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Sreejeev AT, Joseph D, Krishnan AS, Pasricha R, Gupta S, Ahuja R, Sharma N, Sikdar D, Raut S, Sasi A, Gupta M. Weekly assessment of volumetric and dosimetric changes during volumetric modulated arc therapy of locally advanced head and neck carcinoma: Implications for adaptive radiation therapy-A prospective study. Head Neck 2024; 46:1547-1556. [PMID: 38436506 DOI: 10.1002/hed.27710] [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: 11/06/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Chemoradiation in head and neck carcinoma (HNC) shows significant anatomical resulting in erroneous dose deposition in the target or the organ at risk (OAR). Adaptive radiotherapy (ART) can overcome this. Timing of significant target and OAR changes with dosimetric impact; thus, most suitable time and frequency of ART is unclear. METHODS This dosimetric study used prospective weekly non-contrast CT scans in 12 HNC patients (78 scans). OARs and TVs were manually contoured after registration with simulation scan. Dose overlay done on each scan without reoptimization. Dosimetric and volumetric variations assessed. RESULTS Commonest site was oropharynx. Gross Tumor Volume (GTV) reduced from 47.5 ± 19.2 to 17.8 ± 10.7 cc. Nodal GTV reduced from 15.7 ± 18.8 to 4.7 ± 7.1 cc. Parotid showed mean volume loss of 35%. T stage moderately correlated with GTV regression. CONCLUSION Maximum GTV changes occurred after 3 weeks. Best time to do single fixed interval ART would be by the end of 3 weeks.
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Affiliation(s)
| | - Deepa Joseph
- Department of Radiation Oncology, AIIMS, Rishikesh, India
| | - Ajay S Krishnan
- Department of Radiation Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Centre, Varanasi, India
| | | | - Sweety Gupta
- Department of Radiation Oncology, AIIMS, Rishikesh, India
| | - Rachit Ahuja
- Department of Radiation Oncology, Shri Mahant Indiresh Hospital, Dehradun, India
| | - Nidhi Sharma
- Department of Radiation Oncology, AIIMS, Rishikesh, India
| | | | - Sagar Raut
- Department of Radiation Oncology, AIIMS, Rishikesh, India
| | | | - Manoj Gupta
- Department of Radiation Oncology, AIIMS, Rishikesh, India
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Simopoulou F, Kyrgias G, Georgakopoulos I, Avgousti R, Armpilia C, Skarlos P, Softa V, Theodorou K, Kouloulias V, Zygogianni A. Does adaptive radiotherapy for head and neck cancer favorably impact dosimetric, clinical, and toxicity outcomes?: A review. Medicine (Baltimore) 2024; 103:e38529. [PMID: 38941415 DOI: 10.1097/md.0000000000038529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
PURPOSE The current review aims to summarize the international experience of the impact of adaptive radiotherapy on dosimetry and clinical and toxicity outcomes. Additionally, it might trigger Radiation Oncologists to use ART and evaluate whether ART improves target volume coverage and/or normal tissue sparing and, consequently, therapeutic results. MATERIALS AND METHODS We conducted an electronic literature search of PubMed/MEDLINE and ScienceDirect from January 2007 to January 2023. The search adhered to the PRISMA guidelines and employed keywords such as ART, HNC, parotid gland, and target volume. Furthermore, we examined the reference lists for studies pertinent to the present review. This study included both retrospective and prospective studies that were considered for inclusion. CONCLUSION ART replanning appears to be a sustainable strategy to minimize toxicity by improving normal tissue sparing. Furthermore, it can enhance target volume coverage by correctly determining the specific dose to be delivered to the tumor. In conclusion, this review confirmed that ART benefits dosimetric, clinical/therapeutic, and toxicity outcomes.
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Affiliation(s)
- Foteini Simopoulou
- Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
| | - George Kyrgias
- Radiation Oncology Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioannis Georgakopoulos
- Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
| | - Rafaela Avgousti
- Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
| | - Christina Armpilia
- Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
| | - Pantelis Skarlos
- Radiation Oncology Department, Metropolitan Hospital, Piraeus, Greece
| | - Vasiliki Softa
- Medical Physics Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Kiki Theodorou
- Medical Physics Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vassilis Kouloulias
- Radiation Oncology Unit, 2nd Department of Radiology, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
| | - Anna Zygogianni
- Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens (NKUOA), Athens, Greece
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Ghosh Laskar S, Sinha S, Kumar A, Samanta A, Mohanty S, Kale S, Khan F, Lewis Salins S, Murthy V. Reducing Salivary Toxicity with Adaptive Radiotherapy (ReSTART): A Randomized Controlled Trial Comparing Conventional IMRT to Adaptive IMRT in Head and Neck Squamous Cell Carcinomas. Clin Oncol (R Coll Radiol) 2024; 36:353-361. [PMID: 38575432 DOI: 10.1016/j.clon.2024.03.015] [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: 12/16/2023] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The utility of Adaptive Radiotherapy (ART) in Head and Neck Squamous Cell Carcinoma (HNSCC) remains to be ascertained. While multiple retrospective and single-arm prospective studies have demonstrated its efficacy in decreasing parotid doses and reducing xerostomia, adequate randomized evidence is lacking. METHODS AND ANALYSIS ReSTART (Reducing Salivary Toxicity with Adaptive Radiotherapy) is an ongoing phase III randomized trial of patients with previously untreated, locally advanced HNSCC of the oropharynx, larynx, and hypopharynx. Patients are randomized in a 1:1 ratio to the standard Intensity Modulated Radiotherapy (IMRT) arm {Planning Target Volume (PTV) margin 5 mm} vs. Adaptive Radiotherapy arm (standard IMRT with a PTV margin 3 mm, two planned adaptive planning at 10th and 20th fractions). The stratification factors include the primary site and nodal stage. The RT dose prescribed is 66Gy in 30 fractions for high-risk PTV and 54Gy in 30 fractions for low-risk PTV over six weeks, along with concurrent chemotherapy. The primary endpoint is to compare salivary toxicity between arms using salivary scintigraphy 12 months' post-radiation. To detect a 25% improvement in the primary endpoint at 12 months in the ART arm with a two-sided 5% alpha value and a power of 80% (and 10% attrition ratio), a sample size of 130 patients is required (65 patients in each arm). The secondary endpoints include acute and late toxicities, locoregional control, disease-free survival, overall survival, quality of life, and xerostomia scores between the two arms. DISCUSSION The ReSTART trial aims to answer an important question in Radiation Therapy for HNSCC, particularly in a resource-limited setting. The uniqueness of this trial, compared to other ongoing randomized trials, includes the PTV margins and the xerostomia assessment by scintigraphy at 12 months as the primary endpoint.
