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Chin RI, Schiff JP, Bommireddy A, Kang KH, Andruska N, Price AT, Green OL, Huang Y, Korenblat K, Parikh PJ, Olsen J, Samson PP, Henke LE, Kim H, Badiyan SN. Clinical outcomes of patients with unresectable primary liver cancer treated with MR-guided stereotactic body radiation Therapy: A Six-Year experience. Clin Transl Radiat Oncol 2023; 41:100627. [PMID: 37441543 PMCID: PMC10334127 DOI: 10.1016/j.ctro.2023.100627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 10/15/2022] [Revised: 03/13/2023] [Accepted: 04/11/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose Magnetic resonance-guided stereotactic body radiation therapy (MRgSBRT) with optional online adaptation has shown promise in delivering ablative doses to unresectable primary liver cancer. However, there remain limited data on the indications for online adaptation as well as dosimetric and longer-term clinical outcomes following MRgSBRT. Methods and Materials Patients with unresectable hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and combined biphenotypic hepatocellular-cholangiocarcinoma (cHCC-CCA) who completed MRgSBRT to 50 Gy in 5 fractions between June of 2015 and December of 2021 were analyzed. The necessity of adaptive techniques was evaluated. The cumulative incidence of local progression was evaluated and survival and competing risk analyses were performed. Results Ninety-nine analyzable patients completed MRgSBRT during the study period and 54 % had planning target volumes (PTVs) within 1 cm of the duodenum, small bowel, or stomach at the time of simulation. Online adaptive RT was used in 53 % of patients to correct organ-at-risk constraint violation and/or to improve target coverage. In patients who underwent adaptive RT planning, online replanning resulted in superior target coverage when compared to projected, non-adaptive plans (median coverage ≥ 95 % at 47.5 Gy: 91 % [IQR: 82-96] before adaptation vs 95 % [IQR: 87-99] after adaptation, p < 0.01). The median follow-up for surviving patients was 34.2 months for patients with HCC and 10.1 months for patients with CCA/cHCC-CCA. For all patients, the 2-year cumulative incidence of local progression was 9.8 % (95 % CI: 1.5-18 %) for patients with HCC and 9.0 % (95 % CI: 0.1-18) for patients with CCA/cHCC-CCA. Grade 3 through 5 acute and late clinical gastrointestinal toxicities were observed in < 10 % of the patients. Conclusions MRgSBRT, with the option for online adaptive planning when merited, allows delivery of ablative doses to primary liver tumors with excellent local control with acceptable toxicities. Additional studies evaluating the efficacy and safety of MRgSBRT in the treatment of primary liver cancer are warranted.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Joshua P. Schiff
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | | | - Kylie H. Kang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Alexander T. Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Olga L. Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Kevin Korenblat
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis MO, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Jefferey Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pamela P. Samson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Lauren E. Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Shahed N. Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
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Kim H, Olsen JR, Green OL, Chin RI, Hawkins WG, Fields RC, Hammill C, Doyle MB, Chapman W, Suresh R, Tan B, Pedersen K, Jansen B, DeWees TA, Lu E, Henke LE, Badiyan S, Parikh PJ, Roach MC, Wang-Gillam A, Lim KH. MR-Guided Radiation Therapy With Concurrent Gemcitabine/Nab-Paclitaxel Chemotherapy in Inoperable Pancreatic Cancer: A TITE-CRM Phase I Trial. Int J Radiat Oncol Biol Phys 2023; 115:214-223. [PMID: 35878713 DOI: 10.1016/j.ijrobp.2022.07.015] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Ablative radiation therapy for borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) may limit concurrent chemotherapy dosing and usually is only safely deliverable to tumors distant from gastrointestinal organs. Magnetic resonance guided radiation therapy may safely permit radiation and chemotherapy dose escalation. METHODS AND MATERIALS We conducted a single-arm phase I study to determine the maximum tolerated dose of ablative hypofractionated radiation with full-dose gemcitabine/nab-paclitaxel in patients with BR/LA-PDAC. Patients were treated with gemcitabine/nab-paclitaxel (1000/125 mg/m2) x 1c then concurrent gemcitabine/nab-paclitaxel and radiation. Gemcitabine/nab-paclitaxel and radiation doses were escalated per time-to-event continual reassessment method from 40 to 45 Gy 25 fxs with chemotherapy (600-800/75 mg/m2) to 60 to 67.5 Gy/15 fractions and concurrent gemcitabine/nab-paclitaxel (1000/100 mg/m2). The primary endpoint was maximum tolerated dose of radiation as defined by 60-day dose limiting toxicity (DLT). DLT was treatment-related G5, G4 hematologic, or G3 gastrointestinal requiring hospitalization >3 days. Secondary endpoints included resection rates, local progression free survival (LPFS), distant metastasis free survival (DMFS), and overall survival (OS). RESULTS Thirty patients enrolled (March 2015-February 2019), with 26 evaluable patients (2 progressed before radiation, 1 was determined ineligible for radiation during planning, 1 withdrew consent). One DLT was observed. The DLT rate was 14.1% (3.3%-24.9%) with a maximum tolerated dose of gemcitabine/nab-paclitaxel (1000/100 mg/m2) and 67.5 Gy/15 fractions. At a median follow-up of 40.6 months for living patients the median OS was 14.5 months (95% confidence interval [CI], 10.9-28.2 months). The median OS for patients with Eastern Collaborative Oncology Group 0 and carbohydrate antigen 19-9 <90 were 34.1 (95% CI, 13.6-54.1) and 43.0 (95% CI, 8.0-not reached) months, respectively. Two-year LPFS and DMFS were 85% (95% CI, 63%-94%) and 57% (95% CI, 34%-73%), respectively. CONCLUSIONS Full-dose gemcitabine/nab-paclitaxel with ablative magnetic resonance guided radiation therapy dosing is safe in patients with BR/LA-PDAC, with promising LPFS and DMFS.
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Affiliation(s)
- Hyun Kim
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri.
