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Lin CH, Que J, Ho SY. HyperArcTM volumetric modulated arc therapy for hypopharyngeal cancer with solitary recurrence in the cervical vertebra: A case report and literature review. Medicine (Baltimore) 2024; 103:e38427. [PMID: 38847726 PMCID: PMC11155512 DOI: 10.1097/md.0000000000038427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/10/2024] [Indexed: 06/10/2024] Open
Abstract
RATIONALE It is difficult to reirradiate head and neck cancers because of the toxicity from previous radiation dose delivery. Conventional volumetric modulated arc therapy (VMAT) and intensity-modulated radiation therapy often have poor target coverage. The new HyperArcTM VMAT (HA-VMAT) planning approach reportedly has better target coverage, higher conformity, and can spare normal organs compared to conventional VMAT; however, research on recurrent head and neck cancers is limited. Here, we report the clinical outcomes of HA-VMAT for previously irradiated hypopharyngeal cancer with solitary recurrence in the first cervical vertebra (C1). PATIENT CONCERNS A 52-year-old Asian male was diagnosed with a hypopharyngeal cancer. The patient received concurrent chemoradiotherapy with a radiation dose of 70 Gy in 33 fractions and achieved complete clinical response. Two years later, solitary recurrence was observed in the C1 vertebra. DIAGNOSES Solitary recurrence in the C1 vertebra. INTERVENTIONS Owing to concerns regarding the toxicity to adjacent organs, we decided to use HA-VMAT to achieve better tumor coverage and critical organ sparing. OUTCOMES Tumor regression was observed on the imaging. At 9 months follow-up, the patient was disease-free and had no late toxicities. LESSONS This is the first report regarding the clinical outcomes of HA-VMAT for previously irradiated hypopharyngeal cancer with solitary recurrence over the C1 vertebra. HA-VMAT achieves highly conformal dose distribution and excellent sparing of critical organs. There was a favorable initial clinical response with no toxicity. Long-term follow-up is essential in such cases.
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Affiliation(s)
- Chia-Hui Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
- Center of General Education, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Jenny Que
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Sheng-Yow Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
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Jung H, Yoon J, Dona Lemus O, Tanny S, Zhou Y, Milano M, Usuki K, Hardy S, Zheng D. Dosimetric evaluation of LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery with more than 20 targets: comparing MME, HyperArc, and RapidArc. Radiat Oncol 2024; 19:19. [PMID: 38326813 PMCID: PMC10848506 DOI: 10.1186/s13014-024-02416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND To compare the dosimetric quality of three widely used techniques for LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery (fSRS) with more than 20 targets: dynamic conformal arc (DCA) in BrainLAB Multiple Metastases Elements (MME) module and volumetric modulated arc therapy (VMAT) using RapidArc (RA) and HyperArc (HA) in Varian Eclipse. METHODS Ten patients who received single-isocenter fSRS with 20-37 targets were retrospectively replanned using MME, RA, and HA. Various dosimetric parameters, such as conformity index (CI), Paddick CI, gradient index (GI), normal brain dose exposures, maximum organ-at-risk (OAR) doses, and beam-on times were extracted and compared among the three techniques. Wilcoxon signed-rank test was used for statistical analysis. RESULTS All plans achieved the prescribed dose coverage goal of at least 95% of the planning target volume (PTV). HA plans showed superior conformity compared to RA and MME plans. MME plans showed superior GI compared to RA and HA plans. RA plans resulted in significantly higher low and intermediate dose exposure to normal brain compared to HA and MME plans, especially for lower doses of ≥ 8Gy and ≥ 5Gy. No significant differences were observed in the maximum dose to OARs among the three techniques. The beam-on time of MME plans was about two times longer than RA and HA plans. CONCLUSIONS HA plans achieved the best conformity, while MME plans achieved the best dose fall-off for LINAC-based single-isocenter multi-target multi-fraction SRS with more than 20 targets. The choice of the optimal technique should consider the trade-offs between dosimetric quality, beam-on time, and planning effort.
