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Polizzi M, Weiss E, Jan N, Ricco A, Kim S, Urdaneta A, Rosu‐Bubulac M. Rectal deformation management with IGRT in prostate radiotherapy: Can it be managed with rigid alignment alone? J Appl Clin Med Phys 2024; 25:e14241. [PMID: 38193605 PMCID: PMC11005986 DOI: 10.1002/acm2.14241] [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: 02/01/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 01/10/2024] Open
Abstract
PURPOSE It is challenging to achieve appropriate target coverage of the prostate with Image Guided Radiation Therapy (IGRT) while simultaneously constraining rectal doses within planned values when there is significant variability in rectal filling and shape. We investigated if rectum planning goals can be fulfilled using rigid CBCT-based on-board alignment to account for interfraction rectal deformations. METHODS Delivered rectal doses corresponding to prostate alignment ("PR") and anterior rectum alignment ("AR") for 239 daily treatments from 13 patients are reported. Rectal doses were estimated by rigidly mapping the planned dose on the daily CT derived from the daily CBCT according to respective alignment shifts. Rectum V95% (rV95%) was used for analyses. RESULTS Compared to "PR", "AR" alignment increased rV95% for an average of 34.4% across all patients. rV95% (cc) averaged over all fractions was significant from planning values for 10/13 patients for "PR" and for 9/13 for "AR". 3/13 patients had reproducible anatomy. Of patients with non-reproducible anatomy, three had dosimetrically more favorable, while seven had less favorable anatomies. Most shift differences (82.3%) between the "PR" and "AR" alignments larger than 2 mm resulted in rV95% changes larger than 2 cc. Most shift differences (82.2%) of 2 mm or less between the "PR" and "AR" alignments resulted in rV95% changes less than 2 cc. The average percentage of fractions among patients in which anterior or posterior shifts for "AR" and "PR" alignment was larger than the PTV margins was 9.1% (0.0%-37.5%) and 1.3% (0%-10%). CONCLUSION Rectal deformation and subsequent inconsistent interfraction separation between prostate and rectal wall translate into anatomical changes that cannot always be mitigated with rigid alignment. If systematic differences exist due to a non-reproducible planning anatomy, attempts to restore the planned rectal doses through anterior rectum alignment produce rather small improvements and may result in unacceptable target underdosage.
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Affiliation(s)
- Mitchell Polizzi
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Elisabeth Weiss
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Nuzhat Jan
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Anthony Ricco
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Siyong Kim
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Alfredo Urdaneta
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Mihaela Rosu‐Bubulac
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Alexander S, Oelfke U, Westley R, McNair H, Tree A. Prostate cancer image guided radiotherapy: Why the commotion over rectal volume and motion? Clin Transl Radiat Oncol 2023; 43:100685. [PMID: 37842073 PMCID: PMC10570575 DOI: 10.1016/j.ctro.2023.100685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Distended rectums on pre-radiotherapy scans are historically associated with poorer outcomes in patients treated with two-dimensional IGRT. Subsequently, strict rectal tolerances and preparation regimes were implemented. Contemporary IGRT, daily online registration to the prostate, corrects interfraction motion but intrafraction motion remains. We re-examine the need for rectal management strategies when using contemporary IGRT by quantifying rectal volume and its effect on intrafraction motion. Materials and methods Pre and during radiotherapy rectal volumes and intrafraction motion were retrospectively calculated for 20 patients treated in 5-fractions and 20 treated in 20-fractions. Small (rectal volume at planning-CT ≤ median), and large (volume > median) subgroups were formed, and rectal volume between timepoints and subgroups compared. Rectal volume and intrafraction motion correlation was examined using Spearman's rho. Intrafraction motion difference between small and large subgroups and between fractions with rectal volume < or ≥ 90 cm3 were assessed. Results Median rectal volume was 74 cm3, 64 cm3 and 65 cm3 on diagnostic-MRI, planning-CT and treatment imaging respectively (ns). No significant correlation was found between patient's rectal volume at planning-CT and median intrafraction motion, nor treatment rectal volume and intrafraction motion for individual fractions. No significant difference in intrafraction motion between small and large subgroups presented and for fractions where rectal volume breached 90 cm3, motion during that fraction was not significantly greater. Conclusion Larger rectal volumes before radiotherapy and during treatment did not cause greater intrafraction motion. Findings support the relaxation of strict rectal diameter tolerances and do not support the need for rectal preparation when delivering contemporary IGRT to the prostate.
