenges and future directions in AI-based biomarkers to improve cancer diagnosis and radiotherapy treatment.
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Affiliation(s)
- Yaru Pang
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Hui Wang
- Department of Chemical Engineering, University College London, London, United Kingdom
| | - He Li
- Department of Engineering, University of Cambridge, Cambridge, United Kingdom
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Brighi C, Keall PJ, Holloway LC, Walker A, Whelan B, de Witt Hamer PC, Verburg N, Aly F, Chen C, Koh ES, Waddington DEJ. An investigation of the conformity, feasibility, and expected clinical benefits of multiparametric MRI-guided dose painting radiotherapy in glioblastoma. Neurooncol Adv 2022; 4:vdac134. [PMID: 36105390 PMCID: PMC9466270 DOI: 10.1093/noajnl/vdac134] [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] [Indexed: 11/14/2022] Open
Abstract
Background New technologies developed to improve survival outcomes for glioblastoma (GBM) continue to have limited success. Recently, image-guided dose painting (DP) radiotherapy has emerged as a promising strategy to increase local control rates. In this study, we evaluate the practical application of a multiparametric MRI model of glioma infiltration for DP radiotherapy in GBM by measuring its conformity, feasibility, and expected clinical benefits against standard of care treatment. Methods Maps of tumor probability were generated from perfusion/diffusion MRI data from 17 GBM patients via a previously developed model of GBM infiltration. Prescriptions for DP were linearly derived from tumor probability maps and used to develop dose optimized treatment plans. Conformity of DP plans to dose prescriptions was measured via a quality factor. Feasibility of DP plans was evaluated by dose metrics to target volumes and critical brain structures. Expected clinical benefit of DP plans was assessed by tumor control probability. The DP plans were compared to standard radiotherapy plans. Results The conformity of the DP plans was >90%. Compared to the standard plans, DP (1) did not affect dose delivered to organs at risk; (2) increased mean and maximum dose and improved minimum dose coverage for the target volumes; (3) reduced minimum dose within the radiotherapy treatment margins; (4) improved local tumor control probability within the target volumes for all patients. Conclusions A multiparametric MRI model of GBM infiltration can enable conformal, feasible, and potentially beneficial dose painting radiotherapy plans.
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Affiliation(s)
- Caterina Brighi
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Paul J Keall
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Lois C Holloway
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
- Centre for Medical Radiation Physics, University of Wollongong , Wollongong, Australia
| | - Amy Walker
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
- Centre for Medical Radiation Physics, University of Wollongong , Wollongong, Australia
| | - Brendan Whelan
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
| | - Philip C de Witt Hamer
- Brain Tumor Center Amsterdam , Amsterdam UMC, Amsterdam , The Netherlands
- Department of Neurosurgery , Amsterdam UMC, Amsterdam , The Netherlands
| | - Niels Verburg
- Brain Tumor Center Amsterdam , Amsterdam UMC, Amsterdam , The Netherlands
- Department of Neurosurgery , Amsterdam UMC, Amsterdam , The Netherlands
| | - Farhannah Aly
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - Cathy Chen
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - Eng-Siew Koh
- Ingham Institute for Applied Medical Research , Sydney , Australia
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres , Liverpool , Australia
| | - David E J Waddington
- ACRF Image X Institute, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney , Sydney , Australia
- Ingham Institute for Applied Medical Research , Sydney , Australia
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Papoutsis I, Skjei Knudtsen I, Peter Skaug Sande E, Louni Rekstad B, Öllers M, van Elmpt W, Røthe Arnesen M, Malinen E. Positron emission tomography guided dose painting by numbers of lung cancer: Alanine dosimetry in an anthropomorphic phantom. Phys Imaging Radiat Oncol 2022; 21:101-107. [PMID: 35243040 PMCID: PMC8885607 DOI: 10.1016/j.phro.2022.02.013] [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: 09/01/2021] [Revised: 02/19/2022] [Accepted: 02/20/2022] [Indexed: 11/27/2022] Open
Abstract
DPBN was delivered to a phantom based on the anatomy of a lung cancer patient examined by FDG PET/CT prior to radiotherapy. Alanine dosimetry showed that DPBN can be delivered with high accuracy to the tumour in the anthropomorphic phantom. For regions outside the tumour, high correspondence between planned and delivered doses were also found. Positioning errors can lead to large deviations and potentially sub-optimal tumor doses.
Background and purpose Dose painting by numbers (DPBN) require a high degree of dose modulation to fulfill the image-based voxel wise dose prescription. The aim of this study was to assess the dosimetric accuracy of 18F-fluoro-2-deoxy-glucose positron emission tomography(18F-FDG-PET)-based DPBN in an anthropomorphic lung phantom using alanine dosimetry. Materials and methods A linear dose prescription based on 18F-FDG-PET image intensities within the gross tumor volume (GTV) of a lung cancer patient was employed. One DPBN scheme with low dose modulation (Scheme A; minimum/maximum fraction dose to the GTV 2.92/4.26 Gy) and one with a high modulation (Scheme B; 2.81/4.52 Gy) were generated. The plans were transferred to a computed tomograpy (CT) scan of a thorax phantom based on CT images of the patient. Using volumetric modulated arc therapy (VMAT), DPBN was delivered to the phantom with embedded alanine dosimeters. A plan was also delivered to an intentionally misaligned phantom. Absorbed doses at various points in the phantom were measured by alanine dosimetry. Results A pointwise comparison between GTV doses from prescription, treatment plan calculation and VMAT delivery showed high correspondence, with a mean and maximum dose difference of <0.1 Gy and 0.3 Gy, respectively. No difference was found in dosimetric accuracy between scheme A and B. The misalignment caused deviations up to 1 Gy between prescription and delivery. Conclusion DPBN can be delivered with high accuracy, showing that the treatment may be applied correctly from a dosimetric perspective. Still, misalignment may cause considerable dosimetric erros, indicating the need for patient immobilization and monitoring.
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Zeng J, Bowen SR. Treatment Intensification in Locally Advanced/Unresectable NSCLC Through Combined Modality Treatment and Precision Dose Escalation. Semin Radiat Oncol 2021; 31:105-111. [PMID: 33610266 DOI: 10.1016/j.semradonc.2020.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The best survival for patients with unresectable, locally advanced NSCLC is currently achieved through concurrent chemoradiation followed by durvalumab for a year. Despite the best standard of care treatment, the majority of patients still develop disease recurrence, which could be distant and/or local. Trials continue to try and improve outcomes for patients with unresectable NSCLC, typically through treatment intensification, with the addition of more systemic agents, or more radiation dose to the tumor. Although RTOG 0617 showed that uniform dose escalation across an unselected population of patients undergoing chemoradiation is not beneficial, efforts continue to select patients and tumor subsets that are likely to benefit from dose escalation. This review describes some of the ongoing therapeutic trials in unresectable NSCLC, with an emphasis on quantitative imaging and precision radiation dose escalation.
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Affiliation(s)
- Jing Zeng
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA.
| | - Stephen R Bowen
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
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8
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Radioresistant tumours: From identification to targeting. Cancer Radiother 2020; 24:699-705. [PMID: 32753241 DOI: 10.1016/j.canrad.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
From surviving fraction to tumour curability, definitions of tumour radioresistance may vary depending on the view angle. Yet, mechanisms of radioresistance have been identified and involve tumour-specific oncogenic signalling pathways, tumour metabolism and proliferation, tumour microenvironment/hypoxia, genomics. Correlations between tumour biology (histology) and imaging allow theragnostic approaches that use non-invasive biological imaging using tracer functionalization of tumour pathway biomarkers, imaging of hypoxia, etc. Modelling dose prescription function based on their tumour radio-resistant factor enhancement ratio, related to metabolism, proliferation, hypoxia is an area of investigation. Yet, the delivery of dose painting by numbers/voxel-based radiotherapy with low lineal energy transfer particles may be limited by the degree of modulation complexity needed to achieve the doses needed to counteract radioresistance. Higher lineal energy transfer particles or combinations of different particles, or combinations with drugs and devices such as done with radioenhancing nanoparticles may be promising.