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Affiliation(s)
- Hyunuk Jung
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA.
| | - Jihyung Yoon
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Olga Dona Lemus
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sean Tanny
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Yuwei Zhou
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Michael Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Kenneth Usuki
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sara Hardy
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Dandan Zheng
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
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3
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Lai JL, Liu SP, Jiang XX, Liu J, Li A, Li B, Li XK, Ye XJ, Lei KJ, Zhou L. Can Optical Surface Imaging Replace Non-coplanar Cone-beam Computed Tomography for Non-coplanar Set-up Verification in Single-isocentre Non-coplanar Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Single and Multiple Brain Metastases? Clin Oncol (R Coll Radiol) 2023; 35:e657-e665. [PMID: 37778972 DOI: 10.1016/j.clon.2023.09.007] [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: 03/30/2023] [Revised: 08/03/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
AIMS To conduct a direct comparison regarding the non-coplanar positioning accuracy between the optical surface imaging system Catalyst HDTM and non-coplanar cone-beam computed tomography (NC-CBCT) in intracranial single-isocentre non-coplanar stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (HSRT). MATERIALS AND METHODS Twenty patients with between one and five brain metastases who underwent single-isocentre non-coplanar volumetric modulated arc therapy (NC-VMAT) SRS or HSRT were enrolled in this study. For each non-zero couch angle, both Catalyst HDTM and NC-CBCT were used for set-up verification prior to beam delivery. The set-up error reported by Catalyst HDTM was compared with the set-up error derived from NC-CBCT, which was defined as the gold standard. Additionally, the dose delivery accuracy of each non-coplanar field after using Catalyst HDTM and NC-CBCT for set-up correction was measured with SRS MapCHECKTM. RESULTS The median set-up error differences (absolute values) between the two positioning methods were 0.30 mm, 0.40 mm, 0.50 mm, 0.15°, 0.10° and 0.10° in the vertical, longitudinal, lateral, yaw, pitch and roll directions, respectively. The largest absolute set-up error differences regarding translation and rotation were 1.5 mm and 1.1°, which occurred in the longitudinal and yaw directions, respectively. Only 35.71% of the pairs of measurements were within the tolerance of 0.5 mm and 0.5° simultaneously. In addition, the non-coplanar field with NC-CBCT correction yielded a higher gamma passing rate than that with Catalyst HDTM correction (P < 0.05), especially for evaluation criteria of 1%/1 mm with a median increase of 12.8%. CONCLUSIONS Catalyst HDTM may not replace NC-CBCT for non-coplanar set-up corrections in single-isocentre NC-VMAT SRS and HSRT for single and multiple brain metastases. The potential role of Catalyst HDTM in intracranial SRS/HSRT needs to be further studied in the future.
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Affiliation(s)
- J L Lai
- Radiotherapy Physics & Technology Center, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - S P Liu
- Radiotherapy Physics & Technology Center, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X X Jiang
- Radiotherapy Physics & Technology Center, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - J Liu
- Department of Oncology, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - A Li
- Radiotherapy Physics & Technology Center, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - B Li
- Radiotherapy Physics & Technology Center, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X K Li
- West China Clinical Medical College of Sichuan University, Chengdu, Sichuan, China
| | - X J Ye
- Department of Oncology, Yibin Second People's Hospital, Yibin, Sichuan, China
| | - K J Lei
- Department of Oncology, Yibin Second People's Hospital, Yibin, Sichuan, China
| | - L Zhou
- Thoracic Oncology Ward, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.