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Affiliation(s)
- S Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - A Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - A Samanta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Mohanty
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Kale
- Department of Medical Physics, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - F Khan
- Clinical Research Secretariat (CRS), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Lewis Salins
- Department of Radiation Oncology, Kasturba Medical College, Manipal, India.
| | - V Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
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Nuyts S, Bollen H, Eisbruch A, Strojan P, Mendenhall WM, Ng SP, Ferlito A. Adaptive radiotherapy for head and neck cancer: Pitfalls and possibilities from the radiation oncologist's point of view. Cancer Med 2024; 13:e7192. [PMID: 38650546 PMCID: PMC11036082 DOI: 10.1002/cam4.7192] [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: 01/11/2024] [Revised: 03/19/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with head and neck cancer (HNC) may experience substantial anatomical changes during the course of radiotherapy treatment. The implementation of adaptive radiotherapy (ART) proves effective in managing the consequent impact on the planned dose distribution. METHODS This narrative literature review comprehensively discusses the diverse strategies of ART in HNC and the documented dosimetric and clinical advantages associated with these approaches, while also addressing the current challenges for integration of ART into clinical practice. RESULTS AND CONCLUSION Although based on mainly non-randomized and retrospective trials, there is accumulating evidence that ART has the potential to reduce toxicity and improve quality of life and tumor control in HNC patients treated with RT. However, several questions remain regarding accurate patient selection, the ideal frequency and timing of replanning, and the appropriate way for image registration and dose calculation. Well-designed randomized prospective trials, with a predetermined protocol for both image registration and dose summation, are urgently needed to further investigate the dosimetric and clinical benefits of ART.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of OncologyKU LeuvenLeuvenBelgium
- Department of Radiation OncologyLeuven Cancer Institute, University Hospitals LeuvenLeuvenBelgium
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of OncologyKU LeuvenLeuvenBelgium
- Department of Radiation OncologyLeuven Cancer Institute, University Hospitals LeuvenLeuvenBelgium
| | - Avrahram Eisbruch
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Primoz Strojan
- Department of Radiation Oncology Institute of OncologyUniversity of LjubljanaLjubljanaSlovenia
| | - William M. Mendenhall
- Department of Radiation OncologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Sweet Ping Ng
- Department of Radiation OncologyOlivia Newton‐John Cancer and Wellness Centre, Austin HealthMelbourneAustralia
| | - Alfio Ferlito
- Coordinator International Head and Neck Scientific GroupUdineItaly
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Gan Y, Langendijk JA, van der Schaaf A, van den Bosch L, Oldehinkel E, Lin Z, Both S, Brouwer CL. An efficient strategy to select head and neck cancer patients for adaptive radiotherapy. Radiother Oncol 2023; 186:109763. [PMID: 37353058 DOI: 10.1016/j.radonc.2023.109763] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND AND PURPOSE Adaptive radiotherapy (ART) is workload intensive but only benefits a subgroup of patients. We aimed to develop an efficient strategy to select candidates for ART in the first two weeks of head and neck cancer (HNC) radiotherapy. MATERIALS AND METHODS This study retrospectively enrolled 110 HNC patients who underwent modern photon radiotherapy with at least 5 weekly in-treatment re-scan CTs. A semi auto-segmentation method was applied to obtain the weekly mean dose (Dmean) to OARs. A comprehensive NTCP-profile was applied to obtain NTCP's. The difference between planning and actual values of Dmean (ΔDmean) and dichotomized difference of clinical relevance (BIOΔNTCP) were used for modelling to determine the cut-off maximum ΔDmean of OARs in week 1 and 2 (maxΔDmean_1 and maxΔDmean_2). Four strategies to select candidates for ART, using cut-off maxΔDmean were compared. RESULTS The Spearman's rank correlation test showed significant positive correlation between maxΔDmean and BIOΔNTCP (p-value <0.001). For major BIOΔNTCP (>5%) of acute and late toxicity, 10.9% and 4.5% of the patients were true candidates for ART. Strategy C using both cut-off maxΔDmean_1 (3.01 and 5.14 Gy) and cut-off maxΔDmean_2 (3.41 and 5.30 Gy) showed the best sensitivity, specificity, positive and negative predictive values (0.92, 0.82, 0.38, 0.99 for acute toxicity and 1.00, 0.92, 0.38, 1.00 for late toxicity, respectively). CONCLUSIONS We propose an efficient selection strategy for ART that is able to classify the subgroup of patients with >5% BIOΔNTCP for late toxicity using imaging in the first two treatment weeks.