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9
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Skórska M, Piotrowski T. Personalized radiotherapy treatment planning based on functional imaging. Rep Pract Oncol Radiother 2017; 22:327-330. [DOI: 10.1016/j.rpor.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/19/2017] [Indexed: 11/30/2022] Open
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Skorska M, Piotrowski T, Ryczkowski A. Comparison of dose distribution for head and neck cancer patients with and without dose painting escalation during radiotherapy realized with tomotherapy unit. Br J Radiol 2017; 90:20170019. [PMID: 28555505 DOI: 10.1259/bjr.20170019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine and quantify the percentage dose increase to organs at risk (OARs) with multiple-level dose painting (DP) for patients with head and neck cancer in comparison with standard regimen. METHODS 12 patients who had undergone fluorine-18 fludeoxyglucose (18F-FDG) positron emission tomography (PET)/CT scan were retrospectively enrolled. Two treatment plans-one using DP escalation and one without-were optimized for each patient base on PET/CT data. The following variables were assessed: dose to OARs and target volumes; execution time; equivalent uniform dose; and normal tissue complication probability. RESULTS No statistically significant differences in beam-on time were observed between plans with and without DP. However, significantly higher doses were observed for all DP-escalated plans in the OARs, with only two exceptions: the brain stem and V60Gy for the mandible. Multiple-level DP resulted in dose increases ranging from 3.0% to 12.9%, depending on the OAR. The largest increase was seen for the parotid glands and the smallest for the mandible. Significant differences in the equivalent uniform dose were observed only for the parotid glands and spinal column, where the dose without DP was lower. The normal tissue complication probability for most OARs was very small. CONCLUSION Importantly, even though DP escalation resulted in higher doses to OARs vs conventional treatment planning, these usually did not exceed the dose tolerance levels. However, clinical trials are necessary to confirm the benefits of DP and to guarantee no additional toxicity. Advances in knowledge: Multiple-level DP by numbers resulted in 3.0-12.9% dose increase, depending on the OAR. Our findings may suggest that DP escalation to very high doses is feasible for about 83% of patients without higher toxicity; however, it still should be confirmed on a larger group of patients.
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Affiliation(s)
- Malgorzata Skorska
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
| | - Tomasz Piotrowski
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland.,2 Department of Electroradiology, University of Medical Sciences, Poznan, Poland
| | - Adam Ryczkowski
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
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Lee E, Zeng J, Miyaoka RS, Saini J, Kinahan PE, Sandison GA, Wong T, Vesselle HJ, Rengan R, Bowen SR. Functional lung avoidance and response-adaptive escalation (FLARE) RT: Multimodality plan dosimetry of a precision radiation oncology strategy. Med Phys 2017; 44:3418-3429. [PMID: 28453861 DOI: 10.1002/mp.12308] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 03/22/2017] [Accepted: 04/21/2017] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Nonsmall cell lung cancer (NSCLC) patient radiation therapy (RT) is planned without consideration of spatial heterogeneity in lung function or tumor response. We assessed the dosimetric and clinical feasibility of functional lung avoidance and response-adaptive escalation (FLARE) RT to reduce dose to [99m Tc]MAA-SPECT/CT perfused lung while redistributing an escalated boost dose within [18 F]FDG-PET/CT-defined biological target volumes (BTV). METHODS Eight stage IIB-IIIB NSCLC patients underwent FDG-PET/CT and MAA-SPECT/CT treatment planning scans. Perfused lung objectives were derived from scatter/collimator/attenuation-corrected MAA-SPECT uptake relative to ITV-subtracted lung to maintain < 20 Gy mean lung dose (MLD). Prescriptions included 60 Gy to the planning target volume (PTV) and concomitant boost of 74 Gy mean to biological target volumes (BTV = GTV + PET gradient segmentation) scaled to each BTV voxel by relative FDG-PET SUV. Dose-painting-by-numbers prescriptions were integrated into commercial treatment planning systems via uptake threshold discretization. Dose constraints for lung, heart, cord, and esophagus were defined. FLARE RT plans were optimized with volumetric modulated arc therapy (VMAT), proton pencil beam scanning (PBS) with 3%-3 mm robust optimization, and combination of PBS (avoidance) plus VMAT (escalation). The high boost dose region was evaluated within a standardized SUVpeak structure. FLARE RT plans were compared to reference VMAT plans. Linear regression between radiation dose to BTV and normalized FDG PET SUV at every voxel was conducted, from which Pearson linear correlation coefficients and regression slopes were extracted. Spearman rank correlation coefficients were estimated between radiation dose to lung and normalized SPECT uptake. Dosimetric differences between treatment modalities were evaluated by Friedman nonparametric paired test with multiple sampling correction. RESULTS No unacceptable violations of PTV and normal tissue objectives were observed in 24 FLARE RT plans. Compared to reference VMAT plans, FLARE VMAT plans achieved a higher mean dose to BTV (73.7 Gy 98195. 61.3 Gy), higher mean dose to SUVpeak (89.7 Gy vs. 60.8 Gy), and lower mean dose to highly perfused lung (7.3 Gy vs. 14.9 Gy). These dosimetric gains came at the expense of higher mean heart dose (9.4 Gy vs. 5.8 Gy) and higher maximum cord dose (50.1 Gy vs. 44.6 Gy) relative to the reference VMAT plans. Between FLARE plans, FLARE VMAT achieved higher dose to the SUVpeak ROI than FLARE PBS (89.7 Gy vs. 79.2 Gy, P = 0.01), while FLARE PBS delivered lower dose to lung than FLARE VMAT (11.9 Gy vs. 15.6 Gy, P < 0.001). Voxelwise linear dose redistribution slope between BTV dose and FDG PET uptake was higher in magnitude for FLARE PBS + VMAT (0.36 Gy per %SUVmax ) compared to FLARE VMAT (0.27 Gy per %SUVmax ) or FLARE PBS alone (0.17 Gy per %SUVmax ). CONCLUSIONS FLARE RT is clinically feasible with VMAT and PBS. A combination of PBS for functional lung avoidance and VMAT for FDG PET dose escalation balanced target and normal tissue objective tradeoffs. These results provide a technical platform for testing of FLARE RT safety and efficacy within a precision radiation oncology trial.
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Affiliation(s)
- Eunsin Lee
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Robert S Miyaoka
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center, 1570 N 115th Ave, Seattle, WA, 98133, USA
| | - Paul E Kinahan
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - George A Sandison
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, 1570 N 115th Ave, Seattle, WA, 98133, USA
| | - Hubert J Vesselle
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Stephen R Bowen
- Departments of Radiation Oncology and Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
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12
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Grimes DR, Warren DR, Warren S. Hypoxia imaging and radiotherapy: bridging the resolution gap. Br J Radiol 2017; 90:20160939. [PMID: 28540739 PMCID: PMC5603947 DOI: 10.1259/bjr.20160939] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Oxygen distribution is a major determinant of treatment success in radiotherapy, with well-oxygenated tumour regions responding by up to a factor of three relative to anoxic volumes. Conversely, tumour hypoxia is associated with treatment resistance and negative prognosis. Tumour oxygenation is highly heterogeneous and difficult to measure directly. The recent advent of functional hypoxia imaging modalities such as fluorine-18 fluoromisonidazole positron emission tomography have shown promise in non-invasively determining regions of low oxygen tension. This raises the prospect of selectively increasing dose to hypoxic subvolumes, a concept known as dose painting. Yet while this is a promising approach, oxygen-mediated radioresistance is inherently a multiscale problem, and there are still a number of substantial challenges that must be overcome if hypoxia dose painting is to be successfully implemented. Current imaging modalities are limited by the physics of such systems to have resolutions in the millimetre regime, whereas oxygen distribution varies over a micron scale, and treatment delivery is typically modulated on a centimetre scale. In this review, we examine the mechanistic basis and implications of the radiobiological oxygen effect, the factors influencing microscopic heterogeneity in tumour oxygenation and the consequent challenges in the interpretation of clinical hypoxia imaging (in particular fluorine-18 fluoromisonidazole positron emission tomography). We also discuss dose-painting approaches and outline challenges that must be addressed to improve this treatment paradigm.
