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Tan HQ, Koh CWY, Lew KS, Yeap PL, Chua CGA, Lee JKH, Wibawa A, Master Z, Lee JCL, Park SY. Real-time gated proton therapy with a reduced source to imager distance: Commissioning and quality assurance. Phys Med 2024; 122:103380. [PMID: 38805761 DOI: 10.1016/j.ejmp.2024.103380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/12/2024] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Real-time gated proton therapy (RGPT) is a motion management technique unique to the Hitachi particle therapy system. It uses pulsed fluoroscopy to track an implanted fiducial marker. There are currently no published guidelines on how to conduct the commissioning and quality assurance. In this work we reported on our centre's commissioning workflow and our daily and monthly QA procedures. METHODS Six commissioning measurements were designed for RGPT. The measurements include imaging qualities, fluoroscopic exposures, RGPT marker tracking accuracy, temporal gating latency, fiducial marker tracking fidelity and an end-to-end proton dosimetry measurement. Daily QA consists of one measurement on marker localization accuracy. Four months daily QA trends are presented. Monthly QA consists of three measurementson the gating latency, fluoroscopy imaging quality and dosimetry verification of gating operation with RGPT. RESULTS The RGPT was successfully commissioned in our centre. The air kerma rates were within 15 % from specifications and the marker tracking accuracies were within 0.245 mm. The gating latencies for turning the proton beam on and off were 119.5 and 50.0 ms respectively. The 0.4x10.0 mm2 Gold AnchorTM gave the best tracking results with visibility up to 30 g/cm2. Gamma analysis showed that dose distribution of a moving and static detectors had a passing rate of more than 95 % at 3 %/3mm. The daily marker localization QA results were all less than 0.2 mm. CONCLUSION This work could serve as a good reference for other upcoming Hitachi particle therapy centres who are interested to use RGPT as their motion management solution.
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Affiliation(s)
- Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore.
| | | | - Kah Seng Lew
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Ping Lin Yeap
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | | | - Andrew Wibawa
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Zubin Master
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Sung Yong Park
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore
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Shimomura A, Wu T, Rusu I, Kishan AU, Tree AC, Solanki AA, Liauw SL. Monitoring Intrafraction Motion of the Prostate During Radiation Therapy: Suggested Practice Points From a Focused Review. Pract Radiat Oncol 2024; 14:146-153. [PMID: 37875222 DOI: 10.1016/j.prro.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE External beam radiation therapy to the prostate is typically delivered after verification of prostatic position with image guidance. Prostate motion can occur during the delivery of each radiation treatment between the time of localization imaging and completion of treatment. The objective of this work is to review the literature on intrafraction motion (IFM) of the prostate during radiation therapy and offer clinical recommendations on management. METHODS AND MATERIALS A comprehensive literature review was conducted on prostate motion during prostate cancer radiation therapy. Information was organized around 3 key clinical questions, followed by an evidence-based recommendation. RESULTS IFM of the prostate during radiation therapy is typically ≤3 mm and is unlikely to compromise prostate dosimetry to a clinically meaningful degree for men treated in a relatively short treatment duration with planning target volume (PTV) margins of ≥3 to 5 mm. IFM of 5 mm or more has been observed in up to ∼10% of treatment fractions, with limited dosimetric effect related to the infrequency of occurrence and longer fractionation of therapy. IFM can be monitored in continuous or discontinuous fashion with a variety of imaging platforms. Correction of IFM may have the greatest value when tighter PTV margins are desired (such as with stereotactic body radiation therapy or intraprostatic nodule boosting), ultrahypofractionated courses, or when treatment time exceeds several minutes. CONCLUSIONS This focused review summarizes literature and provides practical recommendations regarding IFM in the treatment of prostate cancer with external beam radiation therapy.
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Affiliation(s)
- Aoi Shimomura
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Tianming Wu
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Iris Rusu
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois.