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Gregucci F, Di Guglielmo FC, Surgo A, Carbonara R, Laera L, Ciliberti MP, Gentile MA, Calbi R, Caliandro M, Sasso N, Davi' V, Bonaparte I, Fanelli V, Giraldi D, Tortora R, Internò V, Giuliani F, Surico G, Signorelli F, Lombardi G, Fiorentino A. Reirradiation with radiosurgery or stereotactic fractionated radiotherapy in association with regorafenib in recurrent glioblastoma. Strahlenther Onkol 2023:10.1007/s00066-023-02172-9. [PMID: 37987802 DOI: 10.1007/s00066-023-02172-9] [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: 06/27/2023] [Accepted: 10/01/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE No standard treatment has yet been established for recurrent glioblastoma (GBM). In this context, the aim of the current study was to evaluate safety and efficacy of reirradiation (re-RT) by radiosurgery or fractionated stereotactic radiotherapy (SRS/FSRT) in association with regorafenib. METHODS Patients with a histological or radiological diagnosis of recurrent GBM who received re-RT by SRS/FSRT and regorafenib as second-line systemic therapy were included in the analysis. RESULTS From January 2020 to December 2022, 21 patients were evaluated. The median time between primary/adjuvant RT and disease recurrence was 8 months (range 5-20). Median re-RT dose was 24 Gy (range 18-36 Gy) for a median number of 5 fractions (range 1-6). Median regorafenib treatment duration was 12 weeks (range 3-26). Re-RT was administered before starting regorafenib or in the week off regorafenib during the course of chemotherapy. The median and the 6‑month overall survival (OS) from recurrence were 8.4 months (95% confidence interval [CI] 6.9-12.7 months) and 75% (95% CI 50.9-89.1%), respectively. The median progression-free survival (PFS) from recurrence was 6 months (95% CI 3.7-8.5 months). The most frequent side effects were asthenia that occurred in 10 patients (8 cases of grade 2 and 2 cases of grade 3), and hand-foot skin reaction (2 patients grade 3, 3 patients grade 2). Adverse events led to permanent regorafenib discontinuation in 2 cases, while in 5/21 cases (23.8%), a dose reduction was administered. One patient experienced dehiscence of the surgical wound after reintervention and during regorafenib treatment, while another patient reported intestinal perforation that required hospitalization. CONCLUSION For recurrent GBM, re-RT with SRT/FSRT plus regorafenib is a safe treatment. Prospective trials are necessary.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy.
| | | | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | | | - Roberto Calbi
- Department of Radiology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Valerio Davi'
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Vincenzo Fanelli
- Department of Neurosurgery, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - David Giraldi
- Department of Neurosurgery, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Romina Tortora
- Centro Orientamento Oncologico (COrO), Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Valeria Internò
- Department of Medical Oncology, Ospedale San Paolo, Bari, Italy
| | | | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Giuseppe Lombardi
- Department of Medical Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti-Bari, Italy
- Department of Medicine and Surgery, LUM University, Casamassima-Bari, Italy
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Pokhrel D, Misa J, McCarthy S, Yang ES. Two novel stereotactic radiotherapy methods for locally advanced, previously irradiated head and neck cancers patients. Med Dosim 2023; 49:114-120. [PMID: 37867087 DOI: 10.1016/j.meddos.2023.09.003] [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: 07/21/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023]
Abstract
To determine the feasibility and utility of conebeam CT-guided stereotactic radiotherapy for locally recurrent, previously irradiated head and neck cancer (HNC) patients on the Halcyon, a ring delivery system (RDS). This research aims to quantify plan quality, treatment delivery accuracy, and overall efficacy by comparing against novel clinical TrueBeam HyperArc method. Ten recurrent HNC patients who were treated at our institution on TrueBeam (6MV-FFF) for 30 to 40 Gy in 3 to 5 fractions with noncoplanar HyperArc plans were re-planned on Halcyon (6MV-FFF). These plans were re-planned with the same Acuros-based dose engine. Additionally, we used site-specific full/partial coplanar VMAT arcs. PTV coverage, mean dose to GTV, maximum dose to organs-at-risk (OAR), beam-on time (BOT), and quality assurance (QA) results were investigated and compared. Halcyon provided highly conformal HNC SRT plans with slightly superior mean PTVD99 coverage (96.7% vs 95.5%, p = 0.071), and slightly lower mean GTV dose (37.8 Gy vs 38.2 Gy, p = 0.241) when compared to the HyperArc plans. Differences in plan conformality and maximum dose to OARs were statistically insignificant. Due to Halcyon's coplanar geometry, D2cm was significantly higher (p = 0.001) but Halcyon did result in a reduced normal brain dose by 1 Gy on average and up to 5.2 Gy in some cases. Halcyon provided similar patient-specific QA pass rates with a 2%/2mm gamma criteria (98.2% vs 98.5%) and independent in-house Monte Carlo second check results (97.7% vs 98.2%), suggesting identical treatment delivery accuracy. Halcyon plans resulted in slightly longer beam-on time (3.16 vs 2.30 minutes, p = 0.010), however door-to-door patient time is expected to be <10 minutes. Compared to clinical TrueBeam HyperArc, Halcyon SRT plans provided similar plan quality and treatment delivery accuracy with a potentially faster overall treatment using fully automated patient setup and verification. Rapid delivery of recurrent HNC SRT may reduce intrafraction motion errors while also improving patient compliance and comfort. To provide high-quality of HNC SRT similar to HyperArc, we recommend Halcyon users consider commissioning this novel method. This method will be useful for remote and underserved patient cohorts including Halcyon-only clinics as well.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine, Medical Physics Graduate Program, Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY 40536, USA.