| | - Jeffrey R Olsen
- University of Colorado School of Medicine, Department of Radiation Oncology, Denver, Colorado
| | - Olga L Green
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Re-I Chin
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - William G Hawkins
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Ryan C Fields
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Chet Hammill
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Majella B Doyle
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - William Chapman
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Rama Suresh
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Benjamin Tan
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Katrina Pedersen
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Brandi Jansen
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Todd A DeWees
- Mayo Clinic, Scottsdale, Division of Biomedical Statistics and Informatics, Scottsdale, Arizona
| | - Esther Lu
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, Missouri
| | - Lauren E Henke
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Shahed Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Parag J Parikh
- Henry Ford Health System, Department of Radiation Oncology, Detroit, Michigan
| | - Michael C Roach
- Hawai'i Pacific Health, Department of Radiation Oncology, Honolulu, Hawaii
| | - Andrea Wang-Gillam
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Kian-Huat Lim
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
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Price AT, Knutson NC, Kim T, Green OL. Commissioning a secondary dose calculation software for a 0.35 T MR-linac. J Appl Clin Med Phys 2022; 23:e13452. [PMID: 35166011 PMCID: PMC8906210 DOI: 10.1002/acm2.13452] [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: 12/21/2020] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022] Open
Abstract
Secondary external dose calculations for a 0.35 T magnetic resonance image-guided radiation therapy (MRgRT) are needed within the radiation oncology community to follow safety standards set forth within the field. We evaluate the commercially available software, RadCalc, in its ability to accurately perform monitor unit dose calculations within a magnetic field. We also evaluate the potential effects of a 0.35 T magnetic field upon point dose calculations. Monitor unit calculations were evaluated with (wMag) and without (noMag) a magnetic field considerations in RadCalc for the ViewRay MRIdian. The magnetic field is indirectly accounted for by using asymmetric profiles for calculation. The introduction of double-stacked multi-leaf collimator leaves was also included in the monitor unit calculations and a single transmission value was determined. A suite of simple and complex geometries with a variety field arrangements were calculated for each method to demonstrate the effect of the 0.35 T magnetic field on monitor unit calculations. Finally, 25 patient-specific treatment plans were calculated using each method for comparison. All simple geometries calculated in RadCalc were within 2% of treatment planning system (TPS) values for both methods, except for a single noMag off-axis comparison. All complex muilt-leaf collimator (MLC) pattern calculations were within 5%. All complex phantom geometry calculations were within 5% except for a single field within a lung phantom at a distal point. For the patient calculations, the noMag method average percentage difference was 0.09 ± 2.5% and the wMag average percentage difference was 0.08 ± 2.5%. All results were within 5% for the wMag method. We performed monitor unit calculations for a 0.35 T MRgRT system using a commercially available secondary monitor unit dose calculation software and demonstrated minimal impact of the 0.35 T magnetic field on monitor unit dose calculations. This is the first investigation demonstrating successful calculations of dose using RadCalc in the low-field 0.35 T ViewRay MRIdian system.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nels C Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Taeho Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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Price AT, Kennedy WR, Henke LE, Brown SR, Green OL, Thomas MA, Ginn J, Zoberi I. Implementing stereotactic accelerated partial breast irradiation using magnetic resonance guided radiation therapy. Radiother Oncol 2021; 164:275-281. [PMID: 34624406 DOI: 10.1016/j.radonc.2021.09.023] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Accelerated partial breast irradiation (APBI) seeks to reduce irradiated volumes and radiation exposure for patients while maintaining acceptable clinical outcomes. Magnetic resonance image-guided radiotherapy (MRgRT) provides excellent soft-tissue contrast for treatment localization, which can reduce setup uncertainty, thus reducing margins in the external beam setting. Additionally, stereotactic body radiotherapy (SBRT)-style regimens with high gradients can also be executed. This MR-guided stereotactic APBI (MRgS-APBI) approach can be utilized for a lower number of fractions and spare a greater volume of healthy tissues compared to conventional 3D external beam APBI. METHODS Our MRgS-APBI program was developed for two prospective non-randomized phase I/II clinical trials (20Gyx1 and 8.5Gyx3). Both breast SBRT treatment planning and MRgRT delivery techniques were described in this study. Simulation included both CT and MRI with specialized immobilization to accommodate MR-guided setup and cine-MRI treatment gating. Dosimetry data from 48 single-fraction and 19 three-fraction patients were collected and evaluated. This included planning objectives and SBRT-specific indices. During treatment, setup errors were calculated to evaluate setup reproducibility and duty cycle was calculated using cine-MRI data during gated delivery. RESULTS In both the single- and three- fraction trials combined, 88.5% of the possible dosimetric objectives across all patients were met during planning. The majority of the planning objectives were easily achievable indicating the potential for stricter objectives for subsequent S-APBI treatments. The average magnitude of setup uncertainties was 1.0 cm ± 0.6 cm across all treatments. In the three-fraction trial, the average beam-on duty-cycle for the MRI-gated delivery was 83.0 ± 13.0%. There were no technical MRgS-APBI related issues that resulted in discontinuation of treatment across all patients. CONCLUSION SBRT-style dosimetry and delivery for APBI is feasible using MR-guidance. The program development and dosimetric outcomes reported here can serve as a guide for other institutions considering the clinical implementation of MR-guided stereotactic APBI.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Sean R Brown
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - John Ginn
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States.
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Henke LE, Stanley JA, Robinson C, Srivastava A, Contreras JA, Curcuru A, Green OL, Massad LS, Kuroki L, Fuh K, Hagemann A, Mutch D, McCourt C, Thaker P, Powell M, Markovina S, Grigsby PW, Schwarz JK, Chundury A. Phase I Trial of Stereotactic MRI-Guided Online Adaptive Radiation Therapy (SMART) for the Treatment of Oligometastatic Ovarian Cancer. Int J Radiat Oncol Biol Phys 2021; 112:379-389. [PMID: 34474109 DOI: 10.1016/j.ijrobp.2021.08.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/18/2021] [Accepted: 08/24/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Stereotactic body radiation therapy is increasingly used to treat a variety of oligometastatic histologies, but few data exist for ovarian cancer. Ablative stereotactic body radiation therapy dosing is challenging in sites like the abdomen, pelvis, and central thorax due to proximity and motion of organs at risk. A novel radiation delivery method, stereotactic magnetic-resonance-guided online-adaptive radiation therapy (SMART), may improve the therapeutic index of stereotactic body radiation therapy through enhanced soft-tissue visualization, real-time nonionizing imaging, and ability to adapt to the anatomy-of-the-day, with the goal of producing systemic-therapy-free intervals. This phase I trial assessed feasibility, safety, and dosimetric advantage of SMART to treat ovarian oligometastases. METHODS AND MATERIALS Ten patients with recurrent oligometastatic ovarian cancer underwent SMART for oligometastasis ablation. Initial plans prescribed 35 Gy/5 fractions with goal 95% planning target volume coverage by 95% of prescription, with dose escalation permitted, subject to strict organ-at-risk dose constraints. Daily adaptive planning was used to protect organs-at-risk and/or increase target dose. Feasibility (successful delivery of >80% of fractions in the first on-table attempt) and safety of this approach was evaluated, in addition to efficacy, survival metrics, quality-of-life, prospective timing and dosimetric outcomes. RESULTS Ten women with seventeen ovarian oligometastases were treated with SMART, and 100% of treatment fractions were successfully delivered. Online adaptive plans were selected at time of treatment for 58% of fractions, due to initial plan violation of organs-at-risk constraints (84% of adapted fractions) or observed opportunity for planning target volume dose escalation (16% of adapted fractions), with a median on-table time of 64 minutes. A single Grade ≥3 acute (within 6 months of SMART) treatment-related toxicity (duodenal ulcer) was observed. Local control at 3 months was 94%; median progression-free survival was 10.9 months. Median Kaplan-Meier estimated systemic-therapy-free survival after radiation completion was 11.5 months, with concomitant quality-of-life improvements. CONCLUSIONS SMART is feasible and safe for high-dose radiation therapy ablation of ovarian oligometastases of the abdomen, pelvis, and central thorax with minimal toxicity, high rates of local control, and prolonged systemic-therapy-free survival translating into improved quality-of-life.
