Dosimetric comparison between IMRT and VMAT in irradiation for peripheral and central lung cancer

The Era of Precision Medicine: Advancing Treatment Paradigms for Small Cell Lung Cancer

Small cell lung cancer (SCLC) remains a challenge prognostically. A clinically silent early stage and predilection for early metastasis leads to over half of patients presenting with metastatic disease at the time of diagnosis. Akin to many other cancers, once SCLC metastasizes, current therapies begin to lose their effectiveness. The future of SCLC rests in innovative treatments aimed at improving patient outcomes. Chemotherapy and radiation remain the backbone treatment for SCLC. Most patients diagnosed with SCLC begin treatment with combination chemotherapy consisting of a platinum analog and topoisomerase inhibitor with or without concurrent radiation. Disease progression or recurrence warrants new treatment approaches. New chemotherapy combinations and advances in radiation precision offer patients novel approaches using the same backbone of treatment used in many other cancers. The introduction of newer therapeutic approaches, such as immune checkpoint inhibitors, small molecule targeted therapies, bispecific antibodies, and antibody-drug conjugates offer a bright future for patients with SCLC who fail first-line therapy. This review will focus on advancing treatment paradigms for SCLC in the era of precision medicine. Such a study might be helpful for pulmonologists and oncologists to manage precisely patients with SCLC.

Quantitative beam optimization for radiotherapy of peripheral lung lesions: A pilot study in stereotactic body radiotherapy

BACKGROUND

To quantify beam optimization for stereotactic body radiotherapy (SBRT) of peripheral lung lesions.

METHOD

The new beam optimization approach was based on maximizing the therapeutic gain (TG) of the beam set by minimizing the average physical depth of the lesion with respect to the beam's eye view (BEV). The new approach was evaluated by replanning the 25 SBRT lesions retrospectively to assess if a better plan is achievable in all aspects. Difference in 25 Gy isodose line volume (IDLV25 Gy), IDLV20 Gy, IDLV15 Gy, IDLV10 Gy, and IDLV5 Gy between the two plan cohorts were calculated as a measure of plan size and fitted in a linear regression model against the changes in the lesion depth with respect to the BEV to assess the relationship between the changes in the treatment depth and that of the plan size.

RESULTS

Beam optimization achieved a better plan in all cases by lowering the depth of treatment with an average of % 20.03 ± 12.30 (3.66%-45.78%). As the depth of treatment decreases, the size of the plan also decreases. We observed a reduction of % 4.64 ± 4.55 (0.02%-21.58%, p < 3.8 × 10-5), %5.16 ± 5.54 (0.03%-24.68%, p < 0.005), %6.46 ± 6.95 (-1.35%-29.05%, p < 0.009), %12.83 ± 9.06 (0.89%-37.65%, p < 0.0001), and %14.01 ± 9.87 (1.43%-41.84%, p < 4.5 × 10-6) in IDLV25 Gy, IDLV20 Gy, IDLV15 Gy, IDLV10 Gy, and IDLV5 Gy, respectively.

CONCLUSION

Physical depth of the lesion with respect to the BEV is inversely proportional to the TG of a beam-set and can be used as a robust and standard metric to select an appropriate beam-set for SBRT of the peripheral lung lesions. Further evaluation warrants the utility of such concept in routine clinical use.

A deep learning-informed interpretation of why and when dose metrics outside the PTV can affect the risk of distant metastasis in SBRT NSCLC patients

PURPOSE

Recent papers suggested a correlation between the risk of distant metastasis (DM) and dose outside the PTV, though conclusions in different publications conflicted. This study resolves these conflicts and provides a compelling explanation of prognostic factors.

MATERIALS AND METHODS

A dataset of 478 NSCLC patients treated with SBRT (IMRT or VMAT) was analyzed. We developed a deep learning model for DM prediction and explainable AI was used to identify the most significant prognostic factors. Subsequently, the prognostic power of the extracted features and clinical details were analyzed using conventional statistical methods.

RESULTS

Treatment technique, tumor features, and dosiomic features in a 3 cm wide ring around the PTV (PTV3cm) were identified as the strongest predictors of DM. The Hazard Ratio (HR) for Dmean,PTV3cm was significantly above 1 (p < 0.001). There was no significance of the PTV3cm dose after treatment technique stratification. However, the dose in PTV3cm was found to be a highly significant DM predictor (HR > 1, p = 0.004) when analyzing only VMAT patients with small and spherical tumors (i.e., sphericity > 0.5).

