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Gonzalez BD, Choo S, Janssen JJ, Hazelton J, Latifi K, Leach CR, Bailey S, Jim HS, Oswald LB, Woolverton M, Murphy M, Schilowitz EL, Frakes JM, Robinson EJ, Hoffe S. Novel Virtual Reality App for Training Patients on MRI-guided Radiation Therapy. Adv Radiat Oncol 2024; 9:101477. [PMID: 38681889 PMCID: PMC11043805 DOI: 10.1016/j.adro.2024.101477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/09/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Patients receiving respiratory gated magnetic resonance imaging-guided radiation therapy (MRIgRT) for abdominal targets must hold their breath for ≥25 seconds at a time. Virtual reality (VR) has shown promise for improving patient education and experience for diagnostic MRI scan acquisition. We aimed to develop and pilot-test the first VR app to educate, train, and reduce anxiety and discomfort in patients preparing to receive MRIgRT. Methods and Materials A multidisciplinary team iteratively developed a new VR app with patient input. The app begins with minigames to help orient patients to using the VR device and to train patients on breath-holding. Next, app users are introduced to the MRI linear accelerator vault and practice breath-holding during MRIgRT. In this quality improvement project, clinic personnel and MRIgRT-eligible patients with pancreatic cancer tested the VR app for feasibility, acceptability, and potential efficacy for training patients on using breath-holding during MRIgRT. Results The new VR app experience was tested by 19 patients and 67 clinic personnel. The experience was completed on average in 18.6 minutes (SD = 5.4) by patients and in 14.9 (SD = 3.5) minutes by clinic personnel. Patients reported the app was "extremely helpful" (58%) or "very helpful" (32%) for learning breath-holding used in MRIgRT and "extremely helpful" (28%) or "very helpful (50%) for reducing anxiety. Patients and clinic personnel also provided qualitative feedback on improving future versions of the VR app. Conclusion The VR app was feasible and acceptable for training patients on breath-holding for MRIgRT. Patients eligible for MRIgRT for pancreatic cancer and clinic personnel reported on future improvements to the app to enhance its usability and efficacy.
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Affiliation(s)
- Brian D. Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Sylvia Choo
- Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | | | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | | | - Shannon Bailey
- Morsani College of Medicine, University of South Florida, Tampa, FL
- Center for Advanced Medical Learning and Simulation, University of South Florida, Tampa, FL
| | - Heather S.L. Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Laura B. Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | | | | | | | | | | | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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2
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Rong Y, Chen Q, Fu Y, Yang X, Al-Hallaq HA, Wu QJ, Yuan L, Xiao Y, Cai B, Latifi K, Benedict SH, Buchsbaum JC, Qi XS. NRG Oncology Assessment of Artificial Intelligence Deep Learning-Based Auto-segmentation for Radiation Therapy: Current Developments, Clinical Considerations, and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:261-280. [PMID: 37972715 PMCID: PMC11023777 DOI: 10.1016/j.ijrobp.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 09/16/2023] [Accepted: 10/14/2023] [Indexed: 11/19/2023]
Abstract
Deep learning neural networks (DLNN) in Artificial intelligence (AI) have been extensively explored for automatic segmentation in radiotherapy (RT). In contrast to traditional model-based methods, data-driven AI-based models for auto-segmentation have shown high accuracy in early studies in research settings and controlled environment (single institution). Vendor-provided commercial AI models are made available as part of the integrated treatment planning system (TPS) or as a stand-alone tool that provides streamlined workflow interacting with the main TPS. These commercial tools have drawn clinics' attention thanks to their significant benefit in reducing the workload from manual contouring and shortening the duration of treatment planning. However, challenges occur when applying these commercial AI-based segmentation models to diverse clinical scenarios, particularly in uncontrolled environments. Contouring nomenclature and guideline standardization has been the main task undertaken by the NRG Oncology. AI auto-segmentation holds the potential clinical trial participants to reduce interobserver variations, nomenclature non-compliance, and contouring guideline deviations. Meanwhile, trial reviewers could use AI tools to verify contour accuracy and compliance of those submitted datasets. In recognizing the growing clinical utilization and potential of these commercial AI auto-segmentation tools, NRG Oncology has formed a working group to evaluate the clinical utilization and potential of commercial AI auto-segmentation tools. The group will assess in-house and commercially available AI models, evaluation metrics, clinical challenges, and limitations, as well as future developments in addressing these challenges. General recommendations are made in terms of the implementation of these commercial AI models, as well as precautions in recognizing the challenges and limitations.
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Affiliation(s)
- Yi Rong
- Mayo Clinic Arizona, Phoenix, AZ
| | - Quan Chen
- City of Hope Comprehensive Cancer Center Duarte, CA
| | - Yabo Fu
- Memorial Sloan Kettering Cancer Center, Commack, NY
| | | | | | | | - Lulin Yuan
- Virginia Commonwealth University, Richmond, VA
| | - Ying Xiao
- University of Pennsylvania/Abramson Cancer Center, Philadelphia, PA
| | - Bin Cai
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Stanley H Benedict
- University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | | | - X Sharon Qi
- University of California Los Angeles, Los Angeles, CA
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Naghavi AO, Bryant JM, Kim Y, Weygand J, Redler G, Sim AJ, Miller J, Coucoules K, Michael LT, Gloria WE, Yang G, Rosenberg SA, Ahmed K, Bui MM, Henderson-Jackson EB, Lee A, Lee CD, Gonzalez RJ, Feygelman V, Eschrich SA, Scott JG, Torres-Roca J, Latifi K, Parikh N, Costello J. Habitat escalated adaptive therapy (HEAT): a phase 2 trial utilizing radiomic habitat-directed and genomic-adjusted radiation dose (GARD) optimization for high-grade soft tissue sarcoma. BMC Cancer 2024; 24:437. [PMID: 38594603 PMCID: PMC11003059 DOI: 10.1186/s12885-024-12151-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS), have significant inter- and intra-tumoral heterogeneity, with poor response to standard neoadjuvant radiotherapy (RT). Achieving a favorable pathologic response (FPR ≥ 95%) from RT is associated with improved patient outcome. Genomic adjusted radiation dose (GARD), a radiation-specific metric that quantifies the expected RT treatment effect as a function of tumor dose and genomics, proposed that STS is significantly underdosed. STS have significant radiomic heterogeneity, where radiomic habitats can delineate regions of intra-tumoral hypoxia and radioresistance. We designed a novel clinical trial, Habitat Escalated Adaptive Therapy (HEAT), utilizing radiomic habitats to identify areas of radioresistance within the tumor and targeting them with GARD-optimized doses, to improve FPR in high-grade STS. METHODS Phase 2 non-randomized single-arm clinical trial includes non-metastatic, resectable high-grade STS patients. Pre-treatment multiparametric MRIs (mpMRI) delineate three distinct intra-tumoral habitats based on apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) sequences. GARD estimates that simultaneous integrated boost (SIB) doses of 70 and 60 Gy in 25 fractions to the highest and intermediate radioresistant habitats, while the remaining volume receives standard 50 Gy, would lead to a > 3 fold FPR increase to 24%. Pre-treatment CT guided biopsies of each habitat along with clip placement will be performed for pathologic evaluation, future genomic studies, and response assessment. An mpMRI taken between weeks two and three of treatment will be used for biological plan adaptation to account for tumor response, in addition to an mpMRI after the completion of radiotherapy in addition to pathologic response, toxicity, radiomic response, disease control, and survival will be evaluated as secondary endpoints. Furthermore, liquid biopsy will be performed with mpMRI for future ancillary studies. DISCUSSION This is the first clinical trial to test a novel genomic-based RT dose optimization (GARD) and to utilize radiomic habitats to identify and target radioresistance regions, as a strategy to improve the outcome of RT-treated STS patients. Its success could usher in a new phase in radiation oncology, integrating genomic and radiomic insights into clinical practice and trial designs, and may reveal new radiomic and genomic biomarkers, refining personalized treatment strategies for STS. TRIAL REGISTRATION NCT05301283. TRIAL STATUS The trial started recruitment on March 17, 2022.
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Affiliation(s)
- Arash O Naghavi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| | - J M Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Youngchul Kim
- Department of Bioinformatics and Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joseph Weygand
- Department of Radiation Oncology and Applied Sciences, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Austin J Sim
- Department of Radiation Oncology, James Cancer Hospital, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Justin Miller
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kaitlyn Coucoules
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Lauren Taylor Michael
- Clinical Trials Office, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Warren E Gloria
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - George Yang
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Stephen A Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kamran Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marilyn M Bui
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Andrew Lee
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Caitlin D Lee
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ricardo J Gonzalez
- Department of Sarcoma, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Steven A Eschrich
- Department of Bioinformatics and Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jacob G Scott
- Translational Hematology and Oncology Research, Radiation Oncology Department, Cleveland Clinic, Cleveland, OH, USA
| | - Javier Torres-Roca
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nainesh Parikh
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Costello
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Mills M, Miller J, Liveringhouse C, Bryant JM, Kawahara Y, Feygelman V, Latifi K, Yang G, Johnstone PA, Naghavi AO. Novel Postoperative Hypofractionated Accelerated Radiation Dose-Painting Approach for Soft Tissue Sarcoma. Adv Radiat Oncol 2024; 9:101391. [PMID: 38495036 PMCID: PMC10943519 DOI: 10.1016/j.adro.2023.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/21/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Hypofractionated radiation therapy (RT) offers benefits in the treatment of soft tissue sarcomas (STS), including exploitation of the lower α/β, patient convenience, and cost. This study evaluates the acute toxicity of a hypofractionated accelerated RT dose-painting (HARD) approach for postoperative treatment of STS. Methods and Materials This is a retrospective review of 53 consecutive patients with STS who underwent resection followed by postoperative RT. Standard postoperative RT dosing for R0/R1/gross disease with sequential boost (50 Gy + 14/16/20 Gy in 32-35 fractions) were replaced with dose-painting, which adapts dose based on risk of disease burden, to 50.4 and 63, 64.4, 70 Gy in 28 fractions, respectively. The first 10 patients were replanned with a sequential boost RT approach and dosimetric indices were compared. Time-to-event outcomes, including local control, regional control, distant control, and overall survival, were estimated with Kaplan-Meier analysis. Results Median follow-up was 25.2 months. Most patients had high-grade (59%) STS of the extremity (63%) who underwent resection with either R1 (40%) or close (36%) margins. Four patients experienced grade 3 acute dermatitis which resolved by the 3-month follow-up visit. The 2-year local control, regional control, distant control, and overall survival were 100%, 92%, 68%, and 86%, respectively. Compared with the sequential boost plan, HARD had a significantly lower field size (total V50 Gy; P = .002), bone V50 (P = .031), and maximum skin dose (P = .008). Overall treatment time was decreased by 4 to 7 fractions, which translated to a decrease in estimated average treatment cost of $3056 (range, $2651-$4335; P < .001). Conclusions In addition to benefits in cost, convenience, and improved biologic effect in STS, HARD regimen offers a safe treatment approach with dosimetric advantages compared with conventional sequential boost, which may translate to improved long-term toxicity.
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Affiliation(s)
- Matthew Mills
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Justin Miller
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Casey Liveringhouse
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - John M. Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Yuki Kawahara
- University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - George Yang
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Peter A. Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Arash O. Naghavi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Koo J, Caudell J, Latifi K, Moros EG, Feygelman V. Essentially unedited deep-learning-based OARs are suitable for rigorous oropharyngeal and laryngeal cancer treatment planning. J Appl Clin Med Phys 2024; 25:e14202. [PMID: 37942993 DOI: 10.1002/acm2.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
Quality of organ at risk (OAR) autosegmentation is often judged by concordance metrics against the human-generated gold standard. However, the ultimate goal is the ability to use unedited autosegmented OARs in treatment planning, while maintaining the plan quality. We tested this approach with head and neck (HN) OARs generated by a prototype deep-learning (DL) model on patients previously treated for oropharyngeal and laryngeal cancer. Forty patients were selected, with all structures delineated by an experienced physician. For each patient, a set of 13 OARs were generated by the DL model. Each patient was re-planned based on original targets and unedited DL-produced OARs. The new dose distributions were then applied back to the manually delineated structures. The target coverage was evaluated with inhomogeneity index (II) and the relative volume of regret. For the OARs, Dice similarity coefficient (DSC) of areas under the DVH curves, individual DVH objectives, and composite continuous plan quality metric (PQM) were compared. The nearly identical primary target coverage for the original and re-generated plans was achieved, with the same II and relative volume of regret values. The average DSC of the areas under the corresponding pairs of DVH curves was 0.97 ± 0.06. The number of critical DVH points which met the clinical objectives with the dose optimized on autosegmented structures but failed when evaluated on the manual ones was 5 of 896 (0.6%). The average OAR PQM score with the re-planned dose distributions was essentially the same when evaluated either on the autosegmented or manual OARs. Thus, rigorous HN treatment planning is possible with OARs segmented by a prototype DL algorithm with minimal, if any, manual editing.
