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Guel DNB, Laverick N, MacLaren L, MacLeod N, Glegg M, Lamb G, Houston P, Carruthers R, Grocutt L, Valentine RM. Adaptive radiotherapy for muscle invasive bladder cancer: a retrospective audit of two bladder filling protocols. Radiat Oncol 2024; 19:92. [PMID: 39030548 PMCID: PMC11264890 DOI: 10.1186/s13014-024-02484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/28/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Radical radiotherapy for muscle-invasive bladder cancer (MIBC) is challenging due to large variations in bladder shape, size and volume during treatment, with drinking protocols often employed to mitigate geometric uncertainties. Utilising adaptive radiotherapy together with CBCT imaging to select a treatment plan that best fits the bladder target and reduce normal tissue irradiation is an attractive option to compensate for anatomical changes. The aim of this retrospective study was to compare a bladder empty (BE) protocol to a bladder filling (BF) protocol with regards to variations in target volumes, plan of the day (PoD) selection and plan dosimetry throughout treatment. METHODS Forty patients were included in the study; twenty were treated with a BE protocol and twenty with a BF protocol to a total prescribed dose of 55 Gy in 20 fractions. Small, medium and large bladder plans were generated using three different CTV to PTV margins. Bladder (CTV) volumes were delineated on planning CTs and online pre-treatment CBCTs. Differences in CTV volumes throughout treatment, plan selection, PTV volumes and resulting dose metrics were compared for both protocols. RESULTS Mean bladder volume differed significantly on both the planning CTs and online pre-treatment CBCTs between the protocols (p < 0.05). Significant differences in bladder volumes were observed between the planning CT and pre-treatment CBCTs for BF (p < 0.05) but not for BE (p = 0.11). Both protocols saw a significant decrease in bladder volume between first and final treatment fractions (p < 0.05). Medium plans were preferentially selected for BE whilst when using the BF protocol the small plan was chosen most frequently. With no significant change to PTV coverage between the protocols, the volume of body receiving 25.0-45.8 Gy was found to be significantly smaller for BE patients (p < 0.05). CONCLUSIONS This work provides evidence in favour of a BE protocol compared to a BF protocol for radical radiotherapy for MIBC. The smaller treatment volumes observed in the BE protocol led to reduced OAR and total body doses and were also observed to be more consistent throughout the treatment course. These results highlight improvements in dosimetry for patients who undergo a BE protocol for MIBC.
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Affiliation(s)
- Diana Nohemi Briceño Guel
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8QQ, UK
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicola Laverick
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Linda MacLaren
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Nicholas MacLeod
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Martin Glegg
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Gillian Lamb
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Peter Houston
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Ross Carruthers
- Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
| | - Laura Grocutt
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK
- CRUK RadNet Glasgow, University of Glasgow, Glasgow, G61 1QH, UK
| | - Ronan M Valentine
- Radiotherapy Physics, Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow, G12 0YN, UK.
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Yock AD, Cooney A, Morales‐Paliza M, Shinohara E, Homann K. Empirical analysis of a plan-of-the-day strategy to approximate daily online reoptimization for prostate CBCT-guided adaptive radiotherapy. J Appl Clin Med Phys 2024; 25:e14221. [PMID: 38029380 PMCID: PMC10795443 DOI: 10.1002/acm2.14221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE Adaptive radiotherapy (ART) can improve the dose delivered to the patient in the presence of anatomic variations. However, the required time, effort, and clinical resources are intensive. This work analyzed a plan-of-the-day (POD) approach on clinical patients treated with online ART to explore implementations that balance dosimetric benefit and clinical resource cost. METHODS Eight patients treated to the prostate and proximal seminal vesicles with 26 fractions of CBCT-guided, daily online ART were retrospectively analyzed. With a plan library composed of daily adaptive plans from the initial week of treatment and the original plan, the effect of a POD approach starting the following week was investigated by simulating use of these previously generated plans under 3- and 6-degree-of-freedom patient alignment. The plan selected for each treatment was that from the library that maximized the Dice similarity coefficient of the clinical target volume with that of the current treatment fraction. The resulting distribution of several target coverage and organ-at-risk dose metrics are described relative to those achieved with the daily online reoptimized adaptive technique. RESULTS The values of target coverage and organ-at-risk dose metrics varied across patients and metrics. The POD schemas closely approximated the reference values from a fully reoptimized adaptive plan yet required less than 20% of the reoptimization effort. The POD schemas also had a much greater effect on target coverage metrics than 6-degree-of-freedom registration did. Organ-at-risk dose metrics also varied considerably across patients but did not exhibit a consistent dependence on the particular schema. CONCLUSIONS POD schemas were able to achieve the vast majority of the dosimetric benefit of daily online ART with a small fraction of the online reoptimization effort. Strategies like this might allow for more practical and strategic implementation of ART so as to benefit a greater number of patients.
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Affiliation(s)
- Adam D. Yock
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Annie Cooney
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Manuel Morales‐Paliza
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Shinohara
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kenneth Homann
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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Yock AD, Ahmed M, Masick S, Morales‐Paliza M, Kluwe C, Shinde A, Kirschner A, Shinohara E. Triggering daily online adaptive radiotherapy in the pelvis: Dosimetric effects and procedural implications of trigger parameter-value selection. J Appl Clin Med Phys 2023; 24:e14060. [PMID: 37276079 PMCID: PMC10562041 DOI: 10.1002/acm2.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 05/01/2023] [Accepted: 05/19/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Online adaptive radiotherapy (ART) can address dosimetric consequences of variations in anatomy by creating a new plan during treatment. However, ART is time- and labor-intensive and should be implemented in a resource-conscious way. Adaptive triggers composed of parameter-value pairs may direct the judicious use of online ART. PURPOSE This work analyzed our clinical experience using CBCT-based daily online ART to demonstrate how a conceptual framework based on adaptive triggers affects the dosimetric and procedural impact of ART. METHODS Sixteen patients across several pelvic sites were treated with CBCT-based daily online ART. Differences in standardized dose metrics were compared between the original plan, the original plan recalculated on the daily anatomy, and an adaptive plan. For each metric, trigger values were analyzed in terms of the proportion of treatments adapted and the distribution of metric values. RESULTS Target coverage metrics were compromised due to anatomic variation with the average change per treatment ranging from -0.90 to -0.05 Gy, -0.47 to -0.02 Gy, -0.31 to -0.01 Gy, and -12.45% to -2.65% for PTV D99%, PTV D95%, CTV D99%, and CTV V100%, respectively. These were improved using the adaptive plan (-0.03 to 0.01 Gy, -0.02 to 0.00 Gy, -0.03 to 0.00 Gy, and -4.70% to 0.00%, respectively). Increasingly strict triggers resulted in a non-linear increase in the proportion of treatments adapted and improved the distribution of metric values with diminishing returns. Some organ-at-risk (OAR) metrics were compromised by anatomic variation and improved using the adaptive plan, but changes in most OAR metrics were randomly distributed. CONCLUSIONS Daily online ART improved target coverage across multiple pelvic treatment sites and techniques. These effects were larger than those for OAR metrics, suggesting that maintaining target coverage was our primary benefit of CBCT-based daily online ART. Analyses like these can determine online ART triggers from a cost-benefit perspective.
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Affiliation(s)
- Adam D. Yock
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Mahmoud Ahmed
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah Masick
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Manuel Morales‐Paliza
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Christien Kluwe
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Ashwin Shinde
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Austin Kirschner
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Shinohara
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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Optimized Adaptive Radiotherapy with Individualized Plan Library for Muscle-Invasive Bladder Cancer Using Internal Target Volume Generation. Cancers (Basel) 2022; 14:cancers14194674. [PMID: 36230598 PMCID: PMC9564375 DOI: 10.3390/cancers14194674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary The bladder is a mobile target and is subject to filling variation. This poses a considerable challenge for effective radiotherapy (RT) delivery. We applied an internal target volume to the plan library to resolve intra-fractional errors caused by bladder filling during treatment. Adaptive radiotherapy using ITV is easy to perform and a feasible treatment approach. In this study, image-guided RT-based adaptive RT showed good survival outcomes with a high local control rate. Abstract The bladder is subject to filling variation, which poses a challenge to radiotherapy (RT) delivery. We aimed to assess feasibility and clinical outcomes in patients with bladder cancer treated with adaptive RT (ART) using individualized plan libraries. We retrospectively analyzed 19 patients who underwent RT for muscle-invasive bladder cancer (MIBC) in 2015–2021. Four planning computed tomography (CT) scans were acquired at 15-min intervals, and a library of three intensity-modulated RT plans were generated using internal target volumes (ITVs). A post-treatment cone-beam CT (CBCT) scan was acquired daily to assess intra-fraction filling and coverage. All patients completed the treatment, with 408 post-treatment CBCT scans. The bladder was out of the planning target volume (PTV) range in 12 scans. The volumes of the evaluated PTV plans were significantly smaller than those of conventional PTV. The 1-year and 2-year overall survival rates were 88.2% and 63.7%, respectively. Of eight cases that experienced recurrence, only two developed MIBC. There were no grade 3 or higher RT-related adverse events. ART using plan libraries and ITVs demonstrated good survival outcomes with a high local control rate. Irradiated normal tissue volume and treatment margins may be reduced through this approach, potentially resulting in lower toxicity rates.
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Hansen CR, Hussein M, Bernchou U, Zukauskaite R, Thwaites D. Plan quality in radiotherapy treatment planning - Review of the factors and challenges. J Med Imaging Radiat Oncol 2022; 66:267-278. [PMID: 35243775 DOI: 10.1111/1754-9485.13374] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022]
Abstract
A high-quality treatment plan aims to best achieve the clinical prescription, balancing high target dose to maximise tumour control against sufficiently low organ-at-risk dose for acceptably low toxicity. Treatment planning (TP) includes multiple steps from simulation/imaging and segmentation to technical plan production and reporting. Consistent quality across this process requires close collaboration and communication between clinical and technical experts, to clearly understand clinical requirements and priorities and also practical uncertainties, limitations and compromises. TP quality depends on many aspects, starting from commissioning and quality management of the treatment planning system (TPS), including its measured input data and detailed understanding of TPS models and limitations. It requires rigorous quality assurance of the whole planning process and it links to plan deliverability, assessable by measurement-based verification. This review highlights some factors influencing plan quality, for consideration for optimal plan construction and hence optimal outcomes for each patient. It also indicates some challenges, sources of difference and current developments. The topics considered include: the evolution of TP techniques; dose prescription issues; tools and methods to evaluate plan quality; and some aspects of practical TP. The understanding of what constitutes a high-quality treatment plan continues to evolve with new techniques, delivery methods and related evidence-based science. This review summarises the current position, noting developments in the concept and the need for further robust tools to help achieve it.
