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Guo Y, Liu Z, Feng S, Cai H, Zhang Q. Clinical Viability of an Active Spot Scanning Beam Delivery System With a Newly Developed Carbon-Ion Treatment Planning System. Adv Radiat Oncol 2024; 9:101503. [PMID: 38883996 PMCID: PMC11177064 DOI: 10.1016/j.adro.2024.101503] [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: 07/27/2023] [Accepted: 01/19/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose Although active spot scanning irradiation technique is theoretically superior to passive-scattered broad beam irradiation with respect to normal tissue sparing, corroborations of the clinical benefit of carbon-ion spot scanning have remained scarce. This study aims to investigate the feasibility and clinical implementation of an active spot scanning beam calculation algorithm in a homemade carbon-ion treatment planning system by comparing it with a conventional passive uniform scanning technique. Methods and Materials Carbon-ion plans were initially formulated using spot/uniform scanning methods in 22 participants enrolled in a prospective observational clinical trial. Subsequently, 2 additional plans were designed, resulting in 3 carbon-ion plans for each participant: uniform and spot scanning with miniridge filters of 2 mm and 4 mm, respectively. Results The findings revealed no significant differences in dose homogeneity; however, significant differences in dose conformity were found between the active and passive scanning plans. For dose drop-off outside the target volume, the average gradient index values were 1.94 (95% CI, 1.79%-2.09%), 1.87 (95% CI, 1.73%-2.01%), and 3.20 (95% CI, 2.80%-3.61%) for the miniridge filters of 2 mm and 4 mm, and uniform scanning plans, respectively. The pretreatment tumor volume was 124.7 cm3 (range, 54.2-234 cm3), and the average shrinkage observed was 38.4% (95% CI, 17.6%-59.4%). Seven participants experienced grade 1 acute toxicity, and 4 experienced grade 2 acute toxicity. However, none of the patients developed grade 3 acute toxicity. Conclusions Increasing evidence suggests that potential clinical advantages of spot scanning delivery underlie its technical characteristics. As one among the few institutions currently using carbon-ion radiation therapy, the investigation also provides promising safety and efficacy outcomes from the initial groups of treated participants, thereby contributing to the established clinical evidence supporting the effectiveness and superiority of carbon-ion therapy.
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Affiliation(s)
- Yixiao Guo
- Department of Radiation Oncology, Gansu Provincial Hospital, Lanzhou, P.R. China
| | - Zhiqiang Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, Gansu, P.R. China
| | - Shifang Feng
- Department of Radiation Oncology, Gansu Provincial Hospital, Lanzhou, P.R. China
| | - Hongyi Cai
- Department of Radiation Oncology, Gansu Provincial Hospital, Lanzhou, P.R. China
| | - Qiuning Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, Gansu, P.R. China
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Sharma DS, Padanthaiyil NM, Krishnan G, Arjunan M, Reddy AK, Mahammood S, Gayen S, Thiyagarajan R, Gaikwad U, Sudarsan RT, Chilukuri S, Jalali R. Critical Appraisal of Paediatric Embryonal Cancers Treated with Image-guided Intensity-modulated Proton Therapy. Clin Oncol (R Coll Radiol) 2023; 35:227-236. [PMID: 36609026 DOI: 10.1016/j.clon.2022.12.003] [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: 09/20/2022] [Revised: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023]
Abstract
AIM To carry out a comprehensive critical appraisal of image-guided intensity-modulated proton therapy practice for craniospinal irradiation (CSI). MATERIALS AND METHODS An image-guided intensity-modulated proton therapy database of 45 consecutive paediatric patients with central nervous system embryonal malignancies treated between January 2019 and April 2022 were critically appraised for demography, diagnosis, treatment planning strategy and treatment delivery accuracy. RESULTS Most patients (median age: 7.5 years; male:female ratio: 34:11) had medulloblastoma (56%), followed by recurrent ependymoma (19%), pinealoblastoma (5%), germ cell (5%) and others (15%). The dose to the planning target volume-craniospinal (PTV-CS; length 39.06-79.59 cm) varied from 21 to 35 GyRBE, whereas the combined median dose to craniospinal and boost was 54 GyRBE. In all patients, the 95% isodose line covered the cribriform plate completely and optic nerves mostly, with a median V95% of 100% and 82.96%, keeping Dmax to the lens <3.9 GyRBE. In