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Affiliation(s)
- Jihye Koo
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Physics, University of South Florida, Tampa, Florida, USA
| | - Jimmy Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Vladimir Feygelman
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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6
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Nasser N, Perez BA, Penagaricano JA, Caudell JJ, Oliver DE, Latifi K, Moros EG, Redler G. Technical feasibility of novel immunostimulatory low-dose radiation for polymetastatic disease with CBCT-based online adaptive and conventional approaches. J Appl Clin Med Phys 2024:e14303. [PMID: 38377378 DOI: 10.1002/acm2.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/15/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
PURPOSE A workflow/planning strategy delivering low-dose radiation therapy (LDRT) (1 Gy) to all polymetastatic diseases using conventional planning/delivery (Raystation/Halcyon = "conventional") and the AI-based Ethos online adaptive RT (oART) platform is developed/evaluated. METHODS Using retrospective data for ten polymetastatic non-small cell lung cancer patients (5-52 lesions each) with PET/CTs, gross tumor volumes (GTVs) were delineated using PET standardized-uptake-value (SUV) thresholding. A 1 cm uniform expansion of GTVs to account for setup/contour uncertainty and organ motion-generated planning target volumes (PTVs). Dose optimization/calculation used the diagnostic CT from PET/CT. Dosimetric objectives were: Dmin,0.03cc ≥ 95% (acceptable variation (Δ) ≥ 90%), V100% ≥ 95% (Δ ≥ 90%), and D0.03cc ≤ 120% (Δ ≤ 125%). Additionally, online adaptation was simulated. When available, subsequent diagnostic CT was used to represent on-treatment CBCT. Otherwise, the CT from PET/CT used for initial planning was deformed to simulate clinically representative changes. RESULTS All initial plans generated, both for Raystation and Ethos, achieved clinical goals within acceptable variation. For all patients, Dmin,0.03cc ≥ 95%, V100% ≥ 95%, and D0.03cc ≤ 120% goals were achieved for 84.8%/99.5%, 97.7%/98.7%, 97.4%/92.3%, in conventional/Ethos plans, respectively. The ratio of 50% isodose volume to PTV volume (R50% ), maximum dose at 2 cm from PTV (D2cm ), and the ratio of the 100% isodose volume to PTV volume (conformity index) in Raystation/Ethos plans were 7.9/5.9; 102.3%/88.44%; and 0.99/1.01, respectively. In Ethos, online adapted plans maintained PTV coverage whereas scheduled plans often resulted in geographic misses due to changes in tumor size, patient position, and body habitus. The average total duration of the oART workflow was 26:15 (min:sec) ranging from 6:43 to 57:30. The duration of each oART workflow step as a function of a number of targets showed a low correlation coefficient for influencer generation and editing (R2 = 0.04 and 0.02, respectively) and high correlation coefficient for target generation, target editing and plan generation (R2 = 0.68, 0.63 and 0.69, respectively). CONCLUSIONS This study demonstrates feasibility of conventional planning/treatment with Raystation/Halcyon and highlights efficiency gains when utilizing semi-automated planning/online-adaptive treatment with Ethos for immunostimulatory LDRT conformally delivered to all sites of polymetastatic disease.
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Affiliation(s)
- Nour Nasser
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Physics, University of South Florida, Tampa, Florida, USA
| | - Bradford A Perez
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jose A Penagaricano
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jimmy J Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Daniel E Oliver
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Gage Redler
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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7
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Liveringhouse C, Netzley A, Bryant JM, Linkowski LC, Weygand J, Sandoval ML, Dohm A, Dookhoo M, Kelley S, Rosenberg SA, Latifi K, Torres-Roca JF, Johnstone PA, Yamoah K, Grass GD. Trimodal Therapy Using an MR-guided Radiation Therapy Partial Bladder Tumor Boost in Muscle Invasive Bladder Cancer. Adv Radiat Oncol 2023; 8:101268. [PMID: 38047218 PMCID: PMC10692296 DOI: 10.1016/j.adro.2023.101268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/03/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Bladder preservation with trimodal therapy (TMT; maximal tumor resection followed by chemoradiation) is an effective paradigm for select patients with muscle invasive bladder cancer. We report our institutional experience of a TMT protocol using nonadaptive magnetic resonance imaging-guided radiation therapy (MRgRT) for partial bladder boost (PBB). Methods and Materials A retrospective analysis was performed on consecutive patients with nonmetastatic muscle invasive bladder cancer who were treated with TMT using MRgRT between 2019 and 2022. Patients underwent intensity modulated RT-based nonadaptive MRgRT PBB contoured on True fast imaging with steady state precession (FISP) images (full bladder) followed sequentially by computed tomography-based RT to the whole empty bladder and pelvic lymph nodes with concurrent chemotherapy. MRgRT treatment time, table shifts, and dosimetric parameters of target coverage and normal tissue exposure were described. Prospectively assessed acute and late genitourinary and gastrointestinal (GI) toxicity were reported. Two-year local control was assessed with Kaplan-Meier methods. Results Seventeen patients were identified for analysis. PBB planning target volume margins were ≤8 mm in 94% (n = 16) of cases. Dosimetric target coverage parameters were favorable and all normal tissue dose constraints were met. For MRgRT PBB fractions, median table shifts were 0.4 cm (range, 0-3.15), 0.45 cm (0-2.65), and 0.75 cm (0-4.8) in the X, Y, and Z planes, respectively. Median treatment time for MRgRT PBB fractions was 9 minutes (range, 6.9-17.4). We identified 32 out of 100 total MRgRT fractions that may have benefitted from online adaptation based on changes in organ position relative to planning target volume, predominantly because of small bowel (13/32, 41%) or rectum (8/32, 25%). Two patients discontinued RT prematurely. The incidence of highest-grade acute genitourinary toxicity was 1 to 2 (69%) and 3 (6%), whereas the incidence of acute GI toxicity was 1 to 2 (81%) and 3 (6%). There were no late grade 3 events; 17.6% had late grade 2 cystitis and none had late GI toxicity. With median follow-up of 18.2 months (95% CI, 12.4-22.5), the local control rate was 92%, and no patient has required salvage cystectomy. Conclusions Nonadaptive MRgRT PBB is feasible with favorable dosimetry and low resource utilization. Larger studies are needed to evaluate for potential benefits in toxicity and local control associated with this approach in comparison to standard treatment techniques.
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Affiliation(s)
- Casey Liveringhouse
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Alexander Netzley
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - John M. Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Joseph Weygand
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Maria L. Sandoval
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ammoren Dohm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marsha Dookhoo
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Stacey Kelley
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Javier F. Torres-Roca
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Peter A.S. Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - G. Daniel Grass
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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8
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Bryant JM, Doniparthi A, Weygand J, Cruz-Chamorro R, Oraiqat IM, Andreozzi J, Graham J, Redler G, Latifi K, Feygelman V, Rosenberg SA, Yu HHM, Oliver DE. Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions. Cancers (Basel) 2023; 15:5200. [PMID: 37958374 PMCID: PMC10649155 DOI: 10.3390/cancers15215200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Magnetic resonance imaging (MRI) provides excellent visualization of central nervous system (CNS) tumors due to its superior soft tissue contrast. Magnetic resonance-guided radiotherapy (MRgRT) has historically been limited to use in the initial treatment planning stage due to cost and feasibility. MRI-guided linear accelerators (MRLs) allow clinicians to visualize tumors and organs at risk (OARs) directly before and during treatment, a process known as online MRgRT. This novel system permits adaptive treatment planning based on anatomical changes to ensure accurate dose delivery to the tumor while minimizing unnecessary toxicity to healthy tissue. These advancements are critical to treatment adaptation in the brain and spinal cord, where both preliminary MRI and daily CT guidance have typically had limited benefit. In this narrative review, we investigate the application of online MRgRT in the treatment of various CNS malignancies and any relevant ongoing clinical trials. Imaging of glioblastoma patients has shown significant changes in the gross tumor volume over a standard course of chemoradiotherapy. The use of adaptive online MRgRT in these patients demonstrated reduced target volumes with cavity shrinkage and a resulting reduction in radiation dose to uninvolved tissue. Dosimetric feasibility studies have shown MRL-guided stereotactic radiotherapy (SRT) for intracranial and spine tumors to have potential dosimetric advantages and reduced morbidity compared with conventional linear accelerators. Similarly, dosimetric feasibility studies have shown promise in hippocampal avoidance whole brain radiotherapy (HA-WBRT). Next, we explore the potential of MRL-based multiparametric MRI (mpMRI) and genomically informed radiotherapy to treat CNS disease with cutting-edge precision. Lastly, we explore the challenges of treating CNS malignancies and special limitations MRL systems face.
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Affiliation(s)
- John Michael Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ajay Doniparthi
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA;
| | - Joseph Weygand
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ruben Cruz-Chamorro
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ibrahim M. Oraiqat
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jacqueline Andreozzi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jasmine Graham
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Daniel E. Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
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Liveringhouse C, Palm RF, Bryant JMM, Mills MN, Yang GQ, Latifi K, Naghavi AO. Association between Tumor Volume Change on MRI with Surgical Margin Status, Pathological Response, and Local Control Following Pre-Operative Radiation Therapy for Soft Tissue Sarcoma. Int J Radiat Oncol Biol Phys 2023; 117:e319. [PMID: 37785142 DOI: 10.1016/j.ijrobp.2023.06.2356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The clinical significance of radiographic progression during pre-operative radiation therapy (RT) for soft tissue sarcoma (STS) remains unclear. We sought to evaluate associations between radiographic change on T1 post-contrast (T1c) and T2 weighted magnetic resonance imaging (MRI) with percent pathological response (PR%), positive surgical margins (+SM), and local control (LC). MATERIALS/METHODS We retrospectively identified patients with STS undergoing neoadjuvant RT who had both pre- and post-RT MRI prior to surgical resection. Gross tumor volumes were contoured on pre- and post-RT T1c and T2 MRI sequences and relative change in volume from baseline was calculated. Radiographic classification was defined as response (>30% reduction), progression (>30% increase), or stable (≤30% reduction or ≤30% increase). Chi squared, Fishers Exact, and Kruskal Wallis (KW) tests were used to assess differences between groups. Linear and binary logistic regression models used to assess associations between MRI response and PR% and +SM, respectively. LC was modeled with Kaplan Meier methods and log rank tests. RESULTS A total of 68 STS patients were identified, with a median follow up of 49 months (range 7-229). With a median age of 60.5 years (25-88) and tumor size of 10.8cm (2.7-25.7), the most common histologies were undifferentiated pleomorphic sarcoma (UPS; 32.4%) and myxoid liposarcoma (ML; 16.2%), and were primarily grade 2-3 disease (89.7%). With a median RT dose of 50 Gy in 25 fractions (44-60Gy), the median radiographic volume change was 2% (-86.4 to 953.6%) and -2.1% (-89.6 to 962.5%) for T1c and T2, respectively. Radiographic classification of response/stable/progression was 25.4%/49.2%/25.4% and 27.9%/52.5%/19.7% for T1c and T2, respectively. Histology (ML vs. UPS) and grade (1 vs. 3) were predictors for radiographic response on both T1c (72.7% vs 18.8%, p = 0.03 and 71.4% vs. 10.4%, p = 0.03) and T2 (71.5% vs. 18.2%, p = 0.02 and 71.4% vs. 14.6%, p = 0.002), respectively. With 6 +SM (8.8%), the rate of +SM for response/stable/progression was 20%/10.3%/0% in T1c (p = 0.2) and 5.9%/12.5%/0% in T2 (p = 0.5). As a continuous variable, neither relative change on T1c (p = 0.2) or T2 (p = 0.4) were associated with +SM. With an overall median PR% of 64% (0-100%), the median PR% was significantly different for response/stable/progression for both T1c (95%/42%/73%, p = 0.02) and T2 (95%/50%/87.5%, p = 0.04). Radiographic change on neither T1c (p = 0.4) or T2 (p = 0.5) were associated with PR% on a continuous basis. With a total of 4 local recurrences, there was no significant difference in LC by radiographic classification on either T1c (p = 0.65) or T2 (p = 0.85). CONCLUSION While radiographic response may be correlated with pathological response, radiographic progression on either T1c or T2 following neoadjuvant RT was not associated with a detriment in surgical margins or local control. These findings suggest that STS radiographic "pseudoprogression" is not associated with worse outcome.