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Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia.,Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - David Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
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Åström LM, Behrens CP, Calmels L, Sjöström D, Geertsen P, Mouritsen LS, Serup-Hansen E, Lindberg H, Sibolt P. Online adaptive radiotherapy of urinary bladder cancer with full re-optimization to the anatomy of the day: initial experience and dosimetric benefits. Radiother Oncol 2022; 171:37-42. [DOI: 10.1016/j.radonc.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 12/25/2022]
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Shepherd M, Graham S, Ward A, Zwart L, Cai B, Shelley C, Booth J. Pathway for radiation therapists online advanced adapter training and credentialing. Tech Innov Patient Support Radiat Oncol 2021; 20:54-60. [PMID: 34917781 PMCID: PMC8665404 DOI: 10.1016/j.tipsro.2021.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/15/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Online Adaptive Radiation Therapy (oART) provides a solution to account for daily patient variations, but wide spread implementation is hindered by human resources and training. Physicians can mentor Radiation Therapists (RTTs) through traditional tasks such as contouring and plan approval. With evidence-based credentialing activities, decision support aids and ‘on-call’ caveats, RTTs can lead the oART workflow and a ‘Clinician-Lite’ approach. Compliance with legislative, regulatory and medico-legal governing bodies can be addressed through post-graduate study, advanced practice pathways, exemptions and delegation of task.
Online adaptive radiotherapy (oART) is an emerging advanced treatment option for cancer patients worldwide. Current oART practices using magnetic resonance (MR) and cone beam computed tomography (CBCT) based imaging are resource intensive and require physician presence, which is a barrier to widespread implementation. Global evidence demonstrates Radiation Therapists (RTTs) can lead the oART workflow with decision support tools and on ‘on-call’ caveats in a ‘clinician-lite’ approach without significantly compromising on treatment accuracy, speed or patient outcomes. With careful consideration of jurisdictional regulations and guidance from the multi-disciplinary team, RTTs can elevate beyond traditional scopes of practice. By implementing robust and evidence-based credentialing activities, they enable service sustainability and expand the real-world gains of adaptive radiotherapy to a greater number of cancer patients worldwide. This work summarises the evidence for RTT-led oART treatments and proposes a pathway for training and credentialing.
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Affiliation(s)
- Meegan Shepherd
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonard, NSW 2065, Australia
| | - Siobhan Graham
- Queen's Hospital, BHRUT NHS Trust, Rom Valley Way, Romford RM1 0AG, UK
| | - Amy Ward
- Queen's Hospital, BHRUT NHS Trust, Rom Valley Way, Romford RM1 0AG, UK
| | - Lissane Zwart
- Medisch Spectrum Twente (MST), Koningstraat 1, 7512 KZ Enschede, Netherlands
| | - Bin Cai
- UT Southwestern Medical Center, Harry Hines Blvd, Dallas, TX 75390, USA
| | | | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd, St Leonard, NSW 2065, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Camperdown, NSW 2004, Australia
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Dower K, Ford A, Sandford M, Doherty A, Greenham S, Kerin L, Dwyer P, Hansen C, Westhuyzen J, Shakespeare T. Retrospective evaluation of planning margins for patients undergoing radical radiation therapy treatment for bladder cancer using volumetric modulated arc therapy and cone beam computed tomography. J Med Radiat Sci 2021; 68:371-378. [PMID: 34288566 PMCID: PMC8656189 DOI: 10.1002/jmrs.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 06/20/2021] [Accepted: 07/09/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Current contouring guidelines for curative radiation therapy for muscle-invasive bladder cancer (MIBC) recommend margins of 1.5-2.0 cm, applied to the clinical target volume (CTV). This study assessed whether the use of volumetric modulated arc therapy (VMAT), cone beam computed tomography (CBCT) and strict bladder preparation allowed for a reduced planning target volume (PTV) expansion, resulting in lower doses to surrounding organs at risk (OARs). METHODS Daily CBCT images for 12 patients (382 scans total) were retrospectively reviewed against four potential PTV margins created on and exported with the reference CT scan. To form the PTVs, three isotropic expansions of 0.5, 1.0 and 1.5 cm were applied to the CTV, as well as an anisotropic expansion of 1.5 cm superiorly and 1.0 cm in all other dimensions. Following treatment completion, the CBCTs were visually assessed to determine the margins encapsulating the bladder. For retrospective planning purposes, the 1.0-cm and anisotropic margins were compared with the previously recommended margins to determine differences in OAR doses. RESULTS The 0.5-, 1.0- and 1.5-cm isotropic margins (IM) and the anisotropic margin (ANIM) covered the CTV in 46.1, 96.8, 100 and 100% of CBCTs retrospectively. Doses to OARs were significantly lower for the reduced margin plans for the small bowel, rectum and sigmoid. CONCLUSION Bladder planning target volumes may be safely reduced. We endorse a PTV margin of 1.0cm anteriorly, posteriorly and inferiorly with 1.0-1.5 cm superiorly for radical whole bladder cases using strict bladder preparation, VMAT and pretreatment CBCTs.
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Affiliation(s)
- Kathleene Dower
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Andriana Ford
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Michael Sandford
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Andrew Doherty
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Stuart Greenham
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Luke Kerin
- Mid North Coast Cancer Institute Port MacquariePort MacquarieNew South WalesAustralia
| | - Patrick Dwyer
- Northern NSW Cancer InstituteLismoreNew South WalesAustralia
| | - Carmen Hansen
- Mid North Coast Cancer Institute Port MacquariePort MacquarieNew South WalesAustralia
| | - Justin Westhuyzen
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
| | - Thomas Shakespeare
- Mid North Coast Cancer Institute Coffs HarbourCoffs HarbourNew South WalesAustralia
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Holm AIS, Nyeng TB, S. Møller D, Assenholt MS, Hansen R, Nyvang L, Ravkilde T, Thomsen MS, Hoffmann L. Density calibrated cone beam CT as a tool for adaptive radiotherapy. Acta Oncol 2021; 60:1275-1282. [PMID: 34224288 DOI: 10.1080/0284186x.2021.1945678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Visual inspections of anatomical changes observed on daily cone-beam CT (CBCT) images are often used as triggers for radiotherapy plan adaptation to avoid unacceptable dose levels to the target or OARs. Direct CBCT dose calculations would improve the ability to adapt only those plans where dosimetric changes are observed. This study investigates the accuracy of dose calculations on CBCTs. MATERIALS AND METHODS Calibration curves were obtained for CBCT imagers at nine identical accelerators. CBCT scans of a phantom with different density inserts were recorded for two scan modes (Head-Neck and Pelvis) and mean calibration curves were calculated. Subsequently, CBCT scans of the phantom with six different density inserts were recorded, the dose distributions on the CBCTs were calculated and compared to dose on the planning CT (pCT). The uncertainty was quantified by the dosimetric difference between the pCT and the CBCT. The two mean calibration curves were used to calculate the daily delivered CBCT dose for ten Head-Neck-, eleven Lung-, and ten pelvic patients. Additional patient calculations were performed using low-HU empirically corrected calibration curves. Patient doses were compared on target coverage and mean dose, and D1cc for OARs. RESULTS The dose differences between pCT and CBCT for phantom data were small for all DVH parameters, with mean deviations below ±0.6% for both CBCT modes. For patient data, it was found that low-HU corrected calibration curves performed the best. The mean deviations for the mean dose and coverage of the target were 0.2%±0.7% and 0.1%±0.6%, across all patient groups. CONCLUSION Dose calculation on CBCT images results in target coverage and mean dose with an accuracy of the order of 1%, which makes this acceptable for clinical use. The CBCT mode specific calibration curves can be used at all identical imaging devices and for all patient groups.