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Jank EA, Cetnar AJ. Exploring the Use of Contour-Based Intrafraction Motion Review for Spine Stereotactic Body Radiation Therapy Treatments. Adv Radiat Oncol 2024; 9:101351. [PMID: 38405323 PMCID: PMC10885588 DOI: 10.1016/j.adro.2023.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Patient motion during radiation therapy treatment is a concern, especially for spine stereotactic body radiation therapy cases where the sharper dose gradient presents a toxicity threat to the spinal cord. Intrafraction motion review (IMR) is an application used to monitor patient position during treatment. The presence of spinal fixation hardware presents an opportunity for motion tracking to manually pause the beam. Methods and Materials A cohort of 17 clinicians were shown a video of the imaging console during a simulated treatment. Participants decided after each triggered image if they would pause the treatment beam, indicating that they believed the phantom to have moved outside of clinical tolerance. A spine phantom with hardware intact was positioned on a motion platform, which was programmed to make shifts ranging in size from 0.5 to 1.5 mm. A 1-mm isotropic expansion contour from the hardware was overlayed on the triggered planar x-ray images using the IMR application. Results User perception sensitivity did not exceed 0.5 until there was a physical shift of 1.4 mm, indicating that most users will not be able to reliably discriminate submillimeter shifts using contour-based shift identification. Conclusions If adaptations to standard of care are implemented clinically, the proposed method should be evaluated and the role of training and education should be examined before implementation. However, contour-based IMR could still provide beneficial information for larger intrafraction motion during treatment and could be valuable for identifying gross anatomic motion during treatment.
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Affiliation(s)
- Erika A. Jank
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ashley J. Cetnar
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Winter JD, Reddy V, Li W, Craig T, Raman S. Impact of technological advances in treatment planning, image guidance, and treatment delivery on target margin design for prostate cancer radiotherapy: an updated review. Br J Radiol 2024; 97:31-40. [PMID: 38263844 PMCID: PMC11027310 DOI: 10.1093/bjr/tqad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/22/2023] [Accepted: 11/21/2023] [Indexed: 01/25/2024] Open
Abstract
Recent innovations in image guidance, treatment delivery, and adaptive radiotherapy (RT) have created a new paradigm for planning target volume (PTV) margin design for patients with prostate cancer. We performed a review of the recent literature on PTV margin selection and design for intact prostate RT, excluding post-operative RT, brachytherapy, and proton therapy. Our review describes the increased focus on prostate and seminal vesicles as heterogenous deforming structures with further emergence of intra-prostatic GTV boost and concurrent pelvic lymph node treatment. To capture recent innovations, we highlight the evolution in cone beam CT guidance, and increasing use of MRI for improved target delineation and image registration and supporting online adaptive RT. Moreover, we summarize new and evolving image-guidance treatment platforms as well as recent reports of novel immobilization strategies and motion tracking. Our report also captures recent implementations of artificial intelligence to support image guidance and adaptive RT. To characterize the clinical impact of PTV margin changes via model-based risk estimates and clinical trials, we highlight recent high impact reports. Our report focusses on topics in the context of PTV margins but also showcase studies attempting to move beyond the PTV margin recipes with robust optimization and probabilistic planning approaches. Although guidelines exist for target margins conventional using CT-based image guidance, further validation is required to understand the optimal margins for online adaptation either alone or combined with real-time motion compensation to minimize systematic and random uncertainties in the treatment of patients with prostate cancer.
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Affiliation(s)
- Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Varun Reddy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
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Lee-Poprocki H, Ritter AR, Upadhyay R, Perlow HK, Ayan AS, Cetnar AJ, Degnan M, Scharschmidt TJ, Mendel E, Blakaj DM, Thomas EM, Chakravarthy VB, Elder JB, Palmer JD. Novel Intrafraction Motion Tracking During Postoperative Spine Stereotactic Irradiation for a Patient With Carbon Fiber Fixation Hardware. Pract Radiat Oncol 2023; 13:510-516. [PMID: 37516957 DOI: 10.1016/j.prro.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 07/31/2023]
Abstract
Carbon-fiber reinforced (CFR) polyetheretherketone hardware is an alternative to traditional metal hardware used for spinal fixation surgeries before postoperative radiation therapy for patients with spinal metastases. CFR hardware's radiolucency decreases metal artifact, improving visualization and accuracy of treatment planning. We present the first clinical use and proof of principle of CFR spinal hardware with tantalum markers used for successful tracking of intrafraction motion (IM) using Varian TrueBeam IMR (Intrafraction Motion Review) software module during postoperative spine stereotactic radiation. A 63-year-old woman with history of endometrial cancer presented with acute back pain. Imaging demonstrated pathologic T12 vertebral fracture with cord compression. She underwent T12 vertebrectomy with circumferential decompression and posterior instrumented T10-L2 fusion at our facility using CFR-polyetheretherketone hardware with tantalum screw markers followed by postoperative stereotactic body radiation therapy to 3000 cGy in 5 fractions delivered to T11-T12. Tantalum screw markers were used for IMR tracking. During irradiation, 260 kV images were acquired, and IMR software was able to identify and track markers. During the entire treatment, the IM motions were less than 3 mm. This is the first presented case of CFR spinal hardware with tantalum markers used for successful IMR tracking of IM during daily spine stereotactic treatment. Future work will be needed to improve workflow and create a spine-specific IMR protocol.