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Affiliation(s)
- S.E. Alexander
- The Royal Marsden NHS Foundation Trust, United Kingdom and The Institute of Cancer Research, United Kingdom
| | - U. Oelfke
- The Joint Department of Physics, the Royal Marsden Hospital and the Institute of Cancer Research, United Kingdom
| | - R. Westley
- The Royal Marsden NHS Foundation Trust, United Kingdom and The Institute of Cancer Research, United Kingdom
| | - H.A. McNair
- The Royal Marsden NHS Foundation Trust, United Kingdom and The Institute of Cancer Research, United Kingdom
| | - A.C. Tree
- The Royal Marsden NHS Foundation Trust, United Kingdom and The Institute of Cancer Research, United Kingdom
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3
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Qiu Z, Olberg S, den Hertog D, Ajdari A, Bortfeld T, Pursley J. Online adaptive planning methods for intensity-modulated radiotherapy. Phys Med Biol 2023; 68:10.1088/1361-6560/accdb2. [PMID: 37068488 PMCID: PMC10637515 DOI: 10.1088/1361-6560/accdb2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/17/2023] [Indexed: 04/19/2023]
Abstract
Online adaptive radiation therapy aims at adapting a patient's treatment plan to their current anatomy to account for inter-fraction variations before daily treatment delivery. As this process needs to be accomplished while the patient is immobilized on the treatment couch, it requires time-efficient adaptive planning methods to generate a quality daily treatment plan rapidly. The conventional planning methods do not meet the time requirement of online adaptive radiation therapy because they often involve excessive human intervention, significantly prolonging the planning phase. This article reviews the planning strategies employed by current commercial online adaptive radiation therapy systems, research on online adaptive planning, and artificial intelligence's potential application to online adaptive planning.
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Affiliation(s)
- Zihang Qiu
- Department of Business Analytics, University of Amsterdam, The Netherlands
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Sven Olberg
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Dick den Hertog
- Department of Business Analytics, University of Amsterdam, The Netherlands
| | - Ali Ajdari
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
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Robbins J, van Herk M, Eiben B, Green A, Vásquez Osorio E. Probabilistic evaluation of plan quality for time-dependent anatomical deformations in head and neck cancer patients. Phys Med 2023; 109:102579. [PMID: 37068428 DOI: 10.1016/j.ejmp.2023.102579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/14/2023] [Accepted: 04/05/2023] [Indexed: 04/19/2023] Open
Abstract
PURPOSE In addition to patient set-up uncertainties, anatomical deformations, e.g., weight loss, lead to time-dependent differences between the planned and delivered dose in a radiotherapy course that currently cannot easily be predicted. The aim of this study was to create time-varying prediction models to describe both the average and residual anatomical deformations. METHODS Weekly population-based principal component analysis models were generated from on-treatment cone-beam CT scans (CBCTs) of 30 head and neck cancer patients, with additional data of 35 patients used as a validation cohort. We simulated treatment courses accounting for a) anatomical deformations, b) set-up uncertainties and c) a combination of both. The dosimetric effects of the simulated deformations were compared to a direct dose accumulation based on deformable registration of the CBCT data. RESULTS Set-up uncertainties were seen to have a larger effect on the organ at risk (OAR) doses than anatomical deformations for all OARs except the larynx and the primary CTV. Distributions from simulation results were in good agreement with those of the accumulated dose. CONCLUSIONS We present a novel method of modelling time-varying organ deformations in head and neck cancer. The effect on the OAR doses from these deformations are smaller than the effect of set-up uncertainties for most OARs. These models can, for instance, be used to predict which patients could benefit from adaptive radiotherapy, prior to commencing treatment.
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Affiliation(s)
- Jennifer Robbins
- The University of Manchester, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom.
| | - Marcel van Herk
- The University of Manchester, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
| | - Björn Eiben
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom; Centre for Medical Image Computing, Radiotherapy Image Computing Group, Department of Medical Physics and Biomedical Engineering University College London, London, United Kingdom
| | - Andrew Green
- The University of Manchester, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
| | - Eliana Vásquez Osorio
- The University of Manchester, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom.