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Affiliation(s)
- Anne I. S. Holm
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Tine B. Nyeng
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ditte S. Møller
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne S. Assenholt
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Rune Hansen
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Nyvang
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Ravkilde
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Mette S. Thomsen
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Hoffmann
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
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Khalifa J, Supiot S, Pignot G, Hennequin C, Blanchard P, Pasquier D, Magné N, de Crevoisier R, Graff-Cailleaud P, Riou O, Cabaillé M, Azria D, Latorzeff I, Créhange G, Chapet O, Rouprêt M, Belhomme S, Mejean A, Culine S, Sargos P. Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder. Radiother Oncol 2021; 161:95-114. [PMID: 34118357 DOI: 10.1016/j.radonc.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations. METHODS AND MATERIALS In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy. RESULTS A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence. CONCLUSION The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France
| | - Géraldine Pignot
- Department of Urology, Institut Paoli Calmettes, Marseille, France
| | | | - Pierre Blanchard
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, Lille, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | | | - Pierre Graff-Cailleaud
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Olivier Riou
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | | | - David Azria
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | | | - Olivier Chapet
- Department of Radiotherapy, Hospices Civils de Lyon, France
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpétrière, APHP Sorbonne Université, Paris, France
| | - Sarah Belhomme
- Department of Medical Physics, Institut Bergonié, Bordeaux, France
| | - Arnaud Mejean
- Department of Urology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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12
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Huddart R, Hafeez S, Lewis R, McNair H, Syndikus I, Henry A, Staffurth J, Dewan M, Vassallo-Bonner C, Moinuddin SA, Birtle A, Horan G, Rimmer Y, Venkitaraman R, Khoo V, Mitra A, Hughes S, Gibbs S, Kapur G, Baker A, Hansen VN, Patel E, Hall E. Clinical Outcomes of a Randomized Trial of Adaptive Plan-of-the-Day Treatment in Patients Receiving Ultra-hypofractionated Weekly Radiation Therapy for Bladder Cancer. Int J Radiat Oncol Biol Phys 2021; 110:412-424. [PMID: 33316362 PMCID: PMC8114997 DOI: 10.1016/j.ijrobp.2020.11.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Hypofractionated radiation therapy can be used to treat patients with muscle-invasive bladder cancer unable to have radical therapy. Toxicity is a key concern, but adaptive plan-of the day (POD) image-guided radiation therapy delivery could improve outcomes by minimizing the volume of normal tissue irradiated. The HYBRID trial assessed the multicenter implementation, safety, and efficacy of this strategy. METHODS HYBRID is a Phase II randomized trial that was conducted at 14 UK hospitals. Patients with T2-T4aN0M0 muscle-invasive bladder cancer unsuitable for radical therapy received 36 Gy in 6 weekly fractions, randomized (1:1) to standard planning (SP) or adaptive planning (AP) using a minimization algorithm. For AP, a pretreatment cone beam computed tomography (CT) was used to select the POD from 3 plans (small, medium, and large). Follow-up included standard cystoscopic, radiologic, and clinical assessments. The primary endpoint was nongenitourinary Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3 (≥G3) toxicity within 3 months of radiation therapy. A noncomparative single stage design aimed to exclude ≥30% toxicity rate in each planning group in patients who received ≥1 fraction of radiation therapy. Local control at 3-months (both groups combined) was a key secondary endpoint. RESULTS Between April 15, 2014, and August 10, 2016, 65 patients were enrolled (SP, n = 32; AP, n = 33). The median follow-up time was 38.8 months (interquartile range [IQR], 36.8-51.3). The median age was 85 years (IQR, 81-89); 68% of participants (44 of 65) were male; and 98% of participants had grade 3 urothelial cancer. In 63 evaluable participants, CTCAE ≥G3 nongenitourinary toxicity rates were 6% (2 of 33; 95% confidence interval [CI], 0.7%-20.2%) for the AP group and 13% (4 of 30; 95% CI, 3.8%-30.7%) for the SP group. Disease was present in 9/48 participants assessed at 3 months, giving a local control rate of 81.3% (95% CI, 67.4%-91.1%). CONCLUSIONS POD adaptive radiation therapy was successfully implemented across multiple centers. Weekly ultrahypofractionated 36 Gy/6 fraction radiation therapy is safe and provides good local control rates in this older patient population.
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Affiliation(s)
- Robert Huddart
- The Institute of Cancer Research, London, United Kingdom; Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- The Institute of Cancer Research, London, United Kingdom
| | - Helen McNair
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabelle Syndikus
- Radiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ann Henry
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - Monisha Dewan
- The Institute of Cancer Research, London, United Kingdom
| | | | - Syed Ali Moinuddin
- Academic unit of Oncology, Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Alison Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Gail Horan
- Queen Elizabeth Hospital Kings Lynn NHS Trust, Kings Lynn, United Kingdom
| | - Yvonne Rimmer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Vincent Khoo
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Anita Mitra
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Simon Hughes
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Stephanie Gibbs
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom
| | - Gaurav Kapur
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Angela Baker
- Radiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Emma Patel
- Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
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Cabaillé M, Gaston R, Belhomme S, Giraud A, Rouffilange J, Roubaud G, Sargos P. [Plan of the day adaptive radiotherapy for bladder cancer: Dosimetric and clinical results]. Cancer Radiother 2021; 25:308-315. [PMID: 33422418 DOI: 10.1016/j.canrad.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To account of individual intra-pelvic anatomical variations in muscle invasive bladder cancer (MIBC) irradiation, adaptive radiotherapy (ART) using a personalized plan library may have dosimetric and clinical benefits. MATERIAL AND METHODS The data from ten patients treated for localized MIBC according to the "plan of the day" (P0oD) individualized ART technique were collected and retrospectively analysed. Target volumes and organs at risk (OAR) were delineated at different bladder fill rates, resulting in two or three treatment plans. Daily Cone-Beam CT (CBCT) was used for the selection of PoD at each fraction. Retrospectively, we delineated rectal, intestinal and target volumes on each CBCT, to assess target volume coverage and dose sparing to healthy tissues. A comparison with the conventional radiotherapy technique was performed. The secondary objectives were toxicity and efficacy. RESULTS The target coverage was respected with the adaptive treatment: 97.3% for the bladder Clinical Target Volume (CTV) (99.5; [60.1-100]) and 98% for the bladder+lymph nodes CTV (98.6; [85.4-100]). Concerning OAR, the volume of healthy tissue spared was 43.7% on average and the V45Gy for the small bowel was 43,4cc (35; [0-129]) (versus 57,6cc). The rectal D50 was on average 18,7Gy for the adaptive treatment (15.9; [2.4-44.1]) versus 17Gy with the conventional approach. With a median follow-up of 2.94 years (95% CI: [0.92-4.02]), we observed three grade 3 toxicities (30%). No grade 4 toxicity was observed. The 2-year overall survival and progression-free survival rates were 65.6% (95% CI: [26-87.6]) and 45.7% (95% CI: [14.3-73]), respectively. CONCLUSION The ART technique using a PoD strategy showed a reduction of the irradiated healthy tissue volume while maintaining a similar bladder coverage, with an acceptable rate of toxicity.
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Affiliation(s)
- M Cabaillé
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France
| | - R Gaston
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - S Belhomme
- Département de Physique Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - A Giraud
- Unité de Recherche Épidémiologique et Clinique, Institut Bergonié, 33076 Bordeaux cedex, France
| | - J Rouffilange
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - G Roubaud
- Département d'Oncologie Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - P Sargos
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France.
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Cabaillé M, Khalifa J, Tessier AM, Belhomme S, Créhange G, Sargos P. [A review of adaptive radiotherapy for bladder cancer]. Cancer Radiother 2021; 25:271-278. [PMID: 33402293 DOI: 10.1016/j.canrad.2020.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Radiation therapy (RT) for muscle invasive bladder cancer (MIBC) is challenging, with observed variations in bladder shape and size resulting in inappropriate coverage of the target volumes (CTV). Large margins were historically applied around the CTV, increasing the dose delivered to organs at risk (OAR). With repositioning imaging and visualization of soft tissues during image guided RT, an opportunity to consider these movements and deformations appeared possible with an adaptive RT approach (ART). MATERIALS AND METHODS A bibliographic search on the PubMed database has been done in January 2019. Studies focusing on patients with MIBC, treating on ART, with the objectives of feasibility, clinical and/or dosimetric evaluation and comparison with a standard irradiation technique were eligible. The purpose of this review was to define the different ART techniques used in clinical practice, to discuss their advantages compared to conventional RT in terms of target volume's coverage and OAR dose and to describe their feasibility in clinical practice. RESULTS A total of 30 studies were selected. The strategies known as "composite offline", "plan of the day" not individualized or individualized, and "re-optimization" have been identified. All the studies have shown a significant benefit of ART in target coverage and dose of OAR, especially the rectum and small bowel. All ART plans produced are not used during RT sessions. Inter-observer variability for the selection of these plans can be observed. The practical implementation within a department required staff education and training, and increases the duration of treatment preparation. The "A-POLO" approach seems to be the most suitable for practice. CONCLUSION ART is the technique of choice for bladder cancer RT. The "plan of the day" approach, individualized according to the A-POLO methodology, seems to be the most effective. The emergence of daily re-optimization, especially using MRI-Linac, is promising. The correlation between dosimetric benefits and clinical efficacy and safety results should be demonstrated into future trials.
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Affiliation(s)
- M Cabaillé
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - J Khalifa
- Département de radiothérapie, Institut universitaire du Cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - A M Tessier
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - G Créhange
- Département de radiothérapie, Institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - P Sargos
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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Hafeez S, Webster A, Hansen VN, McNair HA, Warren-Oseni K, Patel E, Choudhury A, Creswell J, Foroudi F, Henry A, Kron T, McLaren DB, Mitra AV, Mostafid H, Saunders D, Miles E, Griffin C, Lewis R, Hall E, Huddart R. Protocol for tumour-focused dose-escalated adaptive radiotherapy for the radical treatment of bladder cancer in a multicentre phase II randomised controlled trial (RAIDER): radiotherapy planning and delivery guidance. BMJ Open 2020; 10:e041005. [PMID: 33384390 PMCID: PMC7780718 DOI: 10.1136/bmjopen-2020-041005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily radiotherapy delivered with radiosensitisation offers patients with muscle invasive bladder cancer (MIBC) comparable outcomes to cystectomy with functional organ preservation. Most recurrences following radiotherapy occur within the bladder. Increasing the delivered radiotherapy dose to the tumour may further improve local control. Developments in image-guided radiotherapy have allowed bladder tumour-focused 'plan of the day' radiotherapy delivery. We aim to test within a randomised multicentre phase II trial whether this technique will enable dose escalation with acceptable rates of toxicity. METHODS AND ANALYSIS Patients with T2-T4aN0M0 unifocal MIBC will be randomised (1:1:2) between standard/control whole bladder single plan radiotherapy, standard dose adaptive tumour-focused radiotherapy or dose-escalated adaptive tumour-focused radiotherapy (DART). Adaptive tumour-focused radiotherapy will use a library of three plans (small, medium and large) for treatment. A cone beam CT taken prior to each treatment will be used to visualise the anatomy and inform selection of the most appropriate plan for treatment.Two radiotherapy fractionation schedules (32f and 20f) are permitted. A minimum of 120 participants will be randomised in each fractionation cohort (to ensure 57 evaluable DART patients per cohort).A comprehensive radiotherapy quality assurance programme including pretrial and on-trial components is instituted to ensure standardisation of radiotherapy planning and delivery.The trial has a two-stage non-comparative design. The primary end point of stage I is the proportion of patients meeting predefined normal tissue constraints in the DART group. The primary end point of stage II is late Common Terminology Criteria for Adverse Events grade 3 or worse toxicity aiming to exclude a rate of >20% (80% power and 5% alpha, one sided) in each DART fractionation cohort. Secondary end points include locoregional MIBC control, progression-free survival overall survival and patient-reported outcomes. ETHICS AND DISSEMINATION This clinical trial is approved by the London-Surrey Borders Research Ethics Committee (15/LO/0539). The results when available will be disseminated via peer-reviewed scientific journals, conference presentations and submission to regulatory authorities. TRIAL REGISTRATION NUMBER NCT02447549; Pre-results.