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Affiliation(s)
- C Liveringhouse
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - R F Palm
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - J M M Bryant
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - M N Mills
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - G Q Yang
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - K Latifi
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - A O Naghavi
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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10
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Singh P, Figura NB, Sawyer C, Latifi K, Oliver DE, Grass D, Johnstone PAS, Yamoah K, Frakes JM, Hoffe S, Palm RF. Adrenal Stereotactic Body Radiation Therapy: Do Dosimetric Factors Predict for Grade 2+ Lymphopenia? Int J Radiat Oncol Biol Phys 2023; 117:e151-e152. [PMID: 37784736 DOI: 10.1016/j.ijrobp.2023.06.972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Recent studies suggest improvement in outcomes in multiple oligometastatic tumor sites with immunotherapy (IO) and radiation therapy (RT). However, RT may induce lymphopenia that can be immunosuppressive and dosimetric consensus is lacking on parameters predicting grade ≥2 lymphopenia. In this study, we evaluated lymphopenia post receipt of stereotactic body RT (SBRT) for adrenal metastases to see if we could identify any modifiable treatment planning factors. MATERIALS/METHODS Patients with adrenal oligometastases who were treated with conventional SBRT or MRI-guided (MRgSBRT), had absolute lymphocyte count (ALC) and white blood cell count (WBC) data available within 6 weeks before and after their radiation treatment, and had contouring data available for review were included in this IRB approved retrospective study. Lymphopenia was graded for ALC as: Grade 1 (1.0-0.8 no/ul), Grade 2 (<0.8 - 0.5 no/ul), Grade 3 (<0.5-0.2 no/ul), Grade 4 (<0.2 no/ul). The vertebral bodies (VB), at the level of the planning treatment volume (PTV) and one above and below, and the spleen were contoured. Dosimetric variables of interest included spleen and VB mean dose (Gy) as well as V2.5-20 Gy in 2.5 Gy increments. Regression analyses were used to identify dosimetric variables associated with absolute and relative difference in ALC post-SBRT. RESULTS A total of 30 patients were identified with a slight male predominance (N = 17, 57%) and most commonly left adrenal (N = 17) versus right adrenal (N = 10, 33%) or bilateral metastases (N = 3, 10%). Grade 2+ lymphopenia was observed in N = 7 patients pre-SBRT (23%) and N = 17 patients post-SBRT (57%). N = 26 (87%) of the patients had previous chemotherapies and N = 17 (57%) had previous immunotherapy. Multiple primary tumor types were represented with the most common non-small cell lung cancer (N = 14, 47%), followed by melanoma (N = 4, 13%) and small cell lung cancer (N = 3, 10%). Most patients were treated with non-MRgSBRT (N = 19, 63%) vs MRgRT (N = 11, 37%) and all received SBRT in 5 fractions with median dose 50 Gy (Range: 25 - 60 Gy). The median pre-SBRT ALC was 1.13 (Range: 0.39 - 2.96) and median post-SBRT ALC was 0.72 (Range: 0.11 - 4.15). On linear regression analysis, there was no significant association between post SBRT ALC nor lymphopenia grade with splenic or vertebral body dose, treatment laterality, or SBRT dose. CONCLUSION In this retrospective series of predominately metastatic lung cancer patients treated with adrenal SBRT, we observed high rates of post SBRT grade 2+ lymphopenia, yet no dosimetric parameter was predictive, not even for left-sided lesions. Future work includes clinical validation of these findings in a larger population, likely with multi-institutional collaboration, and further study of the investigation of the IO/RT sequencing issues in such heavily pre-treated patients.
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Affiliation(s)
- P Singh
- USF Health Morsani College of Medicine, Tampa, FL
| | - N B Figura
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - C Sawyer
- H. Lee Moffitt Cancer Center & Research Institute, Department of Radiation Oncology, Tampa, FL; University of South Florida, Physics Department, Tampa, FL
| | - K Latifi
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - D E Oliver
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - D Grass
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - P A S Johnstone
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - J M Frakes
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - S Hoffe
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - R F Palm
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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11
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Choo S, Gonzalez B, Hazelton J, Robinson E, Mohan S, Leach C, Bailey SKT, Latifi K, Hoffe S. Toward Burnout Prevention: Can One Short Virtual Reality Relaxation and Mindfulness Training Session for Staff and Patients Decrease Stress and Improve Subjective Sense of Wellbeing? Int J Radiat Oncol Biol Phys 2023; 117:e507. [PMID: 37785590 DOI: 10.1016/j.ijrobp.2023.06.1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Mental wellness of healthcare workers has deteriorated recently, increasing burnout rates. Cancer patients are also often highly distressed, reporting fear, pain, and fatigue. Relaxation and mindfulness training have been shown to decrease stress and anxiety. Currently, the use of virtual reality (VR) for relaxation and mindfulness for cancer patients and oncology clinical staff is an ongoing area of research. We aimed to test the preliminary efficacy of incorporating an innovative digital therapeutic (DTx) we developed at our center in this population. MATERIALS/METHODS Cancer patients and clinic staff from one institution's Gastrointestinal and Radiation Oncology departments participated in the immersive VR-enhanced relaxation and mindfulness experience for this IRB-exempt study. Users completed a pre-VR survey via iPad assessing baseline knowledge and practice of stress reduction techniques, baseline stress, and familiarity with VR. In the VR app deployed on an Oculus Quest 2, users chose a relaxing water scene (e.g., stream, beach) and optional soothing background music. Users could also choose a relaxation or mindfulness training audio track. A post-VR survey assessed whether the experience affected their subjective stress and sense of wellbeing ("Yes" or "No") as well as the feasibility of using the app. A binomial test on a single proportion was used to test whether more participants (>50%) indicated their stress was reduced following the VR training than did not. Post-VR qualitative verbal feedback was also collected to identify future changes to the VR app. RESULTS Six patients, a patient's son, and forty-three employees used the VR app. Users were aged ≤ 30 years old (18%), 30-50 years (60%), and 50-70 years (22%). Users completed the VR experience in a median of 14 min (IQR: 11-19 min). In the pre-survey, most (78%) reported they felt stress at this point in their lives. In the post-survey, significantly more than the expected proportion of participants (>50%) reported feeling less stressed after using the VR app (88%, n = 44, p <0.001). Most (90%) reported that the VR app improved their subjective sense of wellbeing. All (100%) users reported it was easy to learn the VR controls. Nearly all (96%) reported they would be interested in using this VR app again, including 30% and 38% who reported they would be "extremely likely" and "very likely," respectively, to use the app again. CONCLUSION These findings suggest our VR relaxation and mindfulness training was well accepted and could be integrated into the hospital setting in short sessions. Further work should be done based on participant feedback to expand the offerings of this VR app to offer a wider range of relaxation experiences and gamified psychological interventions that can help de-stress, recharge, and build resiliency.
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Affiliation(s)
- S Choo
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - B Gonzalez
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - E Robinson
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - S Mohan
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - C Leach
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - S K T Bailey
- University of South Florida Morsani College of Medicine, Tampa, FL; Center for Advanced Medical Learning and Simulation, Tampa, FL
| | - K Latifi
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - S Hoffe
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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12
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Weygand J, Armstrong T, Bryant JM, Andreozzi JM, Oraiqat IM, Nichols S, Liveringhouse CL, Latifi K, Yamoah K, Costello JR, Frakes JM, Moros EG, El Naqa IM, Naghavi AO, Rosenberg SA, Redler G. Accurate, repeatable, and geometrically precise diffusion-weighted imaging on a 0.35 T magnetic resonance imaging-guided linear accelerator. Phys Imaging Radiat Oncol 2023; 28:100505. [PMID: 38045642 PMCID: PMC10692914 DOI: 10.1016/j.phro.2023.100505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/04/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Background and purpose Diffusion weighted imaging (DWI) allows for the interrogation of tissue cellularity, which is a surrogate for cellular proliferation. Previous attempts to incorporate DWI into the workflow of a 0.35 T MR-linac (MRL) have lacked quantitative accuracy. In this study, accuracy, repeatability, and geometric precision of apparent diffusion coefficient (ADC) maps produced using an echo planar imaging (EPI)-based DWI protocol on the MRL system is illustrated, and in vivo potential for longitudinal patient imaging is demonstrated. Materials and methods Accuracy and repeatability were assessed by measuring ADC values in a diffusion phantom at three timepoints and comparing to reference ADC values. System-dependent geometric distortion was quantified by measuring the distance between 93 pairs of phantom features on ADC maps acquired on a 0.35 T MRL and a 3.0 T diagnostic scanner and comparing to spatially precise CT images. Additionally, for five sarcoma patients receiving radiotherapy on the MRL, same-day in vivo ADC maps were acquired on both systems, one of which at multiple timepoints. Results Phantom ADC quantification was accurate on the 0.35 T MRL with significant discrepancies only seen at high ADC. Average geometric distortions were 0.35 (±0.02) mm and 0.85 (±0.02) mm in the central slice and 0.66 (±0.04) mm and 2.14 (±0.07) mm at 5.4 cm off-center for the MRL and diagnostic system, respectively. In the sarcoma patients, a mean pretreatment ADC of 910x10-6 (±100x10-6) mm2/s was measured on the MRL. Conclusions The acquisition of accurate, repeatable, and geometrically precise ADC maps is possible at 0.35 T with an EPI approach.
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Affiliation(s)
- Joseph Weygand
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | | | | | | | - Steven Nichols
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kosj Yamoah
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Jessica M. Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eduardo G. Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Issam M. El Naqa
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Machine Learning, Moffitt Cancer Center, Tampa, FL, USA
| | - Arash O. Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Gage Redler
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
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13
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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Lotey R, Latifi K, Moros EG, Feygelman V. Evaluation of an MRI linac magnetic isocenter walkout with gantry rotation in the presence of angle-specific corrections. Phys Med Biol 2023; 68. [PMID: 36958055 DOI: 10.1088/1361-6560/acc724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/23/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To reduce the magnetic isocenter position variation with gantry rotation on an 0.35 T MRI-guided linac to a practically negligible level.
Approach: Central frequency (CF) offset, eddy current calibration, cross-term calibration, gradient delay, and gradient offsets are tuned for each MR linac installation at every 30⁰ of gantry rotation and stored in a look-up table (LUT). During treatment, the CF is tuned only once in the beginning at an arbitrary gantry angle. After that, imaging paramters are offset based on the stored LUT values for any given gantry angle.
Main results: For the same hardware configuration, the implemenation of the gantry-angle-specific parameter corrections reduced the total isocenters range range of travel in the transverse plane from 1.1 to 0.3 mm and from 0.8 to 0.2 mm in horizontal and vetical directions, respectively. With the longitudinal shift always being negligible (≤0.2 mm), the radius of the sphere encompassing the isocenter locations was reduced from 0.6 to 0.2 mm. Geometric distortion improved as well; in particular, the gantry-angle-averaged maximum longitudinal distortion within a 35 cm diameter sphere was reduced from 1.4 to 0.8 mm. Since the CF is tuned only once during treatment, imaging may resume promptly after the gantry reaches the next target position.
Significance: The MRI-guided linear accelerator was conceived primarily as an instrument for precision image-guided therapy. Thus, it is important to keep the treatment and imaging isocentres as close as possible while minimizing the geometric distortion. The described solution reduces the walkout of the imaging isocenter to a small fraction of 1 mm, while keeping geometric distortion in a substantial volume below 1 mm. The approach is robust and does not increase the overall procedure time.
