A joint physics and radiobiology DREAM team vision - Towards better response prediction models to advance radiotherapy

Radiotherapy developed empirically through experience balancing tumour control and normal tissue toxicities. Early simple mathematical models formalized this practical knowledge and enabled effective cancer treatment to date. Remarkable advances in technology, computing, and experimental biology now create opportunities to incorporate this knowledge into enhanced computational models. The ESTRO DREAM (Dose Response, Experiment, Analysis, Modelling) workshop brought together experts across disciplines to pursue the vision of personalized radiotherapy for optimal outcomes through advanced modelling. The ultimate vision is leveraging quantitative models dynamically during therapy to ultimately achieve truly adaptive and biologically guided radiotherapy at the population as well as individual patient-based levels. This requires the generation of models that inform response-based adaptations, individually optimized delivery and enable biological monitoring to provide decision support to clinicians. The goal is expanding to models that can drive the realization of personalized therapy for optimal outcomes. This position paper provides their propositions that describe how innovations in biology, physics, mathematics, and data science including AI could inform models and improve predictions. It consolidates the DREAM team's consensus on scientific priorities and organizational requirements. Scientifically, it stresses the need for rigorous, multifaceted model development, comprehensive validation and clinical applicability and significance. Organizationally, it reinforces the prerequisites of interdisciplinary research and collaboration between physicians, medical physicists, radiobiologists, and computational scientists throughout model development. Solely by a shared understanding of clinical needs, biological mechanisms, and computational methods, more informed models can be created. Future research environment and support must facilitate this integrative method of operation across multiple disciplines.

Optimal beam angle selection and knowledge-based planning significantly reduces radiotherapy dose to organs at risk for lung cancer patients

BACKGROUND

Lung cancer patients struggle with high toxicity rates. This study investigates if IMRT plans with individually set beam angles or uni-lateral VMAT plans results in dose reduction to OARs. We investigate if introduction of a RapidPlan model leads to reduced dose to OARs. Finally, the model is validated prospectively.

MATERIAL AND METHODS

Seventy-four consecutive lung cancer patients treated with IMRT were included. For all patients, new IMRT plans were made by an experienced dose planner re-tuning beam angles aiming for minimized dose to the lungs and heart. Additionally, VMAT plans were made. The IMRT plans were selected as input for a RapidPlan model, which was used to generate 74 new IMRT plans. The new IMRT plans were used as input for a second RapidPlan model. This model was clinically implemented and used for generation of clinical treatment plans. Dosimetric parameters were compared using a Wilcoxon signed rank test or a 1-sided student's t-test. p < .05 was considered significant.

RESULTS

IMRT plans significantly reduced mean doses to lungs (MLD) and heart (MHD) by 1.6 Gy and 1.7 Gy in mean compared to VMAT plans. MLD was significantly (p < .001) reduced from 10.8 Gy to 9.4 Gy by using the second RapidPlan model. MHD was significantly (p < .001) reduced from 4.9 Gy to 3.9 Gy. The model was validated in prospectively collected treatment plans showing significantly lower MLD after the implementation of the second RapidPlan model.

CONCLUSION

Introduction of RapidPlan and beam angles selected based on the target and OARs position reduces dose to OARs.

The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

Leaf structural and hydraulic adjustment with respect to air humidity and canopy position in silver birch (Betula pendula)

Climate change scenarios predict an increase in air temperature and precipitation in northern temperate regions of Europe by the end of the century. Increasing atmospheric humidity inevitably resulting from more frequent rainfall events reduces water flux through vegetation, influencing plants' structure and functioning. We investigated the extent to which artificially elevated air humidity affects the anatomical structure of the vascular system and hydraulic conductance of leaves in Betula pendula. A field experiment was carried out at the Free Air Humidity Manipulation (FAHM) site with a mean increase in relative air humidity (RH) by 7% over the ambient level across the growing period. Leaf hydraulic properties were determined with a high-pressure flow meter; changes in leaf anatomical structure were studied by means of conventional light microscopy and digital image processing techniques. Leaf development under elevated RH reduced leaf-blade hydraulic conductance and petiole conductivity and had a weak effect on leaf vascular traits (vessel diameters decreased), but had no significant influence on stomatal traits or tissue proportions in laminae. Both hydraulic traits and relevant anatomical characteristics demonstrated pronounced trends with respect to leaf location in the canopy-they increased from crown base to top. Stomatal traits were positively correlated with several petiole and leaf midrib vascular traits. The reduction in leaf hydraulic conductance in response to increasing air humidity is primarily attributable to reduced vessel size, while higher hydraulic efficiency of upper-crown foliage is associated with vertical trends in the size of vascular bundles, vessel number and vein density. Although we observed co-ordinated adjustment of vascular and hydraulic traits, the reduced leaf hydraulic efficiency could lead to an imbalance between hydraulic supply and transpiration demand under the extreme environmental conditions likely to become more frequent in light of global climate change.

Energy layer optimization strategies for intensity-modulated proton therapy of lung cancer patients

PURPOSE

When treating lung cancer patients with intensity-modulated proton therapy (IMPT), target coverage can only be guaranteed when utilizing motion mitigation. The three motion mitigation techniques, gating, breath-hold, and dose repainting, all benefit from a more rapid application of the treatment plan. A lower limit for the ungated treatment time is defined by the number of energy layers in the IMPT plan. By limiting this number during treatment planning, IMPT could become more viable for lung cancer patients. We investigate to what extend the number of layers can be reduced in single-field optimization (SFO) and multifield optimization (MFO) plans and which implications it has on the plan quality and robustness.