| | - Josh Misa
- Department of Radiation Medicine, Medical Physics Graduate Program, Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Shane McCarthy
- Department of Radiation Medicine, Medical Physics Graduate Program, Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Eddy S Yang
- Department of Radiation Medicine, Medical Physics Graduate Program, Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY 40536, USA
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Kim J, Kim TG, Park B, Kim H, Song YG, Lee HW, Kim YZ, Ji JH, Kim SH, Kim SM, Lee JH, Kim H. Dosimetric comparison between RapidArc and HyperArc in hippocampal-sparing whole-brain radiotherapy with a simultaneous integrated boost. Med Dosim 2023; 49:69-76. [PMID: 37718172 DOI: 10.1016/j.meddos.2023.08.007] [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: 06/20/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
The HyperArc technique is known for generating high-quality radiosurgical treatment plans for intracranial lesions or hippocampal-sparing whole-brain radiotherapy (WBRT). However, there is no reported feasibility of using the HyperArc technique in hippocampal-sparing WBRT with a simultaneous integrated boost (SIB). This study aimed to compare dosimetric parameters of 2 commercially-available volumetric-modulated arc radiotherapy techniques, HyperArc and RapidArc, when using hippocampal-sparing WBRT with a SIB to treat brain metastases. Treatment plans using HyperArc and RapidArc techniques were generated retrospectively for 19 previously treated patients (1 to 3 brain metastases). The planning target volumes for the whole brain (excluding the hippocampal avoidance region; PTVWB) and metastases (PTVmet) were prescribed 25 and 45 Gy, respectively, in 10 fractions. Each plan included homogeneous and inhomogeneous delivery to the PTVmet. Dosimetric parameters for the target (conformity index [CI], homogeneity index [HI], target coverage [D95%]), and nontarget organs at risk were compared for the HyperArc and RapidArc plans. For homogeneous delivery, dosimetric parameters, including mean CI, HI, and target coverage in PTVWB and PTVmet, were superior for HyperArc than RapidArc plans (all p < 0.01). The PTVWB and PTVmet target coverage for HyperArc plans was significantly greater than for RapidArc plans (96.17% vs 93.38%, p < 0.01; 94.02% vs 92.21%, p < 0.01, respectively). HyperArc plans had significantly lower mean hippocampal Dmax and Dmin values than RapidArc plans (Dmax: 15.53 Gy vs, 16.71 Gy, p < 0.01; Dmin: 8.33 Gy vs 8.93 Gy, p < 0.01, respectively). Similarly, inhomogeneous delivery of hyperArc produced a superior target and lower hippocampal dosimetric parameters than RapidArc, except for the HI of PTVmet (all p < 0.01). HyperArc generated superior conformity and target coverage with lower hippocampal doses than RapidArc. HyperArc could be an attractive technique for hippocampal-sparing WBRT with an SIB.