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Affiliation(s)
- Rajiv Lotey
- ViewRay Inc, 2 Thermo Fisher Way, Oakwood Village, Ohio, 44146, UNITED STATES
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, Florida, 33612, UNITED STATES
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, Florida, 33612, UNITED STATES
| | - Vladimir Feygelman
- Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, Florida, 33612, UNITED STATES
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15
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Sandoval ML, Sim AJ, Bryant JM, Bhandari M, Wuthrick EJ, Perez BA, Dilling TJ, Redler G, Andreozzi J, Nardella L, Feygelman V, Latifi K, Rosenberg SA. MR-Guided SBRT/Hypofractionated RT for Metastatic and Primary Central and Ultracentral Lung Lesions. JTO Clin Res Rep 2023; 4:100488. [PMID: 37159821 PMCID: PMC10163640 DOI: 10.1016/j.jtocrr.2023.100488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction The recent results from the Nordic-HILUS study indicate stereotactic body radiation therapy (SBRT) is associated with high-grade toxicity for ultracentral (UC) tumors. We hypothesized that magnetic resonance-guided SBRT (MRgSBRT) or hypofractionated radiation therapy (MRgHRT) enables the safe delivery of high-dose radiation to central and UC lung lesions. Methods Patients with UC or central lesions were treated with MRgSBRT/MRgHRT with real-time gating or adaptation. Central lesions were defined as per the Radiation Therapy Oncology Group and UC as per the HILUS study definitions: (1) group A or tumors less than 1 cm from the trachea and/or mainstem bronchi; or (2) group B or tumors less than 1 cm from the lobar bronchi. The Kaplan-Meier estimate and log-rank test were used to estimate survival. Associations between toxicities and other patient factors were tested using the Mann-Whitney U test and Fisher's exact test. Results A total of 47 patients were included with a median follow-up of 22.9 months (95% confidence interval: 16.4-29.4). Most (53%) had metastatic disease. All patients had central lesions and 55.3% (n = 26) had UC group A. The median distance from the proximal bronchial tree was 6.0 mm (range: 0.0-19.0 mm). The median biologically equivalent dose (α/β = 10) was 105 Gy (range: 75-151.2). The most common radiation schedule was 60 Gy in eight fractions (40.4%). Most (55%) had previous systemic therapy, 32% had immunotherapy and 23.4% had previous thoracic radiation therapy. There were 16 patients who underwent daily adaptation. The 1-year overall survival was 82% (median = not reached), local control 87% (median = not reached), and progression-free survival 54% (median = 15.1 mo, 95% confidence interval: 5.1-25.1). Acute toxicity included grade 1 (26%) and grade 2 (21%) with only two patients experiencing grade 3 (4.3%) in the long term. No grade 4 or 5 toxicities were seen. Conclusions Previous studies noted high rates of toxicity after SBRT to central and UC lung lesions, with reports of grade 5 toxicities. In our cohort, the use of MRgSBRT/MRgHRT with high biologically effective doses was well tolerated, with two grade 3 toxicities and no grade 4/5.
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Bryant JM, Sim AJ, Feygelman V, Latifi K, Rosenberg SA. Adaptive hypofractionted and stereotactic body radiotherapy for lung tumors with real-time MRI guidance. Front Oncol 2023; 13:1061854. [PMID: 36776319 PMCID: PMC9911810 DOI: 10.3389/fonc.2023.1061854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
The treatment of central and ultracentral lung tumors with radiotherapy remains an ongoing clinical challenge. The risk of Grade 5 toxicity with ablative radiotherapy doses to these high-risk regions is significant as shown in recent prospective studies. Magnetic resonance (MR) image-guided adaptive radiotherapy (MRgART) is a new technology and may allow the delivery of ablative radiotherapy to these high-risk regions safely. MRgART is able to achieve this by utilizing small treatment margins, real-time gating/tracking and on-table plan adaptation to maintain dose to the tumor but limit dose to critical structures. The process of MRgART is complex and has nuances and challenges for the treatment of lung tumors. We outline the critical steps needed for appropriate delivery of MRgART for lung tumors safely and effectively.
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Affiliation(s)
- John M. Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Austin J. Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States,Department of Radiation Oncology, Comprehensive Cancer Center – The James Cancer Hospital, Columbus, OH, United States
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States,*Correspondence: Stephen A. Rosenberg,
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Sim AJ, Hoffe SE, Latifi K, Palm RF, Feygelman V, Leuthold S, Dookhoo M, Dennett M, Rosenberg SA, Frakes JM. A Practical Workflow for Magnetic Resonance-Guided Stereotactic Body Radiation Therapy to the Pancreas. Pract Radiat Oncol 2023; 13:e45-e53. [PMID: 35901947 DOI: 10.1016/j.prro.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 01/10/2023]
Abstract
The increased adoption of stereotactic body radiation therapy has allowed for delivery of higher doses, potentially associated with better outcomes but at the risk of higher toxicity. The intimate association of radiosensitive organs at risk (eg, stomach, duodenum, bowel) has historically limited the delivery of ablative doses to the pancreas. The advent of magnetic resonance-guided radiation therapy with improved soft-tissue contrast allows for gated delivery without an internal target volume and online adaptive replanning to maximize the therapeutic ratio. Patient selection requires additional resources, including increased patient on-table time, physician time, and physics support. Within our center's workflow, integrating an educational video at consultation as well as optimizing biofeedback mechanisms have significantly improved the experience for our patients.
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Affiliation(s)
- Austin J Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Susan Leuthold
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marsha Dookhoo
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Maria Dennett
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Stephen A Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jessica M Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
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Keit E, Liveringhouse C, Figura N, Weygand J, Sandoval ML, Garcia G, Peters J, Nieder M, Faramand R, Khimani F, Kim S, Robinson TJ, Johnstone PAS, Penagaricano J, Latifi K. Feasibility and Toxicity of Full-Body Volumetric Modulated Arc Therapy Technique for High-Dose Total Body Irradiation. Technol Cancer Res Treat 2023; 22:15330338231180779. [PMID: 37287260 DOI: 10.1177/15330338231180779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Introduction: High-dose total body irradiation (TBI) is often part of myeloablative conditioning in acute leukemia. Modern volumetric modulated arc therapy (VMAT)-based plans employ arcs to the inferior-most portion of the body that can be simulated in a head-first position and use 2D planning for the inferior body which can result in heterogeneous doses. Here, we describe our institution's unique protocol for delivering high-dose TBI entirely with VMAT and retrospectively compare dosimetric outcomes with helical tomotherapy (HT) plans. Additionally, we describe our method of oropharyngeal mucosal sparing that was implemented after fatal mucositis occurred in two patients. Methods: Thirty-one patients were simulated and treated in head-first (HFS) and feet-first (FFS) orientations. Patients were treated with VMAT (n = 26) or HT (n = 5). In VMAT plans, to synchronize doses between the orientations, images were deformably registered and the HFS dose was transferred to the FFS plan and used as a background dose when optimizing plans. Six to eight isocenters with two arcs per isocenter were generated. HT was delivered with an established technique. Patients were treated to 13.2 Gy over eight twice daily fractions. Dosimetric outcomes and toxicities were retrospectively compared. Results: Prescription dose and organ at risk (OAR) constraints were met for all patients. Lower lung doses were achieved with VMAT relative to HT plans (7.4 vs 7.7 Gy, P = .009). Statistically significant improvement in mucositis was not achieved after adopting a mucosal-sparing technique, however lower doses to the oropharyngeal mucosal were achieved (6.9 vs 14.1 Gy, P = .009), and no further mucositis-related deaths occurred. Conclusions: This full-body VMAT method of TBI achieves dose goals, eliminates risk of heterogenous doses within the femur, and demonstrates that selective OAR sparing with the purpose of reducing TBI-related morbidity and mortality is possible at any institution with a VMAT-capable linear accelerator.
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Affiliation(s)
- Emily Keit
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Casey Liveringhouse
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nicholas Figura
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joseph Weygand
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Maria L Sandoval
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Genevieve Garcia
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Julia Peters
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael Nieder
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rawan Faramand
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Farhad Khimani
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sungjune Kim
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Timothy J Robinson
- Department of Therapeutic Radiology, Yale Cancer Center, New Haven, CT, USA
| | - Peter A S Johnstone
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jose Penagaricano
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Moffitt Cancer CenterLee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Pandey S, Kutuk T, Mills M, Abdalah M, Stringfield O, Latifi K, Moreno W, Ahmed K, Raghunand N. NIMG-01. PREDICTING POST-STEREOTACTIC RADIOTHERAPY MAGNETIC RESONANCE IMAGE OUTCOMES OF BREAST CANCER METASTASES TO THE BRAIN. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
Stereotactic radiosurgery (SRS) is a cornerstone in the management of Breast Cancer Metastases to the Brain (BCMB). While control rates are high following SRS, radiation necrosis is a rare but potentially devastating long-term toxicity. There is a clinical need for automated/semi-automated methods to assess tumor response and optimize the RT plans for local control with minimal long-term toxicity. Multiparametric MRI (mpMRI), particularly Apparent Diffusion Coefficient of water (ADC) maps, contain information that is mechanistically relatable to voxel-level tumor response to RT. We report a deep learning-based approach to predict post-SRS ADC maps, FLAIR, T2-weighted (T2W), T1-weighted unenhanced (T1W) and contrast-enhanced (T1WCE) images, from pre-SRS T1W, T1WCE, T2W and FLAIR images, ADC maps, and the delivered RT dose map. These “forward models” will enable the radiation oncologist to simulate radiologic outcomes and iteratively optimize RT plans for local control with minimal toxicity.
METHODS
We trained a variant of the pix2pix Generative Adversarial Network (GAN) on MRI and RT dose map data from 18 BCMB patients treated with stereotactic radiation with confirmed controlled and locally recurrent metastases. Patients were treated with stereotactic radiation dose of 1-40 Gy between 2013-2019.
RESULTS
On test data from 6 BCMB patients, the trained forward model predicted post-SRS ADC values within the Gross Tumor Volume (GTV) that were broadly in agreement with ground truth post-SRS ADC maps. In agreement with expectations, the forward model also predicts increasing post-RT ADC within the GTV with increasing simulated RT doses in the range of 1-71 Gy. We have also explored an inverse model to predict the RT dose map required to produce “prescribed” post-SRS ADC values within the GTV.
CONCLUSIONS
We envision that the forward models will assist the radiation oncologist in initial RT dose plan optimization, while the inverse model may be useful for daily RT plan optimization.
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Affiliation(s)
| | - Tugce Kutuk
- Miami Cancer Institute, Baptist Health South Florida , Miami, FL , USA
| | - Matthew Mills
- H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
| | - Mahmoud Abdalah
- H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
| | - Olya Stringfield
- H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
| | - Kujtim Latifi
- H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
| | | | - Kamran Ahmed
- H. Lee Moffitt Cancer Center & Research Institute , Tampa , USA
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Sandoval M, Youssef I, Latifi K, Grass D, Torres-Roca J, Rosenberg S, Yamoah K, Johnstone P. Clinical Outcomes of Prostate SBRT Using Non-Adaptive MR-Guided Radiotherapy (MRgRT). Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Bryant J, Bhandari M, Liveringhouse C, Weygand J, Cruz-Chamorro R, Sandoval M, Sim A, Frakes J, Redler G, Andreozzi J, Nardella L, Feygelman V, Latifi K, Rosenberg S. Online Adaptive MR-Guided Radiotherapy (MRgRT) in UltraCentral (UC) Lung Lesions: Cumulative Delivered Dose as Assessed with Rigid Fusion (RF) Analysis Shows Significant Improvement in Clinically Relevant Parameters. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.2268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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22
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Koo J, Caudell JJ, Latifi K, Jordan P, Shen S, Adamson PM, Moros EG, Feygelman V. Comparative evaluation of a prototype deep learning algorithm for autosegmentation of normal tissues in head and neck radiotherapy. Radiother Oncol 2022; 174:52-58. [PMID: 35817322 DOI: 10.1016/j.radonc.2022.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To introduce and validate a newly developed deep-learning (DL) auto-segmentation algorithm for head and neck (HN) organs at risk (OARs) and to compare its performance with a published commercial algorithm. METHODS A total of 864 HN cancer cases were available to train and evaluate a prototype algorithm. The algorithm is based on a fully convolutional network with combined U-Net and V-net. A Dice loss plus Cross-Entropy Loss function with Adam optimizer was used in training. For 75 validation cases, OAR sets were generated with three DL-based models (A: the prototype model trained with gold data, B: a commercial software trained with the same data, and C: the same software trained with data from another institution). The auto-segmented structures were evaluated with Dice similarity coefficient (DSC), Hausdorff distance (HD), voxel-penalty metric (VPM) and DSC of area under dose-volume histograms. A subjective qualitative evaluation was performed on 20 random cases. RESULTS Overall trend was for the prototype algorithm to be the closest to the gold data by all five metrics. The average DSC/VPM/HD for algorithms A, B, and C were 0.81/84.1/1.6 mm, 0.74/62.8/3.2 mm, and 0.66/46.8/3.3 mm, respectively. 93% of model A structures were evaluated to be clinically useful. CONCLUSION The superior performance of the prototype was validated, even when trained with the same data. In addition to the challenges of perfecting the algorithms, the auto-segmentation results can differ when the same algorithm is trained at different institutions.