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5
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Shinde P, Jadhav A, Shankar V, Dhoble SJ. Evaluation of the dosimetric influence of interfractional 6D setup error in hypofractionated prostate cancer treated with IMRT and VMAT using daily kV-CBCT. J Med Imaging Radiat Sci 2022; 53:693-703. [PMID: 36289030 DOI: 10.1016/j.jmir.2022.09.026] [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: 05/04/2022] [Revised: 09/01/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Prostate cancer is one of the most common malignant tumors in men and is usually treated with advanced intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). Significant uncorrected interfractional 6-Dimensional setup errors could impact the delivered dose. The aim of this study was to assess the dosimetric impact of 6D interfractional setup errors in hypofractionated prostate cancer using daily kilovoltage cone-beam computed tomography (kV-CBCT). METHODS This retrospective study comprised twenty prostate cancer patients treated with hypofractionated IMRT (8) and VMAT (12) with daily kV-CBCT image guidance. Interfraction 6D setup errors along lateral, longitudinal, vertical, pitch, roll, and yaw axes were evaluated for 400 CBCTs. For targets and organs at risk (OARs), the dosimetric impact of rotational error (RError), translational error (TError), and translational plus rotational error (T+RError) were evaluated on kV-CBCT images. RESULTS The single fraction maximum TError ranged from 12-20 mm, and the RError ranged from 2.80-3.00. The maximum mean absolute dose variation ΔD in D98% (dose to 98% volume) of CTV-55 and PTV-55 was -0.66±0.82 and -5.94±3.8 Gy, respectively, in the T+RError. The maximum ΔD (%) for D98% and D0.035cc in CTV-55 was -4.29% and 2.49%, respectively, while in PTV-55 it was -24.9% and 2.36%. The mean dose reduction for D98% in CTV-55 and D98% and D95% in PTV-55 was statistically significant (p<0.05) for TError and T+RError. The mean dose variation for Dmean and D50% in the rectum was statistically significant (p<0.05) for TError and T+RError. CONCLUSION The uncorrected interfractional 6D setup error results in significant target underdosing and OAR overdosing in prostate cancer. This emphasizes the need to correct interfractional 6D setup errors daily in IMRT and VMAT.
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Affiliation(s)
| | - Anand Jadhav
- Department of Radiation Oncology, Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, 400004, India
| | - V Shankar
- Department of Radiation Oncology, Apollo Cancer Center, Chennai, 600035, India
| | - S J Dhoble
- Department of Physics, R. T. M. Nagpur University, Nagpur, 440033, India
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Ong A, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Master Z, Wright C. Application of an automated dose accumulation workflow in high-risk prostate cancer - validation and dose-volume analysis between planned and delivered dose. Med Dosim 2021; 47:92-97. [PMID: 34740517 DOI: 10.1016/j.meddos.2021.09.004] [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: 05/21/2021] [Revised: 07/28/2021] [Accepted: 09/09/2021] [Indexed: 10/19/2022]
Abstract
Inter-fraction organ variations cause deviations between planned and delivered doses in patients receiving radiotherapy for prostate cancer. This study compared planned (DP) vs accumulated doses (DA) obtained from daily cone-beam computed tomography (CBCT) scans in high-risk- prostate cancer with pelvic lymph nodes irradiation. An intensity-based deformable image registration algorithm used to estimate contours for DA was validated using geometrical agreement between radiation oncologist's and deformable image registration algorithm propagated contours. Spearman rank correlations (rs) between geometric measures and changes in organ volumes were evaluated for 20 cases. Dose-volume (DV) differences between DA and DP were compared (Wilcoxon rank test, p < 0.05). A novel region-of-interest (ROI) method was developed and mean doses were analyzed. Geometrical measures for the prostate and organ-at-risk contours were within clinically acceptable criteria. Inter-group mean (± SD) CBCT volumes for the rectum were larger compared to planning CT (pCT) (51.1 ± 11.3 cm3vs 46.6 ± 16.1 cm3), and were moderately correlated with variations in pCT volumes, rs = 0.663, p < 0.01. Mean rectum DV for DA was higher at V30-40 Gy and lower at V70-75 Gy, p < 0.05. Mean bladder CBCT volumes were smaller compared to pCT (198.8 ± 55 cm3vs 211.5 ± 89.1 cm3), and was moderately correlated with pCT volumes, rs = 0.789, p < 0.01. Bladder DA was higher at V30-65 Gy and lower at V70-75 Gy (p < 0.05). For the ROI method, rectum and bladder DA were lower at 5 to 10 mm (p < 0.01) as compared to DP, whilst bladder DA was higher than DP at 20 to 50 mm (p < 0.01). Generated DA demonstrated significant differences in organ-at-risk doses as compared to DP. A well-constructed workflow incorporating a ROI DV-extraction method has been validated in terms of efficiency and accuracy designed for seamless integration in the clinic to guide future plan adaptation.