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Affiliation(s)
- Shaista Hafeez
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Amanda Webster
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Vibeke N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Helen A McNair
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Karole Warren-Oseni
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Patel
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Ananya Choudhury
- Division of Cancer Studies, The University of Manchester, Manchester, UK
- Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Joanne Creswell
- Department of Urology, James Cook University Hospital, Middlesbrough, UK
| | - Farshad Foroudi
- Department of Radiation Oncology, Austin Health, Heidelberg, Victoria, Australia
| | - Ann Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, West Yorkshire, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Duncan B McLaren
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Anita V Mitra
- Cancer Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hugh Mostafid
- The Stokes Centre for Urology, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Daniel Saunders
- Department of Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Robert Huddart
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
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16
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Sibolt P, Andersson LM, Calmels L, Sjöström D, Bjelkengren U, Geertsen P, Behrens CF. Clinical implementation of artificial intelligence-driven cone-beam computed tomography-guided online adaptive radiotherapy in the pelvic region. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 17:1-7. [PMID: 33898770 PMCID: PMC8057957 DOI: 10.1016/j.phro.2020.12.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 12/31/2022]
Abstract
Background and purpose Studies have demonstrated the potential of online adaptive radiotherapy (oART). However, routine use has been limited due to resource demanding solutions. This study reports on experiences with oART in the pelvic region using a novel cone-beam computed tomography (CBCT)-based, artificial intelligence (AI)-driven solution. Material and methods Automated pre-treatment planning for thirty-nine pelvic cases (bladder, rectum, anal, and prostate), and one hundred oART simulations were conducted in a pre-clinical release of Ethos (Varian Medical Systems, Palo Alto, CA). Plan quality, AI-segmentation accuracy, oART feasibility and an integrated calculation-based quality assurance solution were evaluated. Experiences from the first five clinical oART patients (three bladder, one rectum and one sarcoma) are reported. Results Auto-generated pre-treatment plans demonstrated similar planning target volume (PTV) coverage and organs at risk doses, compared to institution reference. More than 75% of AI-segmentations during simulated oART required none or minor editing and the adapted plan was superior in 88% of cases. Limitations in AI-segmentation correlated to cases where AI model training was lacking. The five first treated patients complied well with the median adaptive procedure duration of 17.6 min (from CBCT acceptance to treatment delivery start). The treated bladder patients demonstrated a 42% median primary PTV reduction, indicating a 24%-30% reduction in V45Gy to the bowel cavity, compared to non-ART. Conclusions A novel commercial oART solution was demonstrated feasible for various pelvic sites. Clinically acceptable AI-segmentation and auto-planning enabled adaptation within reasonable timeslots. Possibilities for reduced PTVs observed for bladder cancer indicated potential for toxicity reductions.
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Affiliation(s)
- Patrik Sibolt
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lina M Andersson
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Lucie Calmels
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - David Sjöström
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Ulf Bjelkengren
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Poul Geertsen
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Claus F Behrens
- Department of Oncology, Herlev & Gentofte Hospital, Herlev, Denmark
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Bertholet J, Anastasi G, Noble D, Bel A, van Leeuwen R, Roggen T, Duchateau M, Pilskog S, Garibaldi C, Tilly N, García-Mollá R, Bonaque J, Oelfke U, Aznar MC, Heijmen B. Patterns of practice for adaptive and real-time radiation therapy (POP-ART RT) part II: Offline and online plan adaption for interfractional changes. Radiother Oncol 2020; 153:88-96. [PMID: 32579998 PMCID: PMC7758781 DOI: 10.1016/j.radonc.2020.06.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/08/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The POP-ART RT study aims to determine to what extent and how intrafractional real-time respiratory motion management (RRMM), and plan adaptation for interfractional anatomical changes (ART) are used in clinical practice and to understand barriers to implementation. Here we report on part II: ART using more than one plan per target per treatment course. MATERIALS AND METHODS A questionnaire on the current practice of ART, wishes for expansion or implementation, and barriers to implementation was distributed worldwide. Four types of ART were discriminated: daily online replanning, online plan library, protocolled offline replanning (all three based on a protocol), and ad-hoc offline replanning. RESULTS The questionnaire was completed by 177 centres from 40 countries. ART was used by 61% of respondents (31% with protocol) for a median (range) of 3 (1-8) tumour sites. CBCT/MVCT was the main imaging modality except for online daily replanning (11 users) where 10 users used MR. Two thirds of respondents wished to implement ART for a new tumour site; 40% of these had plans to do it in the next 2 years. Human/material resources and technical limitations were the main barriers to further use and implementation. CONCLUSIONS ART was used for a broad range of tumour sites, mainly with ad-hoc offline replanning and for a median of 3 tumour sites. There was a large interest in implementing ART for more tumour sites, mainly limited by human/material resources and technical limitations. Daily online replanning was primarily performed on MR-linacs.
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Affiliation(s)
- Jenny Bertholet
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, United Kingdom; Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Gail Anastasi
- Department of Medical Physics, Royal Surrey County Hospital, St. Luke's Cancer Centre, Guildford, United Kingdom
| | - David Noble
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, United Kingdom
| | - Arjan Bel
- Amsterdam UMC, Department of Radiation Oncology, The Netherlands
| | - Ruud van Leeuwen
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Toon Roggen
- Applied Research, Varian Medical Systems Imaging Laboratory GmbH, Dättwil, Switzerland
| | | | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway; Department of Physics and Technology, University of Bergen, Norway
| | - Cristina Garibaldi
- IEO, European Institute of Oncology IRCCS, Unit of Radiation Research, Milan, Italy
| | - Nina Tilly
- Elekta Instruments AB, Stockholm, Sweden; Medical Radiation Physics, Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Rafael García-Mollá
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospital General Universitario de Valencia, Spain
| | - Jorge Bonaque
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castelló de la Plana, Spain
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, United Kingdom
| | - Marianne C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, United Kingdom; Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Ben Heijmen
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
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18
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Hunt A, Hanson I, Dunlop A, Barnes H, Bower L, Chick J, Cruickshank C, Hall E, Herbert T, Lawes R, McQuaid D, McNair H, Mitchell A, Mohajer J, Morgan T, Oelfke U, Smith G, Nill S, Huddart R, Hafeez S. Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer. Clin Transl Radiat Oncol 2020; 25:46-51. [PMID: 33015380 PMCID: PMC7522378 DOI: 10.1016/j.ctro.2020.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/15/2022] Open
Abstract
Whole bladder magnetic resonance image-guided radiotherapy using the 1.5 Telsa MR-linac is feasible. Full online adaptive planning workflow based on the anatomy seen at each fraction was performed. This was delivered within 45 min. Intra-fraction bladder filling did not compromise target coverage. Patients reported acceptable tolerance of treatment.
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Affiliation(s)
- A. Hunt
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - I. Hanson
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - A. Dunlop
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - H. Barnes
- The Royal Marsden NHS Foundation Trust, London, UK
| | - L. Bower
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - J. Chick
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - C. Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - E. Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - T. Herbert
- The Royal Marsden NHS Foundation Trust, London, UK
| | - R. Lawes
- The Royal Marsden NHS Foundation Trust, London, UK
| | - D. McQuaid
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - H. McNair
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - A. Mitchell
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - J. Mohajer
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - T. Morgan
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - U. Oelfke
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - G. Smith
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S. Nill
- The Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - R. Huddart
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S. Hafeez
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
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Dos Reis RB, Muglia VF, Rodrigues AA, Viani G. Editorial Comment: Endoclips as novel fiducial markers in trimodality bladder preserving therapy of muscle-invasive bladder carcinoma: feasibility and patient out-comes. Int Braz J Urol 2020; 47:100-102. [PMID: 33047915 PMCID: PMC7712691 DOI: 10.1590/s1677-5538.ibju.2019.0713.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rodolfo Borges Dos Reis
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Valdair Francisco Muglia
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
| | - Antônio Antunes Rodrigues
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Gustavo Viani
- Departamento de Imagens Médicas, Radioterapia e Oncohematologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
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Bleeker M, Goudschaal K, Bel A, Sonke JJ, Hulshof MCCM, van der Horst A. Feasibility of cone beam CT-guided library of plans strategy in pre-operative gastric cancer radiotherapy. Radiother Oncol 2020; 149:49-54. [PMID: 32387491 DOI: 10.1016/j.radonc.2020.04.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The stomach displays large anatomical changes in size, shape and position, which implies the need for plan adaptation for gastric cancer patients who receive pre-operative radiotherapy. We evaluated the feasibility and necessity of a CBCT-guided library of plans (LoP) strategy in gastric cancer radiotherapy. METHODS Eight gastric cancer patients treated with 24-25 fractions of single-plan radiotherapy with daily CBCT imaging were included. The target was delineated on the pre-treatment CT and first 5 CBCTs to create a patient-specific LoP. Plan selections were performed by 12 observers in a training stage (2-3 CBCTs per patient) and an assessment stage (17 CBCTs per patient). The observers were asked to select the smallest plan that encompassed the target on the CBCT. A total of 136 plan selections were evaluated in the assessment stage. RESULTS Delineations on CBCTs showed that in 90% of the 40 delineated fractions part of the CTV was outside the PTV based on the pre-treatment CT. At least two-thirds of the observers agreed on the selected plan in 65.2% and 70% of the fractions in the training stage and the assessment stage, respectively. For each patient, at least two different plans from the LoP were the most selected plan. CONCLUSION A CBCT-guided patient-specific LoP strategy is feasible for gastric cancer patients, yielding good agreement in plan selections. Unless generous margins are used to avoid frequent geometric misses, it is likely that part of the target will be missed with single-plan radiotherapy.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Karin Goudschaal
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Plan Selection in Proton Therapy of Locally Advanced Prostate Cancer with Simultaneous Treatment of Multiple Targets. Int J Radiat Oncol Biol Phys 2020; 106:630-638. [DOI: 10.1016/j.ijrobp.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 10/25/2019] [Accepted: 11/07/2019] [Indexed: 12/28/2022]
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Patel E, Tsang Y, Baker A, Callender J, Hafeez S, Hall E, Hansen VN, Lewis R, McNair H, Miles E, Huddart R. Quality assuring "Plan of the day" selection in a multicentre adaptive bladder trial: Implementation of a pre-accrual IGRT guidance and assessment module. Clin Transl Radiat Oncol 2019; 19:27-32. [PMID: 31388568 PMCID: PMC6675972 DOI: 10.1016/j.ctro.2019.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Hypofractionated bladder RT with or without image guided adaptive planning (HYBRID) is a multicentre clinical trial investigating "Plan of the Day" (PoD) adaptive radiotherapy for bladder cancer. To ensure correct PoD selection a pre-accrual guidance and assessment module was developed as part of an image guided radiotherapy quality assurance (IGRT QA) credentialing programme. This study aimed to evaluate its feasibility and effectiveness across multiple recruiting centres. MATERIALS AND METHODS Individuals from participating centres remotely accessed an image database in order to complete the PoD module. An assessment score of ≥83% was required in order to receive QA approval. A questionnaire was used to gather user feedback on the module. PoD decisions for the first patient at each recruiting centre were retrospectively reviewed for protocol adherence. RESULTS 71 radiation therapists (RTTs) from 10 centres completed the PoD module. The median assessment score was 92% (Range: 58-100%) with 79% of RTTs passing the assessment on first attempt. All questionnaire respondents reported that the PoD module prepared them for plan selection. In 51/60 of on-trial treatments reviewed, the PoD selected by the centre agreed with QA reviewers. CONCLUSIONS The PoD QA module was successfully implemented in a multicentre trial and enabled pre-accrual assessment of protocol understanding. This increased operator confidence and resulted in appropriate PoD selection on-trial.