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Affiliation(s)
| | | | | | | | | | | | | | - Thomas J Scharschmidt
- Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Vikram B Chakravarthy
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
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Kuo HC, Della-Biancia C, Damato AL, Happersett L, Lim SB, Cerviño LI, Shasha D, Berry S. Clinical Experience and Feasibility of Using 2D-kVimage Online Intervention in the Ultrafractionated Stereotactic Radiation Treatment of Prostate Cancer. Pract Radiat Oncol 2023; 13:e308-e318. [PMID: 36476984 DOI: 10.1016/j.prro.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This study reports clinical experience and feasibility of using a 2-dimensional (2D)-kV image system with online intervention in the ultrafractionated stereotactic body radiation treatment (UF-SBRT) of prostate cancer. METHODS AND MATERIALS Fifteen patients with prostate cancer who had a low- to intermediate-risk marker implanted received UF-SBRT with online 2D-kV image tracking and a manual beam interruption strategy with a 2-mm motion threshold. A total of 180 kV paired setup images and 1272 intrabeam 2D-kV images were analyzed to evaluate the setup deviation and intratreatment target deviation. Correlation of expected treatment interruptions with a set of parameters (eg, image and treatment time; direction of deviation) was performed (Spearman test). A subset of the data from 22 fractions was re-evaluated to check the differences in analysis results between using the planning position and using the pretreatment setup position as a reference. Margins based on the derived system and random errors were calculated to evaluate the feasibility of the workflow in ensuring prostate coverage during treatment. RESULTS Mean target motion in 3D propagated from 1.0 mm (setup at 0 minutes) to 2.0 mm (beam on at 7 minutes) to 2.4 mm (end at 13.5 minutes). Out of 75 fractions, 50 were found to require beam interruption. Interruption had a strong correlation with prostate motion along the longitudinal direction and had moderate correlation with prostate motion along the vertical direction and the prostate's treatment starting position along vertical and longitudinal directions. Using the pretreatment position as a reference for intrabeam monitoring, the magnitude of motion deviation from the reference position was reduced by 0.3 mm at a vertical direction and 0.4 mm at lateral and longitudinal directions. The calculated 3D margin to ensure target coverage was 3.7 mm, 4.6 mm, and 5.0 mm in lateral, vertical, and longitudinal directions, respectively. CONCLUSIONS Prostate motion propagated over time. It is feasible to use a 2D-kV online intrabeam monitoring system with a proper intervention scheme to perform UF-SBRT for prostate cancer.
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Affiliation(s)
- Hsiang-Chi Kuo
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Cesar Della-Biancia
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Antonio L Damato
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura Happersett
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seng Boh Lim
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura I Cerviño
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Shasha
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Berry
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Kaur G, Lehmann J, Greer PB, Martin J, Simpson J. Clinical validation of the Varian Truebeam intra-fraction motion review (IMR) system for prostate treatment guidance. Phys Eng Sci Med 2023; 46:131-140. [PMID: 36472802 DOI: 10.1007/s13246-022-01204-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
This study quantified the performance of Intra-fraction Motion Review (IMR) during prostate Stereotactic Body Radiotherapy (SBRT) treatments. IMR was evaluated using prostate motion data from patients treated in an SBRT clinical trial (PROMETHEUS, NCT00587990).IMR measured prostate displacements were compared to those of two 3D motion management methods: Kilovoltage Intra-fraction Motion management (KIM) and MV/kV triangulation. A planning study assessing the impact of a defined prostate motion (2-5 mm) on the PTV coverage with and without IMR was performed. A clinically relevant IMR search region for prostate cancer SBRT treatments was determined using a customised anthropomorphic pelvis phantom with implanted gold seeds and a motion platform. IMR showed submillimeter agreement with corresponding 2D projections from both KIM and MV/kV triangulation. However, IMR detected actual displacements consistently in considerably fewer frames than KIM (3D), with the actual numbers depending on the settings. The Default Search Region (DSR) method employing a circular search region proved superior to user-contoured structures in detecting clinically relevant prostate motion. Reducing the DSR search region radius can reduce the impact of the 2D nature of IMR and improve the detectability of actual motion (by 10% per 0.5 mm reduction) but must be balanced against increased beam interruptions from minor, clinically irrelevant motion. The use of IMR for SBRT prostate treatments has the potential to improve target dose coverage (minimum dose to 98% of the PTV, D98%) by > 20% compared to treatment without IMR. Calculated D98% of IMR monitored treatments with motion was within 1.5% of plans without motion.