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Affiliation(s)
- Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jennifer A Stanley
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
| | - Amar Srivastava
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jessika A Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Austen Curcuru
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - L Stewart Massad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Lindsay Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine Fuh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Andrea Hagemann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - David Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Carolyn McCourt
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Premal Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Matthew Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Perry W Grigsby
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Julie K Schwarz
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Anupama Chundury
- Department of Radiation Oncology, Rutgers University, New Brunswick, New Jersey
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McGee KP, Tyagi N, Bayouth JE, Cao M, Fallone BG, Glide‐Hurst CK, Goerner FL, Green OL, Kim T, Paulson ES, Yanasak NE, Jackson EF, Goodwin JH, Dieterich S, Jordan DW, Hugo GD, Bernstein MA, Balter JM, Kanal KM, Hazle JD, Pelc NJ. Findings of the AAPM Ad Hoc committee on magnetic resonance imaging in radiation therapy: Unmet needs, opportunities, and recommendations. Med Phys 2021; 48:4523-4531. [PMID: 34231224 PMCID: PMC8457147 DOI: 10.1002/mp.14996] [Citation(s) in RCA: 3] [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: 01/03/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 02/03/2023] Open
Abstract
The past decade has seen the increasing integration of magnetic resonance (MR) imaging into radiation therapy (RT). This growth can be contributed to multiple factors, including hardware and software advances that have allowed the acquisition of high-resolution volumetric data of RT patients in their treatment position (also known as MR simulation) and the development of methods to image and quantify tissue function and response to therapy. More recently, the advent of MR-guided radiation therapy (MRgRT) - achieved through the integration of MR imaging systems and linear accelerators - has further accelerated this trend. As MR imaging in RT techniques and technologies, such as MRgRT, gain regulatory approval worldwide, these systems will begin to propagate beyond tertiary care academic medical centers and into more community-based health systems and hospitals, creating new opportunities to provide advanced treatment options to a broader patient population. Accompanying these opportunities are unique challenges related to their adaptation, adoption, and use including modification of hardware and software to meet the unique and distinct demands of MR imaging in RT, the need for standardization of imaging techniques and protocols, education of the broader RT community (particularly in regards to MR safety) as well as the need to continue and support research, and development in this space. In response to this, an ad hoc committee of the American Association of Physicists in Medicine (AAPM) was formed to identify the unmet needs, roadblocks, and opportunities within this space. The purpose of this document is to report on the major findings and recommendations identified. Importantly, the provided recommendations represent the consensus opinions of the committee's membership, which were submitted in the committee's report to the AAPM Board of Directors. In addition, AAPM ad hoc committee reports differ from AAPM task group reports in that ad hoc committee reports are neither reviewed nor ultimately approved by the committee's parent groups, including at the council and executive committee level. Thus, the recommendations given in this summary should not be construed as being endorsed by or official recommendations from the AAPM.
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Affiliation(s)
- Kiaran P. McGee
- Department of RadiologyMayo ClinicRochesterMinnesota55905USA
| | - Neelam Tyagi
- Department of Medical PhysicsMemorial Sloan‐Kettering Cancer CenterNew YorkNew York10065USA
| | - John E. Bayouth
- Department of Radiation OncologyUniversity of WisconsinMadisonWisconsin53792‐0600USA
| | - Minsong Cao
- Department of Radiation OncologyUniversity of California, Los AngelesLos AngelesCalifornia90095‐6951USA
| | - B. Gino Fallone
- Department of Medical PhysicsCross Cancer InstituteEdmontonAlbertaAB T6G 1Z2Canada
| | | | - Frank L. Goerner
- Department of Radiology/Radiological SciencesQueen's Medical CenterHonoluluHI96813USA
| | - Olga L. Green
- Department of Radiation OncologyWashington University School of MedicineSt. LouisMO63110USA
| | - Taeho Kim
- Department of Radiation OncologyVirginia Commonwealth UniversityGlen AllenVA23059USA
| | - Eric S. Paulson
- Department of Radiation OncologyMedical College of WisconsinMilwaukeeWisconsin53226USA
| | | | - Edward F. Jackson
- Department of Imaging PhysicsUniversity of WisconsinMadisonWI53705USA
| | - James H. Goodwin
- Department of Medical PhysicsUniversity of Vermont Medical CenterBurlingtonVT05401USA
| | - Sonja Dieterich
- Department of Radiation OncologyUC Davis Medical CenterSacramentoCalifornia95817USA
| | - David W. Jordan
- Department of RadiologyUniversity Hospitals Cleveland Medical CenterClevelandOhio44106USA
| | - Geoffrey D. Hugo
- Department of Radiation OncologyWashington University St LouisRichmondVA23298‐0058USA
| | | | - James M. Balter
- Department of Radiation OncologyUniversity of MichiganAnn ArborMI48109USA
| | - Kalpana M. Kanal
- Department of RadiologyUniversity of WashingtonSeattleWA98195‐7987USA
| | - John D. Hazle
- Department of Imaging PhysicsUT MD Anderson Cancer CenterHoustonTX77030‐4095USA
| | - Norbert J. Pelc
- Department of Radiology/Radiological SciencesStanford UniversityStanfordCA94305‐4245USA
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Green OL, Henke LE, Price A, Marko A, Wittland EJ, Rudra S, Kim H, Mutic S, Michalski J, Robinson CG. The Role of MRI-Guided Radiation Therapy for Palliation of Mobile Abdominal Cancers: A Report of Two Cases. Adv Radiat Oncol 2021; 6:100662. [PMID: 33997480 PMCID: PMC8102139 DOI: 10.1016/j.adro.2021.100662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 12/29/2020] [Accepted: 01/12/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Alex Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Areti Marko
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Erin J Wittland
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Soumon Rudra
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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Crockett CB, Samson P, Chuter R, Dubec M, Faivre-Finn C, Green OL, Hackett SL, McDonald F, Robinson C, Shiarli AM, Straza MW, Verhoeff JJC, Werner-Wasik M, Vlacich G, Cobben D. Initial Clinical Experience of MR-Guided Radiotherapy for Non-Small Cell Lung Cancer. Front Oncol 2021; 11:617681. [PMID: 33777759 PMCID: PMC7988221 DOI: 10.3389/fonc.2021.617681] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
Curative-intent radiotherapy plays an integral role in the treatment of lung cancer and therefore improving its therapeutic index is vital. MR guided radiotherapy (MRgRT) systems are the latest technological advance which may help with achieving this aim. The majority of MRgRT treatments delivered to date have been stereotactic body radiation therapy (SBRT) based and include the treatment of (ultra-) central tumors. However, there is a move to also implement MRgRT as curative-intent treatment for patients with inoperable locally advanced NSCLC. This paper presents the initial clinical experience of using the two commercially available systems to date: the ViewRay MRIdian and Elekta Unity. The challenges and potential solutions associated with MRgRT in lung cancer will also be highlighted.
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Affiliation(s)
- Cathryn B. Crockett
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Pamela Samson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Robert Chuter
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Michael Dubec
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Olga L. Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Sara L. Hackett
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Fiona McDonald
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Anna-Maria Shiarli
- Department of Radiotherapy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael W. Straza
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Gregory Vlacich
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - David Cobben
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
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Lewis BC, Gu B, Klett R, Lotey R, Green OL, Kim T. Characterization of radiotherapy component impact on MR imaging quality for an MRgRT system. J Appl Clin Med Phys 2020; 21:20-26. [PMID: 33211375 PMCID: PMC7769410 DOI: 10.1002/acm2.13054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/30/2020] [Accepted: 08/27/2020] [Indexed: 11/15/2022] Open
Abstract
Radiotherapy components of an magnetic resonnace-guided radiotherapy (MRgRT) system can alter the magnetic fields, causing spatial distortion and image deformation, altering imaging and radiation isocenter coincidence and the accuracy of dose calculations. This work presents a characterization of radiotherapy component impact on MR imaging quality in terms of imaging isocenter variation and spatial integrity changes on a 0.35T MRgRT system, pre- and postupgrade of the system. The impact of gantry position, MLC field size, and treatment table power state on imaging isocenter and spatial integrity were investigated. A spatial integrity phantom was used for all tests. Images were acquired for gantry angles 0-330° at 30° increments to assess the impact of gantry position. For MLC and table power state tests all images were acquired at the home gantry position (330°). MLC field sizes ranged from 1.66 to 27.4 cm edge length square fields. Imaging isocenter shift caused by gantry position was reduced from 1.7 mm at gantry 150° preupgrade to 0.9 mm at gantry 120° postupgrade. Maximum spatial integrity errors were 0.5 mm or less pre- and postupgrade for all gantry angles, MLC field sizes, and treatment table power states. However, when the treatment table was powered on, there was significant reduction in SNR. This study showed that gantry position can impact imaging isocenter, but spatial integrity errors were not dependent on gantry position, MLC field size, or treatment table power state. Significant isocenter variation, while reduced postupgrade, is cause for further investigation.