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Affiliation(s)
- Jihye Koo
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA; Department of Physics, University of South Florida, FL, USA.
| | - Jimmy J Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA.
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA.
| | | | | | | | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA.
| | - Vladimir Feygelman
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA.
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Sandoval M, Sim A, Bhandari M, Wuthrick E, Perez B, Dilling T, Redler G, Andreozzi J, Nardella L, Feygelman V, Latifi K, Rosenberg S. OC-0421 MR-Guided SBRT/Hypofractionated RT for Metastatic and Primary Ultracentral and Central Lung Lesions. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02557-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weinfurtner RJ, Abdalah M, Stringfield O, Ataya D, Williams A, Mooney B, Rosa M, Lee MC, Khakpour N, Laronga C, Czerniecki B, Diaz R, Ahmed K, Washington I, Latifi K, Niell BL, Montejo M, Raghunand N. Quantitative Changes in Intratumoral Habitats on MRI Correlate With Pathologic Response in Early-stage ER/PR+ HER2- Breast Cancer Treated With Preoperative Stereotactic Ablative Body Radiotherapy. J Breast Imaging 2022; 4:273-284. [PMID: 36686407 PMCID: PMC9851176 DOI: 10.1093/jbi/wbac013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objective To quantitatively evaluate intratumoral habitats on dynamic contrast-enhanced (DCE) breast MRI to predict pathologic breast cancer response to stereotactic ablative body radiotherapy (SABR). Methods Participants underwent SABR treatment (28.5 Gy x3), baseline and post-SABR MRI, and breast-conserving surgery for ER/PR+ HER2- breast cancer. MRI analysis was performed on DCE T1-weighted images. MRI voxels were assigned eight habitats based on high (H) or low (L) maximum enhancement and the sequentially numbered dynamic sequence of maximum enhancement (H1-4, L1-4). MRI response was analyzed by percent tumor volume remaining (%VR = volume post-SABR/volume pre-SABR), and percent habitat makeup (%HM of habitat X = habitat X voxels/total voxels in the segmented volume). These were correlated with percent tumor bed cellularity (%TC) for pathologic response. Results Sixteen patients completed the trial. The %TC ranged 20%-80%. MRI %VR demonstrated strong correlations with %TC (Pearson R = 0.7-0.89). Pre-SABR tumor %HMs differed significantly from whole breasts (P = 0.005 to <0.00001). Post-SABR %HM of tumor habitat H4 demonstrated the largest change, increasing 13% (P = 0.039). Conversely, combined %HM for H1-3 decreased 17% (P = 0.006). This change correlated with %TC (P < 0.00001) and distinguished pathologic partial responders (≤70 %TC) from nonresponders with 94% accuracy, 93% sensitivity, 100% specificity, 100% positive predictive value, and 67% negative predictive value. Conclusion In patients undergoing preoperative SABR treatment for ER/PR+ HER2- breast cancer, quantitative MRI habitat analysis of %VR and %HM change correlates with pathologic response.
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Affiliation(s)
| | - Mahmoud Abdalah
- Moffitt Cancer Center, Quantitative Imaging Core, Tampa, Fl, USA
| | - Olya Stringfield
- Moffitt Cancer Center, Quantitative Imaging Core, Tampa, Fl, USA
| | - Dana Ataya
- Moffitt Cancer Center, Department of Radiology, Tampa, FL, USA
| | - Angela Williams
- Moffitt Cancer Center, Department of Radiology, Tampa, FL, USA
| | - Blaise Mooney
- Moffitt Cancer Center, Department of Radiology, Tampa, FL, USA
| | - Marilin Rosa
- Moffitt Cancer Center, Department of Pathology, Tampa, FL, USA
| | - Marie C Lee
- Moffitt Cancer Center, Department of Surgery, Tampa, FL, USA
| | | | | | | | - Roberto Diaz
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Kamran Ahmed
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Iman Washington
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Kujtim Latifi
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Bethany L Niell
- Moffitt Cancer Center, Department of Radiology, Tampa, FL, USA
| | - Michael Montejo
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
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Koo J, Latifi K, Caudell J, Jordan P, Shen S, Adamson P, Feygelman V. Development of a Deep Learning-Based Auto-Segmentation of Organs at Risk for Head and Neck Radiotherapy Planning. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2021.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Feygelman V, Latifi K, Bowers M, Greco K, Moros EG, Isacson M, Angerud A, Caudell J. Maintaining dosimetric quality when switching to a Monte Carlo dose engine for head and neck volumetric-modulated arc therapy planning. J Appl Clin Med Phys 2022; 23:e13572. [PMID: 35213089 PMCID: PMC9121035 DOI: 10.1002/acm2.13572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Head and neck cancers present challenges in radiation treatment planning due to the large number of critical structures near the target(s) and highly heterogeneous tissue composition. While Monte Carlo (MC) dose calculations currently offer the most accurate approximation of dose deposition in tissue, the switch to MC presents challenges in preserving the parameters of care. The differences in dose‐to‐tissue were widely discussed in the literature, but mostly in the context of recalculating the existing plans rather than reoptimizing with the MC dose engine. Also, the target dose homogeneity received less attention. We adhere to strict dose homogeneity objectives in clinical practice. In this study, we started with 21 clinical volumetric‐modulated arc therapy (VMAT) plans previously developed in Pinnacle treatment planning system. Those plans were recalculated “as is” with RayStation (RS) MC algorithm and then reoptimized in RS with both collapsed cone (CC) and MC algorithms. MC statistical uncertainty (0.3%) was selected carefully to balance the dose computation time (1–2 min) with the planning target volume (PTV) dose‐volume histogram (DVH) shape approaching that of a “noise‐free” calculation. When the hot spot in head and neck MC‐based treatment planning is defined as dose to 0.03 cc, it is exceedingly difficult to limit it to 105% of the prescription dose, as we were used to with the CC algorithm. The average hot spot after optimization and calculation with RS MC was statistically significantly higher compared to Pinnacle and RS CC algorithms by 1.2 and 1.0 %, respectively. The 95% confidence interval (CI) observed in this study suggests that in most cases a hot spot of ≤107% is achievable. Compared to the 95% CI for the previous clinical plans recalculated with RS MC “as is” (upper limit 108%), in real terms this result is at least as good or better than the historic plans.
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Affiliation(s)
- Vladimir Feygelman
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Mark Bowers
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kevin Greco
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Max Isacson
- RaySearch Laboratories AB, Stockholm, Sweden
| | | | - Jimmy Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Ericsson-Szecsenyi R, Zhang G, Redler G, Feygelman V, Rosenberg S, Latifi K, Ceberg C, Moros EG. Robustness Assessment of Images From a 0.35T Scanner of an Integrated MRI-Linac: Characterization of Radiomics Features in Phantom and Patient Data. Technol Cancer Res Treat 2022; 21:15330338221099113. [PMID: 35521966 PMCID: PMC9083059 DOI: 10.1177/15330338221099113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Radiomics entails the extraction of quantitative imaging biomarkers (or radiomics features) hypothesized to provide additional pathophysiological and/or clinical information compared to qualitative visual observation and interpretation. This retrospective study explores the variability of radiomics features extracted from images acquired with the 0.35 T scanner of an integrated MRI-Linac. We hypothesized we would be able to identify features with high repeatability and reproducibility over various imaging conditions using phantom and patient imaging studies. We also compared findings from the literature relevant to our results. Methods: Eleven scans of a Magphan® RT phantom over 13 months and 11 scans of a ViewRay Daily QA phantom over 11 days constituted the phantom data. Patient datasets included 50 images from ten anonymized stereotactic body radiation therapy (SBRT) pancreatic cancer patients (50 Gy in 5 fractions). A True Fast Imaging with Steady-State Free Precession (TRUFI) pulse sequence was selected, using a voxel resolution of 1.5 mm × 1.5 mm × 1.5 mm and 1.5 mm × 1.5 mm × 3.0 mm for phantom and patient data, respectively. A total of 1087 shape-based, first, second, and higher order features were extracted followed by robustness analysis. Robustness was assessed with the Coefficient of Variation (CoV < 5%). Results: We identified 130 robust features across the datasets. Robust features were found within each category, except for 2 second-order sub-groups, namely, Gray Level Size Zone Matrix (GLSZM) and Neighborhood Gray Tone Difference Matrix (NGTDM). Additionally, several robust features agreed with findings from other stability assessments or predictive performance studies in the literature. Conclusion: We verified the stability of the 0.35 T scanner of an integrated MRI-Linac for longitudinal radiomics phantom studies and identified robust features over various imaging conditions. We conclude that phantom measurements can be used to identify robust radiomics features. More stability assessment research is warranted.
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Affiliation(s)
| | - Geoffrey Zhang
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gage Redler
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Vladimir Feygelman
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Stephen Rosenberg
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kujtim Latifi
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Crister Ceberg
- Department of Medical Radiation Physics, Clinical Sciences, 5193Lund University, Lund, Sweden
| | - Eduardo G Moros
- Radiation Oncology Department, 25301H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Tomaszewski MR, Latifi K, Boyer E, Palm RF, El Naqa I, Moros EG, Hoffe SE, Rosenberg SA, Frakes JM, Gillies RJ. Delta radiomics analysis of Magnetic Resonance guided radiotherapy imaging data can enable treatment response prediction in pancreatic cancer. Radiat Oncol 2021; 16:237. [PMID: 34911546 PMCID: PMC8672552 DOI: 10.1186/s13014-021-01957-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/22/2021] [Indexed: 12/22/2022] Open
Abstract
Background Magnetic Resonance Image guided Stereotactic body radiotherapy (MRgRT) is an emerging technology that is increasingly used in treatment of visceral cancers, such as pancreatic adenocarcinoma (PDAC). Given the variable response rates and short progression times of PDAC, there is an unmet clinical need for a method to assess early RT response that may allow better prescription personalization. We hypothesize that quantitative image feature analysis (radiomics) of the longitudinal MR scans acquired before and during MRgRT may be used to extract information related to early treatment response. Methods Histogram and texture radiomic features (n = 73) were extracted from the Gross Tumor Volume (GTV) in 0.35T MRgRT scans of 26 locally advanced and borderline resectable PDAC patients treated with 50 Gy RT in 5 fractions. Feature ratios between first (F1) and last (F5) fraction scan were correlated with progression free survival (PFS). Feature stability was assessed through region of interest (ROI) perturbation. Results Linear normalization of image intensity to median kidney value showed improved reproducibility of feature quantification. Histogram skewness change during treatment showed significant association with PFS (p = 0.005, HR = 2.75), offering a potential predictive biomarker of RT response. Stability analyses revealed a wide distribution of feature sensitivities to ROI delineation and was able to identify features that were robust to variability in contouring. Conclusions This study presents a proof-of-concept for the use of quantitative image analysis in MRgRT for treatment response prediction and providing an analysis pipeline that can be utilized in future MRgRT radiomic studies. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01957-5.
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Affiliation(s)
- M R Tomaszewski
- Cancer Physiology Department, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.,Translation Imaging Department, Merck & Co, West Point, PA, USA
| | - K Latifi
- Medical Physics Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - E Boyer
- Radiation Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - R F Palm
- Radiation Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - I El Naqa
- Machine Learning Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - E G Moros
- Medical Physics Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - S E Hoffe
- Radiation Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - S A Rosenberg
- Radiation Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J M Frakes
- Radiation Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - R J Gillies
- Cancer Physiology Department, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.