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Affiliation(s)
- Yong Gan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands; Shantou University, Cancer Hospital of Shantou University Medical College, Department of Radiotherapy, China.
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Arjen van der Schaaf
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Lisa van den Bosch
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Edwin Oldehinkel
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Zhixiong Lin
- Shantou University, Cancer Hospital of Shantou University Medical College, Department of Radiotherapy, China
| | - Stefan Both
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Charlotte L Brouwer
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
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Castelli J, Thariat J, Benezery K, Hasbini A, Gery B, Berger A, Liem X, Guihard S, Chapet S, Thureau S, Auberdiac P, Pommier P, Ruffier A, Perrier L, Devillers A, Campillo-Gimenez B, de Crevoisier R. Weekly Adaptive Radiotherapy vs Standard Intensity-Modulated Radiotherapy for Improving Salivary Function in Patients With Head and Neck Cancer: A Phase 3 Randomized Clinical Trial. JAMA Oncol 2023; 9:1056-1064. [PMID: 37261806 PMCID: PMC10236337 DOI: 10.1001/jamaoncol.2023.1352] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/08/2023] [Indexed: 06/02/2023]
Abstract
Importance Xerostomia is a major toxic effect associated with intensity-modulated radiotherapy (IMRT) for oropharyngeal cancers. Objective To assess whether adaptive radiotherapy (ART) improves salivary function compared with IMRT in patients with head and neck cancer. Design, Setting, and Participants This phase 3 randomized clinical trial was conducted in 11 French centers. Patients aged 18 to 75 years with stage III-IVB squamous cell oropharyngeal cancer treated with chemoradiotherapy were enrolled between July 5, 2013, and October 1, 2018. Data were analyzed from November 2021 to May 2022. Interventions The patients were randomly assigned (1:1) to receive standard IMRT (without replanning) or ART (systematic weekly replanning). Main Outcomes and Measures The primary end point was the frequency of xerostomia, measured by stimulating salivary flow with paraffin. Secondary end points included salivary gland excretory function measured using technetium-99m pertechnetate scintigraphy, patient-reported outcomes (Eisbruch xerostomia-specific questionnaire and the MD Anderson Symptom Inventory for Head and Neck Cancer questionnaire), early and late toxic effects, disease control, and overall and cancer-specific survival. Results A total of 132 patients were randomized, and after 1 exclusion in the ART arm, 131 were analyzed: 66 in the ART arm (mean [SD] age at inclusion, 60 [8] years; 57 [86.4%] male) and 65 in the standard IMRT arm (mean [SD] age at inclusion, 60 [8] years; 57 [87.7%] male). The median follow-up was 26.4 months (IQR, 1.2-31.3 months). The mean (SD) salivary flow (paraffin) at 12 months was 630 (450) mg/min in the ART arm and 584 (464) mg/min in the standard arm (P = .64). The mean (SD) excretory function of the parotid gland at 12 months, measured by scintigraphy, improved in the ART arm (48% [17%]) compared with the standard arm (41% [17%]) (P = .02). The 2-year-overall survival was 76.9% (95% CI, 64.7%-85.4%) in both arms. Conclusions and Relevance This randomized clinical trial did not demonstrate a benefit of ART in decreasing xerostomia compared with standard IMRT. No significant differences were found in secondary end points except for parotid gland excretory function, as assessed by scintigraphy, or in survival rates. Trial Registration ClinicalTrials.gov Identifier: NCT01874587.
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Affiliation(s)
- Joël Castelli
- University of Rennes, CLCC Eugène Marquis, Inserm, LTSI–UMR 1099, Rennes, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, Normandie Universite, Caen, France
| | - Karen Benezery
- Department of Radiotherapy, Centre Antoine Lacassagne, Nice, France
| | - Ali Hasbini
- Radiotherapy, Clinique Pasteur-Lanroze, Brest, France
| | - Bernard Gery
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, Normandie Universite, Caen, France
| | - Antoine Berger
- Department of Radiotherapy, CHU Poitiers, Poitiers, France
| | - Xavier Liem
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Center, Lille, France
| | - Sébastien Guihard
- Department of Radiotherapy, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Sophie Chapet
- Department of Radiotherapy, CHU Tours, Tours, France
| | | | | | - Pascal Pommier
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | | | - Lionel Perrier
- University Lyon, Léon Bérard Cancer Centre, Lyon, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
| | | | - Renaud de Crevoisier
- University of Rennes, CLCC Eugène Marquis, Inserm, LTSI–UMR 1099, Rennes, France
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Suwanraksa C, Bridhikitti J, Liamsuwan T, Chaichulee S. CBCT-to-CT Translation Using Registration-Based Generative Adversarial Networks in Patients with Head and Neck Cancer. Cancers (Basel) 2023; 15:cancers15072017. [PMID: 37046678 PMCID: PMC10093508 DOI: 10.3390/cancers15072017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Recently, deep learning with generative adversarial networks (GANs) has been applied in multi-domain image-to-image translation. This study aims to improve the image quality of cone-beam computed tomography (CBCT) by generating synthetic CT (sCT) that maintains the patient’s anatomy as in CBCT, while having the image quality of CT. As CBCT and CT are acquired at different time points, it is challenging to obtain paired images with aligned anatomy for supervised training. To address this limitation, the study incorporated a registration network (RegNet) into GAN during training. RegNet can dynamically estimate the correct labels, allowing supervised learning with noisy labels. The study developed and evaluated the approach using imaging data from 146 patients with head and neck cancer. The results showed that GAN trained with RegNet performed better than those trained without RegNet. Specifically, in the UNIT model trained with RegNet, the mean absolute error (MAE) was reduced from 40.46 to 37.21, the root mean-square error (RMSE) was reduced from 119.45 to 108.86, the peak signal-to-noise ratio (PSNR) was increased from 28.67 to 29.55, and the structural similarity index (SSIM) was increased from 0.8630 to 0.8791. The sCT generated from the model had fewer artifacts and retained the anatomical information as in CBCT.