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Affiliation(s)
- Emma Patel
- Radiotherapy Physics Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yat Tsang
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Angela Baker
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Shaista Hafeez
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Vibeke Nordmark Hansen
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Helen McNair
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Robert Huddart
- Department of Radiotherapy and Imaging, The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Wilson C, Moseshvili E, Tacey M, Quin I, Lawrentschuk N, Bolton D, Joon DL, Chao M, Dunshea T, Kron T, Foroudi F. Assessment of Intrafraction Motion of the Urinary Bladder Using Magnetic Resonance Imaging (cineMRI). Clin Oncol (R Coll Radiol) 2019; 32:101-109. [PMID: 31607612 DOI: 10.1016/j.clon.2019.09.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/06/2019] [Accepted: 08/29/2019] [Indexed: 11/18/2022]
Abstract
AIM To assess the intrafraction motion of the urinary bladder and delineate the appropriate margin size for radiotherapy planning, for both the full and empty bladder. MATERIALS AND METHODS This was a single-site, single-arm study of 20 patients planned to undergo radical cystectomy for histologically confirmed muscle-invasive bladder cancer. Patients underwent magnetic resonance imaging (cineMRI) of the entire pelvis using a 3-Tesla system, prior to cystectomy. Patients first underwent a cineMRI with a full bladder, then voided and underwent a second MRI with an empty bladder. All MRI sequences were acquired over 18 min. We assessed the differences in bladder filling and subsequent bladder wall displacement, between the empty and full bladder, during a time period consistent with radiotherapy treatment delivery. RESULTS Twenty patients underwent cineMRI of the entire pelvis. The maximum mean directional displacements of the bladder walls over the 18 min duration of the scan for the empty bladders were 9.8 mm superiorly, 1.1 mm inferiorly, 2.39 mm anteriorly, 3.73 mm posteriorly, 2.74 mm to the left and 2.48 mm to the right. The maximal mean displacements for the full bladders were 9.2 mm superiorly, 1.1 mm inferiorly, 2.28 mm anteriorly, 1.08 mm posteriorly, 1.85 mm to the left and 1.73 mm to the right. Statistically significant differences were seen in the posterior, left and right displacements but were quantitatively small. CONCLUSIONS Intrafractional motion secondary to bladder filling showed minimal variation between the full and empty bladder. Similar clinical target volume to planning target volume margins can be applied for the delivery of radiotherapy for a full and empty bladder.
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Affiliation(s)
- C Wilson
- Austin Health, Heidelberg, Victoria, Australia.
| | | | - M Tacey
- Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - I Quin
- GenesisCare, Wembley, Western Australia, Australia
| | | | - D Bolton
- Austin Health, Heidelberg, Victoria, Australia
| | - D L Joon
- Austin Health, Heidelberg, Victoria, Australia
| | - M Chao
- Austin Health, Heidelberg, Victoria, Australia
| | - T Dunshea
- Austin Health, Heidelberg, Victoria, Australia; MIA Radiology, Heidelberg, Victoria, Australia
| | - T Kron
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Foroudi
- Austin Health, Heidelberg, Victoria, Australia
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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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Song YP, McWilliam A, Hoskin PJ, Choudhury A. Organ preservation in bladder cancer: an opportunity for truly personalized treatment. Nat Rev Urol 2019; 16:511-522. [PMID: 31197260 DOI: 10.1038/s41585-019-0199-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
Radical treatment of many solid tumours has moved from surgery to multimodal organ preservation strategies combining systemic and local treatments. Trimodality bladder-preserving treatment (TMT) comprises maximal transurethral resection of the bladder tumour followed by radiotherapy and concurrent radiosensitizing treatment, thereby sparing the urinary bladder. From the patient's perspective, the choice of maintaining quality of life without a negative effect on the chances of cure and long-term survival is attractive. In muscle-invasive bladder cancer (MIBC), the evidence shows comparable clinical outcomes between patients undergoing radical cystectomy and TMT. Despite this evidence, many patients continue to be offered radical surgery as the standard-of-care treatment. Improvements in radiotherapy techniques with adaptive radiotherapy and advances in imaging translate to increases in the accuracy of treatment delivery and reductions in long-term toxicities. With the advent of novel biomarkers promising improved prediction of treatment response, stratification of patients for different treatments on the basis of tumour biology could soon be a reality. The future of oncological treatment lies in personalized medicine with the combination of technological and biological advances leading to truly bespoke management for patients with MIBC.
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Affiliation(s)
- Yee Pei Song
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK. .,Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK.
| | - Alan McWilliam
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Peter J Hoskin
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Mount Vernon Cancer Centre, Northwood, Middlesex, United Kingdom
| | - Ananya Choudhury
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
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Green OL, Henke LE, Hugo GD. Practical Clinical Workflows for Online and Offline Adaptive Radiation Therapy. Semin Radiat Oncol 2019; 29:219-227. [PMID: 31027639 DOI: 10.1016/j.semradonc.2019.02.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adaptive radiotherapy emerged over 20 years ago and is now an established clinical practice in a number of organ sites. No one solution for adaptive therapy exists. Rather, adaptive radiotherapy is a process which combines multiple tools for imaging, assessment of need for adaptation, treatment planning, and quality assurance of this process. Workflow is therefore a critical aspect to ensure safe, effective, and efficient implementation of adaptive radiotherapy. In this work, we discuss the tools for online and offline adaptive radiotherapy and introduce workflow concepts for these types of adaptive radiotherapy. Common themes and differences between the workflows are introduced and controversies and areas of active research are discussed.
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Affiliation(s)
- Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Antico M, Prinsen P, Cellini F, Fracassi A, Isola AA, Cobben D, Fontanarosa D. Real-time adaptive planning method for radiotherapy treatment delivery for prostate cancer patients, based on a library of plans accounting for possible anatomy configuration changes. PLoS One 2019; 14:e0213002. [PMID: 30818345 PMCID: PMC6394960 DOI: 10.1371/journal.pone.0213002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE In prostate cancer treatment with external beam radiation therapy (EBRT), prostate motion and internal changes in tissue distribution can lead to a decrease in plan quality. In most currently used planning methods, the uncertainties due to prostate motion are compensated by irradiating a larger treatment volume. However, this could cause underdosage of the treatment volume and overdosage of the organs at risk (OARs). To reduce this problem, in this proof of principle study we developed and evaluated a novel adaptive planning method. The strategy proposed corrects the dose delivered by each beam according to the actual position of the target in order to produce a final dose distribution dosimetrically as similar as possible to the prescribed one. MATERIAL AND METHODS Our adaptive planning method was tested on a phantom case and on a clinical case. For the first, a pilot study was performed on an in-silico pelvic phantom. A "library" of intensity modulated RT (IMRT) plans corresponding to possible positions of the prostate during a treatment fraction was generated at planning stage. Then a 3D random walk model was used to simulate possible displacements of the prostate during the treatment fraction. At treatment stage, at the end of each beam, based on the current position of the target, the beam from the library of plans, which could reproduce the best approximation of the prescribed dose distribution, was selected and delivered. In the clinical case, the same approach was used on two prostate cancer patients: for the first a tissue deformation was simulated in-silico and for the second a cone beam CT (CBCT) taken during the treatment was used to simulate an intra-fraction change. Then, dosimetric comparisons with the standard treatment plan and, for the second patient, also with an isocenter shift correction, were performed. RESULTS For the phantom case, the plan generated using the adaptive planning method was able to meet all the dosimetric requirements and to correct for a misdosage of 13% of the dose prescription on the prostate. For the first clinical case, the standard planning method caused underdosage of the seminal vesicles, respectively by 5% and 4% of the prescribed dose, when the position changes for the target were correctly taken into account. The proposed adaptive planning method corrected any possible missed target coverage, reducing at the same time the dose on the OARs. For the second clinical case, both with the standard planning strategy and with the isocenter shift correction target coverage was significantly worsened (in particular uniformity) and some organs exceeded some toxicity objectives. While with our approach, the most uniform coverage for the target was produced and systematically the lowest toxicity values for the organs at risk were achieved. CONCLUSIONS In our proof of principle study, the adaptive planning method performed better than the standard planning and the isocenter shift methods for prostate EBRT. It improved the coverage of the treatment volumes and lowered the dose to the OARs. This planning method is particularly promising for hypofractionated IMRT treatments in which a higher precision and control on dose deposition are needed. Further studies will be performed to test more extensively the proposed adaptive planning method and to evaluate it at a full clinical level.