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Koo J, Nardella L, Degnan M, Andreozzi J, Yu HHM, Penagaricano J, Johnstone PAS, Oliver D, Ahmed K, Rosenberg SA, Wuthrick E, Diaz R, Feygelman V, Latifi K, Moros EG, Redler G. Triggered kV Imaging During Spine SBRT for Intrafraction Motion Management. Technol Cancer Res Treat 2021; 20:15330338211063033. [PMID: 34855577 PMCID: PMC8649431 DOI: 10.1177/15330338211063033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: To monitor intrafraction motion during spine stereotactic body radiotherapy(SBRT) treatment delivery with readily available technology, we implemented triggered kV imaging using the on-board imager(OBI) of a modern medical linear accelerator with an advanced imaging package. Methods: Triggered kV imaging for intrafraction motion management was tested with an anthropomorphic phantom and simulated spine SBRT treatments to the thoracic and lumbar spine. The vertebral bodies and spinous processes were contoured as the image guided radiotherapy(IGRT) structures specific to this technique. Upon each triggered kV image acquisition, 2D projections of the IGRT structures were automatically calculated and updated at arbitrary angles for display on the kV images. Various shifts/rotations were introduced in x, y, z, pitch, and yaw. Gantry-angle-based triggering was set to acquire kV images every 45°. A group of physicists/physicians(n = 10) participated in a survey to evaluate clinical efficiency and accuracy of clinical decisions on images containing various phantom shifts. This method was implemented clinically for treatment of 42 patients(94 fractions) with 15 second time-based triggering. Result: Phantom images revealed that IGRT structure accuracy and therefore utility of projected contours during triggered imaging improved with smaller CT slice thickness. Contouring vertebra superior and inferior to the treatment site was necessary to detect clinically relevant phantom rotation. From the survey, detectability was proportional to the shift size in all shift directions and inversely related to the CT slice thickness. Clinical implementation helped evaluate robustness of patient immobilization. Based on visual inspection of projected IGRT contours on planar kV images, appreciable intrafraction motion was detected in eleven fractions(11.7%). Discussion: Feasibility of triggered imaging for spine SBRT intrafraction motion management has been demonstrated in phantom experiments and implementation for patient treatments. This technique allows efficient, non-invasive monitoring of patient position using the OBI and patient anatomy as a direct visual guide.
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Affiliation(s)
- Jihye Koo
- 7831University of South Florida, 33620, USA.,25301H. Lee Moffitt Cancer Center, 33612, USA
| | | | - Michael Degnan
- 549472The Ohio State University, 43210, Columbus, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Gage Redler
- 25301H. Lee Moffitt Cancer Center, 33612, USA
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Sandoval M, Latifi K, Parsee A, Andreozzi J, Awasthi S, Fernandez D, Hunt D, Yamoah K. Defining MR-Based Parameters of Treatment Response to Immune-Modulatory Therapy for Grade Group 5 Prostate Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Liveringhouse C, Robinson T, Garcia G, Peters J, Kim S, Latifi K. Dosimetric Comparison of Volumetric Modulated Arc Therapy with Tomotherapy Based Total Body Irradiation for Patients Undergoing Conditioning Prior to Hematopoietic Stem Cell Transplantation for Acute Lymphocytic Leukemia. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Palm R, Boyer E, Fan W, Schell M, Latifi K, Rosenberg S, Hoffe S, Frakes J. Impact of Tumor Dosimetry on Clinical Outcomes after Stereotactic Body Radiation Therapy for Pancreatic Adenocarcinoma. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kutuk T, Pandey S, Mills M, Abdalah M, Stringfield O, Latifi K, Robinson T, Ahmed K, Raghunand N. Utilizing Radiation Dose Maps to Predict Local Failure Following Stereotactic Radiation of Brain Metastases. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McDonald J, Raghunand N, Rejniak K, Frakes J, Song E, Latifi K, Kim D, Carballido E, Denbo J, Pimiento J, Parsee A, Hodul P, Hoffe S, Costello J. Multisequence MRI With Functional Imaging May Improve Pseudoprogression vs. Viable Tumor Determination Following High Dose Adaptive MRgRT in Patients With Pancreatic Adenocarcinoma. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sandoval ML, Youssef I, Latifi K, Grass GD, Torres-Roca J, Rosenberg S, Yamoah K, Johnstone PA. Non-Adaptive MR-Guided Radiotherapy for Prostate SBRT: Less Time, Equal Results. J Clin Med 2021; 10:3396. [PMID: 34362179 PMCID: PMC8347281 DOI: 10.3390/jcm10153396] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of stereotactic body radiation therapy (SBRT) is widely utilized for treatment of localized prostate cancer. Magnetic-resonance-guided radiotherapy (MRgRT) was introduced in 2014 and has recently been implemented in SBRT for prostate cancer as it provides an opportunity for smaller margins and adaptive daily planning. Currently, the only publications of MRgRT for prostate SBRT describe European clinical experiences which utilized adaptive planning. However, adaptive planning adds significantly to the time required for daily treatment. OBJECTIVES Since prostate SBRT has demonstrated acceptable toxicity for several years, we did not consider daily adaptation critical to the process of prostate SBRT. After Institutional Review Board approval, we analyzed and now report our experience using MRgRT without adaptation. METHODS Between 25 September 2019 and 21 December 2020, 35 consecutive patients were treated with MRgRT prostate SBRT at our center. Patients treated with MRgRT included favorable intermediate risk (43%) and unfavorable intermediate risk (54%), and only one patient had low-risk prostate cancer. Nine patients (25%) received adjuvant leuprolide for a median of 4.5 months (range 4-6 m). Our clinical pathway allows for a maximum prostate gland volume of 60 cc; median prostate volume of this cohort was 35.0 cc (range 17-58.4 cc). Median pre-treatment PSA was 6.30 (range 2.55-16.77). Each patient was treated with 36.25 Gy delivered in five fractions over 2 weeks with urethral sparing to a maximal dose of 35 Gy. Target volumes included the prostate gland and proximal seminal vesicles with a 3 mm margin. RESULTS Median follow-up as of 26 May 2021 was 11.97 months (range 4.37-19.80). First follow-up data are available for all patients, with a median of 1.10 month from completion of treatment (0.63-3.40). The median PSA at first visit was 2.75 (range 0.02-9.00) with a median AUA symptom score of 9 (range 1-24). Second follow-up data are available for 34 patients at a median of 4.45 months (range 2.57-8.90). At second follow-up, the median PSA was 1.60 (range 0.02-5.40) with a median AUA symptom score of 6 (range 1-33). Seventeen patients had third follow-up data with a median of 9.77 months (range 4.70-12.33) after SBRT. The median PSA was 1.13 (range 0.02-4.73) with an AUA score of 9 (2-22) at the third follow-up. We observed a statistically significant decrease in PSA between pre-treatment and at first follow-up (p < 0.005). The most common toxicity was grade 2 urethritis, managed in all cases by tamsulosin. One patient developed grade 2 tenesmus relieved by topical steroids. No cases of grade ≥ 3 toxicity were seen in our patient population. CONCLUSIONS By avoiding the extra time required for plan adaptation, MRgRT without daily adaptation allows for successful prostate SBRT with manageable toxicity. We continue to reserve our limited adaptive treatment slots for preoperative pancreatic and ultra-central lung SBRT patients, which require time-intensive respiratory gating and adaptive planning.
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Affiliation(s)
- Maria L. Sandoval
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - Irini Youssef
- Department of Radiation Oncology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA;
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - G. Daniel Grass
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - Javier Torres-Roca
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - Stephen Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
| | - Peter A. Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.L.S.); (K.L.); (G.D.G.); (J.T.-R.); (S.R.); (K.Y.)
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Rong Y, Rosu-Bubulac M, Benedict SH, Cui Y, Ruo R, Connell T, Kashani R, Latifi K, Chen Q, Geng H, Sohn J, Xiao Y. Rigid and Deformable Image Registration for Radiation Therapy: A Self-Study Evaluation Guide for NRG Oncology Clinical Trial Participation. Pract Radiat Oncol 2021; 11:282-298. [PMID: 33662576 PMCID: PMC8406084 DOI: 10.1016/j.prro.2021.02.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/05/2021] [Accepted: 02/16/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The registration of multiple imaging studies to radiation therapy computed tomography simulation, including magnetic resonance imaging, positron emission tomography-computed tomography, etc. is a widely used strategy in radiation oncology treatment planning, and these registrations have valuable roles in image guidance, dose composition/accumulation, and treatment delivery adaptation. The NRG Oncology Medical Physics subcommittee formed a working group to investigate feasible workflows for a self-study credentialing process of image registration commissioning. METHODS AND MATERIALS The American Association of Physicists in Medicine (AAPM) Task Group 132 (TG132) report on the use of image registration and fusion algorithms in radiation therapy provides basic guidelines for quality assurance and quality control of the image registration algorithms and the overall clinical process. The report recommends a series of tests and the corresponding metrics that should be evaluated and reported during commissioning and routine quality assurance, as well as a set of recommendations for vendors. The NRG Oncology medical physics subcommittee working group found incompatibility of some digital phantoms with commercial systems. Thus, there is still a need to provide further recommendations in terms of compatible digital phantoms, clinical feasible workflow, and achievable thresholds, especially for future clinical trials involving deformable image registration algorithms. Nine institutions participated and evaluated 4 commonly used commercial imaging registration software and various versions in the field of radiation oncology. RESULTS AND CONCLUSIONS The NRG Oncology Working Group on image registration commissioning herein provides recommendations on the use of digital phantom/data sets and analytical software access for institutions and clinics to perform their own self-study evaluation of commercial imaging systems that might be employed for coregistration in radiation therapy treatment planning and image guidance procedures. Evaluation metrics and their corresponding values were given as guidelines to establish practical tolerances. Vendor compliance for image registration commissioning was evaluated, and recommendations were given for future development.
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Affiliation(s)
- Yi Rong
- Department of Radiation Oncology, University of California Davis Cancer Center, Sacramento, California; Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Mihaela Rosu-Bubulac
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California Davis Cancer Center, Sacramento, California
| | - Yunfeng Cui
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Russell Ruo
- Department of Medical Physics, McGill University Health Center, Montreal, QC, Canada
| | - Tanner Connell
- Department of Medical Physics, McGill University Health Center, Montreal, QC, Canada
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Quan Chen
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Huaizhi Geng
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Sohn
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Latifi K, Lotey R, Feygelman V. On the MLC leaves alignment in the direction orthogonal to movement. J Appl Clin Med Phys 2021; 22:268-273. [PMID: 34056837 PMCID: PMC8200498 DOI: 10.1002/acm2.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/15/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022] Open
Abstract
The main focus of the recommended spatial accuracy tests for the multi‐leaf collimators (MLC) is calibration of the leaf position along the movement direction and overall alignment to the radiation isocenter. No explicit attention was typically paid to the alignment of the leaves from the opposing banks in the direction orthogonal to movement. This paper is a case study demonstrating that verification of such alignment at the time of acceptance testing is prudent. The original standard MLC (SMLC) on an MRIdian MRI‐guided linac (ViewRay Inc., Mountain View, CA, USA) was upgraded to a high‐speed MLC (HSMLC), which is supposed to be mechanically identical to the SMLC except for the higher drive screw pitch. The results of the end‐to‐end IMRT tests demonstrated unacceptable dosimetric results exemplified by an average and maximum ion chamber (IC) point dose error in the high‐dose low‐gradient region of 2.5 ± 1.4% and 4.6%, respectively. Before the upgrade, those values were 0.3 ± 0.7% and 0.9%, respectively. An exhaustive analysis of possible failure modes eventually zeroed in on the average misalignment of about 1 mm in the Y (along the couch) direction between the right and left upper MLC banks. The MLC was replaced, reducing the Y‐direction misalignment to 0.4 mm. As a result, the average and maximum IC dose‐errors became acceptable 1.0 ± 0.7% and 1.6%, respectively. Simple film and/or chamber array tests during acceptance testing can easily detect Y‐direction misalignments between opposing leaves banks measuring a fraction of a mm at isocenter. Left undetected, such misalignment can cause nontrivial dosimetric consequences.