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Affiliation(s)
- Ashley Ong
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore; Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia.
| | - Kellie Knight
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | - Vanessa Panettieri
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia; Alfred Hospital, Alfred Health Radiation Oncology, Melbourne, Australia
| | - Mathew Dimmock
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | | | - Hong Qi Tan
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Zubin Master
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Caroline Wright
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
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7
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Tamihardja J, Cirsi S, Kessler P, Razinskas G, Exner F, Richter A, Polat B, Flentje M. Cone beam CT-based dose accumulation and analysis of delivered dose to the dominant intraprostatic lesion in primary radiotherapy of prostate cancer. Radiat Oncol 2021; 16:205. [PMID: 34702305 PMCID: PMC8549146 DOI: 10.1186/s13014-021-01933-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Evaluation of delivered dose to the dominant intraprostatic lesion (DIL) for moderately hypofractionated radiotherapy of prostate cancer by cone beam computed tomography (CBCT)-based dose accumulation and target coverage analysis. Methods Twenty-three patients with localized prostate cancer treated with moderately hypofractionated prostate radiotherapy with simultaneous integrated boost (SIB) between December 2016 and February 2020 were retrospectively analyzed. Included patients were required to have an identifiable DIL on bi-parametric planning magnetic resonance imaging (MRI). After import into the RayStation treatment planning system and application of a step-wise density override, the fractional doses were computed on each CBCT and were consecutively mapped onto the planning CT via a deformation vector field derived from deformable image registration. Fractional doses were accumulated for all CBCTs and interpolated for missing CBCTs, resulting in the delivered dose for PTVDIL, PTVBoost, PTV, and the organs at risk. The location of the index lesions was recorded according to the sector map of the Prostate Imaging Reporting and Data System (PIRADS) Version 2.1. Target coverage of the index lesions was evaluated and stratified for location. Results In total, 338 CBCTs were available for analysis. Dose accumulation target coverage of PTVDIL, PTVBoost, and PTV was excellent and no cases of underdosage in DMean, D95%, D02%, and D98% could be detected. Delivered rectum DMean did not significantly differ from the planned dose. Bladder mean DMean was higher than planned with 19.4 ± 7.4 Gy versus 18.8 ± 7.5 Gy, p < 0.001. The penile bulb showed a decreased delivered mean DMean with 29.1 ± 14.0 Gy versus 29.8 ± 14.4 Gy, p < 0.001. Dorsal DILs, defined as DILs in the posterior medial peripheral zone of the prostate, showed a significantly lower delivered dose with a mean DMean difference of 2.2 Gy (95% CI 1.3–3.1 Gy, p < 0.001) compared to ventral lesions. Conclusions CBCT-based dose accumulation showed an adequate delivered dose to the dominant intraprostatic lesion and organs at risk within planning limits. Cautious evaluation of the target coverage for index lesions adjacent to the rectum is warranted to avoid underdosage.
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Affiliation(s)
- Jörg Tamihardja
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Sinan Cirsi
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Patrick Kessler
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Gary Razinskas
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Florian Exner
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Anne Richter
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
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8
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Eckl M, Sarria GR, Springer S, Willam M, Ruder AM, Steil V, Ehmann M, Wenz F, Fleckenstein J. Dosimetric benefits of daily treatment plan adaptation for prostate cancer stereotactic body radiotherapy. Radiat Oncol 2021; 16:145. [PMID: 34348765 PMCID: PMC8335467 DOI: 10.1186/s13014-021-01872-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/27/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hypofractionation is increasingly being applied in radiotherapy for prostate cancer, requiring higher accuracy of daily treatment deliveries than in conventional image-guided radiotherapy (IGRT). Different adaptive radiotherapy (ART) strategies were evaluated with regard to dosimetric benefits. METHODS Treatments plans for 32 patients were retrospectively generated and analyzed according to the PACE-C trial treatment scheme (40 Gy in 5 fractions). Using a previously trained cycle-generative adversarial network algorithm, synthetic CT (sCT) were generated out of five daily cone-beam CT. Dose calculation on sCT was performed for four different adaptation approaches: IGRT without adaptation, adaptation via segment aperture morphing (SAM) and segment weight optimization (ART1) or additional shape optimization (ART2) as well as a full re-optimization (ART3). Dose distributions were evaluated regarding dose-volume parameters and a penalty score. RESULTS Compared to the IGRT approach, the ART1, ART2 and ART3 approaches substantially reduced the V37Gy(bladder) and V36Gy(rectum) from a mean of 7.4cm3 and 2.0cm3 to (5.9cm3, 6.1cm3, 5.2cm3) as well as to (1.4cm3, 1.4cm3, 1.0cm3), respectively. Plan adaptation required on average 2.6 min for the ART1 approach and yielded doses to the rectum being insignificantly different from the ART2 approach. Based on an accumulation over the total patient collective, a penalty score revealed dosimetric violations reduced by 79.2%, 75.7% and 93.2% through adaptation. CONCLUSION Treatment plan adaptation was demonstrated to adequately restore relevant dose criteria on a daily basis. While for SAM adaptation approaches dosimetric benefits were realized through ensuring sufficient target coverage, a full re-optimization mainly improved OAR sparing which helps to guide the decision of when to apply which adaptation strategy.