skeletally immature patients (88.38%), the anterior vertebral body was completely covered in 18.18% and underdosed in 70.15% of the cases, resulting in a median Dmean of 10.11 GyRBE to the oesophagus. Lateral spine coverage was maintained on the edges of the vertebral body in 52.2%, whereas it extended beyond in 48.8%. The median V98% for clinical target volumes and V95% for PTVs of the brain, spine and craniospinal were >97%, with excellent conformity (0.89) and homogeneity (0.07) indices for PTV-CS. All neurological organs at risk received a median Dmax ranging from 36 to 44 GyRBE from the combined CSI and boost regimens. Analysis of patient-specific quality assurance results revealed that 545 (97.67%) planar dosage verification had gamma (3% at 3 mm) values >95%. The online patient set-up verification showed translational and rotational deviation within 2 mm and 0.5° in 88-94% and 97% of the cases. Systematic and random error were within 0.90 mm and 1.71 mm in translation and 0.1° and 0.2° in rotation. CONCLUSION A change in practice pattern was observed. The findings from our comprehensive critical appraisal add to the growing library of CSI practice and may serve as a reference for inter-institutional comparison.
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Affiliation(s)
- D S Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India.
| | - N M Padanthaiyil
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - G Krishnan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - M Arjunan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - A K Reddy
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Mahammood
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Gayen
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R Thiyagarajan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - U Gaikwad
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R T Sudarsan
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
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Gaikwad U, Noufal MP, Sylvia J, Reddy AK, Panda PK, Chilukuri S, Sharma D, Jalali R. Encouraging early outcomes with image guided pencil beam proton therapy for cranio-spinal irradiation: first report from India. Radiat Oncol 2022; 17:115. [PMID: 35773667 PMCID: PMC9248189 DOI: 10.1186/s13014-022-02085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background To report our experience with image guided pencil beam proton beam therapy (PBT) for craniospinal irradiation (CSI). Materials and Methods Between January 2019 and December 2021, we carried out a detailed audit of the first forty patients treated with PBT. We had recorded acute toxicities, reporting early outcomes and discuss limitations of current contouring guidelines during CSI PBT planning. Results Median age of the patient cohort was 8 years, and histologies include 20 medulloblastoma, 7 recurrent ependymoma, 3 pineoblastoma, 3 were germ cell tumors and remaining 7 constituted other diagnoses. Forty percent patients received concurrent chemotherapy. Median CSI dose was 23.4 Gy (Gray; range 21.6–35 Gy). Thirty-five patients (87.5%) completed their CSI without interruption, 5 required hospital admission. No patient had grade 2/ > weight loss during the treatment. Forty-five percent (18) developed grade 1 haematological toxicities and 20% (8) developed grade 2 or 3 toxicities; none had grade 4 toxicities. At median follow up of 12 months, 90% patients are alive of whom 88.9% are having local control. Special consideration with modification in standard contouring used at our institute helped in limiting acute toxicities in paediatric CSI patients. Conclusion Our preliminary experience with modern contemporary PBT using pencil beam technology and daily image guidance in a range of tumours suitable for CSI is encouraging. Patients tolerated the treatment well with acceptable acute toxicity and expected short-term survival outcome. In paediatric CSI patients, modification in standard contouring guidelines required to achieve better results with PBT.
Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02085-4.
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Affiliation(s)
- Utpal Gaikwad
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - M P Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Jacinthlyn Sylvia
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Ashok K Reddy
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Pankaj Kumar Panda
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Srinivas Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Dayananda Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India.