CONCLUSIONS

The main reason for conflicting conclusions in previous papers was inconsistent datasets and insufficient consideration of confounding variables. No causal correlation between the risk of DM and dose outside the PTV was found. However, the mean dose to PTV3cm can be a significant predictor of DM in small spherical targets treated with VMAT, which might clinically imply considering larger PTV margins for smaller, more spherical tumors (e.g., if IGTV > 2 cm, then margin ≤ 7 mm, else margin > 7 mm).

Comparison of photon intensity modulated, hybrid and volumetric modulated arc radiation treatment techniques in locally advanced non-small cell lung cancer

Background and purpose

There is no consensus on the best photon radiation technique for non-small cell lung cancer (NSCLC). This study quantified the differences between commonly used treatment techniques in NSCLC to find the optimal technique.

Materials and methods

Treatment plans were retrospectively generated according to clinical guidelines for 26 stage III NSCLC patients using intensity modulated radiation therapy (IMRT), hybrid, and volumetric modulated arc therapy (VMATC, and VMATV5 optimized for lower lung and heart dose). Plans were evaluated for target coverage, organs at risk dose (including heart substructures) and normal tissue complication probabilities (NTCP).

Results

The comparison showed significant and largest median differences (>1 Gy or >5%) in favor of IMRT for the mediastinal envelope and heart (maximum dose), in favor of the hybrid technique for the lungs (V5Gy of the total lungs and V5Gy of the contralateral lung) and in favor of VMATC for the heart (Dmean), most of the substructures of the heart, and the spinal cord (maximum dose). The VMATV5 technique had significantly lower heart dose compared to the hybrid technique and significantly lower lung dose compared to the VMATC, combining both advantages in one technique. The mean ΔNTCP did not exceed the 2 percent point (pp) for grade 5 (mortality), and 10 pp for grade ≥2 toxicities (radiation pneumonitis and acute esophageal toxicity), but ΔNTCP was mostly in favor of VMATC/V5 for individual patients.

Conclusion

This planning study showed that VMATV5 was preferred as it achieved low lung and heart doses, as well as low NTCPs, simultaneously.

Dosimetric comparison of four radiotherapy techniques for stage III non‑small cell lung cancer

The present study was implemented to compare the dosimetric parameters of the target dose coverage and critical structures in the treatment planning of four radiotherapy techniques [namely, three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), hybrid IMRT (h-IMRT) and volumetric-modulated arc therapy (VMAT)] for stage III non-small cell lung cancer (NSCLC) qualified plans for medical physicists, therapists and physicians. A total of 40 patients confirmed to have stage IIIA or IIIB NSCLC were enrolled, and four plans were designed for each patient. The prescription dose to the planning target volume (PTV) was assigned as 60 Gy in 30 fractions. The conformity index (CI), heterogeneity index (HI) and parameters of organs at risk (OARs) were calculated. For the PTV, the CI for VMAT was found to be the highest of all the four techniques (P<0.05), whereas the HI for the h-IMRT technique was found to be the lowest (P<0.05). Concerning the OARs, for the percentage of lung volume receiving a dose >5 Gy (lung V₅), the highest value was obtained with VMAT (P<0.05), whereas for lung V₃₀ and heart V₃₀, the VMAT and IMRT techniques were found to be better compared with 3D-CRT and h-IMRT (P<0.05). For esophagus V₅₀, the maximal dose (D_max) and mean dose for the IMRT technique displayed the best results (P<0.05), and in the case of the spinal cord, the D_max with VMAT showed a significant advantage over the other techniques (P<0.05). The treatment monitor units (MUs) in IMRT were found to be the largest (P<0.05), whereas the treatment time with VMAT was the shortest (P<0.05). For smaller PTVs, VMAT was the technique that provided the optimal dose distribution and sparing of the heart. Compared with 3D-CRT alone, adding 20% IMRT to the 3D-CRT base plan was shown to improve the plan quality, and IMRT and VMAT, as techniques, had better dose coverage and sparing of OARs. Furthermore, for patients in whom the lung V5 could be kept low enough, VMAT potentially offered a good alternative to the technique to IMRT, thereby offering additional possibilities for sparing of other OARs, and decreasing the MUs and treatment time.

GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer

Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.

Role of water in the crystal structure of LiPCDA monomer and the radiotherapy dose response of EBT-3 film

Purpose

Radiochromic material used in recent commercial films has been suggested as a candidate for in vivo dosimetry because of its dose sensitivity, real‐time response, and atomic composition. It was observed that its sensitive material, lithium pentacosa‐10,12‐diynoate (LiPCDA), can have two distinct forms, with main absorbance peaks at ∼635 and ∼674 nm. The spectrum of the latter is similar to that of pentacosa‐10,12‐diynoic acid (PCDA) used in the commercial predecessor, obtained through desiccation of the commercial film. Water was suggested to be a part of the crystal structure and thus its presence or absence would affect dosimetric parameters. The objective of this study is to: (a) investigate how desiccated commercial films compared to the native form in terms of macroscopic crystal structure, dose–response, signal linearity, and post‐exposure kinetics; (b) demonstrate proof‐of‐concept that the two versions can be combined into one optical dosimeter and measured simultaneously.

Methods

Commercial radiochromic film, EBT‐3, was desiccated for 10 days at 45°C. Using a 6 MV LINAC beam and standard setup of 100 Source to Axis Distance (SAD), 10 cm × 10 cm field size, and 1.5 cm depth, commercial and desiccated films were irradiated to 50, 100, 200, 500, 1000, 2000, 3000 cGy and the latter to 4000, 5000, and 7000 cGy. A custom phantom equipped with optical fibers for real‐time read‐out was used for all measurements. Absorbance spectra were collected at ∼1 Hz before, during, and after irradiation. Data were collected for ∼1 h after the end of irradiation for 200 cGy experiments. The radiation‐induced change in optical density (∆OD) was calculated with a 10 nm band around the primary absorbance peak. The post‐exposure percent optical density change was calculated and compared to ∆OD at the end of irradiation. Both commercial and desiccated films were also irradiated and measured simultaneously as proof‐of‐concept for using two materials within one optical path. For electron microscopy imaging, active materials from commercial and desiccated films were imaged on a scanning electron microscope at an accelerating voltage of 10 kV.

Results

Scanning electron microscope images showed that desiccated film was similar in topographical structure to the commercial EBT‐3 form. It maintained a non‐linear ∆OD with dose but resulted in ∼1/3 signal compared to the commercial film. Evaluation of post‐exposure response showed significantly lower percent increase in ∆OD for desiccated film initially, with no statistically significant difference at 1 h after the end of irradiation. Combining both films and simultaneously measuring their absorbance illustrated that the two absorbance peaks were identifiable and resolvable to allow for an independent determination of dose from each.

Conclusions

Water is implicated in the crystal structure of the EBT‐3 radiochromic film, with its removal through desiccation affecting both dosimetric and spectroscopic characteristics of the material. The two forms of radiochromic material (with and without water) are spectrally resolvable allowing for independent dose determination from each, opening up possibilities for dose measurements at different locations along a single fiber.

Predicting personalised optimal arc parameter using knowledge-based planning model for inoperable locally advanced lung cancer patients to reduce organ at risk doses

Objectives. Volumetric modulated arc therapy (VMAT) allows for reduction of organs at risk (OAR) volumes receiving higher doses, but increases OAR volumes receiving lower radiation doses and can subsequently increasing associated toxicity. Therefore, reduction of this low-dose-bath is crucial. This study investigates personalizing the optimization of VMAT arc parameters (gantry start and stop angles) to decrease OAR doses.Materials and Methods. Twenty previously treated locally advanced non-small cell lung cancer (NSCLC) patients treated with half-arcs were randomly selected from our database. These plans were re-optimized with seven different arcs parameters; optimization objectives were kept constant for all plans. All resulting plans were reviewed by two clinicians and the optimal plan (lowest OAR doses and adequate target coverage) was selected. Furthermore, knowledge-based planning (KBP) model was developed using these plans as 'training data' to predict optimal arc parameters for individual patients based on their anatomy. Treatment plan complexity scores and deliverability measurements were performed for both optimal and original clinical plans.Results.The results show that different arc geometries resulted in different dose distributions to the OAR but target coverage was mostly similar. Different arc geometries were required for different patients to minimize OAR doses. Comparison of the personalized against the standard (2 half-arcs) plans showed a significant reduction in lung V₅(lung volume receiving 5 Gy), mean lung dose and mean heart doses. Reduction in lung V₂₀and heart V₃₀were statistically insignificant. Plan complexity and deliverability measurements show the test plans can be delivered as planned.Conclusions.Our study demonstrated that personalizing arc parameters based on an individual patient's anatomy significantly reduces both lung and heart doses. Dose reduction is expected to reduce toxicity and improve the quality of life for these patients.