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Affiliation(s)
- Jeongho Kim
- Departments of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Tae Gyu Kim
- Departments of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Byungdo Park
- Departments of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Hyunjung Kim
- Departments of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Yun Gyu Song
- Departments of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Hyoun Wook Lee
- Departments of Pathology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Young Zoon Kim
- Departments of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Jun Ho Ji
- Departments of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Seok-Hyun Kim
- Departments of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Sung Min Kim
- Departments of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Jun Ho Lee
- Departments of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Ikawa T, Kanayama N, Arita H, Ohira S, Takano K, Hirata T, Morimoto M, Teshima T, Konishi K. Linear accelerator-based stereotactic radiotherapy for brain metastases, including multiple and large lesions, carries a low incidence of acute toxicities: a retrospective analysis. Radiat Oncol 2023; 18:80. [PMID: 37165431 PMCID: PMC10173492 DOI: 10.1186/s13014-023-02262-z] [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: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Data on acute toxicities after stereotactic radiotherapy (SRT) for brain metastases, including multiple and large lesions, are lacking. We aimed to evaluate the incidence and nature of toxicities immediately after SRT using a linear accelerator. METHODS This retrospective study reviewed the medical records of 315 patients with brain metastases treated with SRT at our institution between May 2019 and February 2022. In total, 439 SRT sessions were performed for 2161 brain metastases. The outcome of interest was immediate side effects (ISEs), defined as new or worsening symptoms occurring during SRT or within 14 days after the end of SRT. RESULTS Grade ≥ 2 and ≥ 3 ISEs occurred in 16 (3.6%) and 7 (1.6%) cases, respectively. Among 63 treatments for 10 or more lesions (range: 10-40), 1 (1.6%) ISE occurred. Among 22 treatments for lesions with a maximum tumor volume of > 10 cc, 2 (9.1%) ISEs occurred. Grade ≥ 3 ISEs included 1, 4, 1, and 1 cases of grade 3 nausea, grade 3 new-onset partial and generalized seizures, grade 3 obstructive hydrocephalus, and grade 5 intracranial hemorrhage, respectively. ISEs were more common in patients with a larger maximum tumor volume, primary sites other than lung and breast cancer, and pre-treatment neurological symptoms. CONCLUSION SRT using a linear accelerator for brain metastases, including multiple and large lesions, is safe, with a low incidence of ISEs. Serious complications immediately after SRT are rare but possible; therefore, careful follow-up is necessary after treatment initiation.
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Affiliation(s)
- Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan.
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hideyuki Arita
- Department of Neurosurgery, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Takano
- Department of Neurosurgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takero Hirata
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masahiro Morimoto
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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8
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Seravalli E, Sierts M, Brand E, Maspero M, David S, Philippens MEP, Voormolen EHJ, Verhoeff JJC. Dosimetric feasibility of direct post-operative MR-Linac-based stereotactic radiosurgery for resection cavities of brain metastases. Radiother Oncol 2023; 179:109456. [PMID: 36592740 DOI: 10.1016/j.radonc.2022.109456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Post-operative radiosurgery (SRS) of brain metastases patients is typically planned on a post-recovery MRI, 2-4 weeks after resection. However, the intracranial metastasis may (re-)grow in this period. Planning SRS directly on the post-operative MRI enables shortening this time interval, anticipating the start of adjuvant systemic therapy, and so decreasing the chance of extracranial progression. The MRI-Linac (MRL) allows the simultaneous execution of the post-operative MRI and SRS treatment. The aim of this work was investigating the dosimetric feasibility of MRL-based post-operative SRS. METHODS MRL treatments based on the direct post-operative MRI were simulated, including thirteen patients with resectable single brain metastases. The gross tumor volume (GTV) was contoured on the direct post-operative scans and compared to the post-recovery MRI GTV. Three plans for each patient were created: a non-coplanar VMAT CT-Linac plan (ncVMAT) and a coplanar IMRT MRL plan (cIMRT) on the direct post-operative MRI, and a ncVMAT plan on the post-recovery MRI as the current clinical standard. RESULTS Between the direct post-operative and post-recovery MRI, 15.5 % of the cavities shrunk by > 2 cc, and 46 % expanded by ≥ 2 cc. Although the direct post-operative cIMRT plans had a higher median gradient index (3.6 vs 2.7) and median V3Gy of the skin (18.4 vs 1.1 cc) compared to ncVMAT plans, they were clinically acceptable. CONCLUSION Direct post-operative MRL-based SRS for resection cavities of brain metastases is dosimetrically acceptable, with the advantages of increased patient comfort and logistics. Clinical benefit of this workflow should be investigated given the dosimetric plausibility.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands.