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Affiliation(s)
- Benjamin C. Lewis
- Department of Radiation OncologyWashington University School of MedicineSt LouisMOUSA
| | - Bruce Gu
- Department of Radiation OncologyWashington University School of MedicineSt LouisMOUSA
| | | | | | - Olga L. Green
- Department of Radiation OncologyWashington University School of MedicineSt LouisMOUSA
| | - Taeho Kim
- Department of Radiation OncologyWashington University School of MedicineSt LouisMOUSA
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10
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Abstract
TPS786 Background: Standard dose radiation therapy has been unsuccessful in inoperable pancreatic cancer; with a negative study (LAP07) for conventional chemoradiation and dropping of the stereotactic body radiation therapy arm in Alliance A021501. Recently, reports of using high dose ablative radiation therapy has been associated with increased survival in retrospective studies. Moreover, technological advances with MRI-guided radiation therapy offer improved targeting and the ability to change the radiation delivery on a daily fashion; allowing ablative radiation doses over one week. However, it is not clear whether this can be done safely on a multiinstitutional basis. Methods: We are conducting the largest prospective study of ablative radiation therapy in pancreatic cancer. The study is a single arm, multi-institutional phase II, industry sponsored study to investigate the safety and efficacy of Stereotactic, MR guided, on-table-Adaptive Radiation Therapy (SMART). Eligibility criteria include locally advanced and borderline resectable pancreatic cancer patients with ECOG PS of 0 or 1; who have non-metastatic disease after a minimum of 3 months of any systemic therapy; including investigational agents. Patients will receive MR-guided radiation therapy to a dose of 50 Gy / 5 fractions; with maximum tumor coverage delivered each fraction that allows keeping the gastrointestinal organs at risk to a dose of 33 Gy or less. Primary endpoint is grade 3 of higher gastrointestinal toxicity at 90 days. Secondary endpoints are overall survival at 2 years, distant progression free survival at 6 months, and changes in patient related quality of life at 3 and 12 months. Target sample size was calculated to show at a significance level 0.05, a reduction of the toxicity rate to 8% or lower by using SMART compared with 15.8%, the toxicity rate of conventionally delivered chemoradiation at a power level 0.8. Given an expected 15% drop-out, the enrollment goal is 133. Descriptive statistics will be used for secondary objectives. The study opened in January, 2019 and is currently opened at 4 centers; with other US and international sites pending. Sponsored by Viewray, Inc. Clinical trial information: NCT03621644.
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Affiliation(s)
| | - Daniel Low
- University of California Los Angeles, Los Angeles, CA
| | - Olga L. Green
- Washington University in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Percy P. Lee
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
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11
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Michael Gach H, Curcuru AN, Wittland EJ, Maraghechi B, Cai B, Mutic S, Green OL. MRI quality control for low-field MR-IGRT systems: Lessons learned. J Appl Clin Med Phys 2019; 20:53-66. [PMID: 31541542 PMCID: PMC6806483 DOI: 10.1002/acm2.12713] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 04/30/2019] [Revised: 06/27/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose To present lessons learned from magnetic resonance imaging (MRI) quality control (QC) tests for low‐field MRI‐guided radiation therapy (MR‐IGRT) systems. Methods MRI QC programs were established for low‐field MRI‐60Co and MRI‐Linac systems. A retrospective analysis of MRI subsystem performance covered system commissioning, operations, maintenance, and quality control. Performance issues were classified into three groups: (a) Image noise and artifact; (b) Magnetic field homogeneity and linearity; and (c) System reliability and stability. Results Image noise and artifacts were attributed to room noise sources, unsatisfactory system cabling, and broken RF receiver coils. Gantry angle‐dependent magnetic field inhomogeneities were more prominent on the MRI‐Linac due to the high volume of steel shielding in the gantry. B0 inhomogeneities measured in a 24‐cm spherical phantom were <5 ppm for both MR‐IGRT systems after using MRI gradient offset (MRI‐GO) compensation on the MRI‐Linac. However, significant signal dephasing occurred on the MRI‐Linac while the gantry was rotating. Spatial integrity measurements were sensitive to gradient calibration and vulnerable to shimming. The most common causes of MR‐IGRT system interruptions were software disconnects between the MRI and radiation therapy delivery subsystems caused by patient table, gantry, and multi‐leaf collimator (MLC) faults. The standard deviation (SD) of the receiver coil signal‐to‐noise ratio was 1.83 for the MRI‐60Co and 1.53 for the MRI‐Linac. The SD of the deviation from the mean for the Larmor frequency was 1.41 ppm for the MRI‐60Co and 1.54 ppm for the MRI‐Linac. The SD of the deviation from the mean for the transmitter reference amplitude was 0.90% for the MRI‐60Co and 1.68% for the MRI‐Linac. High SDs in image stability data corresponded to reports of spike noise. Conclusions There are significant technological challenges associated with implementing and maintaining MR‐IGRT systems. Most of the performance issues were identified and resolved during commissioning.
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Affiliation(s)
- H Michael Gach
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA.,Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
| | - Austen N Curcuru
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
| | - Erin J Wittland
- Department of Radiation Oncology, Barnes Jewish Hospital, St. Louis, Missouri, 63110, USA
| | - Borna Maraghechi
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
| | - Bin Cai
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, 63110, USA
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12
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Olberg S, Zhang H, Kennedy WR, Chun J, Rodriguez V, Zoberi I, Thomas MA, Kim JS, Mutic S, Green OL, Park JC. Synthetic CT reconstruction using a deep spatial pyramid convolutional framework for MR‐only breast radiotherapy. Med Phys 2019; 46:4135-4147. [DOI: 10.1002/mp.13716] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/14/2019] [Accepted: 07/03/2019] [Indexed: 12/31/2022] Open
Affiliation(s)
- Sven Olberg
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
- Department of Biomedical Engineering Washington University in St. Louis St. Louis MO 63110USA
| | - Hao Zhang
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - William R. Kennedy
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Jaehee Chun
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
- Department of Radiation Oncology, Yonsei Cancer Center Yonsei University College of Medicine Seoul South Korea
| | - Vivian Rodriguez
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Imran Zoberi
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Maria A. Thomas
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center Yonsei University College of Medicine Seoul South Korea
| | - Sasa Mutic
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Olga L. Green
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
| | - Justin C. Park
- Department of Radiation Oncology Washington University in St. Louis St. Louis MO 63110USA
- Department of Biomedical Engineering Washington University in St. Louis St. Louis MO 63110USA
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13
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Gach HM, Green OL, Cuculich PS, Wittland EJ, Marko A, Luchtefeld ME, Entwistle JM, Yang D, Wilber DJ, Mutic S, Robinson CG. Lessons Learned From the First Human Low-Field MRI Guided Radiation Therapy of the Heart in the Presence of an Implantable Cardiac Defibrillator. Pract Radiat Oncol 2019; 9:274-279. [DOI: 10.1016/j.prro.2019.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/18/2019] [Accepted: 02/10/2019] [Indexed: 11/16/2022]
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Abstract
Adaptive radiotherapy emerged over 20 years ago and is now an established clinical practice in a number of organ sites. No one solution for adaptive therapy exists. Rather, adaptive radiotherapy is a process which combines multiple tools for imaging, assessment of need for adaptation, treatment planning, and quality assurance of this process. Workflow is therefore a critical aspect to ensure safe, effective, and efficient implementation of adaptive radiotherapy. In this work, we discuss the tools for online and offline adaptive radiotherapy and introduce workflow concepts for these types of adaptive radiotherapy. Common themes and differences between the workflows are introduced and controversies and areas of active research are discussed.