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Affiliation(s)
- Guneet Kaur
- Department of Radiation Oncology, The Mater Hospital, Rocklands Road, Crows Nest, Sydney, NSW, 2065, Australia.
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.
| | - Joerg Lehmann
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Peter B Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - John Simpson
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
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Cardoso M, Sidhom M, Udovitch M, Young T, Arumugam S. Implementing online position monitoring for prostate radiotherapy using an in-house position monitoring system: User experience and impact on workforce. J Med Imaging Radiat Oncol 2023; 67:111-118. [PMID: 36537583 DOI: 10.1111/1754-9485.13499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION To evaluate the feasibility of prostate intrafraction motion monitoring using the SeedTracker real-time image guidance system in order to improve targeting accuracy in prostate radiotherapy. METHODS SeedTracker was used to monitor prostate gold fiducial seeds with kV x-ray imaging during radiotherapy in 30 patients. Feedback from radiation therapists was collected via the use of a user evaluation form. The impact on treatment time was established by using a record and verify system. The effective dose and a risk of exposure-induced cancer death (REID) were estimated for a 60-year-old patient when using the SeedTracker system. RESULTS A total of 22 radiation therapists completed user evaluation forms. The time taken to prepare a reference data set for one patient varied with three (13.6%) radiation therapists taking less than 2 min, 10 (45.5%) between 2 and 4 min, eight (36.4%) between 4 and 6 min and one (4.5%) between 6 and 8 min. The useability of the SeedTracker system was reported as 'easy' by 21 (95.5%) radiation therapists and 'hard' by 1 (4.5%) radiation therapist. Mean treatment time changed from 6 to 7 min with prostate-only radiotherapy treatment and from 6.9 to 10.2 min with prostate and whole pelvis radiotherapy treatments. The maximum effective dose with the SeedTracker was 1.6276 mSv, and increase in REID was 0.007%. CONCLUSION The SeedTracker real-time image guidance system is a feasible tool to use in radiotherapy departments to monitor and correct for prostate intrafraction motion.
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Affiliation(s)
- Michael Cardoso
- Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Udovitch
- Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, New South Wales, Australia
| | - Tony Young
- Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Implementation of triggered kilovoltage imaging for stereotactic radiotherapy of the spine for patients with spinal fixation hardware. Phys Imaging Radiat Oncol 2023; 25:100422. [PMID: 36875327 PMCID: PMC9978845 DOI: 10.1016/j.phro.2023.100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background and purpose Mitigation of intrafraction motion (IM) is valuable in stereotactic radiotherapy (SRT) radiotherapy where submillimeter accuracy is desired. The purpose of this study was to investigate the application of triggered kilovoltage (kV) imaging for spine SRT patients with hardware by correlating kV imaging with patient motion and summarizing implications of tolerance for IM based on calculated dose. Materials and methods Ten plans (33 fractions) were studied, correlating kV imaging during treatment with pre- and post-treatment cone beam computed tomography (CBCT). Images were taken at 20-degree gantry angle intervals during the arc-based treatment. The contour of the hardware with a 1 mm expansion was displayed at the treatment console to manually pause treatment delivery if the hardware was visually detected outside the contour. The treatment CBCTs were compared using retrospective image registration to assess the validity of contour-based method for pausing treatment. Finally, plans were generated to estimate dose volume objective differences in case of 1 mm deviation. Results When kV imaging during treatment was used with the 1 mm contour, 100 % of the post-treatment CBCTs reported consistent results. One patient in the cohort exhibited motion greater than 1 mm during treatment which allowed intervention and re-setup during treatment. The average translational motion was 0.35 mm. Treatment plan comparison at 1 mm deviation showed little differences in calculated dose for the target and cord. Conclusions Utilizing kV imaging during treatment is an effective method of assessing IM for SRT spine patients with hardware without increasing treatment time.