| | - Michelle Sierts
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
| | - Eric Brand
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
| | - Matteo Maspero
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
| | - Szabolcs David
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
| | | | | | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
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Muacevic A, Adler JR. Treatment of Intracranial Tumors With Stereotactic Radiosurgery: Short-Term Results From Cuba. Cureus 2022; 14:e29955. [PMID: 36348852 PMCID: PMC9635578 DOI: 10.7759/cureus.29955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 01/24/2023] Open
Abstract
Background Although international publications on radiosurgery have increased exponentially, reports of heterogeneous series treated with linear accelerator (LINAC) are scarce. Since most intracranial tumors are irregular in size and not spherical, LINACs (Elekta Precise®, Elekta AB, Sweden), fitted with a multi-leaf collimator, allow for precise stereotactic radiosurgery for the entire tumor. Aim To evaluate the effects of LINAC on an outpatient basis with patients diagnosed with various intracranial malignancies. Methodology A retrospective observational study of a series of cases of patients with intracranial lesions treated at the Institute of Oncology and Radiobiology using LINAC was carried out from October 2019 to May 2021 to evaluate the therapeutic results of radiosurgery in patients with intracranial tumors. Results A total of 22 lesions in 20 patients were treated with LINAC. The average age of the patients was 49.7, and the male-female ratio was 1:2. The cases consisted were mostly vestibular schwannoma (7 lesions), metastases from breast cancer (3 lesions), and tuberculum sellae meningioma (2 lesions). The prescription dose covered 99% of the planning target volume in 16 lesions (72.7%) and 100% in six lesions (27.3%) (prescription volume). In meningiomas and schwannomas, doses between 12 and 14 Gy were used, in plasmacytoma 13 Gy, in pilocytic astrocytoma 14 Gy, in cavernoma 15 Gy, in breast cancer metastasis between 18 and 20 Gy, and in lung cancer metastasis 22 Gy. When evaluating local control, 11 patients exhibited stable findings at the six-month control while 10 had partial regression, and a single patient had total regression. Minor complications such as perilesional edema, facial paresthesia, facial paralysis, and transient alopecia were observed in eight of the patients. Conclusions Patients with extra-axial, low-grade malignancy, and posterior fossa lesions were predominant in the studied population. Radiosurgery treatment is associated with good local control of the treated lesions. Complications are infrequent, mild, and predominated by perilesional edema.
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10
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Shen J, Dai Z, Yu J, Yuan Q, Kang K, Chen C, Liu H, Xie C, Wang X. Sub-arc collimator angle optimization based on the conformity index heatmap for VMAT planning of multiple brain metastases SRS treatments. Front Oncol 2022; 12:987971. [PMID: 36147903 PMCID: PMC9487306 DOI: 10.3389/fonc.2022.987971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to investigate the impact of collimator angle optimization in single-isocenter coplanar volume modulated arc therapy (VMAT) stereotactic radiosurgery (SRS) for multiple metastases with respect to dosimetric quality and treatment delivery efficiency. In particular, this is achieved by a novel algorithm of sub-arc collimator angle optimization (SACAO).MethodsTwenty patients with multiple brain metastases were retrospectively included in this study. A multi-leaf collimator (MLC) conformity index (MCI) that is defined as the ratio of the area of target projection in the beam’s eye view (BEV) to the related area fitted by MLC was applied. Accordingly, for each control point, 180 MCI values were calculated with a collimator angle interval of 1°. A two-dimensional heatmap of MCI as a function of control point and collimator angle for each full arc was generated. The optimal segmentation of sub-arcs was achieved by avoiding the worst MCI at each control point. Then, the optimal collimator angle for each sub-arc would be determined by maximizing the summation of MCI. Each patient was scheduled to undergo single-center coplanar VMAT SRS based on either the novel SACAO algorithm or the conventional VMAT with static collimator angle (ST-VMAT). The dosimetric parameters, field sizes, and the monitoring units (Mus) were evaluated.ResultsThe mean dose-volumetric parameters for the target volume of SACAO were comparable to ST-VMAT, while the conformity index (CI), homogeneity index (HI), and gradient index (GI) were reduced by SACAO. Improved sparing of organs at risk (OARs) was also obtained by SACAO. In particular, the SACAO method significantly (p < 0.01) reduced the field size (76.59 ± 32.55 vs. 131.95 ± 56.71 cm2) and MUs (655.35 ± 71.99 vs. 729.85 ± 73.52) by 41.11%.ConclusionsThe SACAO method could be superior in improving the CI, HI, and GI of the targets as well as normal tissue sparing for multiple brain metastases SRS. In particular, SACAO has the potential of increasing treatment efficiency in terms of field size and MU.