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Affiliation(s)
- Maria Antico
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, Queensland, Australia
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
- Delft University of Technology, Delft, The Netherlands
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - Peter Prinsen
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli, IRCCS—Università Cattolica Sacro Cuore, Roma, Italia
| | - Alice Fracassi
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
- University of Rome Tor Vergata, Rome, Italy
| | - Alfonso A. Isola
- Philips Research, Oncology Solutions Department, Eindhoven, The Netherlands
| | - David Cobben
- North West Cancer Centre, Altnagelvin Hospital, Derry-Londonderry, Northern Ireland
- The University of Manchester, Division of Cancer Studies, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Clinical Oncology, Manchester, United Kingdom
| | - Davide Fontanarosa
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
- School of Clinical Sciences, Queensland University of Technology, Gardens Point Campus, Brisbane, QLD, Australia
- * E-mail:
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Efficient and Effective Personalization of PTV Margins During Radiation Therapy for Bladder Cancer. J Med Imaging Radiat Sci 2018; 49:420-427. [DOI: 10.1016/j.jmir.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/20/2022]
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Kong V, Taylor A, Chung P, Rosewall T. Evaluation of resource burden for bladder adaptive strategies: A timing study. J Med Imaging Radiat Oncol 2018; 62:861-865. [DOI: 10.1111/1754-9485.12787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Vickie Kong
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
| | - Amy Taylor
- Sheffield Hallam University; Sheffield UK
| | - Peter Chung
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
| | - Tara Rosewall
- Radiation Medicine Program; Princess Margaret Cancer Centre Toronto Ontario Canada
- Department of Radiation Oncology; University of Toronto; Toronto Ontario Canada
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Pre-clinical experience of an adaptive plan library strategy in radiotherapy of rectal cancer: An inter-observer study. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 6:89-93. [PMID: 33458395 PMCID: PMC7807563 DOI: 10.1016/j.phro.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/28/2018] [Accepted: 06/01/2018] [Indexed: 12/14/2022]
Abstract
Background and purpose The clinical target volume (CTV) in radiotherapy of rectal cancer is subject to large deformations. With a plan library strategy, the treatment may be adapted to these deformations. The purpose of this study was to determine feasibility and consistency in plan selection for a plan library strategy in radiotherapy of rectal cancer. Material and methods Thirty rectal cancer patients were included in this retrospective study with in total 150 CBCT scans. A library of CTVs was constructed with in-house built software using population statistics on daily rectal deformations. The library consisted of five plans based on: the original CTV, two larger, and two smaller CTVs. An inter-observer study (study-I) was performed to test the consistency in plan choices between four observers (all RTTs). After five months the observers were asked to re-evaluate (study-II) the same set of scans based on refined guidelines. Results In study-I the observers reached accordance with the majority choice in 69% of cases. This improved to 87% in study-II. The consensus meeting revealed that inconsistency in choices mainly arose from inadequate instructions, which were later clarified and formulated more accurately. Conclusion Plan selection based on daily CBCT scans for rectal cancer patients is feasible, and can be performed consistently by well-trained RTTs.
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Collins SD, Leech MM. A review of plan library approaches in adaptive radiotherapy of bladder cancer. Acta Oncol 2018; 57:566-573. [PMID: 29299945 DOI: 10.1080/0284186x.2017.1420908] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Large variations in the shape and size of the bladder volume are commonly observed in bladder cancer radiotherapy (RT). The clinical target volume (CTV) is therefore frequently inadequately treated and large isotropic margins are inappropriate in terms of dose to organs at risk (OAR); thereby making adaptive radiotherapy (ART) attractive for this tumour site. There are various methods of ART delivery, however, for bladder cancer, plan libraries are frequently used. MATERIAL AND METHODS A review of published studies on plan libraries for bladder cancer using four databases (Pubmed, Science Direct, Embase and Cochrane Library) was conducted. The endpoints selected were accuracy and feasibility of initiation of a plan library strategy into a RT department. RESULTS Twenty-four articles were included in this review. The majority of studies reported improvement in accuracy with 10 studies showing an improvement in planning target volume (PTV) and CTV coverage with plan libraries, some by up to 24%. Seventeen studies showed a dose reduction to OARs, particularly the small bowel V45Gy, V40Gy, V30Gy and V10Gy, and the rectal V30Gy. However, the occurrence of no suitable plan was reported in six studies, with three studies showing no significant difference between adaptive and non-adaptive strategies in terms of target coverage. In addition, inter-observer variability in plan selection appears to remain problematic. The additional resources, education and technology required for the initiation of plan library selection for bladder cancer may hinder its routine clinical implementation, with eight studies illustrating increased treatment time required. CONCLUSIONS While there is a growing body of evidence in support of plan libraries for bladder RT, many studies differed in their delivery approach. The advent of the clinical use of the MRI-linear accelerator will provide RT departments with the opportunity to consider daily online adaption for bladder cancer as an alternate to plan library approaches.
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Affiliation(s)
- Shane D. Collins
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
| | - Michelle M. Leech
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
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Huddart RA, Birtle A, Maynard L, Beresford M, Blazeby J, Donovan J, Kelly JD, Kirkbank T, McLaren DB, Mead G, Moynihan C, Persad R, Scrase C, Lewis R, Hall E. Clinical and patient-reported outcomes of SPARE - a randomised feasibility study of selective bladder preservation versus radical cystectomy. BJU Int 2017; 120:639-650. [PMID: 28453896 PMCID: PMC5655733 DOI: 10.1111/bju.13900] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To test the feasibility of a randomised trial in muscle-invasive bladder cancer (MIBC) and compare outcomes in patients who receive neoadjuvant chemotherapy followed by radical cystectomy (RC) or selective bladder preservation (SBP), where definitive treatment [RC or radiotherapy (RT)] is determined by response to chemotherapy. PATIENTS AND METHODS SPARE is a multicentre randomised controlled trial comparing RC and SBP in patients with MIBC staged T2-3 N0 M0, fit for both treatment strategies and receiving three cycles of neoadjuvant chemotherapy. Patients were randomised between RC and SBP before a cystoscopy after cycle three of neoadjuvant chemotherapy. Patients with ≤T1 residual tumour received a fourth cycle of neoadjuvant chemotherapy in both groups, followed by radical RT in the SBP group and RC in in the RC group; non-responders in both groups proceeded immediately to RC following cycle three. Feasibility study primary endpoints were accrual rate and compliance with assigned treatment strategy. The phase III trial was designed to demonstrate non-inferiority of SBP in terms of overall survival (OS) in patients whose tumours responded to neoadjuvant chemotherapy. Secondary endpoints included patient-reported quality of life, clinician assessed toxicity, loco-regional recurrence-free survival, and rate of salvage RC after SBP. RESULTS Trial recruitment was challenging and below the predefined target with 45 patients recruited in 30 months (25 RC; 20 SBP). Non-compliance with assigned treatment strategy was frequent, six of the 25 patients (24%) randomised to RC received RT. Long-term bladder preservation rate was 11/15 (73%) in those who received RT per protocol. OS survival was not significantly different between groups. CONCLUSIONS Randomising patients with MIBC between RC and SBP based on response to neoadjuvant chemotherapy was not feasible in the UK health system. Strong clinician and patient preferences for treatments impacted willingness to undergo randomisation and acceptance of treatment allocation. Due to the few participants, firm conclusions about disease and toxicity outcomes cannot be drawn.
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Affiliation(s)
- Robert A. Huddart
- The Institute of Cancer ResearchLondonUK
- Royal Marsden NHS Foundation TrustLondonUK
| | - Alison Birtle
- Royal Preston HospitalPreston and University of ManchesterManchesterUK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Emma Hall
- The Institute of Cancer ResearchLondonUK
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The normal tissue sparing potential of an adaptive plan selection strategy for re-irradiation of recurrent rectal cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2017. [DOI: 10.1016/j.phro.2017.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Adaptive Radiotherapy for Bladder Cancer—A Systematic Review. J Med Imaging Radiat Sci 2017; 48:199-206. [DOI: 10.1016/j.jmir.2016.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/20/2022]
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Hafeez S, McDonald F, Lalondrelle S, McNair H, Warren-Oseni K, Jones K, Harris V, Taylor H, Khoo V, Thomas K, Hansen V, Dearnaley D, Horwich A, Huddart R. Clinical Outcomes of Image Guided Adaptive Hypofractionated Weekly Radiation Therapy for Bladder Cancer in Patients Unsuitable for Radical Treatment. Int J Radiat Oncol Biol Phys 2017; 98:115-122. [PMID: 28586948 PMCID: PMC5392498 DOI: 10.1016/j.ijrobp.2017.01.239] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/23/2017] [Accepted: 01/31/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE AND OBJECTIVES We report on the clinical outcomes of a phase 2 study assessing image guided hypofractionated weekly radiation therapy in bladder cancer patients unsuitable for radical treatment. METHODS AND MATERIALS Fifty-five patients with T2-T4aNx-2M0-1 bladder cancer not suitable for cystectomy or daily radiation therapy treatment were recruited. A "plan of the day" radiation therapy approach was used, treating the whole (empty) bladder to 36 Gy in 6 weekly fractions. Acute toxicity was assessed weekly during radiation therapy, at 6 and 12 weeks using the Common Terminology Criteria for Adverse Events version 3.0. Late toxicity was assessed at 6 months and 12 months using Radiation Therapy Oncology Group grading. Cystoscopy was used to assess local control at 3 months. Cumulative incidence function was used to determine local progression at 1 at 2 years. Death without local progression was treated as a competing risk. Overall survival was estimated using the Kaplan-Meier method. RESULTS Median age was 86 years (range, 68-97 years). Eighty-seven percent of patients completed their prescribed course of radiation therapy. Genitourinary and gastrointestinal grade 3 acute toxicity was seen in 18% (10/55) and 4% (2/55) of patients, respectively. No grade 4 genitourinary or gastrointestinal toxicity was seen. Grade ≥3 late toxicity (any) at 6 and 12 months was seen in 6.5% (2/31) and 4.3% (1/23) of patients, respectively. Local control after radiation therapy was 92% of assessed patients (60% total population). Cumulative incidence of local progression at 1 year and 2 years for all patients was 7% (95% confidence interval [CI] 2%-17%) and 17% (95% CI 8%-29%), respectively. Overall survival at 1 year was 63% (95% CI 48%-74%). CONCLUSION Hypofractionated radiation therapy delivered weekly with a plan of the day approach offers good local control with acceptable toxicity in a patient population not suitable for radical bladder treatment.