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Affiliation(s)
- Miriam Eckl
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Sandra Springer
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marvin Willam
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Arne M Ruder
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Volker Steil
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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9
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Spohn SKB, Sachpazidis I, Wiehle R, Thomann B, Sigle A, Bronsert P, Ruf J, Benndorf M, Nicolay NH, Sprave T, Grosu AL, Baltas D, Zamboglou C. Influence of Urethra Sparing on Tumor Control Probability and Normal Tissue Complication Probability in Focal Dose Escalated Hypofractionated Radiotherapy: A Planning Study Based on Histopathology Reference. Front Oncol 2021; 11:652678. [PMID: 34055621 PMCID: PMC8160377 DOI: 10.3389/fonc.2021.652678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Multiparametric magnetic resonance tomography (mpMRI) and prostate specific membrane antigen positron emission tomography (PSMA-PET/CT) are used to guide focal radiotherapy (RT) dose escalation concepts. Besides improvements of treatment effectiveness, maintenance of a good quality of life is essential. Therefore, this planning study investigates whether urethral sparing in moderately hypofractionated RT with focal RT dose escalation influences tumour control probability (TCP) and normal tissue complication probability (NTCP). Patients and Methods 10 patients with primary prostate cancer (PCa), who underwent 68Ga PSMA-PET/CT and mpMRI followed by radical prostatectomy were enrolled. Intraprostatic tumour volumes (gross tumor volume, GTV) based on both imaging techniques (GTV-MRI and -PET) were contoured manually using validated contouring techniques and GTV-Union was created by summing both. For each patient three IMRT plans were generated with 60 Gy to the whole prostate and a simultaneous integrated boost up to 70 Gy to GTV-Union in 20 fractions by (Plan 1) not respecting and (Plan 2) respecting dose constraints for urethra as well as (Plan 3) respecting dose constraints for planning organ at risk volume for urethra (PRV = urethra + 2mm expansion). NTCP for urethra was calculated applying a Lyman-Kutcher-Burman model. TCP-Histo was calculated based on PCa distribution in co-registered histology (GTV-Histo). Complication free tumour control probability (P+) was calculated. Furthermore, the intrafractional movement was considered. Results Median overlap of GTV-Union and PRV-Urethra was 1.6% (IQR 0-7%). Median minimum distance of GTV-Histo to urethra was 3.6 mm (IQR 2 - 7 mm) and of GTV-Union to urethra was 1.8 mm (IQR 0.0 - 5.0 mm). The respective prescription doses and dose constraints were reached in all plans. Urethra-sparing in Plans 2 and 3 reached significantly lower NTCP-Urethra (p = 0.002) without significantly affecting TCP-GTV-Histo (p = p > 0.28), NTCP-Bladder (p > 0.85) or NTCP-Rectum (p = 0.85), resulting in better P+ (p = 0.006). Simulation of intrafractional movement yielded even higher P+ values for Plans 2 and 3 compared to Plan 1. Conclusion Urethral sparing may increase the therapeutic ratio and should be implemented in focal RT dose escalation concepts.