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Affiliation(s)
- David Robert Grimes
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK.,2 Centre for Advanced and Interdisciplinary Radiation Research (CAIRR), School of Mathematics and Physics, Queen's University Belfast, UK
| | - Daniel R Warren
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK
| | - Samantha Warren
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK.,3 Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
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13
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Jiménez-Ortega E, Ureba A, Vargas A, Baeza JA, Wals-Zurita A, García-Gómez FJ, Barbeiro AR, Leal A. Dose painting by means of Monte Carlo treatment planning at the voxel level. Phys Med 2017; 42:339-344. [PMID: 28412136 DOI: 10.1016/j.ejmp.2017.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/10/2017] [Accepted: 04/03/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To develop a new optimization algorithm to carry out true dose painting by numbers (DPBN) planning based on full Monte Carlo (MC) calculation. METHODS Four configurations with different clustering of the voxel values from PET data were proposed. An optimization method at the voxel level under Lineal Programming (LP) formulation was used for an inverse planning and implemented in CARMEN, an in-house Monte Carlo treatment planning system. RESULTS Beamlet solutions fulfilled the objectives and did not show significant differences between the different configurations. More differences were observed between the segment solutions. The plan for the dose prescription map without clustering was the better solution. CONCLUSIONS LP optimization at voxel level without dose-volume restrictions can carry out true DPBN planning with the MC accuracy.
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Affiliation(s)
- E Jiménez-Ortega
- Dpto. Fisiología Médica y Biofísica, Universidad de Sevilla, Seville, Spain; Instituto de Biomedicina de Sevilla, IBIS, Sevilla, Spain
| | - A Ureba
- Instituto de Biomedicina de Sevilla, IBIS, Sevilla, Spain; Medical Radiation Physics, Stockholm University, Karolinska Institutet, Stockholm, Sweden
| | - A Vargas
- Dpto. Fisiología Médica y Biofísica, Universidad de Sevilla, Seville, Spain
| | - J A Baeza
- Dept. Radiation Oncology, Maastricht University Medical Center, The Netherlands
| | - A Wals-Zurita
- Hospital Universitario Virgen Macarena, Servicio de Radioterapia, Seville, Spain
| | - F J García-Gómez
- Hospital Universitario Virgen Macarena, Servicio de Medicina Nuclear, Seville, Spain
| | - A R Barbeiro
- Dpto. Fisiología Médica y Biofísica, Universidad de Sevilla, Seville, Spain; Instituto de Biomedicina de Sevilla, IBIS, Sevilla, Spain
| | - A Leal
- Dpto. Fisiología Médica y Biofísica, Universidad de Sevilla, Seville, Spain; Instituto de Biomedicina de Sevilla, IBIS, Sevilla, Spain.
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14
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Differding S, Sterpin E, Hermand N, Vanstraelen B, Nuyts S, de Patoul N, Denis JM, Lee JA, Grégoire V. Radiation dose escalation based on FDG-PET driven dose painting by numbers in oropharyngeal squamous cell carcinoma: a dosimetric comparison between TomoTherapy-HA and RapidArc. Radiat Oncol 2017; 12:59. [PMID: 28335778 PMCID: PMC5364636 DOI: 10.1186/s13014-017-0793-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 03/01/2017] [Indexed: 12/31/2022] Open
Abstract
Purpose Validation of dose escalation through FDG-PET dose painting (DP) for oropharyngeal squamous cell carcinoma (SCC) requires randomized clinical trials with large sample size, potentially involving different treatment planning and delivery systems. As a first step of a joint clinical study of DP, a planning comparison was performed between Tomotherapy HiArt® (HT) and Varian RapidArc® (RA). Methods The planning study was conducted on five patients with oropharyngeal SCC. Elective and therapeutic CTVs were delineated based on anatomic information, and the respective PTVs (CTVs + 4 mm) were prescribed a dose of 56 (PTV56) and 70 Gy (PTV70). A gradient-based method was used to delineate automatically the external contours of the FDG-PET volume (GTVPET). Variation of the FDG uptake within the GTVPET was linearly converted into a prescription between 70 and 86 Gy. A dilation of the voxel-by-voxel prescription of 2.5 mm was applied to account for geometric errors in dose delivery (PTVPET). The study was divided in two planning phases aiming at maximizing target coverage (phase I) and lowering doses to OAR (phase II). A Quality-Volume Histogram (QVH) assessed conformity with the DP prescription inside the PTVPET. Results In phase I, for both HT and RA, all plans achieved comparable target coverage for PTV56 and PTV70, respecting the planning objectives. A median value of 99.9 and 97.2% of all voxels in the PTVPET received at least 95% of the prescribed dose for RA and HT, respectively. A median value of 0.0% and 3.7% of the voxels in the PTVPET received 105% or more of prescribed dose for RA and HT, respectively. In phase II, no significant differences were found in OAR sparing. Median treatment times were 13.7 min for HT and 5 min for RA. Conclusions Both HT and RA can generate similar dose distributions for FDG-PET based dose escalation and dose painting in oropharyngeal SCC patients. Electronic supplementary material The online version of this article (doi:10.1186/s13014-017-0793-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Differding
- Department of Radiation Oncology, and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Edmond Sterpin
- Department of Radiation Oncology, and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Nicolas Hermand
- Department of Oncology, Experimental Radiation Oncology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Bianca Vanstraelen
- Department of Oncology, Experimental Radiation Oncology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Sandra Nuyts
- Department of Oncology, Experimental Radiation Oncology, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Radiation Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Nathalie de Patoul
- Department of Radiation Oncology, St-Luc University Hospital, Avenue Hippocrate 10, B-1200, Bruxelles, Belgium
| | - Jean-Marc Denis
- Department of Radiation Oncology, St-Luc University Hospital, Avenue Hippocrate 10, B-1200, Bruxelles, Belgium
| | - John Aldo Lee
- Department of Radiation Oncology, and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Vincent Grégoire
- Department of Radiation Oncology, and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium. .,Department of Radiation Oncology, St-Luc University Hospital, Avenue Hippocrate 10, B-1200, Bruxelles, Belgium.
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15
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Abstract
This article is a short review of PET tracers, which have been used in clinical routine in single institutions. Preliminary anecdotal research supports the use of PET techniques in therapy planning of prostate cancer. The existing literature is discussed. For external beam radiation therapy, the biological target volume definition can only be based on PET imaging. There are not yet any prospective and randomized trials available; therefore, single-institution experiences cannot yet be recommended as clinical routine.
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Affiliation(s)
- Kalevi J A Kairemo
- Department of Molecular Radiotherapy, Docrates Cancer Center, Saukonpaadenranta 2, Helsinki FI-00180, Finland; Department of Nuclear Medicine, Docrates Cancer Center, Saukonpaadenranta 2, Helsinki FI-00180, Finland; Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA.