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Franzese C, Tomatis S, Bianchi SP, Pelizzoli M, Teriaca MA, Badalamenti M, Comito T, Clerici E, Franceschini D, Navarria P, Di Cristina L, Dei D, Galdieri C, Reggiori G, Mancosu P, Scorsetti M. Adaptive Volumetric-Modulated Arc Radiation Therapy for Head and Neck Cancer: Evaluation of Benefit on Target Coverage and Sparing of Organs at Risk. Curr Oncol 2023; 30:3344-3354. [PMID: 36975467 PMCID: PMC10047863 DOI: 10.3390/curroncol30030254] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Radiotherapy is essential in the management of head–neck cancer. During the course of radiotherapy, patients may develop significant anatomical changes. Re-planning with adaptive radiotherapy may ensure adequate dose coverage and sparing of organs at risk. We investigated the consequences of adaptive radiotherapy on head–neck cancer patients treated with volumetric-modulated arc radiation therapy compared to simulated non-adaptive plans: Materials and methods: We included in this retrospective dosimetric analysis 56 patients treated with adaptive radiotherapy. The primary aim of the study was to analyze the dosimetric differences with and without an adaptive approach for targets and organs at risk, particularly the spinal cord, parotid glands, oral cavity and larynx. The original plan (OPLAN) was compared to the adaptive plan (APLAN) and to a simulated non-adaptive dosimetric plan (DPLAN). Results: The non-adaptive DPLAN, when compared to OPLAN, showed an increased dose to all organs at risk. Spinal cord D2 increased from 27.91 (21.06–31.76) Gy to 31.39 (27.66–38.79) Gy (p = 0.00). V15, V30 and V45 of the DPLAN vs. the OPLAN increased by 20.6% (p = 0.00), 14.78% (p = 0.00) and 15.55% (p = 0.00) for right parotid; and 16.25% (p = 0.00), 18.7% (p = 0.00) and 20.19% (p = 0.00) for left parotid. A difference of 36.95% was observed in the oral cavity V40 (p = 0.00). Dose coverage was significantly reduced for both CTV (97.90% vs. 99.96%; p = 0.00) and PTV (94.70% vs. 98.72%; p = 0.00). The APLAN compared to the OPLAN had similar values for all organs at risk. Conclusions: The adaptive strategy with re-planning is able to avoid an increase in dose to organs at risk and better target coverage in head–neck cancer patients, with potential benefits in terms of side effects and disease control.
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Affiliation(s)
- Ciro Franzese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-0282247454
| | - Stefano Tomatis
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Sofia Paola Bianchi
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marco Pelizzoli
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Maria Ausilia Teriaca
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marco Badalamenti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Tiziana Comito
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Elena Clerici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Luciana Di Cristina
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Damiano Dei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Carmela Galdieri
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Giacomo Reggiori
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Pietro Mancosu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
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Chophy A, Gupta S, Singh P, Sharma N, Krishnan AS, Namitha RS, Roushan R, Rastogi A, Nair S, Diundi A, Raju MC, Joseph D, Gupta M. Evaluation of dosimetric and volumetric changes in target volumes and organs at risk during adaptive radiotherapy in head and neck cancer: A prospective study. J Med Imaging Radiat Sci 2023; 54:306-311. [PMID: 36868903 DOI: 10.1016/j.jmir.2023.02.005] [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: 01/09/2023] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND During radiation therapy for head and neck malignancies, most patients experience significant anatomical alterations due to loss of weight, changes in tumor volumes, and immobilization issues. Adaptive radiotherapy adapts to the patient's actual anatomy through repetitive imaging and replanning. In the present study, dosimetric and volumetric changes in target volumes and organs at risk during adaptive radiotherapy in head and neck cancer was evaluated. MATERIAL AND METHODS Thirty-four locally advanced Head and neck carcinoma patients with histologically proven Squamous Cell Carcinoma for curative treatment were included. Rescan was done at the end of 20 fractions of treatment. All quantitative data were analyzed with paired t-Test and Wilcoxon Signed Rank (Z) test. RESULTS Most patients had oropharyngeal carcinoma (52.9%). There were significant volumetric changes in all the parameters - GTV-primary (10.95, p < 0.001), GTV- nodal (5.81, p = 0.001), PTV High Risk (26.1, p < 0.001), PTV - Intermediate Risk (46.9, p = 0.006), PTV - Low Risk (43.9, p = 0.003), lateral neck diameter (0.9, p < 0.001), right parotid volumes (6.36, p < 0.001) and left parotid volumes (4.93, p < 0.001). Dosimetric changes in the organs at risk were non-significant. CONCLUSION Adaptive replanning has been seen to be labour intensive. However, the changes in the volumes of both target and the OARs credit a mid-treatment replanning to be done. Long term follow-up is required to assess locoregional control after adaptive radiotherapy in head and neck cancer.