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Affiliation(s)
- Simon K B Spohn
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ilias Sachpazidis
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rolf Wiehle
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benedikt Thomann
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - August Sigle
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Benndorf
- Department of Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Dimos Baltas
- German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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10
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Zhang Y, Zhang X, Li J, Zeng L, Wang X, Wu X, Li Y, Li X, Zhong R. Analysis of the Influence of Peripheral Anatomical Changes for CBCT-Guided Prostate Cancer Radiotherapy. Technol Cancer Res Treat 2021; 20:15330338211016370. [PMID: 33982618 PMCID: PMC8127575 DOI: 10.1177/15330338211016370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Purpose: To analyze the influence of the bladder and rectum filling and the body contour changes on the prostate target dose. Methods: A total of 190 cone-beam CT (CBCT) image data sets from 16 patients with prostate cancer were used in this study. Dose reconstruction was performed on the virtual CT generated by the deformable planning CT. Then, the effects of the bladder filling, rectal filling, and the patient’s body contour changes of the PCTV1 (the prostate area, B1) and PCTV2 (the seminal vesicle area, B2) on the target dose were analyzed. Correlation analysis was performed for the ratio of bladder and rectal volume variation and the variation of the bladder and rectal dose. Results: The mean Dice coefficients of B1, B2, bladder, and rectum were 0.979, 0.975, 0.888 and 0.827, respectively, and the mean Hausdorff distances were 0.633, 1.505, 2.075, and 1.533, respectively. With the maximum volume variations of 142.04 ml for the bladder and 40.50 ml for the rectum, the changes of V100, V95, D2, and D98 were 1.739 ± 1.762 (%), 0.066 ± 0.169 (%), 0.562 ± 0.442 (%), and 0.496 ± 0.479 (%) in PCTV1 and 1.686 ± 1.051 (%), 0.240 ± 0.215 (%), 1.123 ± 0.925 (%), and 0.924 ± 0.662 (%) in PCTV2, respectively. With a 10% increase in the volume of the bladder and rectum, the V75, V70, and V65 of rectum increased at 0.73 (%), 0.71 (%), and 1.18 (%), and the V75, V70, and V65 of bladder changed at −0.21 (%), −0.32 (%), and −0.39 (%), respectively. Conclusion: Significant correlations were observed between the volume variation and the dose variation of the bladder and rectum. However, when a bladder and rectal filling protocol was adopted, the target dose coverage can be effectively ensured based on CBCT guidance to correct the prostate target position.
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Affiliation(s)
- Yingjie Zhang
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xiangbin Zhang
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jing Li
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Liang Zeng
- Institute of Radiation Medicine, Fudan University, Shanghai, P.R. China
| | - Xuetao Wang
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xiaohong Wu
- Department of Oncology, The Affiliated Hospital of Panzhihua University, Panzhihua, P.R. China
| | - Yan Li
- Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, P.R. China
| | - Xiaoyu Li
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Renming Zhong
- Division of Radiation Physics, Department of Radiotherapy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
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11
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Niebuhr NI, Splinter M, Bostel T, Seco J, Hentschke CM, Floca RO, Hörner-Rieber J, Alber M, Huber P, Nicolay NH, Pfaffenberger A. Biologically consistent dose accumulation using daily patient imaging. Radiat Oncol 2021; 16:65. [PMID: 33823885 PMCID: PMC8025323 DOI: 10.1186/s13014-021-01789-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This work addresses a basic inconsistency in the way dose is accumulated in radiotherapy when predicting the biological effect based on the linear quadratic model (LQM). To overcome this inconsistency, we introduce and evaluate the concept of the total biological dose, bEQDd. METHODS Daily computed tomography imaging of nine patients treated for prostate carcinoma with intensity-modulated radiotherapy was used to compute the delivered deformed dose on the basis of deformable image registration (DIR). We compared conventional dose accumulation (DA) with the newly introduced bEQDd, a new method of accumulating biological dose that considers each fraction dose and tissue radiobiology. We investigated the impact of the applied fractionation scheme (conventional/hypofractionated), uncertainties induced by the DIR and by the assigned α/β-value. RESULTS bEQDd was systematically higher than the conventionally accumulated dose with difference hot spots of 3.3-4.9 Gy detected in six out of nine patients in regions of high dose gradient in the bladder and rectum. For hypofractionation, differences are up to 8.4 Gy. The difference amplitude was found to be in a similar range to worst-case uncertainties induced by DIR and was higher than that induced by α/β. CONCLUSION Using bEQDd for dose accumulation overcomes a potential systematic inaccuracy in biological effect prediction based on accumulated dose. Highest impact is found for serial-type late responding organs at risk in dose gradient regions and for hypofractionation. Although hot spot differences are in the order of several Gray, in dose-volume parameters there is little difference compared with using conventional or biological DA. However, when local dose information is used, e.g. dose surface maps, difference hot spots can potentially change outcomes of dose-response modelling and adaptive treatment strategies.