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16
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Feasibility of voxel-based Dose Painting for recurrent Glioblastoma guided by ADC values of Diffusion-Weighted MR imaging. Phys Med 2016; 32:1651-1658. [DOI: 10.1016/j.ejmp.2016.11.106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/26/2016] [Accepted: 11/15/2016] [Indexed: 01/01/2023] Open
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Berwouts D, Olteanu LAM, Speleers B, Duprez F, Madani I, Vercauteren T, De Neve W, De Gersem W. Intensity modulated arc therapy implementation in a three phase adaptive (18)F-FDG-PET voxel intensity-based planning strategy for head-and-neck cancer. Radiat Oncol 2016; 11:52. [PMID: 27039294 PMCID: PMC4818905 DOI: 10.1186/s13014-016-0629-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 03/28/2016] [Indexed: 12/15/2022] Open
Abstract
Background This study investigates the implementation of a new intensity modulated arc therapy (IMAT) class solution in comparison to a 6-static beam step-and-shoot intensity modulated radiotherapy (s-IMRT) for three-phase adaptive 18F-FDG-PET-voxel-based dose-painting-by-numbers (DPBN) for head-and-neck cancer. Methods We developed 18F-FDG-PET-voxel intensity-based IMAT employing multiple arcs and compared it to clinically used s-IMRT DPBN. Three IMAT plans using 18F-FDG-PET/CT acquired before treatment (phase I), after 8 fractions (phase II) and CT acquired after 18 fractions (phase III) were generated for each of 10 patients treated with 3 s-IMRT plans based on the same image sets. Based on deformable image registration (ABAS, version 0.41, Elekta CMS Software, Maryland Heights, MO), doses of the 3 plans were summed on the pretreatment CT using validated in-house developed software. Dosimetric indices in targets and organs-at-risk (OARs), biologic conformity of treatment plans set at ≤5 %, treatment quality and efficiency were compared between IMAT and s-IMRT for the whole group and for individual patients. Results Doses to most organs-at-risk (OARs) were significantly better in IMAT plans, while target levels were similar for both types of plans. On average, IMAT ipsilateral and contralateral parotid mean doses were 14.0 % (p = 0.001) and 12.7 % (p < 0.001) lower, respectively. Pharyngeal constrictors D50% levels were similar or reduced with up to 54.9 % for IMAT compared to s-IMRT for individual patient cases. IMAT significantly improved biologic conformity by 2.1 % for treatment phases I and II. 3D phantom measurements reported an agreement of ≥95 % for 3 % and 3 mm criteria for both treatment modalities. IMAT delivery time was significantly shortened on average by 41.1 %. Conclusions IMAT implementation significantly improved the biologic conformity as compared to s-IMRT in adaptive dose-escalated DPBN treatments. The better OAR sparing and faster delivery highly improved the treatment efficiency. Electronic supplementary material The online version of this article (doi:10.1186/s13014-016-0629-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dieter Berwouts
- Department of Radiotherapy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium. .,Department of Nuclear Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Luiza Ana Maria Olteanu
- Department of Radiotherapy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | | | - Frédéric Duprez
- Department of Radiotherapy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Indira Madani
- Ghent University, Ghent, Belgium.,Zürich University Hospital, Zürich, Switzerland
| | - Tom Vercauteren
- Department of Radiotherapy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Wilfried De Neve
- Department of Radiotherapy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Ghent University, Ghent, Belgium
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18
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Skórska M, Piotrowski T, Ryczkowski A, Kaźmierska J. Comparison of treatment planning parameters for dose painting head and neck plans delivered with tomotherapy. Br J Radiol 2016; 89:20150970. [PMID: 26828971 DOI: 10.1259/bjr.20150970] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine which physical delivery parameter changes are most suitable for multiple-level dose-painting treatment plans with helical tomotherapy (HT). METHODS A total of 96 treatment plans were generated for 12 patients who had undergone fluorine-18 fludeoxyglucose positron emission tomography/CT ((18)F-FDG-PET/CT) scan to plan head and neck cancer treatment. Based on these PET-CT images, the dose was escalated to 96 Gy in 32 fractions as a function of PET intensity values. The intensity-based prescription was converted into seven discrete dose levels. For the same patient, different HT plans were optimized by varying parameters such as field width (FW), pitch (PF) and modulation factor (MF). Dose conformity was evaluated using quality-volume histograms, quality factors (QFs), weighted index of achievement (IOAw), coldness (IOCw) and hotness (IOHw). Moreover, doses to organs at risk (OARs), target volumes and execution time were analyzed. RESULTS Median QFs were the best for FW = 1.05 cm (QF = 2.10) and the worst for FW = 2.5 cm (QF = 3.04). The same trend was observed for IOAw, IOCw and IOHw. Combination of FW = 1.05 cm and MF = 5 leads to the longest beam-on time (above 25 min), whereas FW = 2.5 cm and MF = 3 lead to the shortest time (below 8 min). Data analyzed based on dose-volume histogram showed that changes in FW had the strongest impact on plan quality, whereas the effect of MF and PF changes was moderate. CONCLUSION HT is suitable for multiple-level dose-painting treatment plans. ADVANCES IN KNOWLEDGE Changes in FW and MF had the greatest impact on dose distribution quality and beam-on time. Changes in PF only influenced doses to the OARs.
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Affiliation(s)
- Malgorzata Skórska
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
| | - Tomasz Piotrowski
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland.,2 Department of Electroradiology, University of Medical Sciences, Poznan, Poland
| | - Adam Ryczkowski
- 1 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
| | - Joanna Kaźmierska
- 2 Department of Electroradiology, University of Medical Sciences, Poznan, Poland.,3 Department of Radiotherapy II, Greater Poland Cancer Centre in Poznan, Poland
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19
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Barragán AM, Differding S, Janssens G, Lee JA, Sterpin E. Feasibility and robustness of dose painting by numbers in proton therapy with contour-driven plan optimization. Med Phys 2015; 42:2006-17. [PMID: 25832091 DOI: 10.1118/1.4915082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To prove the ability of protons to reproduce a dose gradient that matches a dose painting by numbers (DPBN) prescription in the presence of setup and range errors, by using contours and structure-based optimization in a commercial treatment planning system. METHODS For two patients with head and neck cancer, voxel-by-voxel prescription to the target volume (GTVPET) was calculated from (18)FDG-PET images and approximated with several discrete prescription subcontours. Treatments were planned with proton pencil beam scanning. In order to determine the optimal plan parameters to approach the DPBN prescription, the effects of the scanning pattern, number of fields, number of subcontours, and use of range shifter were separately tested on each patient. Different constant scanning grids (i.e., spot spacing = Δx = Δy = 3.5, 4, and 5 mm) and uniform energy layer separation [4 and 5 mm WED (water equivalent distance)] were analyzed versus a dynamic and automatic selection of the spots grid. The number of subcontours was increased from 3 to 11 while the number of beams was set to 3, 5, or 7. Conventional PTV-based and robust clinical target volumes (CTV)-based optimization strategies were considered and their robustness against range and setup errors assessed. Because of the nonuniform prescription, ensuring robustness for coverage of GTVPET inevitably leads to overdosing, which was compared for both optimization schemes. RESULTS The optimal number of subcontours ranged from 5 to 7 for both patients. All considered scanning grids achieved accurate dose painting (1% average difference between the prescribed and planned doses). PTV-based plans led to nonrobust target coverage while robust-optimized plans improved it considerably (differences between worst-case CTV dose and the clinical constraint was up to 3 Gy for PTV-based plans and did not exceed 1 Gy for robust CTV-based plans). Also, only 15% of the points in the GTVPET (worst case) were above 5% of DPBN prescription for robust-optimized plans, while they were more than 50% for PTV plans. Low dose to organs at risk (OARs) could be achieved for both PTV and robust-optimized plans. CONCLUSIONS DPBN in proton therapy is feasible with the use of a sufficient number subcontours, automatically generated scanning patterns, and no more than three beams are needed. Robust optimization ensured the required target coverage and minimal overdosing, while PTV-approach led to nonrobust plans with excessive overdose. Low dose to OARs can be achieved even in the presence of a high-dose escalation as in DPBN.
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Affiliation(s)
- A M Barragán
- Center of Molecular Imaging, Radiotherapy and Oncology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels B-1200, Belgium
| | - S Differding
- Center of Molecular Imaging, Radiotherapy and Oncology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels B-1200, Belgium
| | - G Janssens
- Ion Beam Applications S.A., Louvain-la-Neuve 1348, Belgium
| | - J A Lee
- Center of Molecular Imaging, Radiotherapy and Oncology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels B-1200, Belgium
| | - E Sterpin
- Center of Molecular Imaging, Radiotherapy and Oncology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels B-1200, Belgium
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20
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Lapi SE, Lewis JS, Dehdashti F. Evaluation of hypoxia with copper-labeled diacetyl-bis(N-methylthiosemicarbazone). Semin Nucl Med 2015; 45:177-85. [PMID: 25704389 DOI: 10.1053/j.semnuclmed.2014.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Imaging of hypoxia is important in many diseases states in oncology, cardiology, and neurology. The radiopharmaceutical, copper-labeled diacetyl-bis(N-methylthiosemicarbazone), has been used to assess hypoxia in many studies. In particular, copper-labeled diacetyl-bis(N-methylthiosemicarbazone) has been used in oncologic settings to investigate tumor hypoxia and the role of this parameter in response to therapy and outcome. Some groups have conducted imaging studies assessing the role of hypoxia in cardiovascular and neurologic disorders. Additionally, several groups have made significant progress into understanding the mechanism by which this compound accumulates in cells. Multiple preclinical and clinical studies have been conducted, shedding light on the importance of careful image analysis when using this tracer. This review article focuses on the recent preclinical and clinical studies with this tracer.