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Affiliation(s)
- Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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15
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Henke LE, Green OL, Schiff J, Rodriguez VL, Mutic S, Michalski J, Perkins SM. First Reported Case of Pediatric Radiation Treatment With Magnetic Resonance Image Guided Radiation Therapy. Adv Radiat Oncol 2019; 4:233-236. [PMID: 31011667 PMCID: PMC6460231 DOI: 10.1016/j.adro.2019.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/23/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Stephanie M. Perkins
- Corresponding author. Department of Radiation Oncology, Washington University School of Medicine, Campus Box 8224, 4921 Parkview Place, Floor LL, St. Louis, MO 63110.
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16
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Henke LE, Contreras JA, Green OL, Cai B, Kim H, Roach MC, Olsen JR, Fischer-Valuck B, Mullen DF, Kashani R, Thomas MA, Huang J, Zoberi I, Yang D, Rodriguez V, Bradley JD, Robinson CG, Parikh P, Mutic S, Michalski J. Magnetic Resonance Image-Guided Radiotherapy (MRIgRT): A 4.5-Year Clinical Experience. Clin Oncol (R Coll Radiol) 2018; 30:720-727. [PMID: 30197095 PMCID: PMC6177300 DOI: 10.1016/j.clon.2018.08.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [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: 05/01/2018] [Revised: 07/19/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
AIMS Magnetic resonance image-guided radiotherapy (MRIgRT) has been clinically implemented since 2014. This technology offers improved soft-tissue visualisation, daily imaging, and intra-fraction real-time imaging without added radiation exposure, and the opportunity for adaptive radiotherapy (ART) to adjust for anatomical changes. Here we share the longest single-institution experience with MRIgRT, focusing on trends and changes in use over the past 4.5 years. MATERIALS AND METHODS We analysed clinical information, including patient demographics, treatment dates, disease sites, dose/fractionation, and clinical trial enrolment for all patients treated at our institution using MRIgRT on a commercially available, integrated 0.35 T MRI, tri-cobalt-60 device from 2014 to 2018. For each patient, factors including disease site, clinical rationale for MRIgRT use, use of ART, and proportion of fractions adapted were summated and compared between individual years of use (2014-2018) to identify shifts in institutional practice patterns. RESULTS Six hundred and forty-two patients were treated with 666 unique treatment courses using MRIgRT at our institution between 2014 and 2018. Breast cancer was the most common disease, with use of cine MRI gating being a particularly important indication, followed by abdominal sites, where the need for cine gating and use of ART drove MRIgRT use. One hundred and ninety patients were treated using ART in 1550 fractions, 67.6% (1050) of which were adapted. ART was primarily used in cancers of the abdomen. Over time, breast and gastrointestinal cancers became increasingly dominant for MRIgRT use, hypofractionated treatment courses became more popular, and gastrointestinal cancers became the principal focus of ART. DISCUSSION MRIgRT is widely applicable within the field of radiation oncology and new clinical uses continue to emerge. At our institution to date, applications such as ART for gastrointestinal cancers and accelerated partial breast irradiation (APBI) for breast cancer have become dominant indications, although this is likely to continue to evolve.
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Affiliation(s)
- L E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J A Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - O L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - B Cai
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - H Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - M C Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - B Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D F Mullen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - R Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - M A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - I Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D Yang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - V Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - C G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - P Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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Henke LE, Olsen JR, Contreras JA, Curcuru A, DeWees TA, Green OL, Michalski J, Mutic S, Roach MC, Bradley JD, Parikh PJ, Kashani R, Robinson CG. Stereotactic MR-Guided Online Adaptive Radiation Therapy (SMART) for Ultracentral Thorax Malignancies: Results of a Phase 1 Trial. Adv Radiat Oncol 2018; 4:201-209. [PMID: 30706029 PMCID: PMC6349650 DOI: 10.1016/j.adro.2018.10.003] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [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: 03/06/2018] [Accepted: 10/05/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is an effective treatment for oligometastatic or unresectable primary malignancies, although target proximity to organs at risk (OARs) within the ultracentral thorax (UCT) limits safe delivery of an ablative dose. Stereotactic magnetic resonance (MR)–guided online adaptive radiation therapy (SMART) may improve the therapeutic ratio using reoptimization to account for daily variation in target and OAR anatomy. This study assessed the feasibility of UCT SMART and characterized dosimetric and clinical outcomes in patients treated for UCT lesions on a prospective phase 1 trial. Methods and Materials Five patients with oligometastatic (n = 4) or unresectable primary (n = 1) UCT malignancies underwent SMART. Initial plans prescribed 50 Gy in 5 fractions with goal 95% planning target volume (PTV) coverage by 95% of prescription, subject to strict OAR constraints. Daily real-time online adaptive plans were created as needed to preserve hard OAR constraints, escalate PTV dose, or both, based on daily setup MR image set anatomy. Treatment times, patient outcomes, and dosimetric comparisons were prospectively recorded. Results All initial and daily adaptive plans met strict OAR constraints based on simulation and daily setup MR imaging anatomy, respectively. Four of the 5 patients received ≥1 adapted fraction. Ten of the 25 total delivered fractions were adapted. A total of 30% of plan adaptations were performed to improve PTV coverage; 70% were for reversal of ≥1 OAR violation. Local control by Response Evaluation Criteria in Solid Tumors was 100% at 3 and 6 months. No grade ≥3 acute (within 6 months of radiation completion) treatment-related toxicities were identified. Conclusions SMART may allow PTV coverage improvement and/or OAR sparing compared with nonadaptive SBRT and may widen the therapeutic index of UCT SBRT. In this small prospective cohort, we found that SMART was clinically deliverable to 100% of patients, although treatment delivery times surpassed our predefined, timing-based feasibility endpoint. This technique is well tolerated, offering excellent local control with no identified acute grade ≥3 toxicity.
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Affiliation(s)
- Lauren E. Henke
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey R. Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jessika A. Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Austen Curcuru
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Todd A. DeWees
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Olga L. Green
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Michael C. Roach
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Parag J. Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Clifford G. Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
- Corresponding author. Department of Radiation Oncology, Washington University School of Medicine, Campus Box 8224, 4921 Parkview Place, Floor LL, St Louis, MO 63110.