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Affiliation(s)
- Atokali Chophy
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Sweety Gupta
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India.
| | - Pragya Singh
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Nidhi Sharma
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | | | - R S Namitha
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Ravi Roushan
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Aviral Rastogi
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Sharanya Nair
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Arvind Diundi
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Merin C Raju
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Deepa Joseph
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
| | - Manoj Gupta
- 6th Level, Medical College Block, Department of Radiation Oncology, AIIMS Rishikesh, India
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Evaluation and risk factors of volume and dose differences of selected structures in patients with head and neck cancer treated on Helical TomoTherapy by using Deformable Image Registration tool. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2022. [DOI: 10.2478/pjmpe-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
Introduction: The aim of this study was the evaluation of volume and dose differences in selected structures in patients with head and neck cancer during treatment on Helical TomoTherapy (HT) using a commercially available deformable image registration (DIR) tool. We attempted to identify anatomical and clinical predictive factors for significant volume changes probability.
Material and methods: According to our institutional protocol, we retrospectively evaluated the group of 20 H&N cancer patients treated with HT who received Adaptive Radiotherapy (ART) due to soft tissue alterations spotted on daily MVCT. We compared volumes on initial computed tomography (iCT) and replanning computed tomography (rCT) for clinical target volumes (CTV) – CTV1 (the primary tumor) and CTV2 (metastatic lymph nodes), parotid glands (PG) and body contour (B-body). To estimate the planned and delivered dose discrepancy, the dose from the original plan was registered and deformed to create a simulation of dose distribution on rCT (DIR-rCT).
Results: The decision to replan was made at the 4th week of RT (N = 6; 30%). The average volume reduction in parotid right PG[R] and left PG[L] was 4.37 cc (18.9%) (p < 0.001) and 3.77 cc (16.8%) (p = 0.004), respectively. In N = 13/20 cases, the delivered dose was greater than the planned dose for PG[R] of mean 3 Gy (p < 0.001), and in N = 6/20 patients for PG[L] the mean of 3.6 Gy (p = 0.031). Multivariate regression analysis showed a very strong predictor explaining 88% (R2 = 0.88) and 83% (R2 = 0.83) of the variance based on the mean dose of iPG[R] and iPG[L] (p < 0.001), respectively. No statistically significant correlation between volume changes and risk factors was found.
Conclusions: Dosimetric changes to the target demonstrated the validity of replanning. A DIR tool can be successfully used for dose deformation and ART qualification, significantly reducing the workload of radiotherapy centers. In addition, the mean dose for PG was a significant predictor that may indicate the need for a replan.
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Bak B, Skrobala A, Adamska A, Kazmierska J, Jozefacka N, Piotrowski T, Malicki J. Criteria for Verification and Replanning Based on the Adaptive Radiotherapy Protocol "Best for Adaptive Radiotherapy" in Head and Neck Cancer. Life (Basel) 2022; 12:722. [PMID: 35629389 PMCID: PMC9144703 DOI: 10.3390/life12050722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
No clear criteria have yet been established to guide decision-making for patient selection and the optimal timing of adaptive radiotherapy (ART) based on image-guided radiotherapy (IGRT). We have developed a novel protocol—the Best for Adaptive Radiotherapy (B-ART) protocol—to guide patient selection for ART. The aim of the present study is to describe this protocol, to evaluate its validity in patients with head and neck (HN) cancer, and to identify the anatomical and clinical predictors of the need for replanning. We retrospectively evaluated 82 patients with HN cancer who underwent helical tomotherapy (HT) and subsequently required replanning due to soft tissue changes upon daily MVCT. Under the proposed criteria, patients with anatomical changes >3 mm on three to four consecutive scans are candidates for ART. We compared the volumes on the initial CT scan (iCT) and the replanning CT (rCT) scan for the clinical target volumes (CTV1, referring to primary tumor or tumor bed and CTV2, metastatic lymph nodes) and for the parotid glands (PG) and body contour (B-body). The patients were stratified by primary tumor localization, clinical stage, and treatment scheme. The main reasons for replanning were: (1) a planning target volume (PTV) outside the body contour (n = 70; 85.4%), (2) PG shrinkage (n = 69; 84.1%), (3) B-body deviations (n = 69; 84.1%), and (4) setup deviations (n = 40; 48.8%). The replanning decision was made, on average, during the fourth week of treatment (n = 47; 57.3%). The mean reductions in the size of the right and left PG volumes were 6.31 cc (20.9%) and 5.98 cc (20.5%), respectively (p < 0.001). The reduction in PG volume was ≥30% in 30 patients (36.6%). The volume reduction in all of the anatomical structures was statistically significant. Four variables—advanced stage disease (T3−T4), chemoradiation, increased weight loss, and oropharyngeal localization—were significantly associated with the need for ART. The B-ART protocol provides clear criteria to eliminate random errors, and to allow for an early response to relevant changes in target volumes.
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Affiliation(s)
- Bartosz Bak
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Radiotherapy II, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Agnieszka Skrobala
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Anna Adamska
- Department and Radiotherapy Ward I, Greater Poland Cancer Centre, 61-866 Poznan, Poland;
| | - Joanna Kazmierska
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Radiotherapy II, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Natalia Jozefacka
- Institute of Psychology, Pedagogical University in Krakow, 30-084 Krakow, Poland;
| | - Tomasz Piotrowski
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Julian Malicki
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
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Bak B, Skrobala A, Adamska A, Malicki J. What information can we gain from performing adaptive radiotherapy of head and neck cancer patients from the past 10 years? Cancer Radiother 2021; 26:502-516. [PMID: 34772603 DOI: 10.1016/j.canrad.2021.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 01/10/2023]
Abstract
The aim of the review was to present the current literature status about replanning regarding anatomical and dosimetric changes in the target and OARs in the head and neck region during radiotherapy, to discuss and to analyze factors influencing the decision for adaptive radiotherapy of head and neck cancer patients. Significant progress has been made in head and neck patients' evaluation and qualification for adapted radiotherapy over the past ten years. Many factors leading to anatomical and dosimetric changes during treatment have been identified. Based on the literature, the most common factors triggering re-plan are weight loss, tumor and nodal changes, and parotid glands shrinkage. The fluctuations in dose distribution in the clinical area are significant predictive factors for patients' quality of life and the possibility of recovery. It has been shown that re-planning influence clinical outcomes: local control, disease free survival and overall survival. Regarding literature studies, it seems that adaptive radiotherapy would be the most beneficial for tumors of immense volume or those in the nearest proximity of the OARs. All researchers agree that the timing of re-planning is a crucial challenge, and there are still no clear consensus guidelines for time or criteria of re-planning. Nowadays, thanks to significant technological progress, the decision is mostly made based on observation and supported with IGRT verification. Although further research is still needed, adaptive strategies are evolving and now became the state of the art of modern radiotherapy.