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Affiliation(s)
- Suzanne E Lapi
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO; The Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Jason S Lewis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Farrokh Dehdashti
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO; The Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO.
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21
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Alonzi R. Functional Radiotherapy Targeting using Focused Dose Escalation. Clin Oncol (R Coll Radiol) 2015; 27:601-17. [PMID: 26456478 DOI: 10.1016/j.clon.2015.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 12/12/2022]
Abstract
Various quantitative and semi-quantitative imaging biomarkers have been identified that may serve as valid surrogates for the risk of recurrence after radiotherapy. Tumour characteristics, such as hypoxia, vascularity, cellular proliferation and clonogen density, can be geographically mapped using biological imaging techniques. The potential gains in therapeutic ratio from the precision targeting of areas of intrinsic resistance makes focused dose escalation an exciting field of study. This overview will explore the issues surrounding biologically optimised radiotherapy, including its requirements, feasibility, technical considerations and potential applicability.
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Affiliation(s)
- R Alonzi
- Mount Vernon Cancer Centre, Northwood, UK.
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22
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Arnesen MR, Knudtsen IS, Rekstad BL, Eilertsen K, Dale E, Bruheim K, Helland Å, Løndalen AM, Hellebust TP, Malinen E. Dose painting by numbers in a standard treatment planning system using inverted dose prescription maps. Acta Oncol 2015. [PMID: 26213311 DOI: 10.3109/0284186x.2015.1061690] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dose painting by numbers (DPBN) is a method to deliver an inhomogeneous tumor dose voxel-by-voxel with a prescription based on biological medical images. However, planning of DPBN is not supported by commercial treatment planning systems (TPS) today. Here, a straightforward method for DPBN with a standard TPS is presented. MATERIAL AND METHODS DPBN tumor dose prescription maps were generated from (18)F-FDG-PET images applying a linear relationship between image voxel value and dose. An inverted DPBN prescription map was created and imported into a standard TPS where it was defined as a mock pre-treated dose. Using inverse optimization for the summed dose, a planned DPBN dose distribution was created. The procedure was tested in standard TPS for three different tumor cases; cervix, lung and head and neck. The treatment plans were compared to the prescribed DPBN dose distribution by three-dimensional (3D) gamma analysis and quality factors (QFs). Delivery of the DPBN plans was assessed with portal dosimetry (PD). RESULTS Maximum tumor doses of 149%, 140% and 151% relative to the minimum tumor dose were prescribed for the cervix, lung and head and neck case, respectively. DPBN distributions were well achieved within the tumor whilst normal tissue doses were within constraints. Generally, high gamma pass rates (> 89% at 2%/2 mm) and low QFs (< 2.6%) were found. PD showed that all DPBN plans could be successfully delivered. CONCLUSIONS The presented methodology enables the use of currently available TPSs for DPBN planning and delivery and may therefore pave the way for clinical implementation.
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Affiliation(s)
- Marius Røthe Arnesen
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
- b Department of Physics , University of Oslo , Oslo , Norway
| | - Ingerid Skjei Knudtsen
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
- b Department of Physics , University of Oslo , Oslo , Norway
| | - Bernt Louni Rekstad
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
| | - Karsten Eilertsen
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
| | - Einar Dale
- c Department of Oncology , Oslo University Hospital , Oslo , Norway
| | - Kjersti Bruheim
- c Department of Oncology , Oslo University Hospital , Oslo , Norway
| | - Åslaug Helland
- c Department of Oncology , Oslo University Hospital , Oslo , Norway
| | - Ayca Muftuler Løndalen
- d Department of Radiology and Nuclear Medicine , Oslo University Hospital , Oslo , Norway
| | - Taran Paulsen Hellebust
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
- b Department of Physics , University of Oslo , Oslo , Norway
| | - Eirik Malinen
- a Department of Medical Physics , The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
- b Department of Physics , University of Oslo , Oslo , Norway
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23
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Differding S, Sterpin E, Janssens G, Hanin FX, Lee JA, Grégoire V. Methodology for adaptive and robust FDG-PET escalated dose painting by numbers in head and neck tumors. Acta Oncol 2015; 55:217-25. [PMID: 26079436 DOI: 10.3109/0284186x.2015.1046997] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To develop a methodology for using FDG PET/CT in adaptive dose painting by numbers (DPBN) in head and neck squamous cell carcinoma (HNSCC) patients. Issues related to noise in PET and treatment robustness against geometric errors are addressed. METHODS Five patients with locally advanced HNSCC scheduled for chemo-radiotherapy were imaged with FDG-PET/CT at baseline and 2-3 times during radiotherapy (RT). The GTVPET was segmented with a gradient-based method. A double median filter reduces the impact of noise in the PET uptake-to-dose conversion. Filtered FDG uptake values were linearly converted into a voxel-by-voxel prescription from 70 (median uptake) to 86 Gy (highest uptake). A PTVPET was obtained by applying a dilation of 2.5 mm to the entire prescription. Seven iso-uptake thresholds led to seven sub-levels compatible with the Tomotherapy HiArt(®) Treatment Planning System. Planning aimed to deliver a median dose of 56 Gy and 70 Gy in 35 fractions on the elective and therapeutic PTVs, respectively. Plan quality was assessed with quality volume histogram (QVH). At each time point, plans were generated with a total of 3-4 plans for each patient. Deformable image registration was used for automatic contour propagation and dose summation of the 3 or 4 treatment plans (MIMvista(®)). RESULTS GTVPET segmentations were performed successfully until week 2 of RT but failed in two patients at week 3. QVH analysis showed high conformity for all plans (mean VQ = 0.95 93%; mean VQ = 1.05 3.9%; mean QF 2.2%). Good OAR sparing was achieved while keeping high plan quality. CONCLUSION Our results show that adaptive FDG-PET-based escalated dose painting in patients with locally advanced HNSCC is feasible while respecting strict dose constraints to organs at risk. Clinical studies must be conducted to evaluate toxicities and tumor response of such a strategy.
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Affiliation(s)
- Sarah Differding
- a Department of Radiation Oncology , and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain , Brussels , Belgium
| | - Edmond Sterpin
- a Department of Radiation Oncology , and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain , Brussels , Belgium
| | - Guillaume Janssens
- a Department of Radiation Oncology , and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain , Brussels , Belgium
| | - François-Xavier Hanin
- b Department of Nuclear Medicine , and Center for Molecular Imaging, Radiotherapy and Oncology (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Universite catholique de Louvain, St-Luc University Hospital , Brussels , Belgium
| | - John Aldo Lee
- a Department of Radiation Oncology , and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain , Brussels , Belgium
| | - Vincent Grégoire
- a Department of Radiation Oncology , and Center for Molecular Imaging, Oncology and Radiotherapy (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain , Brussels , Belgium
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Abstract
In this review, image guidance and motion management in radiotherapy for lung cancer is discussed. Motion characteristics of lung tumours and image guidance techniques to obtain motion information are elaborated. Possibilities for management of image guidance and motion in the various steps of the treatment chain are explained, including imaging techniques and beam delivery techniques. Clinical studies using different motion management techniques are reviewed, and finally future directions for image guidance and motion management are outlined.