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MESH Headings
- Aged
- Aged, 80 and over
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Transitional Cell/mortality
- Carcinoma, Transitional Cell/pathology
- Carcinoma, Transitional Cell/radiotherapy
- Cystectomy
- Disease Progression
- Female
- Gastrointestinal Diseases/etiology
- Humans
- Kaplan-Meier Estimate
- Male
- Prospective Studies
- Radiation Dose Hypofractionation
- Radiation Injuries/pathology
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Image-Guided/adverse effects
- Radiotherapy, Image-Guided/methods
- Time Factors
- Treatment Outcome
- Urinary Bladder/radiation effects
- Urinary Bladder Neoplasms/mortality
- Urinary Bladder Neoplasms/pathology
- Urinary Bladder Neoplasms/radiotherapy
- Urination Disorders/etiology
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey.
| | | | | | - Helen McNair
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Karole Warren-Oseni
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Kelly Jones
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | | | | | | | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Vibeke Hansen
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - David Dearnaley
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Alan Horwich
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
| | - Robert Huddart
- The Institute of Cancer Research, London; The Royal Marsden NHS Foundation Trust, Sutton, Surrey
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Kim M, Phillips MH. A feasibility study of dynamic adaptive radiotherapy for nonsmall cell lung cancer. Med Phys 2017; 43:2153. [PMID: 27147327 DOI: 10.1118/1.4945023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The final state of the tumor at the end of a radiotherapy course is dependent on the doses given in each fraction during the treatment course. This study investigates the feasibility of using dynamic adaptive radiotherapy (DART) in treating lung cancers assuming CBCT is available to observe midtreatment tumor states. DART adapts treatment plans using a dynamic programming technique to consider the expected changes of the tumor in the optimization process. METHODS DART is constructed using a stochastic control formalism framework. It minimizes the total expected number of tumor cells at the end of a treatment course, which is equivalent to maximizing tumor control probability, subject to the uncertainty inherent in the tumor response. This formulation allows for nonstationary dose distributions as well as nonstationary fractional doses as needed to achieve a series of optimal plans that are conformal to the tumor over time, i.e., spatiotemporally optimal plans. Sixteen phantom cases with various sizes and locations of tumors and organs-at-risk (OAR) were generated using in-house software. Each case was planned with DART and conventional IMRT prescribing 60 Gy in 30 fractions. The observations of the change in the tumor volume over a treatment course were simulated using a two-level cell population model. Monte Carlo simulations of the treatment course for each case were run to account for uncertainty in the tumor response. The same OAR dose constraints were applied for both methods. The frequency of replanning was varied between 1, 2, 5 (weekly), and 29 times (daily). The final average tumor dose and OAR doses have been compared to quantify the potential dosimetric benefits of DART. RESULTS The average tumor max, min, mean, and D95 doses using DART relative to these using conventional IMRT were 124.0%-125.2%, 102.1%-114.7%, 113.7%-123.4%, and 102.0%-115.9% (range dependent on the frequency of replanning). The average relative maximum doses for the cord and esophagus, mean doses for the heart and lungs, and D05 for the unspecified tissue resulting 84%-102.4%, 99.8%-106.9%, 66.9%-85.6%, 58.2%-78.8%, and 85.2%-94.0%, respectively. CONCLUSIONS It is feasible to apply DART to the treatment of NSCLC using CBCT to observe the midtreatment tumor state. Potential increases in the tumor dose and reductions in the OAR dose, particularly for parallel OARs with mean or dose-volume constraints, could be achieved using DART compared to nonadaptive IMRT.
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Affiliation(s)
- Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington 98195-6043
| | - Mark H Phillips
- Departments of Radiation Oncology and Neurological Surgery, University of Washington, Seattle, Washington 98195-6043
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Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
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Lutkenhaus LJ, Vestergaard A, Bel A, Høyer M, Hulshof MCCM, van Leeuwen CM, Casares-Magaz O, Petersen JB, Søndergaard J, Muren LP. A biological modeling based comparison of two strategies for adaptive radiotherapy of urinary bladder cancer. Acta Oncol 2016; 55:1009-15. [PMID: 27100215 DOI: 10.3109/0284186x.2016.1151548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Adaptive radiotherapy is introduced in the management of urinary bladder cancer to account for day-to-day anatomical changes. The purpose of this study was to determine whether an adaptive plan selection strategy using either the first four cone beam computed tomography scans (CBCT-based strategy) for plan creation, or the interpolation of bladder volumes on pretreatment CT scans (CT-based strategy), is better in terms of tumor control probability (TCP) and normal tissue sparing while taking the clinically applied fractionation schedules also into account. Material and methods With the CT-based strategy, a library of five plans was created. Patients received 55 Gy to the bladder tumor and 40 Gy to the non-involved bladder and lymph nodes, in 20 fractions. With the CBCT-based strategy, a library of three plans was created, and patients received 70 Gy to the tumor, 60 Gy to the bladder and 48 Gy to the lymph nodes, in 30-35 fractions. Ten patients were analyzed for each adaptive plan selection strategy. TCP was calculated applying the clinically used fractionation schedules, as well as a rescaling of the dose from 55 to 70 Gy for the CT-based strategy. For rectum and bowel, equivalent doses in 2 Gy fractions (EQD2) were calculated. Results The CBCT-based strategy resulted in a median TCP of 75%, compared to 49% for the CT-based strategy, the latter improving to 72% upon rescaling the dose to 70 Gy. A median rectum V30Gy (EQD2) of 26% [interquartile range (IQR): 8-52%] was found for the CT-based strategy, compared to 58% (IQR: 55-73%) for the CBCT-based strategy. Also the bowel doses were lower with the CT-based strategy. Conclusions Whereas the higher total bladder TCP for the CBCT-based strategy is due to prescription differences, the adaptive strategy based on CT scans results in the lowest rectum and bowel cavity doses.
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Affiliation(s)
- L. J. Lutkenhaus
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - A. Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - A. Bel
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - M. Høyer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M. C. C. M. Hulshof
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - C. M. van Leeuwen
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - O. Casares-Magaz
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - J. B. Petersen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - J. Søndergaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - L. P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Thörnqvist S, Hysing LB, Tuomikoski L, Vestergaard A, Tanderup K, Muren LP, Heijmen BJM. Adaptive radiotherapy strategies for pelvic tumors - a systematic review of clinical implementations. Acta Oncol 2016; 55:943-58. [PMID: 27055486 DOI: 10.3109/0284186x.2016.1156738] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Introdution: Variation in shape, position and treatment response of both tumor and organs at risk are major challenges for accurate dose delivery in radiotherapy. Adaptive radiotherapy (ART) has been proposed to customize the treatment to these motion/response patterns of the individual patients, but increases workload and thereby challenges clinical implementation. This paper reviews strategies and workflows for clinical and in silico implemented ART for prostate, bladder, gynecological (gyne) and ano-rectal cancers. MATERIAL AND METHODS Initial identification of papers was based on searches in PubMed. For each tumor site, the identified papers were screened independently by two researches for selection of studies describing all processes of an ART workflow: treatment monitoring and evaluation, decision and execution of adaptations. Both brachytherapy and external beam studies were eligible for review. RESULTS The review consisted of 43 clinical studies and 51 in silico studies. For prostate, 1219 patients were treated with offline re-planning, mainly to adapt prostate motion relative to bony anatomy. For gyne 1155 patients were treated with online brachytherapy re-planning while 25 ano-rectal cancer patients were treated with offline re-planning, all to account for tumor regression detected by magnetic resonance imaging (MRI)/computed tomography (CT). For bladder and gyne, 161 and 64 patients, respectively, were treated with library-based online plan selection to account for target volume and shape variations. The studies reported sparing of rectum (prostate and bladder cancer), bladder (ano-rectal cancer) and bowel cavity (gyne and bladder cancer) as compared to non-ART. CONCLUSION Implementations of ART were dominated by offline re-planning and online brachytherapy re-planning strategies, although recently online plan selection workflows have increased with the availability of cone-beam CT. Advantageous dosimetric and outcome patterns using ART was documented by the studies of this review. Despite this, clinical implementations were scarce due to challenges in target/organ re-contouring and suboptimal patient selection in the ART workflows.