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Affiliation(s)
- B Bak
- Radiotherapy Department II, Greater Poland Cancer Center, Poznan, Poland; Department of Electroradiology, University of Medical Science, Poznan, Poland.
| | - A Skrobala
- Department of Electroradiology, University of Medical Science, Poznan, Poland; Department of Medical Physics, Greater Poland Cancer Center, Poznan, Poland
| | - A Adamska
- Radiotherapy Ward I and Department I, Greater Poland Cancer Center, Poznan, Poland
| | - J Malicki
- Department of Electroradiology, University of Medical Science, Poznan, Poland
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13
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Adaptive radiation therapy: When, how and what are the benefits that literature provides? Cancer Radiother 2021; 26:622-636. [PMID: 34688548 DOI: 10.1016/j.canrad.2021.08.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To identify from the current literature when is the right time to replan and to assign thresholds for the optimum process of replanning. Nowadays, adaptive radiotherapy (ART) for head and neck cancer plays an exceptional role consisting of an evaluation procedure of the prominent anatomical and dosimetric variations. By performing complex radiotherapy methods, the credibility of the therapeutic result is crucial. Image guided radiotherapy (IGRT) was developed to ensure locoregional control and thus changes that might occur during radiotherapy be dealt with. MATERIALS AND METHODS An electronic research of articles published in PubMed/MEDLINE and Science Direct databases from January 2004 to October 2020 was performed. Among a total of 127 studies assessed for eligibility, 85 articles were ultimately retained for the review. RESULTS The most noticeable changes have been reported in the middle fraction of the treatment. Therefore, the suggested optimal time to replan is between the third and the fourth week. Anatomical deviations>1cm in the external contour, average weight loss>10%, violation in the dose coverage of the targets>5%, and violation in the dose of the peripherals were some of the thresholds that are currently used, and which lead to replanning. CONCLUSION ART may decrease toxicity and improve local-control. Whether it is beneficial or not, depends ultimately on each patient. However, more investigation of the changes should be performed in future prospective studies to obtain more accurate results.
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Schaly B, Kempe J, Venkatesan V, Mitchell S, Chen J. Alert system for monitoring changes in patient anatomy during radiation therapy of head and neck cancer. J Appl Clin Med Phys 2021; 22:168-174. [PMID: 34302421 PMCID: PMC8364268 DOI: 10.1002/acm2.13342] [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: 02/11/2021] [Revised: 05/20/2021] [Accepted: 06/05/2021] [Indexed: 01/29/2023] Open
Abstract
The purpose of this study is to validate a previously developed algorithm for alerting clinicians when to consider re-CT simulation due to changes in the patient's anatomy during radiation therapy of head and neck cancer. Cone beam computed tomography (CBCT) data were collected prospectively for 77 patients. Each CBCT was mathematically compared to a reference CBCT using the gamma index. We defined the match quality parameter (MQP) as an indicator of CBCT image similarity, where a negative MQP value indicates a poorer CBCT match than the match between the first two CBCT acquired during treatment. If three consecutive MQP values were below a chosen threshold, an "alert" is triggered to indicate action required, for example, possible re-CT simulation. The timing of image review requests made by the radiation therapists and any re-CT/re-plan decisions were documented for each patient's treatment course. The MQP for each patient (including any re-plans) was calculated in a manner that was blinded from the clinical process. The MQP as a function of fraction number was compared to actual clinical decisions in the treatment progress to evaluate alert system performance. There was a total of 93 plans (including re-plans) with 34 positives (action required) and 59 negatives (no action required). The sensitivity of the alert system was 0.76 and the false positive rate was 0.37. Only 1 case out of the 34 positive cases would have been missed by both the alert system and our clinical process. Despite the false negatives and false positives, analysis of the timing of alert triggers showed that the alert system could have resulted in seven fewer clinical misses. The alert system has the potential to be a valuable tool to complement human judgment and to provide a quality assurance safeguard to help improve the delivery of radiation treatment of head and neck cancer.