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Affiliation(s)
- S S Korreman
- Department of Science, Systems and Models, Roskilde University, Roskilde, Denmark
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Bowen SR, Saini J, Chapman TR, Miyaoka RS, Kinahan PE, Sandison GA, Wong T, Vesselle HJ, Nyflot MJ, Apisarnthanarax S. Differential hepatic avoidance radiation therapy: Proof of concept in hepatocellular carcinoma patients. Radiother Oncol 2015; 115:203-10. [PMID: 25934165 DOI: 10.1016/j.radonc.2015.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 03/16/2015] [Accepted: 04/03/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE To evaluate the feasibility of a novel planning concept that differentially redistributes RT dose away from functional liver regions as defined by (99m)Tc-sulphur colloid (SC) uptake on patient SPECT/CT images. MATERIALS AND METHODS Ten HCC patients with different Child-Turcotte-Pugh scores (A5-B9) underwent SC SPECT/CT scans in treatment position prior to RT that were registered to planning CT scans. Proton pencil beam scanning (PBS) therapy plans were optimized to deliver 37.5-60.0Gy (RBE) over 5-15 fractions using single field uniform dose technique robust to range and setup uncertainty. Photon volumetrically modulated arc therapy (VMAT) plans were optimized to the same prescribed dose and minimum target coverage. For both treatment modalities, differential hepatic avoidance RT (DHART) plans were generated to decrease dose to functional liver volumes (FLV) defined by a range of thresholds relative to maximum SC uptake (43-90%) in the tumor-subtracted liver. Radiation dose was redistributed away from regions of increased SC uptake in each FLV by linearly scaling mean dose objectives during PBS or VMAT optimization. DHART planning feasibility was assessed by a significantly negative Spearman's rank correlation (RS) between dose difference and SC uptake. Patient, tumor, and treatment planning characteristics were tested for association to DHART planning feasibility using non-parametric Kruskal-Wallis ANOVA. RESULTS Compared to conventional plans, DHART plans achieved a 3% FLV dose reduction for every 10% SC uptake increase. DHART planning was feasible in the majority of patients with 60% of patients having RS<-0.5 (p<0.01, range -1.0 to 0.2) and was particularly effective in 30% of patients (RS<-0.9). Mean dose to FLV was reduced by up to 20% in these patients. Only fractionation regimen was associated with DHART planning feasibility: 15 fraction courses were more feasible than 5-6 fraction courses (RS<-0.93 vs. RS>-0.60, p<0.02). CONCLUSION Differential avoidance of functional liver regions defined on sulphur colloid SPECT/CT is achievable with either photon VMAT or proton PBS therapy. Further investigation with phantom studies and in a larger cohort of patients may validate the utility of DHART planning for HCC radiotherapy.
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Affiliation(s)
- Stephen R Bowen
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA; University of Washington School of Medicine, Department of Radiology, Seattle, USA.
| | | | - Tobias R Chapman
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Robert S Miyaoka
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - Paul E Kinahan
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - George A Sandison
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, USA
| | - Hubert J Vesselle
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - Matthew J Nyflot
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Smith Apisarnthanarax
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
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Sterpin E, Differding S, Janssens G, Geets X, Grégoire V, Lee JA. Generation of prescriptions robust against geometric uncertainties in dose painting by numbers. Acta Oncol 2015; 54:253-60. [PMID: 24991892 DOI: 10.3109/0284186x.2014.930171] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In the context of dose painting by numbers delivered with intensity-modulated radiotherapy, the robustness of dose distributions against geometric uncertainties can be ensured by robust optimization. As robust optimization is seldom available in treatment planning systems (TPS), we propose an alternative method that reaches the same goal by modifying the heterogeneous dose prescription (based on (18)FDG-PET) and guarantees coverage in spite of systematic and random errors with known standard deviations Σ and σ, respectively. MATERIAL AND METHODS The objective was that 95% of all voxels in the GTVPET received at least 95% of the prescribed dose despite geometric errors. The prescription was modified by a geometric dilation of αΣ for systematic errors and a deconvolution by a Gaussian function of width σ for random errors. For a 90% confidence interval, α = 2.5. Planning was performed on a TomoTherapy system, such that 95% of the voxels received at least 95% of the modified prescription and less than 5% of the voxels received more than 105% of the modified prescription. The applicability of the method was illustrated for two head-and-neck tumors. RESULTS Systematic and random displacements larger than αΣ and σ degraded coverage. Down to 62.8% of the points received at least 95% of prescribed dose for the largest considered displacements (5 mm systematic translation and 3 mm standard deviation for random errors). When systematic and random displacements were smaller than αΣ and σ, no degradation of target coverage was observed. CONCLUSIONS The method led to treatment plans with target coverage robust against geometric uncertainties without the need to incorporate these in the optimizer of the TPS. The methodology was illustrated for head-and-neck cancer but can be potentially extended to all treatment sites.
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Affiliation(s)
- Edmond Sterpin
- Université catholique de Louvain, Center of Molecular Imaging, Radiotherapy and Oncology, Institut de Recherche Expérimentale et Clinique , Brussels , Belgium
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Knudtsen IS, van Elmpt W, Ollers M, Malinen E. Impact of PET reconstruction algorithm and threshold on dose painting of non-small cell lung cancer. Radiother Oncol 2014; 113:210-4. [PMID: 25443496 DOI: 10.1016/j.radonc.2014.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 08/11/2014] [Accepted: 09/22/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE In the current work, we investigate the impact of PET reconstruction methods (RMs) and threshold on two types of dose painting (DP) prescription strategies for non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Sixteen patients with NSCLC underwent an 18F-FDG-PET/CT examination prior to radiotherapy. Six different RMs were used. For both a dose painting by contours (DPBC) and a dose painting by numbers (DPBN) strategy, the prescribed radiation dose within the gross tumor volume (GTV) was mapped according to the spatial distribution of standardized uptake values (SUVs). SUVmax and SUVpeak were used for volume thresholding in DPBC and a linear SUV-dose scaling approach was used for DPBN. Deviations from the dose prescription as determined by the standard RM was scored by a quality factor (QF). RESULTS For DPBC, the mean difference in thresholded boost volume between RMs was typically within 10%. The difference in dose prescription was systematically lower for thresholding based on SUVpeak (largest mean QF 2.8±2.0%) compared to SUVmax (largest mean QF 3.6±3.0%). For DPBN, the resulting dose prescriptions were less dependent on RM and threshold; the largest mean QFs were 1.3±0.3% both for SUVmax and SUVpeak. CONCLUSIONS PET reconstruction algorithms will both influence DPBC and DPBN, although the impact is smaller for DPBN. For some patients, the resulting variations in dose prescriptions may result in clinically different dose distributions. SUVpeak is a more robust thresholding parameter than SUVmax.
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Affiliation(s)
- Ingerid Skjei Knudtsen
- Department of Physics, University of Oslo, Norway; The Intervention Centre, Oslo University Hospital, Norway; Department of Medical Physics, Oslo University Hospital, Norway.
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Michel Ollers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Eirik Malinen
- Department of Physics, University of Oslo, Norway; Department of Medical Physics, Oslo University Hospital, Norway
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Clausen MM, Hansen AE, Lundemann M, Hollensen C, Pommer T, Munck Af Rosenschöld P, Kristensen AT, Kjær A, McEvoy FJ, Engelholm SA. Dose painting based on tumor uptake of Cu-ATSM and FDG: a comparative study. Radiat Oncol 2014; 9:228. [PMID: 25319766 PMCID: PMC4203925 DOI: 10.1186/s13014-014-0228-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 10/02/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hypoxia and increased glycolytic activity of tumors are associated with poor prognosis. The purpose of this study was to investigate differences in radiotherapy (RT) dose painting based on the uptake of 2-deoxy-2-[(18) F]-fluorodeoxyglucose (FDG) and the proposed hypoxia tracer, copper(II)diacetyl-bis(N(4))-methylsemithiocarbazone (Cu-ATSM) using spontaneous clinical canine tumor models. METHODS Positron emission tomography/computed tomography scans of five spontaneous canine sarcomas and carcinomas were obtained; FDG on day 1 and (64)Cu-ATSM on day 2 and 3 (approx. 3 and 24 hours pi.). Sub-volumes for dose escalation were defined by a threshold-based method for both tracers and five dose escalation levels were formed in each sub-volume. Volumetric modulated arc therapy plans were optimized based on the dose escalation regions for each scan for a total of three dose plans for each dog. The prescription dose for the GTV was 45 Gy (100%) and it was linearly escalated to a maximum of 150%. The correlations between dose painting plans were analyzed with construction of dose distribution density maps and quality volume histograms (QVH). Correlation between high-dose regions was investigated with Dice correlation coefficients. RESULTS Comparison of dose plans revealed varying degree of correlation between cases. Some cases displayed a separation of high-dose regions in the comparison of FDG vs. (64)Cu-ATSM dose plans at both time points. Among the Dice correlation coefficients, the high dose regions showed the lowest degree of agreement, indicating potential benefit of using multiple tracers for dose painting. QVH analysis revealed that FDG-based dose painting plans adequately covered approximately 50% of the hypoxic regions. CONCLUSION Radiotherapy plans optimized with the current approach for cut-off values and dose region definitions based on FDG, (64)Cu-ATSM 3 h and 24 h uptake in canine tumors had different localization of the regional dose escalation levels. This indicates that (64)Cu-ATSM at two different time-points and FDG provide different biological information that has to be taken into account when using the dose painting strategy in radiotherapy treatment planning.