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Oyoshi H, Tachibana H, Someya T, Rachi T, Takeda Y, Ariji T. [A Preliminary Study of Optimal Imaging Acquisition Parameters for Fiducial Markers in Liver Stereotactic Body Radiotherapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2021; 77:1400-1410. [PMID: 34924476 DOI: 10.6009/jjrt.2021_jsrt_77.12.1400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In liver stereotactic body radiotherapy (SBRT) using fiducial markers, the accuracy of automatic image recognition of fiducial markers is important, and the imaging dose cannot be neglected in image-guided radiotherapy. Optimal imaging parameters of fiducial markers were investigated for automatic image recognition and imaging dose. We investigated automatic recognition with fiducial markers of different shapes and sizes. In addition, the optimum imaging conditions were examined based on the automatic recognition when the presence or absence of a filter, focal spot size, and phantom thickness were altered using the fiducial markers with a high automatic recognition. The results for different shapes and sizes of fiducial markers showed that larger markers were recognized more automatically, whereas shorter markers were recognized in the correct position. By using the filter, we were able to reduce the imaging dose by one third or one half compared to the case without the filter. The results for the focal spot size showed that using a larger size resulted in higher automatic recognition accuracy than using a smaller size. For the relationship between the automatically recognized imaging conditions and the air kerma when the phantom thickness was altered, it was necessary to keep the tube current-time product constant and increase the tube voltage in order to avoid poor recognition accuracy. The parameters we proposed are effective in shortening the treatment time and reducing the imaging dose because they allow us to acquire images with low doses and high accuracy of automatic recognition.
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Affiliation(s)
- Hajime Oyoshi
- Department of Radiology, National Cancer Center Hospital East
| | - Hidenobu Tachibana
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital East
| | - Takashi Someya
- Department of Radiology, National Cancer Center Hospital East
| | - Toshiya Rachi
- Department of Radiology, National Cancer Center Hospital East
| | - Youhei Takeda
- Department of Radiology, National Cancer Center Hospital East (Current address: Department of Radiology, Shinshu Ueda Medical Center)
| | - Takaki Ariji
- Department of Radiology, National Cancer Center Hospital East
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Koo J, Nardella L, Degnan M, Andreozzi J, Yu HHM, Penagaricano J, Johnstone PAS, Oliver D, Ahmed K, Rosenberg SA, Wuthrick E, Diaz R, Feygelman V, Latifi K, Moros EG, Redler G. Triggered kV Imaging During Spine SBRT for Intrafraction Motion Management. Technol Cancer Res Treat 2021; 20:15330338211063033. [PMID: 34855577 PMCID: PMC8649431 DOI: 10.1177/15330338211063033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: To monitor intrafraction motion during spine stereotactic body radiotherapy(SBRT) treatment delivery with readily available technology, we implemented triggered kV imaging using the on-board imager(OBI) of a modern medical linear accelerator with an advanced imaging package. Methods: Triggered kV imaging for intrafraction motion management was tested with an anthropomorphic phantom and simulated spine SBRT treatments to the thoracic and lumbar spine. The vertebral bodies and spinous processes were contoured as the image guided radiotherapy(IGRT) structures specific to this technique. Upon each triggered kV image acquisition, 2D projections of the IGRT structures were automatically calculated and updated at arbitrary angles for display on the kV images. Various shifts/rotations were introduced in x, y, z, pitch, and yaw. Gantry-angle-based triggering was set to acquire kV images every 45°. A group of physicists/physicians(n = 10) participated in a survey to evaluate clinical efficiency and accuracy of clinical decisions on images containing various phantom shifts. This method was implemented clinically for treatment of 42 patients(94 fractions) with 15 second time-based triggering. Result: Phantom images revealed that IGRT structure accuracy and therefore utility of projected contours during triggered imaging improved with smaller CT slice thickness. Contouring vertebra superior and inferior to the treatment site was necessary to detect clinically relevant phantom rotation. From the survey, detectability was proportional to the shift size in all shift directions and inversely related to the CT slice thickness. Clinical implementation helped evaluate robustness of patient immobilization. Based on visual inspection of projected IGRT contours on planar kV images, appreciable intrafraction motion was detected in eleven fractions(11.7%). Discussion: Feasibility of triggered imaging for spine SBRT intrafraction motion management has been demonstrated in phantom experiments and implementation for patient treatments. This technique allows efficient, non-invasive monitoring of patient position using the OBI and patient anatomy as a direct visual guide.