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Affiliation(s)
- Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Yuan Z, Frazer M, Rishi A, Latifi K, Tomaszewski MR, Moros EG, Feygelman V, Felder S, Sanchez J, Dessureault S, Imanirad I, Kim RD, Harrison LB, Hoffe SE, Zhang GG, Frakes JM. Pretreatment CT and PET radiomics predicting rectal cancer patients in response to neoadjuvant chemoradiotherapy. ACTA ACUST UNITED AC 2021; 26:29-34. [PMID: 33948299 DOI: 10.5603/rpor.a2021.0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 12/12/2020] [Indexed: 01/07/2023]
Abstract
Background The purpose of this study was to characterize pre-treatment non-contrast computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography (PET) based radiomics signatures predictive of pathological response and clinical outcomes in rectal cancer patients treated with neoadjuvant chemoradiotherapy (NACR T). Materials and methods An exploratory analysis was performed using pre-treatment non-contrast CT and PET imaging dataset. The association of tumor regression grade (TRG) and neoadjuvant rectal (NAR) score with pre-treatment CT and PET features was assessed using machine learning algorithms. Three separate predictive models were built for composite features from CT + PET. Results The patterns of pathological response were TRG 0 (n = 13; 19.7%), 1 (n = 34; 51.5%), 2 (n = 16; 24.2%), and 3 (n = 3; 4.5%). There were 20 (30.3%) patients with low, 22 (33.3%) with intermediate and 24 (36.4%) with high NAR scores. Three separate predictive models were built for composite features from CT + PET and analyzed separately for clinical endpoints. Composite features with α = 0.2 resulted in the best predictive power using logistic regression. For pathological response prediction, the signature resulted in 88.1% accuracy in predicting TRG 0 vs. TRG 1-3; 91% accuracy in predicting TRG 0-1 vs. TRG 2-3. For the surrogate of DFS and OS, it resulted in 67.7% accuracy in predicting low vs. intermediate vs. high NAR scores. Conclusion The pre-treatment composite radiomics signatures were highly predictive of pathological response in rectal cancer treated with NACR T. A larger cohort is warranted for further validation.
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Affiliation(s)
- Zhigang Yuan
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Marissa Frazer
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Anupam Rishi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | | | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Vladimir Feygelman
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Seth Felder
- Department of GI Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Julian Sanchez
- Department of GI Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Sophie Dessureault
- Department of GI Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Iman Imanirad
- Department of GI Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Richard D Kim
- Department of GI Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Louis B Harrison
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Geoffrey G Zhang
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Jessica M Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, United States
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Dibs K, Sim AJ, Peñagaricano JA, Latifi K, Garcia GA, Peters JA, Nieder ML, Kim S, Robinson TJ. Gonadal-sparing total body irradiation with the use of helical tomotherapy for nonmalignant indications. ACTA ACUST UNITED AC 2021; 26:153-158. [PMID: 34046227 DOI: 10.5603/rpor.a2021.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/24/2020] [Indexed: 11/25/2022]
Abstract
Background The aim was to demonstrate the feasibility and technique of gonadal sparing total body irradiation (TBI) with helical tomotherapy. Total body irradiation is a common part of the conditioning regimen prior to allogeneic stem cell transplantation. Shielding or dose-reduction to the gonads is often desired to preserve fertility, particularly in young patients undergoing transplant for non-malignant indications. Helical tomotherapy (HT) has been shown to be superior to traditional TBI delivery for organ at risk (OA R) doses and dose homogeneity. Materials and methods We present two representative cases (one male and one female) to illustrate the feasibility of this technique, each of whom received 3Gy in a single fraction prior to allogeneic stem cell transplant for benign indications. The planning target volume (PTV) included the whole body with a subtraction of OA Rs including the lungs, heart, and brain (each contracted by 1cm) as well as the gonads (testicles expanded by 5 cm and ovaries expanded by 0.5 cm). Results For the male patient we achieved a homogeneity index of 1.35 with a maximum and median planned dose to the testes of 0.53 Gy and 0.35 Gy, respectively. In-vivo dosimetry demonstrated an actual received dose of 0.48 Gy. For the female patient we achieved a homogeneity index of 1.13 with a maximum and median planned dose to the ovaries of 1.66 Gy and 0.86 Gy, respectively. Conclusion Gonadal sparing TBI is feasible and deliverable using HT in patients with non-malignant diseases requiring TBI as part of a pre-stem cell transplant conditioning regimen.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The Ohio State University, Columbus OH, United States
| | - Austin J Sim
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - José A Peñagaricano
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - Genevieve A Garcia
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - Julia A Peters
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - Michael L Nieder
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | - Sungjune Kim
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
| | - Timothy J Robinson
- Department of Radiation Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States.,Department of Biostatistics and Bioinformatics, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, United States
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Rishi A, Zhang GG, Yuan Z, Sim AJ, Song EY, Moros EG, Tomaszewski MR, Latifi K, Pimiento JM, Fontaine JP, Mehta R, Harrison LB, Hoffe SE, Frakes JM. Pretreatment CT and 18 F-FDG PET-based radiomic model predicting pathological complete response and loco-regional control following neoadjuvant chemoradiation in oesophageal cancer. J Med Imaging Radiat Oncol 2020; 65:102-111. [PMID: 33258556 DOI: 10.1111/1754-9485.13128] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/21/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION To develop a radiomic-based model to predict pathological complete response (pCR) and outcome following neoadjuvant chemoradiotherapy (NACRT) in oesophageal cancer. METHODS We analysed 68 patients with oesophageal cancer treated with NACRT followed by esophagectomy, who had staging 18F-fluorodeoxyglucose (18 F-FDG) positron emission tomography (PET) and computed tomography (CT) scans performed at our institution. An in-house data-chjmirocterization algorithm was used to extract 3D-radiomic features from the segmented primary disease. Prediction models were constructed and internally validated. Composite feature, Fc = α * FPET + (1 - α) * FCT , 0 ≤ α ≤ 1, was constructed for each corresponding CT and PET feature. Loco-regional control (LRC), recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) were estimated by Kaplan-Meier analysis, and compared using log-rank test. RESULTS Median follow-up was 59 months. pCR was achieved in 34 (50%) patients. Five-year RFS, LRC, MFS and OS were 67.1%, 88.5%, 75.6% and 57.6%, respectively. Tumour Regression Grade (TRG) 0-1 indicative of complete response or minimal residual disease was significantly associated with improved 5-year LRC [93.7% vs 71.8%; P = 0.020; HR 0.19, 95% CI 0.04-0.85]. Four sepjmirote pCR predictive models were built for CT alone, PET alone, CT+PET and composite. CT, PET and CT+PET models had AUC 0.73 ± 0.08, 0.66 ± 0.08 and 0.77 ± 0.07, respectively. The composite model resulted in an improvement of pCR predicting power with AUC 0.87 ± 0.06. Stratifying patients with a low versus high radiomic score showed clinically relevant improvement in 5-year LRC favouring low-score group (91.1% vs. 80%, 95% CI 0.09-1.77, P = 0.2). CONCLUSION The composite CT/PET radiomics model was highly predictive of pCR following NACRT. Validation in larger data sets is warranted to determine whether the model can predict clinical outcomes.
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Affiliation(s)
- Anupam Rishi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Geoffrey G Zhang
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Zhigang Yuan
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Austin J Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Ethan Y Song
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Michal R Tomaszewski
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Jacques-Pierre Fontaine
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Rutika Mehta
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Louis B Harrison
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Sjmiroh E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
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Hunt D, Latifi K, Saini A, Naghavi A, Pow-Sang J, Dhillon J, Torres-Roca J, Grass D, Johnstone P, Fernandez D, Yamoah K. Implementation of a Fiducial-guided Targeted Biopsy Scheme During Prostate Brachytherapy for Radio-genomic Analysis. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Sim AJ, Palm RF, DeLozier KB, Feygelman V, Latifi K, Redler G, Washington IR, Wuthrick EJ, Rosenberg SA. MR-guided stereotactic body radiation therapy for intracardiac and pericardial metastases. Clin Transl Radiat Oncol 2020; 25:102-106. [PMID: 33204858 PMCID: PMC7653008 DOI: 10.1016/j.ctro.2020.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 02/08/2023] Open
Abstract
Radiation is not typical in the standard of care for cardiac metastases. MR-guided radiation uses real-time imaging and offers better soft tissue contrast. Real-time MR-guidance allows for safe high dose radiation to cardiac metastases. MR-guided stereotactic radiation can improve symptoms without acute toxicity.
Aims To assess the safety and efficacy of MR-guided stereotactic body radiation therapy (MRgSBRT) for cardiac metastases. Materials/methods This single institution retrospective analysis evaluated our experience with MRgSBRT for cardiac metastases. Response rate was compared between pre-RT and post-RT imaging. Symptomatic changes were also tracked and documented. Results Between 4/2019 and 3/2020, five patients with cardiac metastases (4 intracardiac and 1 pericardial) were treated with MRgSBRT. Median age at treatment was 73 years (range 64–80) and two patients had pre-existing cardiac disease. Histologies included melanoma and breast adenocarcinoma. Median lesion diameter was 2 cm (range 1.96–5.8 cm). Three patients were symptomatic, one of whom had pulmonary hypertension and RV enlargement. Another patient had an asymptomatic arrythmia. Median PTV prescribed dose was 40 Gy (range 40–50 Gy) and delivered in five fractions on nonconsecutive days. Median PTV volume was 53.4 cc (range 8.7–116.6 cc) and median coverage was 95% (range 84.1–100%). A uniform 3 mm margin was used for real-time gating, allowing a median 7% (range 5–10%) pixel excursion tolerance. Median follow-up was 4.7 months (range 0.9–12.3). Two patients exhibited stable disease, two had a partial response and one exhibited a complete response. All symptomatic patients experienced some relief. There were no acute adverse events, however, one patient without prior cardiac disease developed atrial fibrillation 6 months after treatment. Two patients died of causes unrelated to cardiac MRgSBRT. Conclusion In this largest known series of cardiac metastasis MRgSBRT, real-time image guidance enables safe treatment resulting in good response with improving presenting symptoms without acute adverse events.
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Affiliation(s)
- Austin J Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kirby B DeLozier
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Iman R Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Evan J Wuthrick
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Stephen A Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
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Yuan Z, Fernandez D, Dhillon J, Abraham-Miranda J, Awasthi S, Kim Y, Zhang J, Jain R, Serna A, Pow-Sang JM, Poch M, Li R, Manley B, Fink A, Naghavi A, Torres-Roca JF, Grass GD, Kim S, Latifi K, Hunt D, Johnstone PAS, Yamoah K. Proof-of-principle Phase I results of combining nivolumab with brachytherapy and external beam radiation therapy for Grade Group 5 prostate cancer: safety, feasibility, and exploratory analysis. Prostate Cancer Prostatic Dis 2020; 24:140-149. [PMID: 32651467 DOI: 10.1038/s41391-020-0254-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/05/2020] [Accepted: 07/02/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND To determine whether combining brachytherapy with immunotherapy is safe in prostate cancer (PCa) and provides synergistic effects, we performed a Phase I/II trial on the feasibility, safety, and benefit of concurrent delivery of anti-PD-1 (nivolumab) with high-dose-rate (HDR) brachytherapy and androgen deprivation therapy (ADT) in patients with Grade Group 5 (GG5) PCa. METHODS Eligible patients were aged 18 years or older with diagnosis of GG5 PCa. Patients received ADT, nivolumab every two weeks for four cycles, with two cycles prior to first HDR, and two more cycles prior to second HDR, followed by external beam radiotherapy. The primary endpoint was to determine safety and feasibility. This Phase I/II trial is registered with ClinicalTrials.gov (NCT03543189). RESULTS Between September 2018 and June 2019, six patients were enrolled for the Phase I safety lead-in with a minimum observation period of 3 months after nivolumab administration. Overall, nivolumab was well tolerated in combination with ADT and HDR treatment. One patient experienced a grade 3 dose-limiting toxicity (elevated Alanine aminotransferase and Aspartate aminotransferase) after the second cycle of nivolumab. Three patients (50%) demonstrated early response with no residual tumor detected in ≥4 of 6 cores on biopsy post-nivolumab (4 cycles) and 1-month post-HDR. Increase in CD8+ and FOXP3+/CD4+ T cells in tissues, and CD4+ effector T cells in peripheral blood were observed in early responders. CONCLUSION Combination of nivolumab with ADT and HDR is well tolerated and associated with evidence of increased immune infiltration and antitumor activity.