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Affiliation(s)
- Bryan Schaly
- Physics & Engineering Department, London Regional Cancer Program, London, ON, Canada
| | - Jeff Kempe
- Physics & Engineering Department, London Regional Cancer Program, London, ON, Canada
| | - Varagur Venkatesan
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Sylvia Mitchell
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Jeff Chen
- Departments of Oncology and Medical Biophysics, Western University, London, ON, Canada
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Delaby N, Martin S, Barateau A, Henry O, Perichon N, De Crevoisier R, Chajon E, Castelli J, Lafond C. Implementation of an optimization method for parotid gland sparing during inverse planning for head and neck cancer radiotherapy. Cancer Radiother 2020; 24:28-37. [PMID: 32007370 DOI: 10.1016/j.canrad.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE To guide parotid gland (PG) sparing at the dose planning step, a specific model based on overlap between PTV and organ at risk (Moore et al.) was developed and evaluated for VMAT in head-and-neck (H&N) cancer radiotherapy. MATERIALS AND METHODS One hundred and sixty patients treated for locally advanced H&N cancer were included. A model optimization was first performed (20 patients) before a model evaluation (110 patients). Thirty cases were planned with and without the model to quantify the PG dose sparing. The inter-operator variability was evaluated on one case, planned by 12 operators with and without the model. The endpoints were PG mean dose (Dmean), PTV homogeneity and number of monitor units (MU). RESULTS The PG Dmean predicted by the model was reached in 89% of cases. Using the model significantly reduced the PG Dmean: -6.1±4.3Gy. Plans with the model showed lower PTV dose homogeneity and more MUs (+10.5% on average). For the inter-operator variability, PG dose volume histograms without the optimized model were significantly different compared to those with the model; the Dmean standard deviation for the ipsilateral PG decreased from 2.2Gy to 1.2Gy. For the contralateral PG, this value decreased from 2.9Gy to 0.8Gy. CONCLUSION During the H&N inverse planning, the optimized model guides to the lowest PG achievable mean dose, allowing a significant PG mean dose reduction of -6.1Gy. Integrating this method at the treatment-planning step significantly reduced the inter-patient and inter-operator variabilities.
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Affiliation(s)
- N Delaby
- Centre Eugène Marquis, Unité de Physique Médicale, rue de La Bataille Flandres Dunkerque, CS 44229, 35042 Rennes Cedex, France.
| | - S Martin
- Centre Eugène Marquis, Département de Radiothérapie, rue de La Bataille Flandres Dunkerque, CS 44229, 35042 Rennes Cedex, France
| | - A Barateau
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, 35000 Rennes, France
| | - O Henry
- Centre Eugène Marquis, Unité de Physique Médicale, rue de La Bataille Flandres Dunkerque, CS 44229, 35042 Rennes Cedex, France
| | - N Perichon
- Centre Eugène Marquis, Unité de Physique Médicale, rue de La Bataille Flandres Dunkerque, CS 44229, 35042 Rennes Cedex, France
| | - R De Crevoisier
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, 35000 Rennes, France
| | - E Chajon
- Centre Eugène Marquis, Département de Radiothérapie, rue de La Bataille Flandres Dunkerque, CS 44229, 35042 Rennes Cedex, France
| | - J Castelli
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, 35000 Rennes, France
| | - C Lafond
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, 35000 Rennes, France
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Morgan HE, Sher DJ. Adaptive radiotherapy for head and neck cancer. CANCERS OF THE HEAD & NECK 2020; 5:1. [PMID: 31938572 PMCID: PMC6953291 DOI: 10.1186/s41199-019-0046-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022]
Abstract
Background Although there have been dramatic improvements in radiotherapy for head and neck squamous cell carcinoma (HNSCC), including robust intensity modulation and daily image guidance, these advances are not able to account for inherent structural and spatial changes that may occur during treatment. Many sources have reported volume reductions in the primary target, nodal volumes, and parotid glands over treatment, which may result in unintended dosimetric changes affecting the side effect profile and even efficacy of the treatment. Adaptive radiotherapy (ART) is an exciting treatment paradigm that has been developed to directly adjust for these changes. Main body Adaptive radiotherapy may be divided into two categories: anatomy-adapted (A-ART) and response-adapted ART (R-ART). Anatomy-adapted ART is the process of re-planning patients based on structural and spatial changes occurring over treatment, with the intent of reducing overdosage of sensitive structures such as the parotids, improving dose homogeneity, and preserving coverage of the target. In contrast, response-adapted ART is the process of re-planning patients based on response to treatment, such that the target and/or dose changes as a function of interim imaging during treatment, with the intent of dose escalating persistent disease and/or de-escalating surrounding normal tissue. The impact of R-ART on local control and toxicity outcomes is actively being investigated in several currently accruing trials. Conclusions Anatomy-adapted ART is a promising modality to improve rates of xerostomia and coverage in individuals who experience significant volumetric changes during radiation, while R-ART is currently being studied to assess its utility in either dose escalation of radioresistant disease, or de-intensification of surrounding normal tissue following treatment response. In this paper, we will review the existing literature and recent advances regarding A-ART and R-ART.
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Affiliation(s)
- Howard E Morgan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Rd, Dallas, TX 75390 USA
| | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Rd, Dallas, TX 75390 USA
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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician. Semin Radiat Oncol 2019; 29:258-273. [PMID: 31027643 DOI: 10.1016/j.semradonc.2019.02.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."