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Affiliation(s)
- Jihye Koo
- 7831University of South Florida, 33620, USA.,25301H. Lee Moffitt Cancer Center, 33612, USA
| | | | - Michael Degnan
- 549472The Ohio State University, 43210, Columbus, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Gage Redler
- 25301H. Lee Moffitt Cancer Center, 33612, USA
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Graeper G, Cetnar A, Ayan AS, Weldon M. Interpretation of intrafraction motion review data and method for verification. J Appl Clin Med Phys 2021; 22:196-202. [PMID: 34582118 PMCID: PMC8598153 DOI: 10.1002/acm2.13379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/02/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
The current clinical interface for Varian's intrafraction motion review (IMR) is limited, providing only qualitative data for review at the treatment console. This study provides a method of extracting and interpreting data from combined log files for quantitative evaluation. Combined log files acquired during patient treatment and a parsing code was developed to scan the combined log file looking for unique identifiers pertaining to the data of interest. We were able to extract clinically relevant parameters from the log files including date and time, gantry angle, expected marker position, found marker position, pixel size, and detection result. This study details how to compare IMR data to Calypso investigating dual‐surrogates for intrafraction monitoring during treatment for other researchers to build on these methods. Understanding data recorded during treatment within the combined log files can be helpful in quality improvement of patient care by retrospectively reviewing intrafraction motion.
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Affiliation(s)
- Gavin Graeper
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ashley Cetnar
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Weldon
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Cetnar A, Ayan AS, Graeper G, Weldon M, Woods K, Klamer B, Pan X, Martin DD, Diaz DA, Gupta N. Prospective dual-surrogate validation study of periodic imaging during treatment for accurately monitoring intrafraction motion of prostate cancer patients. Radiother Oncol 2021; 157:40-46. [PMID: 33484751 DOI: 10.1016/j.radonc.2021.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE The goal of this prospective study is to validate the use of periodic imaging during treatment with a fiducial marker detection algorithm using radiofrequency transponders for prostate cancer patients undergoing treatment for radiation therapy. MATERIALS AND METHODS Ten male patients were enrolled in this study and treated for prostate cancer with implanted electromagnetic monitoring beacons. We evaluated the accuracy and limitations of Intrafraction Motion Review (IMR) by comparing the known locations of the beacons using the electromagnetic monitoring system to the position data reported from IMR images. RESULTS A total of 4054 images were taken during treatment. The difference in vector magnitude of the two methods is centered around zero (mean: 0.03 cm, SD: 0.16 cm) and Lin's Concordance Correlation Coefficient (CCC) is 0.99 (95% CI: 0.98, 1) overall. The Euclidean distance between the two methods was close to zero (median: 0.09 cm, IQR: 0.06, 0.14 cm). The difference in distance between any two markers was centered around zero (mean: 0.01 cm, SD: 0.12 cm) and Lin's CCC is 0.97 (95% CI: 0.96, 0.98) overall. CONCLUSION The accuracy of the algorithm for detected markers within the 2D images is comparable to electromagnetic monitoring for fiducial identification when detected. IMR could provide an alternate solution for patients with contraindications of use of an electromagnetic monitoring system and a cost effective alternative to the acquisition of an additional system for patient monitoring, but does not provide data for pre-treatment set-up verification and real-time 3D positioning during treatment.
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Affiliation(s)
- Ashley Cetnar
- The Ohio State University, Department of Radiation Oncology, Columbus, United States.
| | - Ahmet S Ayan
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Gavin Graeper
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Michael Weldon
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Kyle Woods
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Brett Klamer
- The Ohio State University, Department of Biomedical Informatics, Center for Biostatistics, Columbus, United States.
| | - Xueliang Pan
- The Ohio State University, Department of Biomedical Informatics, Center for Biostatistics, Columbus, United States.