METHODS

We have implemented three distinct layer-reducing strategies in the treatment planning system Hyperion; constant energy steps, exponential energy steps, and an adaptive strategy, where the spot weights are exposed to a group sparsity penalty in combination with layer exclusion during optimization. Four levels of increasing layer removal are planned for each strategy. SFO and MFO plans with three treatment fields are created for eleven locally advanced NSCLC patients on the midventilation 4DCT phase to simulate a breath-hold. A minimum dose to the target is ensured for each degree of layer reduction, reflecting the plan quality in the homogeneity index (HI). Plan quality was also assessed by a robustness evaluation, where the patient setup was shifted 2 mm or 4 mm in six directions.

RESULTS

The three strategies result in very similar target coverages and robustness levels as a function of removed layers. The HI increases unacceptably for all the SFO plans after 50% layer removal as compared to the reference plan, while all the MFO plans are clinically acceptable with up to a highest removed percentage of 75%. The robustness level is constant as a function of removed layers. The SFO plans are significantly more robust than the MFO plans with all P-values below 0.001 (Wilcoxon signed-rank). The overall mean D98% CTV dose difference is at 2-mm setup error amplitude: 0.7 Gy (SFO) and 1.9 Gy (MFO), and at 4 mm: 3.2 Gy (SFO) and 5.4 Gy (MFO), respectively.

CONCLUSIONS

The number of layers in MFO plans can be reduced substantially more than in SFO plans without compromising plan quality. Furthermore, as the robustness is independent of the number of layers, it follows that if the level of robustness is acceptable or enforced via robust optimization, MFO plans could be candidates for treatment time reductions via energy layer reductions.

Increasing air humidity influences hydraulic efficiency but not functional vulnerability of xylem in hybrid aspen

Climate models predict greater increases in the frequency than in the amount of precipitation and a consequent rise in atmospheric humidity at high latitudes by the end of the century. We investigated the responses of hydraulic and relevant anatomical traits of xylem to elevated relative humidity of air on a 1-yr-old coppice of hybrid aspen (Populus×wettsteinii) growing in the experimental stand at the Free Air Humidity Manipulation site in Eastern Estonia. The hydraulic conductivity of stems was measured with a high pressure flow meter; artificial cavitation in the stem segments was induced by the air injection method. Specific conductivity of xylem decreased from 4.42 in the control to 3.94kgm^-1s^-1MPa^-1 in the humidification treatment, while the trend was well correlated with increasing wood density. Humidified trees exhibited smaller leaf area at the same xylem cross-sectional area, resulting in 34% higher average Huber values compared to the control. Control and humidity-treated trees differed by neither native embolism level nor susceptibility to dehydration-induced cavitation. Increasing atmospheric humidity reduces the hydraulic efficiency of hybrid aspen trees expressed on a xylem area basis and causes substantial changes in resource allocation between photosynthetic and water transport tissues. This climate trend does not influence stem vulnerability to cavitation.

Reliability of dose volume constraint inference from clinical data

Dose volume histogram points (DVHPs) frequently serve as dose constraints in radiotherapy treatment planning. An experiment was designed to investigate the reliability of DVHP inference from clinical data for multiple cohort sizes and complication incidence rates. The experimental background was radiation pneumonitis in non-small cell lung cancer and the DVHP inference method was based on logistic regression. From 102 NSCLC real-life dose distributions and a postulated DVHP model, an 'ideal' cohort was generated where the most predictive model was equal to the postulated model. A bootstrap and a Cohort Replication Monte Carlo (CoRepMC) approach were applied to create 1000 equally sized populations each. The cohorts were then analyzed to establish inference frequency distributions. This was applied to nine scenarios for cohort sizes of 102 (1), 500 (2) to 2000 (3) patients (by sampling with replacement) and three postulated DVHP models. The Bootstrap was repeated for a 'non-ideal' cohort, where the most predictive model did not coincide with the postulated model. The Bootstrap produced chaotic results for all models of cohort size 1 for both the ideal and non-ideal cohorts. For cohort size 2 and 3, the distributions for all populations were more concentrated around the postulated DVHP. For the CoRepMC, the inference frequency increased with cohort size and incidence rate. Correct inference rates  >[Formula: see text] were only achieved by cohorts with more than 500 patients. Both Bootstrap and CoRepMC indicate that inference of the correct or approximate DVHP for typical cohort sizes is highly uncertain. CoRepMC results were less spurious than Bootstrap results, demonstrating the large influence that randomness in dose-response has on the statistical analysis.

Impact of elevated atmospheric humidity on anatomical and hydraulic traits of xylem in hybrid aspen

This study was performed on hybrid aspen saplings growing at the Free Air Humidity Manipulation site in Estonia. We investigated changes in wood anatomy and hydraulic conductivity in response to increased air humidity. Two hydraulic traits (specific conductivity and leaf-specific conductivity) and four anatomical traits of stem wood-relative vessel area (VA), vessel density (VD), pit area and pit aperture area-were influenced by the humidity manipulation. Stem hydraulic traits decreased in the apical direction, whereas branch hydraulic characteristics tended to be greatest in mid-canopy, associated with branch size. A reduction in VD due to increasing humidity was accompanied by a decrease in vessel lumen diameter, hydraulically weighted mean diameter (Dh), xylem vulnerability index and theoretical hydraulic conductivity. VA and Dh combined accounted for 87.4% of the total variation in kt of branches and 85.5% of that in stems across the treatments. Characters of branch vessels were more stable, and only the vessel-grouping index (the ratio of the total number of vessels to the total number of vessel groupings) was dependent on the interactive effect of the treatment and canopy position. Our results indicate that the increasing atmospheric humidity predicted for high latitudes will result in moderate changes in the structure and functioning of the hybrid aspen xylem.