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Kisivan K, Farkas A, Kovacs P, Glavak C, Lukacs G, Mahr K, Szabo Z, Csima MP, Gulyban A, Toth Z, Kaposztas Z, Lakosi F. Pancreatic SABR using peritumoral fiducials, triggered imaging and breath-hold. Pathol Oncol Res 2023; 29:1611456. [PMID: 38188611 PMCID: PMC10767757 DOI: 10.3389/pore.2023.1611456] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/14/2023] [Indexed: 01/09/2024]
Abstract
Background: We aim to present our linear accelerator-based workflow for pancreatic stereotactic ablative radiotherapy (SABR) in order to address the following issues: intrafractional organ motion management, Cone Beam CT (CBCT) image quality, residual errors with dosimetric consequences, treatment time, and clinical results. Methods: Between 2016 and 2021, 14 patients with locally advanced pancreatic cancer were treated with induction chemotherapy and SABR using volumetric modulated arc therapy (VMAT). Internal target volume (ITV) concept (5), phase-gated (4), or breath hold (5) techniques were used. Treatment was verified by CBCT before and after irradiation, while tumor motion was monitored and controlled by kV triggered imaging and beam hold using peritumoral surgical clips. Beam interruptions and treatment time were recorded. The CBCT image quality was scored and supplemented by an agreement analysis (Krippendorff's-α) of breath-hold CBCT images to determine the position of OARs relative to the planning risk volumes (PRV). Residual errors and their dosimetry impact were also calculated. Progression free (PFS) and overall survival (OS) were assessed by the Kaplan-Meier analysis with acute and late toxicity reporting (CTCAEv4). Results: On average, beams were interrupted once (range: 0-3) per treatment session on triggered imaging. The total median treatment time was 16.7 ± 10.8 min, significantly less for breath-hold vs. phase-gated sessions (18.8 ± 6.2 vs. 26.5 ± 13.4, p < 0.001). The best image quality was achieved by breath hold CBCT. The Krippendorff's-α test showed a strong agreement among five radiation therapists (mean K-α value: 0.8 (97.5%). The mean residual errors were <0.2 cm in each direction resulting in an average difference of <2% in dosimetry for OAR and target volume. Two patients received offline adaptation. The median OS/PFS after induction chemotherapy and SABR was 20/12 months and 15/8 months. No Gr. ≥2 acute/late RT-related toxicity was noted. Conclusion: Linear accelerator based pancreatic SABR with the combination of CBCT and triggered imaging + beam hold is feasible. Peritumoral fiducials improve utility while breath-hold CBCT provides the best image quality at a reasonable treatment time with offline adaptation possibilities. In well-selected cases, it can be an effective alternative in clinics where CBCT/MRI-guided online adaptive workflow is not available.
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Affiliation(s)
- Katalin Kisivan
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Andrea Farkas
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Peter Kovacs
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Csaba Glavak
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Gabor Lukacs
- Department of Medical Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Karoly Mahr
- Department of Medical Oncology, Zala County Szent Raphael Hospital, Zalaegerszeg, Hungary
| | - Zsolt Szabo
- Department of Medical Oncology, Zala County Szent Raphael Hospital, Zalaegerszeg, Hungary
| | - Melinda Petone Csima
- Institute of Education, Hungarian University of Agricultural and Life Sciences, Gödöllő, Hungary
- Faculty of Health Sciences, University of Pecs, Pecs, Hungary
| | - Akos Gulyban
- Department of Medical Physics, Institut Jules Bordet, Brussels, Belgium
- Radiophysics and MRI Physics Laboratory, Université Libre De Bruxelles (ULB), Brussels, Belgium
| | - Zoltan Toth
- Medicopus Nonprofit Ltd., Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- PET Center, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Zsolt Kaposztas
- Department of Surgery, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Lakosi
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- Faculty of Health Sciences, University of Pecs, Pecs, Hungary
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