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Affiliation(s)
- Zhigang Yuan
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Daniel Fernandez
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Jasreman Dhillon
- Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Julieta Abraham-Miranda
- Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Shivanshu Awasthi
- Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Youngchul Kim
- Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Jingsong Zhang
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Rohit Jain
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Amparo Serna
- Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Julio M Pow-Sang
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael Poch
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Roger Li
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Brandon Manley
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Angelina Fink
- Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Arash Naghavi
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Javier F Torres-Roca
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - G Daniel Grass
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Sungjune Kim
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Kujtim Latifi
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Dylan Hunt
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Peter A S Johnstone
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Kosj Yamoah
- Departments of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA. .,Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA.
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Yuan Z, Frazer M, Zhang GG, Latifi K, Moros EG, Feygelman V, Felder S, Sanchez J, Dessureault S, Imanirad I, Kim RD, Harrison LB, Hoffe SE, Frakes JM. CT-based radiomic features to predict pathological response in rectal cancer: A retrospective cohort study. J Med Imaging Radiat Oncol 2020; 64:444-449. [PMID: 32386109 DOI: 10.1111/1754-9485.13044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/13/2020] [Accepted: 04/06/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Innovative biomarkers to predict treatment response in rectal cancer would be helpful in optimizing personalized treatment approaches. In this study, we aimed to develop and validate a CT-based radiomic imaging biomarker to predict pathological response. METHODS We used two independent cohorts of rectal cancer patients to develop and validate a CT-based radiomic imaging biomarker predictive of treatment response. A total of 91 rectal cancer cases treated from 2009 to 2018 were assessed for the tumour regression grade (TRG) (0 = pathological complete response, pCR; 1 = moderate response; 2 = partial response; 3 = poor response). Exploratory analysis was performed by combining pre-treatment non-contrast CT images and patterns of TRG. The models built from the training cohort were further assessed using the independent validation cohort. RESULTS The patterns of pathological response in training and validation groups were TRG 0 (n = 14, 23.3%; n = 6, 19.4%), 1 (n = 31, 51.7%; n = 15, 48.4%), 2 (n = 12, 20.0%; n = 7, 22.6%) and 3 (n = 3, 5.0%; n = 3, 9.7%), respectively. Separate predictive models were built and analysed from CT features for pathological response. For pathological response prediction, the model including 8 radiomic features by random forest method resulted in 83.9% accuracy in predicting TRG 0 vs TRG 1-3 in validation. CONCLUSION The pre-treatment CT-based radiomic signatures were developed and validated in two independent cohorts. This imaging biomarker provided a promising way to predict pCR and select patients for non-operative management.
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Affiliation(s)
- Zhigang Yuan
- Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Marissa Frazer
- Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Kujtim Latifi
- Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Eduardo G Moros
- Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Seth Felder
- GI Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | | | - Iman Imanirad
- GI Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Richard D Kim
- GI Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Sarah E Hoffe
- Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Latifi K, Moros EG, Zhang G, Harrison L, Feygelman V. A Method to Determine the Coincidence of MRI-Guided Linac Radiation and Magnetic Isocenters. Technol Cancer Res Treat 2020; 18:1533033819877986. [PMID: 31537173 PMCID: PMC6755638 DOI: 10.1177/1533033819877986] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To assure accurate treatment delivery on any image-guided radiotherapy system, the
relative positions and walkout of the imaging and radiation isocenters must be
periodically verified and kept within specified tolerances. In this work, we first
validated the multiaxis ion chamber array as a tool for finding the radiation isocenter
position of a magnetic resonance–guided linear accelerator. The treatment couch with the
array on it was shifted in 0.2-mm increments and the reported beam center position was
plotted against that shift and fitted to a straight line, in both X and Y directions. From
the goodness-of-fit and intercepts of the regression lines, the accuracy and precision
were conservatively estimated at 0.2 and 0.1 mm, respectively. This holds true whether the
array is irradiated from the front or from the back, which allows efficient collecting the
data from the 4 cardinal gantry angles with just 2 array positions. The average isocenter
position agreed to within at most 0.4 mm along any cardinal axis with the linac vendor’s
film-based procedure, and the maximum walkout radii were 0.32 mm and 0.53 mm,
respectively. The magnetic resonance imaging isocenter walkout as a function of gantry
angle was studied with 2 different phantoms, one employing a single fiducial at the center
and another extracting the rigid displacement values from the distortion map fit of 523
fiducials dispersed over a large volume. The results were close between the 2 phantoms and
demonstrated variation in the magnetic resonance imaging isocenter location as high as 1.3
mm along a single axis in the transverse plane. Verification of the magnetic resonance
imaging isocenter location versus the gantry angle should be a part of quality assurance
for magnetic resonance-guided linear accelerators.
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Affiliation(s)
- Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Geoffrey Zhang
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Louis Harrison
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Mitin T, Degnin C, Chen Y, Shirvani S, Gillespie E, Hoffe S, Latifi K, Nabavizadeh N, Dengina N, Chernich M, Usychkin S, Kharitonova E, Egorova Y, Pankratov A, Tsimafeyeu I, Thomas CR, Tjulandin S, Likhacheva A. Radiotherapy for Hepatocellular Carcinoma in Russia: a Survey-Based Analysis of Current Practice and the Impact of an Educational Workshop on Clinical Expertise. J Cancer Educ 2020; 35:105-111. [PMID: 30467774 DOI: 10.1007/s13187-018-1447-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Radiation therapy (RT) is an effective treatment modality for hepatocellular carcinoma (HCC), but globally, it is underutilized. In Russia, practice patterns with regard to liver-directed radiation are unknown. Under the auspices of Russian Society of Clinical Oncology (RUSSCO), our team conducted an IRB-approved contouring workshop for Russian radiation oncologists. Pre- and post-workshop surveys were analyzed to determine baseline clinical experience and patterns of care for liver-directed RT among Russian providers. The effect of the contouring workshop on participants' knowledge was tested using mixed effects model. Forty pre-workshop and 24 post-workshop questionnaires were analyzable with a 100% response rate. Sixty percent of respondents had never evaluated a patient with HCC and only 8% (3 out of 40) reported treating an HCC patient with liver-directed RT. Nonetheless, 73% of respondents were comfortable offering liver-directed RT prior to the workshop. After the workshop, 85% of respondents felt comfortable treating a patient with HCC with liver-directed RT and 50% were comfortable recommending stereotactic body radiation therapy (SBRT). Measures of knowledge pertaining to evaluation of HCC patients and selection for appropriate liver-directed therapies were dramatically improved after the workshop. Liver-directed RT is not commonly used in Russia in the management of patients with HCC, and few centers are equipped for motion management. Our contouring workshop resulted in dramatically improved understanding of the evaluation and management of HCC patients. We recommend starting with a more protracted fractionated RT and building experience through attendance of additional educational activities, participation in multidisciplinary liver tumor boards, and prospective analysis of treatment toxicity and outcomes.
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Affiliation(s)
- Timur Mitin
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia
| | - Catherine Degnin
- Biostatistics Shared Resources, OHSU Knight Cancer Institute, Portland, OR, USA
| | - Yiyi Chen
- Biostatistics Shared Resources, OHSU Knight Cancer Institute, Portland, OR, USA
| | - Shervin Shirvani
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, 2946 E Banner Gateway Dr, Gilbert, AZ, 85234, USA
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Natalia Dengina
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia
- Department of Radiotherapy, Ulyanovsk Regional Cancer Center, Ulyanovsk Oblast, Russia
| | - Marina Chernich
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia
- N.N. Blokhin Russian Cancer Center, Moscow, Russia
| | - Sergey Usychkin
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia
- Medscan Clinic, Moscow, Russia
| | | | - Yulia Egorova
- Russian Society of Clinical Oncology (RUSSCO), Moscow, Russia
| | - Alexandr Pankratov
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia
- PET-Technology Center, Balashikha, Russia
| | - Ilya Tsimafeyeu
- Russian Society of Clinical Oncology (RUSSCO), Moscow, Russia
- PET-Technology Center, Balashikha, Russia
- Kidney Cancer Research Bureau, Moscow, Russia
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | | | - Anna Likhacheva
- International Design and Implementation Group for Radiation Oncology workshops (INDIGO), Moscow, Russia.
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, 2946 E Banner Gateway Dr, Gilbert, AZ, 85234, USA.
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Parsee AA, McDonald JA, Jiang K, Latifi K, Mehta R, Frakes JM, Pimiento JM, Hoffe SE. Radiation-induced hepatitis masquerading as metastatic disease: the importance of correlating diagnostic imaging with treatment planning. J Gastrointest Oncol 2020; 11:133-138. [PMID: 32175116 DOI: 10.21037/jgo.2019.09.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We are presenting a 63-year-old Caucasian male who complained of 2 months of progressive dysphagia. Upper endoscopy discovered a mass in the distal esophagus near the gastroesophageal junction. Biopsy was consistent with adenocarcinoma. Endoscopic ultrasound (EUS) showed extension beyond the muscularis propria, with an enlarged paraesophageal lymph node (T3N1). Initial positron emission tomography (PET)/computed tomography (CT) showed hypermetabolic portocaval lymphadenopathy presumed to be metastatic, but otherwise without distant disease extension. Neoadjuvant treatment included induction FOLFOX followed by 5,600 cGy over 28 fractions in combination with 5-FU and oxaliplatin. Approximately 3.5 weeks after completion, a repeat PET/CT revealed reduced uptake in both the primary esophageal mass and regional lymph nodes. Of note there were several new mass-like foci of hypermetabolism in the liver, specifically the left lobe, concerning for metastatic disease. Image-guided biopsy did not show any identifiable lesions, but sampling was performed based on anatomical landmarks. Pathology revealed benign parenchyma with minimal inflammation and mild reactive regeneration. In light of this, the patient proceeded to undergo definitive resection via robotic Ivor-Lewis esophagectomy with only 1 positive lymph node. Given pleural involvement by the tumor, staging was revised to pT4aN1 with final histology characterized as adenosquamous carcinoma. Postoperative course was fairly uneventful, with a mild exacerbation of his chronic heart failure. The patient was discharged on post-operative day 7, with his feeding tube removed at his 2-week post-operative clinic visit. This scenario is of particular educational value from the standpoint that when the post-treatment PET/CT images are registered to the radiotherapy treatment planning CT and dose, the areas of abnormal uptake in the liver fall within the higher dose regions. Given this and the liver biopsy findings, caution should be exercised before declaring progressive disease following radiotherapy without first reviewing the treatment plan.
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Affiliation(s)
- Arthur A Parsee
- Department of Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jordan A McDonald
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Kun Jiang
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Rutika Mehta
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jose M Pimiento
- Department of Surgical Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Tchelebi LT, Romesser PB, Feuerlein S, Hoffe S, Latifi K, Felder S, Chuong MD. Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management. Cancer Control 2020; 27:1073274820969449. [PMID: 33118384 PMCID: PMC7791447 DOI: 10.1177/1073274820969449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.
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Affiliation(s)
- Leila T. Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine,
Hershey, PA, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Sebastian Feuerlein
- Department of Diagnostic Imaging and Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center,
Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL,
USA
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McDonald J, Song E, Frakes J, Extermann M, Latifi K, Kim D, Malafa M, Hodul P, Fleming J, Hoffe S. PATHOLOGIC OUTCOMES OF PATIENTS 65 AND OLDER TREATED WITH SYSTEMIC THERAPY FOLLOWED BY STEREOTACTIC BODY RADIATION THERAPY (SBRT) FOR PANCREATIC CANCER IN A NOVEL LATERAL DECUBITUS TREATMENT POSITION. J Geriatr Oncol 2019. [DOI: 10.1016/s1879-4068(19)31302-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Latifi K, Kim S, Dilling T, Rosenberg S, Gray J, Antonia S, Perez B. Evaluating lung ct density changes among patients with extensive stage small cell lung cancer (ES-SCLC) treated with thoracic radiotherapy (TRT) alone or TRT followed by combined ipilimumab (IPI) and nivolumab (NIVO). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz239.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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