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Affiliation(s)
- Malene Martini Clausen
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Anders Elias Hansen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Technical University of Denmark, DTU Nanotech, Center of Nanomedicine and theranostics, Lyngby, Denmark.
| | - Michael Lundemann
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Christian Hollensen
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Tobias Pommer
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark.
| | - Per Munck Af Rosenschöld
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark.
| | | | - Andreas Kjær
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Fintan J McEvoy
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Svend Aage Engelholm
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Håkansson K, Specht L, Aznar MC, Rasmussen JH, Bentzen SM, Vogelius IR. Prescribing and evaluating target dose in dose-painting treatment plans. Acta Oncol 2014; 53:1251-6. [PMID: 24914483 DOI: 10.3109/0284186x.2014.906747] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Assessment of target dose conformity in multi-dose-level treatment plans is challenging due to inevitable over/underdosage at the border zone between dose levels. Here, we evaluate different target dose prescription planning aims and approaches to evaluate the relative merit of such plans. A quality volume histogram (QVH) tool for history-based evaluation is proposed. MATERIAL AND METHODS Twenty head and neck cancer dose-painting plans with five prescription levels were evaluated, as well as clinically delivered simultaneous integrated boost (SIB) plans from 2010 and 2012. The QVH tool was used for target dose comparison between groups of plans, and to identify and improve a suboptimal dose-painting plan. RESULTS Comparison of 2010 and 2012 treatment plans with the QVH tool demonstrated that 2012 plans have decreased underdosed volume at the expense of increased overdosed volume relative to the 2010 plans. This shift had not been detected previously. One suboptimal dose-painting plan was compared to the 'normal zone' of the QVH tool and could be improved by re-optimization. CONCLUSION The QVH tool provides a method to assess target dose conformity in dose-painting and multi-dose-level plans. The tool can be useful for quality assurance of multi-center trials, and for visualizing the development of treatment planning in routine clinical practice.
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Affiliation(s)
- Katrin Håkansson
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
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Abstract
AIMS Cu-diacetyl-bis(N4-methylthiosemicarbazone) (Cu-ATSM) is a hypoxia-avid, positron emitter radiotracer. The primary aim of this study is to assess the efficacy of pretherapy Cu-ATSM PET/CT as a prognostic factor of response to therapy. The secondary aims are to investigate if there is a difference between early and late PET/CT scans and if there is a difference between the biologic tumor volume (BTV) in radiotherapy treatment planning calculated between Cu-ATSM and F-FDG, and to assess if Cu-ATSM is a prognostic marker of disease progression. METHODS Eleven patients with head and neck cancer treated with chemoradiotherapy were enrolled prospectively; both Cu-ATSM and F-FDG PET/CT scans before and after treatment were obtained. The Cu-ATSM scans were performed after 1 hour (early) and 16 hours (late). RESULTS All patients had stage III or IV squamous cell head and neck cancer; 7 of 11 patients had nodal metastasis, and 22 cancer foci were detected with Cu-ATSM. SUVmax was 16.2 ± 7.9, and there was no significant SUVmax difference between early and late imaging. F-FDG SUVmax before therapy was 15.6 ± 9.4, whereas F-FDG SUVmax after therapy was 1.5 ± 1.2. Sensitivity and specificity values of Cu-ATSM calculated with receiver operating characteristic curves were 100% and 50% considering the SUVmax and 100% and 33% considering the volume, respectively. No difference has been found between the BTV contoured with Cu-ATSM and F-FDG. CONCLUSIONS The Cu-ATSM scans showed high sensitivity but low specificity in predicting neoadjuvant chemoradiotherapy response. No difference was noted between early and late scans. F-FDG and Cu-ATSM provided similar results about delineation of BTV.
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Skyt PS, Petersen JBB, Yates ES, Poulsen PR, Ravkilde TL, Balling P, Muren LP. Dosimetric verification of complex radiotherapy with a 3D optically based dosimetry system: dose painting and target tracking. Acta Oncol 2013; 52:1445-50. [PMID: 23957684 DOI: 10.3109/0284186x.2013.813965] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The increasing complexity of radiotherapy (RT) has motivated research into three-dimensional (3D) dosimetry. In this study we investigate the use of 3D dosimetry with polymerizing gels and optical computed tomography (optical CT) as a verification tool for complex RT: dose painting and target tracking. MATERIALS AND METHODS For the dose painting studies, two dosimeters were irradiated with a seven-field intensity modulated radiotherapy (IMRT) plan with and without dose prescription based on a hypoxia image dataset of a head and neck patient. In the tracking experiments, two dosimeters were irradiated with a volumetric modulated arc therapy (VMAT) plan with and without clinically measured prostate motion and a third with both motion and target tracking. To assess the performance, 3D gamma analyses were performed between measured and calculated stationary dose distributions. RESULTS Gamma pass-rates of 95.3% and 97.3% were achieved for the standard and dose-painted IMRT plans. Gamma pass-rates of 91.4% and 54.4% were obtained for the stationary and moving dosimeter, respectively, while tracking increased the pass-rate for the moving dosimeter to 90.4%. CONCLUSIONS This study has shown that the 3D dosimetry system can reproduce and thus verify complex dose distributions, also when influenced by motion.
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Affiliation(s)
- Peter S Skyt
- Department of Medical Physics, Aarhus University/Aarhus University Hospital , Aarhus , Denmark
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Hoeben BAW, Bussink J, Troost EGC, Oyen WJG, Kaanders JHAM. Molecular PET imaging for biology-guided adaptive radiotherapy of head and neck cancer. Acta Oncol 2013; 52:1257-71. [PMID: 24003853 DOI: 10.3109/0284186x.2013.812799] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Integration of molecular imaging PET techniques into therapy selection strategies and radiation treatment planning for head and neck squamous cell carcinoma (HNSCC) can serve several purposes. First, pre-treatment assessments can steer decisions about radiotherapy modifications or combinations with other modalities. Second, biology-based objective functions can be introduced to the radiation treatment planning process by co-registration of molecular imaging with planning computed tomography (CT) scans. Thus, customized heterogeneous dose distributions can be generated with escalated doses to tumor areas where radiotherapy resistance mechanisms are most prevalent. Third, monitoring of temporal and spatial variations in these radiotherapy resistance mechanisms early during the course of treatment can discriminate responders from non-responders. With such information available shortly after the start of treatment, modifications can be implemented or the radiation treatment plan can be adapted tailing the biological response pattern. Currently, these strategies are in various phases of clinical testing, mostly in single-center studies. Further validation in multicenter set-up is needed. Ultimately, this should result in availability for routine clinical practice requiring stable production and accessibility of tracers, reproducibility and standardization of imaging and analysis methods, as well as general availability of knowledge and expertise. Small studies employing adaptive radiotherapy based on functional dynamics and early response mechanisms demonstrate promising results. In this context, we focus this review on the widely used PET tracer (18)F-FDG and PET tracers depicting hypoxia and proliferation; two well-known radiation resistance mechanisms.