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Affiliation(s)
- Nina I Niebuhr
- Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany. .,Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany.
| | - Mona Splinter
- Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Tilman Bostel
- Clinical Cooperation Unit "Radiation Oncology", German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Joao Seco
- Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany.,Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Clemens M Hentschke
- Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ralf O Floca
- Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Medical Image Computing, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Clinical Cooperation Unit "Radiation Oncology", German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Alber
- Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Huber
- Clinical Cooperation Unit "Radiation Oncology", German Cancer Research Center (DKFZ), Heidelberg, Germany.,Molecular Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nils H Nicolay
- Clinical Cooperation Unit "Radiation Oncology", German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Freiburg University Medical Center, Freiburg, Germany
| | - Asja Pfaffenberger
- Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Institute for Radiooncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
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12
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Splinter M, Sachpazidis I, Bostel T, Fechter T, Zamboglou C, Thieke C, Jäkel O, Huber PE, Debus J, Baltas D, Nicolay NH. Dosimetric Impact of the Positional Imaging Frequency for Hypofractionated Prostate Radiotherapy - A Voxel-by-Voxel Analysis. Front Oncol 2020; 10:564068. [PMID: 33134166 PMCID: PMC7550661 DOI: 10.3389/fonc.2020.564068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/02/2020] [Indexed: 12/25/2022] Open
Abstract
Background To investigate deviations between planned and applied treatment doses for hypofractionated prostate radiotherapy and to quantify dosimetric accuracy in dependence of the image guidance frequency. Methods Daily diagnostic in-room CTs were carried out in 10 patients in treatment position as image guidance for hypofractionated prostate radiotherapy. Fraction doses were mapped to the planning CTs and recalculated, and applied doses were accumulated voxel-wise using deformable registration. Non-daily imaging schedules were simulated by deriving position correction vectors from individual scans and used to rigidly register the following scans until the next repositioning before dose recalculation and accumulation. Planned and applied doses were compared regarding dose-volume indices and TCP and NTCP values in dependence of the imaging and repositioning frequency. Results Daily image-guided repositioning was associated with only negligible deviations of analyzed dose-volume parameters and conformity/homogeneity indices for the prostate, bladder and rectum. Average CTV T did not significantly deviate from the plan values, and rectum NTCPs were highly comparable, while bladder NTCPs were reduced. For non-daily image-guided repositioning, there were significant deviations in the high-dose range from the planned values. Similarly, CTV dose conformity and homogeneity were reduced. While TCPs and rectal NTCPs did not significantly deteriorate for non-daily repositioning, bladder NTCPs appeared falsely diminished in dependence of the imaging frequency. Conclusion Using voxel-by-voxel dose accumulation, we showed for the first time that daily image-guided repositioning resulted in only negligible dosimetric deviations for hypofractionated prostate radiotherapy. Regarding dosimetric aberrations for non-daily imaging, daily imaging is required to adequately deliver treatment.
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Affiliation(s)
- Mona Splinter
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Ilias Sachpazidis
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Tilman Bostel
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Tobias Fechter
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Christian Thieke
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Jäkel
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Peter E Huber
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Nils H Nicolay
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
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13
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Reilly M, Ariani R, Thio E, Roh D, Timoteo M, Cen S, Lei X, Ballas LK. Daily Ultrasound Imaging for Patients Undergoing Postprostatectomy Radiation Therapy Predicts and Ensures Dosimetric Endpoints. Adv Radiat Oncol 2020; 5:1206-1212. [PMID: 33376835 PMCID: PMC7755542 DOI: 10.1016/j.adro.2020.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/10/2020] [Accepted: 09/27/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose Patients who receive radiation therapy (RT) for prostate cancer are routinely positioned through radiographic means. We set out to establish a data-driven process that defines bladder volume required to meet V40/65 constraints using daily bladder ultrasound (US) and comparative cone beam CT (CBCT) before placing a patient on the treatment table. Methods and Materials This was a single institution retrospective study of 20 patients (390 CBCT scans) who received postprostatectomy RT. Each patient received a daily US before treatment. CBCT alignment was performed 3 times a week. The bladder and rectum were contoured on each CBCT and a session dose was recorded. A mixed-effect model was used to estimate trajectory slopes of radiation exposure with organs-at-risk volume increase. Slope differences by V40/65 for prostate fossa (PF) and pelvic lymph nodes (PF/pLN) were tested using a 3-way-interaction term with Bonferroni correction. Results For the 20 patients, 10 received treatment to PF and 10 received RT to the PF/pLN. Predefined bladder constraints were V65 < 50%, V40 < 70%, and rectal constraints were V65 < 35%, V40 < 55%. The CBCT bladder volume (76-578 cm3) was greater than the pretreatment bladder US (87-466 cm3) due to volume filling between measurements (r = 0.8 ± 0.05). Mixed model detected a statistically significant 3-way interaction (P < .01) for bladder volume and V40/65. Both PF and PF/pLN patients showed improvement in V40/65 with an increase in bladder volume. For PF patients, bladder constraints were met when the US volume was >108 cm3 and for PF/pLN patients when the US bladder volume was >200 cm3. Rectal filling showed no association with CBCT volume. Conclusions Daily US of the bladder before postprostatectomy RT allows for dosimetric predictions before daily treatment. This should translate into fewer CBCT for the patient and improved machine throughput. This technique is easy to institute and ensures organs-at-risk volumetric constraints are met based on daily US measurements.