Comparison of combinations of irradiation techniques and jaw conditions in intensity-modulated radiotherapy for lung cancer

Purpose

To assist in the selection of a suitable combination of an irradiation technique and jaw condition in intensity‐modulated radiotherapy (IMRT) and volumetric‐modulated arc radiotherapy (VMAT) for lung cancer treatment plans.

Materials and methods

Thirty patients with lung cancer who underwent radiotherapy were enrolled retrospectively. They were categorized as having central lung cancer, peripheral lung cancer with mediastinal lymph node metastasis (peripheral E lung cancer), and peripheral lung cancer without mediastinal lymph node metastasis (peripheral N lung cancer). Four treatment plans were designed for each patient: fixed jaw and adaptive jaw IMRT technique (FJ‐IMRT and JA‐IMRT), and fixed jaw and jaw tracking VMAT technique (FJ‐VMAT and JT‐VMAT). The dose parameters of the four group plans were compared and analyzed.

Results

Compared to FJ‐IMRT, JA‐IMRT significantly reduced the mean dose (D_mean) and volume percentage of 5 Gy (V_5Gy) of the total lung in central and peripheral N lung cancer. Similarly, compared to FJ‐VMAT, JT‐VMAT provided better protection to most organs at risk (OARs), particularly for total lung and heart. In comparison with IMRT, VMAT significantly improved the conformity index (CI) of the planning target volume for the three lung cancer classifications, and it reduced the dose of almost all OARs except V_5Gy and D_mean of the total lung. Moreover, the mean monitor units of the VMAT groups were far lower than the IMRT groups.

Conclusion

Based on the dosimetric findings and considering clinical data published on lung and heart side effects, we propose recommendations on the preferred treatment technique based on tumor location and pulmonary function. For central lung cancer with normal pulmonary function, we advise JT‐VMAT techniques. Conversely, for central lung cancer with poor pulmonary function, we recommend JA‐IMRT techniques. We advocate JA‐IMRT for peripheral E lung cancer. For peripheral N lung cancer, JT‐VMAT techniques are strongly recommended.

GOECP/SEOR radiotherapy guidelines for small-cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.

Effect of intensity-modulated radiation therapy on sciatic nerve injury caused by echinococcosis

Conventional radiotherapy has a good killing effect on femoral echinococcosis. However, the sciatic nerve around the lesion is irreversibly damaged owing to bystander effects. Although intensity-modulated radiation therapy shows great advantages for precise dose distribution into lesions, it is unknown whether intensity-modulated radiation therapy can perfectly protect the surrounding sciatic nerve on the basis of good killing of femoral echinococcosis foci. Therefore, this study comparatively analyzed differences between intensity-modulated radiation therapy and conventional radiotherapy on the basis of safety to peripheral nerves. Pure-breed Meriones meridiani with bilateral femoral echinococcosis were selected as the research object. Intensity-modulated radiation therapy was used to treat left femoral echinococcosis of Meriones meridianus, while conventional radiotherapy was used to treat right femoral echinococcosis of the same Meriones meridianus. The total radiation dose was 40 Gy. To understand whether intensity-modulated radiation therapy and conventional radiotherapy can kill femoral echinococcosis, trypan blue staining was used to detect pathological changes of bone Echinococcus granulosus and protoscolex death after radiotherapy. Additionally, enzyme histochemical staining was utilized to measure acid phosphatase activity in the protoscolex after radiotherapy. One week after radiotherapy, the overall structure of echinococcosis in bilateral femurs of Meriones meridiani treated by intensity-modulated radiation therapy disappeared. There was no significant difference in the mortality rate of protoscoleces of Echinococcus granulosus between the bilateral femurs of Meriones meridiani. Moreover, there was no significant difference in acid phosphatase activity in the protoscolex of Echinococcus granulosus between bilateral femurs. To understand the injury of sciatic nerve surrounding the foci of femoral echinococcosis caused by intensity-modulated radiation therapy and conventional radiotherapy, the ultrastructure of sciatic nerves after radiotherapy was observed by transmission electron microscopy. Additionally, apoptosis of neurons was examined using a terminal-deoxynucleotidyl transferase-mediated dUTP nick end labeling assay, and expression of Bcl-2 and Bax in sciatic nerve tissue was detected by immunohistochemical staining and western blot assay. Our results showed that most neurons in the left sciatic nerve of Meriones meridiani with echinococcosis treated by intensity-modulated radiation therapy had reversible injury, and there was no obvious apoptosis. Compared with conventional radiotherapy, the number of apoptotic cells and Bax expression in sciatic nerve treated by intensity-modulated radiation therapy were significantly decreased, while Bcl-2 expression was significantly increased. Our findings suggest that intensity-modulated radiation therapy has the same therapeutic effect on echinococcosis as conventional radiotherapy, and can reduce apoptosis of the sciatic nerve around foci caused by radiotherapy. Experiments were approved by the Animal Ethics Committee of People’s Hospital of Xinjiang Uygur Autonomous Region, China (Approval No. 20130301A41) on March 1, 2013.