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Affiliation(s)
- Bianca A W Hoeben
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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Volumetric-modulated arc therapy (RapidArc) vs. conventional fixed-field intensity-modulated radiotherapy for 18F-FDG-PET-guided dose escalation in oropharyngeal cancer: A planning study. Med Dosim 2013; 38:18-24. [DOI: 10.1016/j.meddos.2012.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 04/16/2012] [Accepted: 05/08/2012] [Indexed: 11/17/2022]
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Bender ET. Using spatial information about recurrence risk for robust optimization of dose-painting prescription functions. Med Phys 2012; 39:2713-20. [PMID: 22559642 DOI: 10.1118/1.4704499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop a robust method for deriving dose-painting prescription functions using spatial information about the risk for disease recurrence. METHODS Spatial distributions of radiobiological model parameters are derived from distributions of recurrence risk after uniform irradiation. These model parameters are then used to derive optimal dose-painting prescription functions given a constant mean biologically effective dose. RESULTS An estimate for the optimal dose distribution can be derived based on spatial information about recurrence risk. Dose painting based on imaging markers that are moderately or poorly correlated with recurrence risk are predicted to potentially result in inferior disease control when compared the same mean biologically effective dose delivered uniformly. A robust optimization approach may partially mitigate this issue. CONCLUSIONS The methods described here can be used to derive an estimate for a robust, patient-specific prescription function for use in dose painting. Two approximate scaling relationships were observed: First, the optimal choice for the maximum dose differential when using either a linear or two-compartment prescription function is proportional to R, where R is the Pearson correlation coefficient between a given imaging marker and recurrence risk after uniform irradiation. Second, the predicted maximum possible gain in tumor control probability for any robust optimization technique is nearly proportional to the square of R.
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Affiliation(s)
- Edward T Bender
- Department of Human Oncology, University of Wisconsin, Madison, WI 53792, USA.
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Radiotherapy for head and neck tumours in 2012 and beyond: conformal, tailored, and adaptive? Lancet Oncol 2012; 13:e292-300. [PMID: 22748268 DOI: 10.1016/s1470-2045(12)70237-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intensity-modulated radiation therapy (IMRT) is a conformal irradiation technique that enables steep dose gradients. In head and neck tumours this approach spares parotid-gland function without compromise to treatment efficacy. Anatomical and molecular imaging modalities may be used to tailor treatment by enabling proper selection and delineation of target volumes and organs at risk, which in turn lead to dose prescriptions that take into account the underlying tumour biology (eg, human papillomavirus status). Therefore, adaptations can be made throughout the course of radiotherapy, as required. Planned dose increases to parts of the target volumes may also be used to match the radiosensitivity of tumours (so-called dose-painting), assessed by molecular imaging. For swift implementation of tailored and adaptive IMRT, tools and procedures, such as accurate image acquisition and reconstruction, automatic segmentation of target volumes and organs at risk, non-rigid image and dose registration, and dose summation methods, need to be developed and properly validated.
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Spatially resolved regression analysis of pre-treatment FDG, FLT and Cu-ATSM PET from post-treatment FDG PET: an exploratory study. Radiother Oncol 2012; 105:41-8. [PMID: 22682748 DOI: 10.1016/j.radonc.2012.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 05/08/2012] [Accepted: 05/18/2012] [Indexed: 11/22/2022]
Abstract
PURPOSE To quantify associations between pre-radiotherapy and post-radiotherapy PET parameters via spatially resolved regression. MATERIALS AND METHODS Ten canine sinonasal cancer patients underwent PET/CT scans of [(18)F]FDG (FDG(pre)), [(18)F]FLT (FLT(pre)), and [(61)Cu]Cu-ATSM (Cu-ATSM(pre)). Following radiotherapy regimens of 50 Gy in 10 fractions, veterinary patients underwent FDG PET/CT scans at 3 months (FDG(post)). Regression of standardized uptake values in baseline FDG(pre), FLT(pre) and Cu-ATSM(pre) tumour voxels to those in FDG(post) images was performed for linear, log-linear, generalized-linear and mixed-fit linear models. Goodness-of-fit in regression coefficients was assessed by R(2). Hypothesis testing of coefficients over the patient population was performed. RESULTS Multivariate linear model fits of FDG(pre) to FDG(post) were significantly positive over the population (FDG(post) ~ 0.17 · FDG(pre), p = 0.03), and classified slopes of RECIST non-responders and responders to be different (0.37 vs. 0.07, p = 0.01). Generalized-linear model fits related FDG(pre) to FDG(post) by a linear power law (FDG(post) ~ FDG(pre)(0.93),p<0.001). Univariate mixture model fits of FDG(pre) improved R(2) from 0.17 to 0.52. Neither baseline FLT PET nor Cu-ATSM PET uptake contributed statistically significant multivariate regression coefficients. CONCLUSIONS Spatially resolved regression analysis indicates that pre-treatment FDG PET uptake is most strongly associated with three-month post-treatment FDG PET uptake in this patient population, though associations are histopathology-dependent.
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Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br J Radiol 2011; 84:967-96. [PMID: 22011829 DOI: 10.1259/bjr/22373346] [Citation(s) in RCA: 431] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Volumetric modulated arc therapy (VMAT) is a novel radiation technique, which can achieve highly conformal dose distributions with improved target volume coverage and sparing of normal tissues compared with conventional radiotherapy techniques. VMAT also has the potential to offer additional advantages, such as reduced treatment delivery time compared with conventional static field intensity modulated radiotherapy (IMRT). The clinical worldwide use of VMAT is increasing significantly. Currently the majority of published data on VMAT are limited to planning and feasibility studies, although there is emerging clinical outcome data in several tumour sites. This article aims to discuss the current use of VMAT techniques in practice and review the available data from planning and clinical outcome studies in various tumour sites including prostate, pelvis (lower gastrointestinal, gynaecological), head and neck, thoracic, central nervous system, breast and other tumour sites.
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Affiliation(s)
- M Teoh
- Department of Oncology, St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, Surrey, UK.
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Witte M, Shakirin G, Houweling A, Peulen H, van Herk M. Dealing with geometric uncertainties in dose painting by numbers: Introducing the ΔVH1This work was supported by Dutch Cancer Society grant 2007-3895.1. Radiother Oncol 2011; 100:402-6. [DOI: 10.1016/j.radonc.2011.08.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 08/25/2011] [Accepted: 08/26/2011] [Indexed: 10/17/2022]
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Rødal J, Waldeland E, Søvik Å, Malinen E. Dosimetric verification of biologically adapted IMRT. Med Phys 2011; 38:2586-94. [DOI: 10.1118/1.3581406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Bentzen SM, Gregoire V. Molecular imaging-based dose painting: a novel paradigm for radiation therapy prescription. Semin Radiat Oncol 2011; 21:101-10. [PMID: 21356478 PMCID: PMC3052283 DOI: 10.1016/j.semradonc.2010.10.001] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Dose painting is the prescription of a nonuniform radiation dose distribution to the target volume based on functional or molecular images shown to indicate the local risk of relapse. Two prototypical strategies for implementing this novel paradigm in radiation oncology are reviewed: subvolume boosting and dose painting by numbers. Subvolume boosting involves the selection of a "target within the target," defined by image segmentation on the basis of the quantitative information in the image or morphologically, and this is related to image-based target volume selection and delineation. Dose painting by numbers is a voxel-level prescription of dose based on a mathematical transformation of the image intensity of individual pixels. The quantitative use of images to decide both where and how to delivery radiation therapy in an individual case is also called theragnostic imaging. Dose painting targets are imaging surrogates for cellular or microenvironmental phenotypes associated with poor radioresponsiveness. In this review, the focus is on the following positron emission tomography tracers: FDG and choline as surrogates for tumor burden, fluorothymidine as a surrogate for proliferation (or cellular growth fraction) and hypoxia-sensitive tracers, including [(18)F] fluoromisonidazole, EF3, EF5, and (64)Cu-labeled copper(II) diacetyl-di(N(4)-methylthiosemicarbazone) as surrogates of cellular hypoxia. Research advances supporting the clinicobiological rationale for dose painting are reviewed as are studies of the technical feasibility of optimizing and delivering realistic dose painted radiation therapy plans. Challenges and research priorities in this exciting research field are defined and a possible design for a randomized clinical trial of dose painting is presented.
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Affiliation(s)
- Søren M Bentzen
- Departments of Human Oncology, Medical Physics, Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI 53792, USA.
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