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Noufal MP, Sharma SD, Patro K, Arjunan M, Krishnan G, Tyagarajan R, Rana S, Chillukuri S, Jalali R. Impact of spot positional errors in robustly optimized intensity-modulated proton therapy plan of craniospinal irradiation. Radiol Phys Technol 2021; 14:271-278. [PMID: 34089492 DOI: 10.1007/s12194-021-00625-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 11/24/2022]
Abstract
We investigated the influence of random spot positioning errors (SPEs) on dosimetric outcomes of robustly optimized intensity-modulated proton therapy (RB-IMPT) plans in craniospinal irradiation (CSI). Six patients with CSI treated using the RB-IMPT technique were selected. An in-house MATLAB code was used to simulate a random SPE of 1 mm in positive, negative, and both directions for 25%, 50%, and 75% of the total spot positions in the nominal plan. The percentage dose variation (ΔD%) in the six nominal and 54 error-introduced plans was evaluated using standard dose-volume indices, line dose difference, and 3D gamma analysis method. The introduction of a random SPE of 1 mm resulted in a reduction in D99%, D98%, and D95% of both CTVs and PTVs by < 2% compared with the corresponding nominal plans. However, this leads to an increase in D1% of the lens by up to 16.9%. The line dose in the junction region showed ΔD% < 2% for the brain and upper spine and < 4% for the upper and lower spine. The 3D gamma values for 3% at 3 mm and 2% at 2 mm were above 99% and 95%, respectively, in all 54 error-introduced plans. The worst decrease in gamma values was observed for 1% at 1 mm, with values ranging from 64 to 78% for all types of SPE. The RB-IMPT plan for CSI investigated in this study is robust enough for target coverage, even if there are random SPEs of 1 mm. However, this leads to an increase in the dose to the critical organ located close to the target.
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Affiliation(s)
- Manthala Padannayil Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, 400053, India.
| | | | - Katikeshwar Patro
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, 400053, India
| | - Manikandan Arjunan
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, 400053, India
| | - Ganapathy Krishnan
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, 400053, India
| | - Rajesh Tyagarajan
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, 400053, India
| | - Suresh Rana
- Department of Medical Physics, Oklahoma Proton Center, Oklahoma City, OK, 73142, USA
| | - Srinivas Chillukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, Tamil Nadu, India
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Practical aspects of the application of helical tomotherapy for craniospinal irradiation. Sci Rep 2021; 11:6120. [PMID: 33731843 PMCID: PMC7969733 DOI: 10.1038/s41598-021-85574-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
We investigated the practical aspects of the application of craniospinal irradiation using helical tomotherapy (HT-CSI) by evaluating interfractional setup errors and intrafractional movement during each treatment in 83 patients undergoing HT-CSI between January 2014 and December 2018. Interfractional setup errors in each axis (mediolateral; ML, craniocaudal; CC, and anteroposterior; AP) were assessed as differences between pre-treatment megavoltage computed tomography (MVCT) images scanned (zygomatic arch to the C4 spine) and planning CT images. Intrafractional movements were evaluated as the difference between pre-treatment and post-treatment MVCT (T12–L4 spine) images at each fraction. Median interfractional setup error was acceptable in every axis (ML: 1.6 mm, CC: 1.9 mm, AP: 3.1 mm). Seven patients (8.4%) experienced significant intrafractional displacement from 1 to 10 fractions (0.34% for ML, 0.74% for CC, 1.21% for AP). Weight loss grade 1+ during treatment (p = 0.016) was an independent risk factor for significant intrafractional displacement. The risk factor for significant intrafractional movement in pediatric patients was weight loss grade 1+ (p = 0.020), while there was no factor in adults. HT-CSI could be a feasible treatment modality with acceptable setup verification. Inter- and intrafractional errors were acceptable; paying attention to weight loss during treatment is necessary, especially in pediatric patients.