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18
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Green OL, Rankine LJ, Cai B, Curcuru A, Kashani R, Rodriguez V, Li HH, Parikh PJ, Robinson CG, Olsen JR, Mutic S, Goddu SM, Santanam L. First clinical implementation of real-time, real anatomy tracking and radiation beam control. Med Phys 2018; 45:3728-3740. [PMID: 29807390 DOI: 10.1002/mp.13002] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [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: 06/04/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE We describe the acceptance testing, commissioning, periodic quality assurance, and workflow procedures developed for the first clinically implemented magnetic resonance imaging-guided radiation therapy (MR-IGRT) system for real-time tracking and beam control. METHODS The system utilizes real-time cine imaging capabilities at 4 frames per second for real-time tracking and beam control. Testing of the system was performed using an in-house developed motion platform and a commercially available motion phantom. Anatomical tracking is performed by first identifying a target (a region of interest that is either tissue to be treated or a critical structure) and generating a contour around it. A boundary contour is also created to identify tracking margins. The tracking algorithm deforms the anatomical contour (target or a normal organ) on every subsequent cine frame and compares it to the static boundary contour. If the anatomy of interest moves outside the boundary, the radiation delivery is halted until the tracked anatomy returns to treatment portal. The following were performed to validate and clinically implement the system: (a) spatial integrity evaluation; (b) tracking accuracy; (c) latency; (d) relative point dose and spatial dosimetry; (e) development of clinical workflow for gating; and (f) independent verification by an outside credentialing service. RESULTS The spatial integrity of the MR system was found to be within 2 mm over a 45-cm diameter field-of-view. The tracking accuracy for geometric targets was within 1.2 mm. The average system latency was measured to be within 394 ms. The dosimetric accuracy using ionization chambers was within 1.3% ± 1.7%, and the dosimetric spatial accuracy was within 2 mm. The phantom irradiation for the outside credentialing service had satisfactory results, as well. CONCLUSIONS The first clinical MR-IGRT system was validated for real-time tracking and gating capabilities and shown to be reliable and accurate. Patient workflow methods were developed for efficient treatment. Periodic quality assurance tests can be efficiently performed with commercially available equipment to ensure accurate system performance.
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Affiliation(s)
- Olga L Green
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Leith J Rankine
- University of North Carolina at Chapel Hill, Chapel Hill, NC, 27713, USA
| | - Bin Cai
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Austen Curcuru
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | | | - Vivian Rodriguez
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - H Harold Li
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Parag J Parikh
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | | | - Jeffrey R Olsen
- University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Sasa Mutic
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - S M Goddu
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Lakshmi Santanam
- Washington University School of Medicine, St. Louis, MO, 63130, USA
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Cai B, Green OL, Kashani R, Rodriguez VL, Mutic S, Yang D. A practical implementation of physics quality assurance for photon adaptive radiotherapy. Z Med Phys 2018; 28:211-223. [PMID: 29550014 DOI: 10.1016/j.zemedi.2018.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 05/29/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 11/26/2022]
Abstract
The fast evolution of technology in radiotherapy (RT) enabled the realization of adaptive radiotherapy (ART). However, the new characteristics of ART pose unique challenges for efficiencies and effectiveness of quality assurance (QA) strategies. In this paper, we discuss the necessary QAs for ART and introduce a practical implementation. A previously published work on failure modes and effects analysis (FMEA) of ART is introduced first to explain the risks associated with ART sub-processes. After a brief discussion of QA challenges, we review the existing QA strategies and tools that might be suitable for each ART step. By introducing the MR-guided online ART QA processes developed at our institute, we demonstrate a practical implementation. The limitations and future works to develop more robust and efficient QA strategies are discussed at the end.
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Affiliation(s)
- Bin Cai
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Abor, MI, 48109, USA
| | - Vivian L Rodriguez
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA
| | - Deshan Yang
- Department of Radiation Oncology, Washington University, St. Louis, MO 63110, USA.
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Cardenas ML, Mazur TR, Tsien CI, Green OL. A rapid, computational approach for assessing interfraction esophageal motion for use in stereotactic body radiation therapy planning. Adv Radiat Oncol 2017; 3:209-215. [PMID: 29904747 PMCID: PMC6000025 DOI: 10.1016/j.adro.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 03/14/2017] [Revised: 08/30/2017] [Accepted: 10/03/2017] [Indexed: 01/15/2023] Open
Abstract
Purpose We present a rapid computational method for quantifying interfraction motion of the esophagus in patients undergoing stereotactic body radiation therapy on a magnetic resonance (MR) guided radiation therapy system. Methods and materials Patients who underwent stereotactic body radiation therapy had simulation computed tomography (CT) and on-treatment MR scans performed. The esophagus was contoured on each scan. CT contours were transferred to MR volumes via rigid registration. Digital Imaging and Communications in Medicine files containing contour points were exported to MATLAB. In-plane CT and MR contour points were spline interpolated, yielding boundaries with centroid positions, CCT and CMR. MR contour points lying outside of the CT contour were extracted. For each such point, BMR(j), a segment from CCT intersecting BMR(j), was produced; its intersection with the CT contour, BCT(i), was calculated. The length of the segment Sij, between BCT(i) and BMR(j), was found. The orientation θ was calculated from Sij vector components: θ = arctan[(Sij)y / (Sij)x] A set of segments {Sij} was produced for each slice and binned by quadrant with 0° < θ ≤ 90°, 90° < θ ≤ 180°, 180° < θ ≤ 270°, and 270° < θ ≤ 360° for the left anterior, right anterior, right posterior, and left posterior quadrants, respectively. Slices were binned into upper, middle, and lower esophageal (LE) segments. Results Seven patients, each having 3 MR scans, were evaluated, yielding 1629 axial slices and 84,716 measurements. The LE segment exhibited the greatest magnitude of motion. The mean LE measurements in the left anterior, left posterior, right anterior, and right posterior were 5.2 ± 0.07 mm, 6.0 ± 0.09 mm, 4.8 ± 0.08 mm, and 5.1 ± 0.08 mm, respectively. There was considerable interpatient variability. Conclusions The LE segment exhibited the greatest magnitude of mobility compared with the middle and upper esophageal segments. A novel computational method enables personalized, nonuniform esophageal margins to be tailored to individual patients.