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14
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Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, Ozcan F, Colak O, Elcim Y, Gundem E, Dirican B, Beyzadeoglu M. Adaptive radiation therapy of breast cancer by repeated imaging during irradiation. World J Radiol 2020; 12:68-75. [PMID: 32549955 PMCID: PMC7288774 DOI: 10.4329/wjr.v12.i5.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/08/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most frequent cancer among females and also a leading cause of cancer related mortality worldwide. A multimodality treatment approach may be utilized for optimal management of patients with combinations of surgery, radiation therapy (RT) and systemic treatment. RT composes an integral part of breast conserving treatment, and is typically used after breast conserving surgery to improve local control. Recent years have witnessed significant improvements in the discipline of radiation oncology which allow for more focused and precise treatment delivery. Adaptive radiation therapy (ART) is among the most important RT techniques which may be utilized for redesigning of treatment plans to account for dynamic changes in tumor size and anatomy during the course of irradiation. In the context of breast cancer, ART may serve as an excellent tool for patients receiving breast irradiation followed by a sequential boost to the tumor bed. Primary benefits of ART include more precise boost localization and potential for improved normal tissue sparing with adapted boost target volumes particularly in the setting of seroma reduction during the course of irradiation. Herein, we provide a concise review of ART for breast cancer in light of the literature.
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Affiliation(s)
- Omer Sager
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Fatih Ozcan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Onurhan Colak
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Yelda Elcim
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Esin Gundem
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
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15
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Splinter M, Bostel T, Sachpazidis I, Fechter T, Zamboglou C, Jäkel O, Huber PE, Debus J, Baltas D, Nicolay NH. Dosimetric Impact of Interfractional Variations for Post-prostatectomy Radiotherapy to the Prostatic Fossa-Relevance for the Frequency of Position Verification Imaging and Treatment Adaptation. Front Oncol 2019; 9:1191. [PMID: 31788450 PMCID: PMC6856079 DOI: 10.3389/fonc.2019.01191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/21/2019] [Indexed: 12/15/2022] Open
Abstract
Background and purpose: To analyze divergences between the planned and applied treatment doses for post-prostatectomy radiotherapy to the prostatic fossa on a voxel-by-voxel basis based on interfractional anatomic variations and imaging frequency. Materials and methods: For 10 patients receiving intensity-modulated postoperative radiotherapy to the prostatic fossa, position verification was carried out by daily in-room CT imaging in treatment position (340 fraction CTs). Applied fraction doses were recalculated on daily CT scans, and treatment doses were accumulated on a voxel-by-voxel basis after deformable image registration. To simulate weekly imaging, derived weekly position correction vectors were used to rigidly register all daily scans of the respective treatment week onto the planning CT before dose accumulation. Detailed dose statistics of the prescribed and applied treatment doses were compared in relation to the frequency of position verification imaging. Derived NTCP and Pinjury values were calculated for the rectum and bladder. Results: Despite a large variability in the pelvic anatomy, daily CT-based patient repositioning resulted in largely negligible deviations of the analyzed dose-volume, conformity, and uniformity parameters from the planned doses for post-prostatectomy radiotherapy, and only the bladder exhibited significant increases in the accumulated mean and median doses. Derived NTCP for the applied doses to the rectum and bladder and Pinjury values did not significantly deviate from the treatment plan. In contrast, weekly CT-based repositioning resulted in significant decreases of the PTV coverage and dose conformity as well as large deviations of the applied doses to the rectum and bladder from the planned doses. Consecutively, NTCP for the rectum and Pinjury were found falsely reduced for weekly patient repositioning. Conclusions: Our data indicate for the first time in a voxel-by-voxel analysis that daily imaging is required for reliable adaptive delivery of intensity-modulated radiotherapy to the prostatic fossa. This work will help guiding adaptive treatment strategies for post-prostatectomy radiotherapy.
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Affiliation(s)
- Mona Splinter
- Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Clinical Cooperation Unit "Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Tilman Bostel
- Clinical Cooperation Unit "Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Ilias Sachpazidis
- Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Tobias Fechter
- Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Oliver Jäkel
- Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Peter E Huber
- Clinical Cooperation Unit "Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Clinical Cooperation Unit "Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
| | - Nils H Nicolay
- Clinical Cooperation Unit "Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center, Heidelberg, Germany
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