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Sun L, Kirkby C, Smith W. Dosimetric effect of body contour changes for prostate and head and neck volumetric modulated arc therapy plans. J Appl Clin Med Phys 2019; 20:115-124. [PMID: 30927323 PMCID: PMC6448168 DOI: 10.1002/acm2.12571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/01/2019] [Accepted: 02/23/2019] [Indexed: 12/25/2022] Open
Abstract
Body contour changes are commonly seen in prostate and head and neck (H&N) patients undergoing volumetric modulated arc therapy (VMAT) treatments, which may cause a discrepancy between the planned dose and the delivered dose. Dosimetrists, radiation oncologists or medical physicists sometimes are required to visually assess the dosimetric impact of body contour changes and make a judgment call on whether further re‐assessment of the plan is needed. However, an intuitive judgment cannot always be made in a timely manner due to the complexity of VMAT plans as well as the complicated forms of body contour changes. This study evaluated the dosimetric effect of body contour changes for prostate and H&N patients to help with clinical decision‐making. By analyzing the one‐dimensional spatial dose profiles from the original body and the body with different body contour deformations, rules of thumb for dose percentage change and isodose line shift due to body contour changes were ascertained. Moreover, based on dose distribution comparison using three‐dimensional gamma analysis, the response of the clinical prostate and H&N VMAT plans to body contour changes was assessed. Within center specific dose deviation tolerances, prostate patients who had less than 2 cm single side body contour change or less than 1 cm uniform body contour change were unlikely to need plan re‐assessment; H&N VMAT plans with less than 1 cm uniform body contour change or less than 1 cm shoulder superior–inferior positional change were also unlikely to trigger further evaluation. Dose percentage change and isodose line shift were considered independently from the problem of volume changes in this study, but clinically, both aspects must be considered.
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Affiliation(s)
- Lingyue Sun
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, T2N 1N4, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, T2N 4N2, Canada
| | - Charles Kirkby
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, T2N 1N4, Canada.,Department of Oncology, University of Calgary, Calgary, AB, T2N 1N4, Canada.,Department of Medical Physics, Jack Ady Cancer Centre, Lethbridge, AB, T1J 1W5, Canada
| | - Wendy Smith
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, T2N 1N4, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, T2N 4N2, Canada.,Department of Oncology, University of Calgary, Calgary, AB, T2N 1N4, Canada
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Castelli J, Simon A, Lafond C, Perichon N, Rigaud B, Chajon E, De Bari B, Ozsahin M, Bourhis J, de Crevoisier R. Adaptive radiotherapy for head and neck cancer. Acta Oncol 2018; 57:1284-1292. [PMID: 30289291 DOI: 10.1080/0284186x.2018.1505053] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Large anatomical variations can be observed during the treatment course intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC), leading to potential dose variations. Adaptive radiotherapy (ART) uses one or several replanning sessions to correct these variations and thus optimize the delivered dose distribution to the daily anatomy of the patient. This review, which is focused on ART in the HNC, aims to identify the various strategies of ART and to estimate the dosimetric and clinical benefits of these strategies. MATERIAL AND METHODS We performed an electronic search of articles published in PubMed/MEDLINE and Science Direct from January 2005 to December 2016. Among a total of 134 articles assessed for eligibility, 29 articles were ultimately retained for the review. Eighteen studies evaluated dosimetric variations without ART, and 11 studies reported the benefits of ART. RESULTS Eight in silico studies tested a number of replanning sessions, ranging from 1 to 6, aiming primarily to reduce the dose to the parotid glands. The optimal timing for replanning appears to be early during the first two weeks of treatment. Compared to standard IMRT, ART decreases the mean dose to the parotid gland from 0.6 to 6 Gy and the maximum dose to the spinal cord from 0.1 to 4 Gy while improving target coverage and homogeneity in most studies. Only five studies reported the clinical results of ART, and three of those studies included a non-randomized comparison with standard IMRT. These studies suggest a benefit of ART in regard to decreasing xerostomia, increasing quality of life, and increasing local control. Patients with the largest early anatomical and dose variations are the best candidates for ART. CONCLUSION ART may decrease toxicity and improve local control for locally advanced HNC. However, randomized trials are necessary to demonstrate the benefit of ART before using the technique in routine practice.
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Affiliation(s)
- J. Castelli
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - A. Simon
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - C. Lafond
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - N. Perichon
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - B. Rigaud
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - E. Chajon
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - B. De Bari
- Radiotherapy Department, CHU Jean-Minjoz, Besançon, France
| | - M. Ozsahin
- Radiotherapy Department, Lausanne University Hospital, Lausanne, Switzerland
| | - J. Bourhis
- Radiotherapy Department, Lausanne University Hospital, Lausanne, Switzerland
| | - R. de Crevoisier
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
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Castelli J, Simon A, Rigaud B, Chajon E, Thariat J, Benezery K, Vauleon E, Jegoux F, Henry O, Lafond C, de Crevoisier R. Adaptive radiotherapy in head and neck cancer is required to avoid tumor underdose. Acta Oncol 2018; 57:1267-1270. [PMID: 29706107 DOI: 10.1080/0284186x.2018.1468086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- J. Castelli
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- Université de Rennes 1, LTSI, Campus de Beaulieu, Rennes, France
- INSERM, U1099, Campus de Beaulieu, Rennes, France
| | - A. Simon
- Université de Rennes 1, LTSI, Campus de Beaulieu, Rennes, France
- INSERM, U1099, Campus de Beaulieu, Rennes, France
| | - B. Rigaud
- Université de Rennes 1, LTSI, Campus de Beaulieu, Rennes, France
- INSERM, U1099, Campus de Beaulieu, Rennes, France
| | - E. Chajon
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - J. Thariat
- Radiotherapy Department, Centre François Baclesse, Caen, France
| | - K. Benezery
- Radiotherapy Department, Centre Antoine Lacassagne, Nice, France
| | - E. Vauleon
- Department of Oncology, Centre Eugene Marquis, Rennes, France
| | - F. Jegoux
- Head and Neck Department, CHU Rennes, Rennes, France
| | - O. Henry
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - C. Lafond
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- Université de Rennes 1, LTSI, Campus de Beaulieu, Rennes, France
- INSERM, U1099, Campus de Beaulieu, Rennes, France
| | - R. de Crevoisier
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- Université de Rennes 1, LTSI, Campus de Beaulieu, Rennes, France
- INSERM, U1099, Campus de Beaulieu, Rennes, France
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