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Sharma S, Noufal M, Krishnan G, Sawant M, Gaikwad U, Jalali R. Robustly optimized hybrid intensity-modulated proton therapy for craniospinal irradiation. J Cancer Res Ther 2021; 18:1597-1603. [DOI: 10.4103/jcrt.jcrt_740_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Residual positioning errors and uncertainties for pediatric craniospinal irradiation and the impact of image guidance. Radiat Oncol 2020; 15:149. [PMID: 32522233 PMCID: PMC7285717 DOI: 10.1186/s13014-020-01588-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/01/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Optimal alignment is of utmost importance when treating pediatric patients with craniospinal irradiation (CSI), especially with regards to field junctions and multiple isocenters and techniques applying high dose gradients. Here, we investigated the setup errors and uncertainties for pediatric CSI using different setup verification protocols. METHODS A total of 38 pediatric patients treated with CSI were identified for whom treatment records and setup images were available. The setup images were registered retrospectively to the reference image using an automated tool and matching on bony anatomy, subsequently, the impact of different correction protocols was simulated. RESULTS For an action-level (AL)-protocol and a non-action level (NAL)-protocol, the translational residual setup error can be as large as 24 mm for an individual patient during a single fraction, and the rotational error as large as 6.1°. With daily IGRT, the maximum setup errors were reduced to 1 mm translational and 5.4° rotational versus 1 mm translational and 2.4° rotational for 3- and 6- degrees of freedom (DoF) couch shifts, respectively. With a daily 6-DoF IGRT protocol for a wide field junction irradiation technique, the residual positioning uncertainty was below 1 mm and 1° for translational and rotational directions, respectively. The largest rotational uncertainty was found for the patients' roll even though this was the least common type of rotational error, while the largest translational uncertainty was found in the patients' anterior-posterior-axis. CONCLUSIONS These results allow for informed margin calculation and robust optimization of treatments. Daily IGRT is the superior choice for setup of pediatric patients treated with CSI, although centers that do not have this option could use the results presented here to improve their margins and uncertainty estimates for a more accurate treatment alignment.
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Hong CS, Kim MJ, Kim J, Chang KH, Park K, Kim DW, Han MC, Yoon HI, Kim JS, Lee H. Feasibility of hybrid TomoHelical- and TomoDirect-based volumetric gradient matching technique for total body irradiation. Radiat Oncol 2019; 14:233. [PMID: 31856870 PMCID: PMC6924057 DOI: 10.1186/s13014-019-1435-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tomotherapy-based total body irradiation (TBI) is performed using the head-first position (HFP) and feet-first position (FFP) due to treatment length exceeding the 135 cm limit. To reduce the dosimetric variation at the match lines, we propose and verify a volumetric gradient matching technique (VGMT) by combining TomoHelical (TH) and TomoDirect (TD) modes. METHODS Two planning CT image sets were acquired with HFP and FFP using 15 × 55 × 18 cm3 of solid water phantom. Planning target volume (PTV) was divided into upper, lower, and gradient volumes. The junction comprised 2-cm thick five and seven gradient volumes (5-GVs and 7-GVs) to create a dose distribution with a gentle slope. TH-IMRT and TD-IMRT plans were generated with 5-GVs and 7-GVs. The setup error in the calculated dose was assessed by shifting dose distribution of the FFP plan by 5, 10, 15, and 20 mm in the longitudinal direction and comparing it with the original. Doses for 95% (D95) and 5% of the PTV (D5) were calculated for all simulated setup error plans. Absolute dose measurements were performed using an ionization chamber in the junction. RESULTS The TH&TD plan produced a linear gradient in junction volume, comparable to that of the TH&TH plan. D5 of the PTV was 110% of the prescribed dose when the FFP plan was shifted 0.7 cm and 1.2 cm in the superior direction for 5-GVs and 7-GVs. D95 of the PTV decreased to < 90% of the prescribed dose when the FF plan was shifted 1.1 cm and 1.3 cm in the inferior direction for 5-GVs and 7-GVs. The absolute measured dose showed a good correlation with the calculated dose in the gradient junction volume. The average percent difference (±SD) in all measured points was - 0.7 ± 1.6%, and the average dose variations between depths was - 0.18 ± 1.07%. CONCLUSION VGMT can create a linear dose gradient across the junction area in both TH&TH and TH&TD and can minimize the dose sensitivity to longitudinal setup errors in tomotherapy-based TBI.
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Affiliation(s)
- Chae-Seon Hong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Min-Joo Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Jihun Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Kyung Hwan Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Kwangwoo Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Dong Wook Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Min Cheol Han
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea.
| | - Ho Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, South Korea.
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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