| | - Douglas D Martin
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Dayssy A Diaz
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
| | - Nilendu Gupta
- The Ohio State University, Department of Radiation Oncology, Columbus, United States
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Liauw SL, Ni L, Wu T, Arif F, Cloutier D, Posner MC, Kozloff M, Kindler HL. A prospective trial of stereotactic body radiation therapy for unresectable pancreatic cancer testing ablative doses. J Gastrointest Oncol 2020; 11:1399-1407. [PMID: 33457009 DOI: 10.21037/jgo-20-187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We explored the safety and efficacy of ablative doses of stereotactic body radiation therapy (SBRT) for unresectable pancreatic cancer. Methods This phase I/II trial included patients with unresectable pancreatic cancer previously treated with any number of cycles of induction chemotherapy. Patients were enrolled according to a 3+3 dose escalation design at 10, 12.5, and 15 Gy ×3, with subsequent patients at the maximally tolerated dose (MTD). Treatment was delivered to gross tumor delineated with MRI fusion using image-guidance to fiducial markers. Dose-limiting toxicity (DLT) was defined as grade 3+ toxicity within 30 days. Secondary endpoints included late gastrointestinal (GI) toxicity, freedom from local failure (FFLF), and survival. Results Fifteen patients received a median 10 cycles of chemotherapy. There were no DLTs, and the MTD was 15 Gy ×3. Thirty-day toxicity included grade 2 nausea (46%) and grade 2 diarrhea (7%). Median survival after SBRT was 12.8 months (23 months after diagnosis) and median relapse-free survival was 7 months. At 1-year, FFLF was 80%. Four patients had grade 3+ GI bleeding after 30 days (median 6 months). Grade 3+ GI bleeding was associated with tumor volume (P=0.01), heterogeneity of dose within the planning target volume (PTV) (V120, P=0.03), and duodenal dose (V26-30 Gy, P<0.2). Conclusions This aggressive SBRT regimen demonstrated limited 30-day morbidity, a moderate degree of local control, and a moderate risk for late GI bleeding. Further work is necessary to define the most appropriate hypofractionated radiation therapy (RT) regimen in the ablative dose range.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Tianming Wu
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Fauzia Arif
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Denise Cloutier
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mitchell C Posner
- Department of Surgical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mark Kozloff
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Hedy L Kindler
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
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Lessard R, Tremblay NM, Plourde MÉ, Guillot M. An open-source software for monitoring intrafraction motion during external beam radiation therapy based on superimposition of contours of projected ROIs on cine-MV images. J Appl Clin Med Phys 2020; 21:173-182. [PMID: 32506590 PMCID: PMC7484890 DOI: 10.1002/acm2.12940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To present an open‐source software (https://github.com/CHUSRadOncPhys/FluoMV) for monitoring intrafraction motion that is based on the visualization of superimposed contours of projected region‐of‐interests from DICOM RTSTRUCT files on cine‐MV images acquired and displayed in real‐time during radiation therapy delivery. Clinical use with prostate gold fiducial markers is presented. Methods Projections of regions of interest (ROI) in the reference frame of the electronic portal imaging device are computed offline for different gantry angles before the first treatment fraction. During treatment delivery, the contrast of portal images is automatically adjusted using a histogram equalization algorithm. The projections associated with the current gantry angle are then superimposed on the images in real time. This allows the therapist to evaluate if the imaged structures of interest remain within their respective contours during treatment delivery and to potentially interrupt the treatment if deemed necessary. The spatial accuracy of the method was evaluated by imaging a ball bearing phantom in a set‐up where the position of the projected ROI is highly sensitive to gantry angle errors. The visibility of fiducial markers during one fraction of seven different volumetric modulated arc therapy (VMAT) prostate treatments is characterized. Results The geometric validation showed a negligible systematic error μ < 0.1 mm for the position of the projections. The random errors associated with the time accuracy of the gantry angle readout were characterized by standard deviations σ ≤ 0.6 mm. The VMAT clinical treatments showed that the fiducial markers were frequently visible, allowing for a meaningful clinical use. Conclusions The results demonstrate that the method presented is sufficiently accurate to be used for intrafraction monitoring of patients. The fact that this method could be implemented on many modern linacs at little to no cost and with no additional dose delivered to the patients makes this solution very attractive for improving patient care and safety in radiation therapy.
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Affiliation(s)
- Rémi Lessard
- Département de radio-oncologie, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, Québec, J1H 5N4, Canada
| | - Nicolas M Tremblay
- Département de radio-oncologie, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, Québec, J1H 5N4, Canada
| | - Marc-Émile Plourde
- Département de radio-oncologie, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, Québec, J1H 5N4, Canada.,Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, J1H 5N4, Canada
| | - Mathieu Guillot
- Département de radio-oncologie, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, Québec, J1H 5N4, Canada.,Département de médecine nucléaire et radiobiologie, Université de Sherbrooke, Sherbrooke, Québec, J1H 5N4, Canada
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