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Affiliation(s)
| | | | | | - Olga L Green
- Washington University in St. Louis, St. Louis, Missouri
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Henke LE, Kashani R, Przybysz D, Hilliard J, Curcuru A, Green OL, Bradley JD, Robinson CG. (S009) In Silico Trial of MR-Guided Mid-Treatment Adaptive Planning for Hypofractionated Stereotactic Radiotherapy in Centrally Located Thoracic Tumors. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.045] [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: 12/01/2022]
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Liu S, Mazur TR, Li H, Curcuru A, Green OL, Sun B, Mutic S, Yang D. A method to reconstruct and apply 3D primary fluence for treatment delivery verification. J Appl Clin Med Phys 2016; 18:128-138. [PMID: 28291913 PMCID: PMC5689871 DOI: 10.1002/acm2.12017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/24/2016] [Indexed: 01/14/2023] Open
Abstract
Motivation In this study, a method is reported to perform IMRT and VMAT treatment delivery verification using 3D volumetric primary beam fluences reconstructed directly from planned beam parameters and treatment delivery records. The goals of this paper are to demonstrate that 1) 3D beam fluences can be reconstructed efficiently, 2) quality assurance (QA) based on the reconstructed 3D fluences is capable of detecting additional treatment delivery errors, particularly for VMAT plans, beyond those identifiable by other existing treatment delivery verification methods, and 3) QA results based on 3D fluence calculation (3DFC) are correlated with QA results based on physical phantom measurements and radiation dose recalculations. Methods Using beam parameters extracted from DICOM plan files and treatment delivery log files, 3D volumetric primary fluences are reconstructed by forward‐projecting the beam apertures, defined by the MLC leaf positions and modulated by beam MU values, at all gantry angles using first‐order ray tracing. Treatment delivery verifications are performed by comparing 3D fluences reconstructed using beam parameters in delivery log files against those reconstructed from treatment plans. Passing rates are then determined using both voxel intensity differences and a 3D gamma analysis. QA sensitivity to various sources of errors is defined as the observed differences in passing rates. Correlations between passing rates obtained from QA derived from both 3D fluence calculations and physical measurements are investigated prospectively using 20 clinical treatment plans with artificially introduced machine delivery errors. Results Studies with artificially introduced errors show that common treatment delivery problems including gantry angle errors, MU errors, jaw position errors, collimator rotation errors, and MLC leaf position errors were detectable at less than normal machine tolerances. The reported 3DFC QA method has greater sensitivity than measurement‐based QA methods. Statistical analysis‐based Spearman's correlations shows that the 3DFC QA passing rates are significantly correlated with passing rates of physical phantom measurement‐based QA methods. Conclusion Among measurement‐less treatment delivery verification methods, the reported 3DFC method is less demanding than those based on full dose re‐calculations, and more comprehensive than those that solely checks beam parameters in treatment log files. With QA passing rates correlating to measurement‐based passing rates, the 3DFC QA results could be useful for complementing the physical phantom measurements, or verifying treatment deliveries when physical measurements are not available. For the past 4+ years, the reported method has been implemented at authors’ institution 1) as a complementary metric to physical phantom measurements for pretreatment, patient‐specific QA of IMRT and VMAT plans, and 2) as an important part of the log file‐based automated verification of daily patient treatment deliveries. It has been demonstrated to be useful in catching both treatment plan data transfer errors and treatment delivery problems.
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Affiliation(s)
- Shi Liu
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Thomas R Mazur
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Harold Li
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Austen Curcuru
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Olga L Green
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Baozhou Sun
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Sasa Mutic
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
| | - Deshan Yang
- Department of Radiation Oncology, School of Medicine, Washington University, St. Louis, MO, USA
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Hu Y, Rankine L, Green OL, Kashani R, Li HH, Li H, Nana R, Rodriguez V, Santanam L, Shvartsman S, Victoria J, Wooten HO, Dempsey JF, Mutic S. Characterization of the onboard imaging unit for the first clinical magnetic resonance image guided radiation therapy system. Med Phys 2016; 42:5828-37. [PMID: 26429257 DOI: 10.1118/1.4930249] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To characterize the performance of the onboard imaging unit for the first clinical magnetic resonance image guided radiation therapy (MR-IGRT) system. METHODS The imaging performance characterization included four components: ACR (the American College of Radiology) phantom test, spatial integrity, coil signal to noise ratio (SNR) and uniformity, and magnetic field homogeneity. The ACR phantom test was performed in accordance with the ACR phantom test guidance. The spatial integrity test was evaluated using a 40.8 × 40.8 × 40.8 cm(3) spatial integrity phantom. MR and computed tomography (CT) images of the phantom were acquired and coregistered. Objects were identified around the surfaces of 20 and 35 cm diameters of spherical volume (DSVs) on both the MR and CT images. Geometric distortion was quantified using deviation in object location between the MR and CT images. The coil SNR test was performed according to the national electrical manufacturers association (NEMA) standards MS-1 and MS-9. The magnetic field homogeneity test was measured using field camera and spectral peak methods. RESULTS For the ACR tests, the slice position error was less than 0.10 cm, the slice thickness error was less than 0.05 cm, the resolved high-contrast spatial resolution was 0.09 cm, the resolved low-contrast spokes were more than 25, the image intensity uniformity was above 93%, and the percentage ghosting was less than 0.22%. All were within the ACR recommended specifications. The maximum geometric distortions within the 20 and 35 cm DSVs were 0.10 and 0.18 cm for high spatial resolution three-dimensional images and 0.08 and 0.20 cm for high temporal resolution two dimensional cine images based on the distance-to-phantom-center method. The average SNR was 12.0 for the body coil, 42.9 for the combined torso coil, and 44.0 for the combined head and neck coil. Magnetic field homogeneities at gantry angles of 0°, 30°, 60°, 90°, and 120° were 23.55, 20.43, 18.76, 19.11, and 22.22 ppm, respectively, using the field camera method over the 45 cm DSV. CONCLUSIONS The onboard imaging unit of the first commercial MR-IGRT system meets ACR, NEMA, and vendor specifications.
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Affiliation(s)
- Yanle Hu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110 and Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona 85054
| | - Leith Rankine
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Rojano Kashani
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - H Harold Li
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Hua Li
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Roger Nana
- ViewRay, Inc., Oakwood Village, Ohio 44146
| | - Vivian Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Lakshmi Santanam
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | | | | | - H Omar Wooten
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | | | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
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Fischer-Valuck BW, Green OL, Gay HA, Mutic S, Michalski JM. Vector analysis of bladder cancer patient setup utilizing a magnetic resonance image-guided radiation therapy (MR-IGRT) system. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.412] [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: 11/20/2022] Open
Abstract
412 Background: Inter and intra-fraction anatomy changes in patients undergoing radiation therapy (RT) for bladder cancer (BC) are common but have thus far been studied with implanted fiducial markers, limited quality 2-D orthogonal films and computed tomography (CT). The adverse impact of daily set-up variation could be more significant than appreciated. Our goal was to employ the soft tissue imaging capabilities of an integrated magnetic resonance image-guided RT (MR-IGRT) system to analyze daily positioning. Methods: Fourteen patients with BC were treated on a MR-IGRT system. Patient setup was performed via volumetric MR imaging with a resolution of 0.15 x 0.15 cm. Alignment was performed according to skin marks then shifts assessed by comparing the treatment volume from the planning CT to the daily MR image. 240 pretreatment MR images were analyzed and 3 shifts were recorded for each image. A vector shift was calculated by combining the square root of the combined sum of the shifts squared. Number of times that the vector of combined shifts would have exceeded the planning tumor volume (PTV) was recorded. Results: Daily volumetric MR imaging allowed for accurate alignment and daily monitoring of bladder volume and normal tissue anatomy. Recorded shifts of the treated volume were 0.9±0.5 cm in the right/left direction, 0.7±0.3 cm in the anterior/posterior direction, and 0.7±0.4 cm in the cranio-caudal direction. In 66 (28%) of cases the vector shift was initially greater than the PTV margin. For 2 patients, pre-treatment MR imaging revealed the tumor reduced in size and dose to the bowel would have exceeded constraints, and treatment adaptation was performed to reduce normal tissue toxicity. Using CTCAE criteria, no grade 3 or higher toxicities have been reported. Conclusions: Accurate and reproducible treatment delivery is required to avoid marginal misses to the target volume as well as excess dose to normal tissue. MR-IGRT allows for excellent soft tissue visualization which enables for the avoidance of potential setups errors by allowing daily alignment changes to ensure the target is included in the PTV. It also allows the ability to make treatment changes based on anatomy variations.