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Affiliation(s)
- Sara Thörnqvist
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Thing RS, Bernchou U, Mainegra-Hing E, Hansen O, Brink C. Hounsfield unit recovery in clinical cone beam CT images of the thorax acquired for image guided radiation therapy. Phys Med Biol 2016; 61:5781-802. [DOI: 10.1088/0031-9155/61/15/5781] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Potential dosimetric benefit of an adaptive plan selection strategy for short-course radiotherapy in rectal cancer patients. Radiother Oncol 2016; 119:525-30. [DOI: 10.1016/j.radonc.2016.04.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 11/20/2022]
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Hafeez S, Warren-Oseni K, McNair HA, Hansen VN, Jones K, Tan M, Khan A, Harris V, McDonald F, Lalondrelle S, Mohammed K, Thomas K, Thompson A, Kumar P, Dearnaley D, Horwich A, Huddart R. Prospective Study Delivering Simultaneous Integrated High-dose Tumor Boost (≤70 Gy) With Image Guided Adaptive Radiation Therapy for Radical Treatment of Localized Muscle-Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2016; 94:1022-30. [PMID: 27026308 DOI: 10.1016/j.ijrobp.2015.12.379] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Image guided adaptive radiation therapy offers individualized solutions to improve target coverage and reduce normal tissue irradiation, allowing the opportunity to increase the radiation tumor dose and spare normal bladder tissue. METHODS AND MATERIALS A library of 3 intensity modulated radiation therapy plans were created (small, medium, and large) from planning computed tomography (CT) scans performed at 30 and 60 minutes; treating the whole bladder to 52 Gy and the tumor to 70 Gy in 32 fractions. A "plan of the day" approach was used for treatment delivery. A post-treatment cone beam CT (CBCT) scan was acquired weekly to assess intrafraction filling and coverage. RESULTS A total of 18 patients completed treatment to 70 Gy. The plan and treatment for 1 patient was to 68 Gy. Also, 1 patient's plan was to 70 Gy but the patient was treated to a total dose of 65.6 Gy because dose-limiting toxicity occurred before dose escalation. A total of 734 CBCT scans were evaluated. Small, medium, and large plans were used in 36%, 48%, and 16% of cases, respectively. The mean ± standard deviation rate of intrafraction filling at the start of treatment (ie, week 1) was 4.0 ± 4.8 mL/min (range 0.1-19.4) and at end of radiation therapy (ie, week 5 or 6) was 1.1 ± 1.6 mL/min (range 0.01-7.5; P=.002). The mean D98 (dose received by 98% volume) of the tumor boost and bladder as assessed on the post-treatment CBCT scan was 97.07% ± 2.10% (range 89.0%-104%) and 99.97% ± 2.62% (range 96.4%-112.0%). At a median follow-up period of 19 months (range 4-33), no muscle-invasive recurrences had developed. Two patients experienced late toxicity (both grade 3 cystitis) at 5.3 months (now resolved) and 18 months after radiation therapy. CONCLUSIONS Image guided adaptive radiation therapy using intensity modulated radiation therapy to deliver a simultaneous integrated tumor boost to 70 Gy is feasible, with acceptable toxicity, and will be evaluated in a randomized trial.
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Affiliation(s)
- Shaista Hafeez
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom.
| | - Karole Warren-Oseni
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Helen A McNair
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Vibeke N Hansen
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kelly Jones
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Melissa Tan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Attia Khan
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Victoria Harris
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Kabir Mohammed
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Thompson
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Pardeep Kumar
- The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - David Dearnaley
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Alan Horwich
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Robert Huddart
- The Institute of Cancer Research, London, United Kingdom; The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
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Lutkenhaus LJ, van Os RM, Bel A, Hulshof MCCM. Clinical results of conformal versus intensity-modulated radiotherapy using a focal simultaneous boost for muscle-invasive bladder cancer in elderly or medically unfit patients. Radiat Oncol 2016; 11:45. [PMID: 26993980 PMCID: PMC4797227 DOI: 10.1186/s13014-016-0618-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For elderly or medically unfit patients with muscle-invasive bladder cancer, cystectomy or chemotherapy are contraindicated. This leaves radical radiotherapy as the only treatment option. It was the aim of this study to retrospectively analyze the treatment outcome and associated toxicity of conformal versus intensity-modulated radiotherapy (IMRT) using a focal simultaneous tumor boost for muscle-invasive bladder cancer in patients not suitable for cystectomy. METHODS One hundred eighteen patients with T2-4 N0-1 M0 bladder cancer were analyzed retrospectively. Median age was 80 years. Treatment consisted of either a conformal box technique or IMRT and included a simultaneous boost to the tumor. To enable an accurate boost delivery, fiducial markers were placed around the tumor. Patients were treated with 40 Gy in 20 fractions to the elective treatment volumes, and a daily tumor boost up to 55-60 Gy. RESULTS Clinical complete response was seen in 87 % of patients. Three-year overall survival was 44 %, with a locoregional control rate of 73 % at 3 years. Toxicity was low, with late urinary and intestinal toxicity rates grade ≥ 2 of 14 and 5 %, respectively. The use of IMRT reduced late intestinal toxicity, whereas fiducial markers reduced acute urinary toxicity. CONCLUSIONS Radical radiotherapy using a focal boost is feasible and effective for elderly or unfit patients, with a 3-year locoregional control of 73 %. Toxicity rates were low, and were reduced by the use of IMRT and fiducial markers.
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Affiliation(s)
- Lotte J Lutkenhaus
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Rob M van Os
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Vestergaard A, Hafeez S, Muren LP, Nill S, Høyer M, Hansen VN, Grønborg C, Pedersen EM, Petersen JB, Huddart R, Oelfke U. The potential of MRI-guided online adaptive re-optimisation in radiotherapy of urinary bladder cancer. Radiother Oncol 2016; 118:154-9. [PMID: 26631646 DOI: 10.1016/j.radonc.2015.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Adaptive radiotherapy (ART) using plan selection is being introduced clinically for bladder cancer, but the challenge of how to compensate for intra-fractional motion remains. The purpose of this study was to assess target coverage with respect to intra-fractional motion and the potential for normal tissue sparing in MRI-guided ART (MRIGART) using isotropic (MRIGARTiso), an-isotropic (MRIGARTanIso) and population-based margins (MRIGARTpop). MATERIALS AND METHODS Nine bladder cancer patients treated in a phase II trial of plan selection underwent 6-7 weekly repeat MRI series, each with volumetric scans acquired over a 10 min period. Adaptive re-planning on the 0 min MRI scans was performed using density override, simulating a hypo-fractionated schedule. Target coverage was evaluated on the 10 min scan to quantify the impact of intra-fractional motion. RESULTS MRIGARTanIso reduced the course-averaged PTV by median 304 cc compared to plan selection. Bladder shifts affected target coverage in individual fractions for all strategies. Two patients had a v95% of the bladder below 98% for MRIGARTiso. MRIGARTiso decreased the bowel V25 with 15-46 cc compared to MRIGARTpop. CONCLUSION Online re-optimised ART has a considerable normal tissue sparing potential. MRIGART with online corrections for target shift during a treatment fraction should be considered in ART for bladder cancer.
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Affiliation(s)
- Anne Vestergaard
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark; Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Shaista Hafeez
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Ludvig P Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Simeon Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Morten Høyer
- Department of Oncology, AarhusUniversity/Aarhus University Hospital, Denmark
| | - Vibeke N Hansen
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Caroline Grønborg
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Erik M Pedersen
- Department of Radiology, Aarhus University/Aarhus University Hospital, Denmark
| | - Jørgen B Petersen
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Robert Huddart
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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46
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A comparison between two clinically applied plan library strategies in adaptive radiotherapy of bladder cancer. Radiother Oncol 2015; 117:448-52. [DOI: 10.1016/j.radonc.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/28/2015] [Accepted: 10/09/2015] [Indexed: 11/18/2022]
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47
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Henriques de Figueiredo B, Petit A, Sargos P, Kantor G, Pouypoudat C, Saut O, Zacharatou C, Antoine M. Radiothérapie adaptative en routine : point de vue de l’oncologue radiothérapeute. Cancer Radiother 2015; 19:446-9. [DOI: 10.1016/j.canrad.2015.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
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48
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Bonnes pratiques de radiothérapie guidée par l’image. Cancer Radiother 2015; 19:489-500. [DOI: 10.1016/j.canrad.2015.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/16/2015] [Indexed: 11/22/2022]
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Grau C, Overgaard J, Høyer M, Tanderup K, Lindegaard JC, Muren LP. Biology-guided adaptive radiotherapy (BiGART) is progressing towards clinical reality. Acta Oncol 2015; 54:1245-50. [PMID: 26390238 DOI: 10.3109/0284186x.2015.1076992] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Cai Grau
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Jens Overgaard
- b Department of Experimental Clinical Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Morten Høyer
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Kari Tanderup
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
| | | | - Ludvig Paul Muren
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
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Grønborg C, Vestergaard A, Høyer M, Söhn M, Pedersen EM, Petersen JB, Agerbæk M, Muren LP. Intra-fractional bladder motion and margins in adaptive radiotherapy for urinary bladder cancer. Acta Oncol 2015; 54:1461-6. [PMID: 26313410 DOI: 10.3109/0284186x.2015.1062138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The bladder is a tumour site well suited for adaptive radiotherapy (ART) due to large inter-fractional changes, but it also displays considerable intra-fractional motion. The aim of this study was to assess target coverage with a clinically applied method for plan selection ART and to estimate population-based and patient-specific intra-fractional margins, also relevant for a future re-optimisation strategy. MATERIAL AND METHODS Nine patients treated in a clinical phase II ART trial of daily plan selection for bladder cancer were included. In the library plans, 5 mm isotropic margins were added to account for intra-fractional changes. Pre-treatment and weekly repeat magnetic resonance imaging (MRI) series were acquired in which a full three-dimensional (3D) volume was scanned every second min for 10 min (a total of 366 scans in 61 series). Initially, the bladder clinical target volume (CTV) was delineated in all scans. The t = 0 min scan was then rigidly registered to the planning computed tomography (CT) and plan selections were simulated using the CTV_0 (at t = 0 min). To assess intra-fractional motion, coverage of the CTV_10 (at t = 10 min) was quantified using the applied PTV. Population-based margins were calculated using the van Herk margin recipe while patient-specific margins were calculated using a linear model. RESULTS For 49% of the cases, the CTV_10 extended more than 5 mm outside the CTV_0. However, in 58 of the 61 cases (97%) CTV_10 was covered by the selected PTV. Population-based margins of 14 mm Sup/Ant, 9 mm Post and 5 mm Inf/Lat were sufficient to cover the bladder. Using patient-specific margins, the overlap between PTV and bowel-cavity was reduced from 137 cm(3) with the plan selection strategy to 24 cm(3). CONCLUSION In this phase II ART trial, 5 mm isotropic margin for intra-fractional motion was sufficient even though considerable intra-fractional motion was observed. In online re-optimised ART, population-based margin can be applied although patient-specific margins are preferable.
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Affiliation(s)
- Caroline Grønborg
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Anne Vestergaard
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Morten Høyer
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Matthias Söhn
- c Department of Radiation Oncology , University Hospital Grosshadern , LMU Munich, Munich , Germany
| | - Erik M Pedersen
- d Department of Radiology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Jørgen B Petersen
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Mads Agerbæk
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Ludvig P Muren
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
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