A robust VMAT delivery solution for single-fraction lung SABR utilizing FFF beams minimizing dosimetric compromise

Peripheral lung lesions treated with a single fraction of stereotactic ablative body radiotherapy (SABR) utilizing volumetric modulated arc therapy (VMAT) delivery and flattening filter‐free (FFF) beams represent a potentially high‐risk scenario for clinically significant dose blurring effects due to interplay between the respiratory motion of the lesion and dynamic multi‐leaf collimators (MLCs). The aim of this study was to determine an efficient means of developing low‐modulation VMAT plans in the Eclipse treatment planning system (v15.5, Varian Medical Systems, Palo Alto, USA) in order to minimize this risk, while maintaining dosimetric quality. The study involved 19 patients where an internal target volume (ITV) was contoured to encompass the entire range of tumor motion, and a planning target volume (PTV) created using a 5‐mm isotropic expansion of this contour. Each patient had seven plan variations created, with each rescaled to achieve the clinical planning goal for PTV coverage. All plan variations used the same field arrangement, and consisted of one dynamic conformal arc therapy (DCAT) plan, and six VMAT plans with varying degrees of modulation restriction, achieved through utilizing different combinations of the aperture shape controller (ASC) in the calculation parameters, and monitor unit (MU) objective during optimization. The dosimetric quality was assessed based on RTOG conformity indices (CI100/CI50), as well as adherence to dose–volume metrics used clinically at our institution. Plan complexity was assessed based on the modulation factor (MU/cGy) and the field edge metric. While VMAT plans with the least modulation restriction achieved the best dosimetry, it was found that there was no clinically significant trade‐off in terms of dose to organs at risk and conformity by reducing complexity. Furthermore, it was found that utilizing the ASC and MU objective could reduce plan complexity to near‐DCAT levels with improved dosimetry, which may be sufficiently robust to overcome the interplay effect.

IMRT dose verification considering passing rate and respiratory motion

The aim of the present study was to investigate the association between the dynamic intensity-modulated radiation therapy planned γ analysis passing rate and respiratory amplitude (A) and period (T) for different tumor volumes. A total of 30 patients with malignant lung tumors were divided into three groups: A; B; and C. The average tumor volumes (V) in the A, B and C groups were 635, 402 and 213 cm³, respectively. The simulated A values were set at 0, 5, 10, 15, 20 and 25 mm. The T values were set at 4, 5 and 6 sec. The γ analysis passing rate was calculated under different conditions (dose difference, 3%; distance difference, 3 mm). Compared with the γ analysis passing rate in the A group (A=0, static; T=4, 5, 6 sec), the γ analysis passing rate deviation (A=5 mm) was <3.3%. However, this difference was not statistically significant (P>0.05). With a gradual increase in A value, the passing rate decreased. The deviation between the 3 groups was <2.5% at the same A value (T=4, 5 and 6 sec). A descending trend of passing rate with increased A value was revealed. At the same A and T values, the passing rate decreased with decreased tumor volume. At the same tumor volume, the passing rate decreased when the A value increased. The respiratory cycle was not demonstrated to be associated with the passing rate. Overall, these results suggest that the A value should be controlled in clinical radiotherapy.