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Affiliation(s)
| | - Olga L Green
- Washington University in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Hiram Alberto Gay
- Washington University in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Sasa Mutic
- Washington University in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Jeff M. Michalski
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Zhang L, Hu Y, Du D, Green OL, Wooten HO, Li HH. Three-dimensional polymer gel dosimetry using an onboard 0.35 T magnetic resonance imaging scanner: A simulation study. J Med Phys 2015; 40:176-80. [PMID: 26500405 PMCID: PMC4594388 DOI: 10.4103/0971-6203.165081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lei Zhang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yanle Hu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dongsu Du
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H Omar Wooten
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H Harold Li
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA ; Center for Materials Innovation, Washington University, St. Louis, Missouri, USA
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Noel CE, Parikh PJ, Spencer CR, Green OL, Hu Y, Mutic S, Olsen JR. Comparison of onboard low-field magnetic resonance imaging versus onboard computed tomography for anatomy visualization in radiotherapy. Acta Oncol 2015. [PMID: 26206517 DOI: 10.3109/0284186x.2015.1062541] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND Onboard magnetic resonance imaging (OB-MRI) for daily localization and adaptive radiotherapy has been under development by several groups. However, no clinical studies have evaluated whether OB-MRI improves visualization of the target and organs at risk (OARs) compared to standard onboard computed tomography (OB-CT). This study compared visualization of patient anatomy on images acquired on the MRI-(60)Co ViewRay system to those acquired with OB-CT. MATERIAL AND METHODS Fourteen patients enrolled on a protocol approved by the Institutional Review Board (IRB) and undergoing image-guided radiotherapy for cancer in the thorax (n = 2), pelvis (n = 6), abdomen (n = 3) or head and neck (n = 3) were imaged with OB-MRI and OB-CT. For each of the 14 patients, the OB-MRI and OB-CT datasets were displayed side-by-side and independently reviewed by three radiation oncologists. Each physician was asked to evaluate which dataset offered better visualization of the target and OARs. A quantitative contouring study was performed on two abdominal patients to assess if OB-MRI could offer improved inter-observer segmentation agreement for adaptive planning. RESULTS In total 221 OARs and 10 targets were compared for visualization on OB-MRI and OB-CT by each of the three physicians. The majority of physicians (two or more) evaluated visualization on MRI as better for 71% of structures, worse for 10% of structures, and equivalent for 14% of structures. 5% of structures were not visible on either. Physicians agreed unanimously for 74% and in majority for > 99% of structures. Targets were better visualized on MRI in 4/10 cases, and never on OB-CT. CONCLUSION Low-field MR provides better anatomic visualization of many radiotherapy targets and most OARs as compared to OB-CT. Further studies with OB-MRI should be pursued.
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Affiliation(s)
- Camille E Noel
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Parag J Parikh
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Christopher R Spencer
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Olga L Green
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Yanle Hu
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Sasa Mutic
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Jeffrey R Olsen
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
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Altman MB, Kavanaugh JA, Wooten HO, Green OL, DeWees TA, Gay H, Thorstad WL, Li H, Mutic S. A framework for automated contour quality assurance in radiation therapy including adaptive techniques. Phys Med Biol 2015; 60:5199-209. [DOI: 10.1088/0031-9155/60/13/5199] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Li HH, Rodriguez VL, Green OL, Hu Y, Kashani R, Wooten HO, Yang D, Mutic S. Patient-specific quality assurance for the delivery of (60)Co intensity modulated radiation therapy subject to a 0.35-T lateral magnetic field. Int J Radiat Oncol Biol Phys 2014; 91:65-72. [PMID: 25442343 DOI: 10.1016/j.ijrobp.2014.09.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/18/2014] [Accepted: 09/08/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE This work describes a patient-specific dosimetry quality assurance (QA) program for intensity modulated radiation therapy (IMRT) using ViewRay, the first commercial magnetic resonance imaging-guided RT device. METHODS AND MATERIALS The program consisted of: (1) a 1-dimensional multipoint ionization chamber measurement using a customized 15-cm(3) cube-shaped phantom; (2) 2-dimensional (2D) radiographic film measurement using a 30- × 30- × 20-cm(3) phantom with multiple inserted ionization chambers; (3) quasi-3D diode array (ArcCHECK) measurement with a centrally inserted ionization chamber; (4) 2D fluence verification using machine delivery log files; and (5) 3D Monte Carlo (MC) dose reconstruction with machine delivery files and phantom CT. RESULTS Ionization chamber measurements agreed well with treatment planning system (TPS)-computed doses in all phantom geometries where the mean ± SD difference was 0.0% ± 1.3% (n=102; range, -3.0%-2.9%). Film measurements also showed excellent agreement with the TPS-computed 2D dose distributions where the mean passing rate using 3% relative/3 mm gamma criteria was 94.6% ± 3.4% (n=30; range, 87.4%-100%). For ArcCHECK measurements, the mean ± SD passing rate using 3% relative/3 mm gamma criteria was 98.9% ± 1.1% (n=34; range, 95.8%-100%). 2D fluence maps with a resolution of 1 × 1 mm(2) showed 100% passing rates for all plan deliveries (n=34). The MC reconstructed doses to the phantom agreed well with planned 3D doses where the mean passing rate using 3% absolute/3 mm gamma criteria was 99.0% ± 1.0% (n=18; range, 97.0%-100%), demonstrating the feasibility of evaluating the QA results in the patient geometry. CONCLUSIONS We developed a dosimetry program for ViewRay's patient-specific IMRT QA. The methodology will be useful for other ViewRay users. The QA results presented here can assist the RT community to establish appropriate tolerance and action limits for ViewRay's IMRT QA.
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Affiliation(s)
- H Harold Li
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.
| | - Vivian L Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Yanle Hu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Rojano Kashani
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - H Omar Wooten
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Deshan Yang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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Yaddanapudi S, Oddiraju S, Rodriguez V, Green OL, Low DA, Rangaraj D, Mutic S, Goddu SM. Independent verification of transferred delivery sinogram between two dosimetrically matched helical tomotherapy machines: a protocol for patient-specific quality assurance. Phys Med Biol 2012; 57:5617-31. [PMID: 22892686 DOI: 10.1088/0031-9155/57/17/5617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to independently verify the transferred delivery sinogram between two dosimetrically matched helical tomotherapy machines with the goal of eliminating redundant quality assurance (QA) measurements on the second machine. The equivalence of the two machines was evaluated based on both geometric and dosimetric beam characteristics, including measuring open field per cent depth doses (PDD), longitudinal and transverse profiles and helical delivery of clinical patient treatment plans measured in phantoms. QA of 56 patient plans was studied. The delivery sinogram on the secondary machine was computed by accounting for the differences in the MLC characteristics of the two machines. Computed sinograms were compared against the transferred sinograms by tomotherapy's data management system for the same 56 patient plans. The PDD, transverse and longitudinal dose profiles agreed within ±1% between the two machines. Ionization chamber and planar dose measurements with the Iba MatriXX device on both machines for the 56 patients were found to be within ±3% of the doses computed by the tomotherapy treatment planning system. For all 56 patients, the differences between computed sinograms and DMS-converted sinograms were within ±2%. The matched tomotherapy machines had similar beam characteristics. The sinogram-based QA was validated using point and planar dose measurements and found to be acceptable for clinical use.
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Affiliation(s)
- Sridhar Yaddanapudi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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