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Affiliation(s)
- Jiuling Shen
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
| | - Zhitao Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
- *Correspondence: Xiaoyong Wang, ; Zhitao Dai,
| | - Jing Yu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
| | - Qingqing Yuan
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Kailian Kang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Cheng Chen
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
| | - Hui Liu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
| | - Xiaoyong Wang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, China
- *Correspondence: Xiaoyong Wang, ; Zhitao Dai,
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11
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Oliver PAK, Wood TR, Baldwin LN. A customizable, open-source Winston-Lutz system for multi-target, single isocentre radiotherapy. Biomed Phys Eng Express 2022; 8. [PMID: 36049388 DOI: 10.1088/2057-1976/ac8e72] [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: 07/14/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To present and share an open-source system (phantom and software) for verifying the targeting accuracy of linac-based, single-isocenter, multi-target radiotherapy. This quality assurance test extends the traditional Winston-Lutz test, which considers a single target located at isocentre. APPROACH Plans for a 3D-printed phantom are provided, which can be customized to accommodate various target (BB) positions. Given BB positions and gantry/collimator/couch combinations, the software generates multi-leaf collimator positions to facilitate multi-target Winston-Lutz (MTWL) plan creation. The software determines deviations between detected and expected BB positions on MV images resulting from MTWL plan delivery. BBs are located using a Hough circle detection algorithm, which is modified to favour the detection of circles: (1) having reasonable size, (2) that are contained within the radiation field, and (3) having reasonable pixel intensities. Validation was performed in two ways: (1) using synthetic data with zero targeting errors and (2) by measuring real linac targeting errors and comparing against results obtained using a commercial system. MAIN RESULTS Validation using the synthetic data yielded a mean (maximum) absolute discrepancy of 0.11 mm (0.21 mm), which is comparable to the synthetic phantom resolution (0.2 mm). The mean (maximum) absolute discrepancy compared to the commercial system is 0.13 mm (0.43 mm). These values are similar to results obtained with repeated deliveries of the same MTWL plan with the same phantom setup. Both validation tests yield reasonable results and are therefore considered successful. The MTWL test was performed independently by three physicists on two linacs to investigate repeatability, resulting in a mean (maximum) absolute discrepancy of 0.14 mm (0.51 mm) among the various attempts. SIGNIFICANCE Successful completion of this quality assurance test, using our customizable and open-source system, provides confidence that multi-target, single isocentre radiotherapy treatments can be delivered with sufficient geometric accuracy according to the chosen tolerance level.
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Affiliation(s)
- Patricia A K Oliver
- Dept. of Oncology, Div. of Medical Physics, University of Alberta, 11560 University Avenue, Edmonton, Alberta, T6G 1Z2, CANADA
| | - Tania R Wood
- Dept. of Medical Physics, Alberta Health Services, Cross Cancer Institute, 11560 University Avenue, Edmonton, Alberta, T6G 1Z2, CANADA
| | - Lesley N Baldwin
- Dept. of Oncology, Medical Physics Division, University of Alberta, 11560 University Ave, Edmonton, Alberta, T6G 1Z2, CANADA
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12
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Gregucci F, Surgo A, Carbonara R, Laera L, Ciliberti MP, Gentile MA, Caliandro M, Sasso N, Bonaparte I, Fanelli V, Tortora R, Paulicelli E, Surico G, Lombardi G, Signorelli F, Fiorentino A. Radiosurgery and Stereotactic Brain Radiotherapy with Systemic Therapy in Recurrent High-Grade Gliomas: Is It Feasible? Therapeutic Strategies in Recurrent High-Grade Gliomas. J Pers Med 2022; 12:jpm12081336. [PMID: 36013284 PMCID: PMC9410141 DOI: 10.3390/jpm12081336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose. For recurrent high-grade gliomas (HGG), no standard therapeutic approach has been reported; thus, surgery, chemotherapy, and re-irradiation (re-RT) may all be proposed. The aim of the study was to evaluate safety and efficacy of re-RT by radiosurgery or fractionated stereotactic radiotherapy (SRS/FSRT) in association to chemotherapy in patients with recurrent HGG. Material/Methods: All patients with histological diagnosis of HGG that suffered by recurrent disease diagnosed by magnetic resonance imaging (MRI), according to Response Assessment in Neuro-Oncology (RANO) criteria, after primary/adjuvant chemo-radiotherapy treatment and underwent to re-RT by SRS/FSRT were included in the analysis. Second-line chemotherapy was administered. Outcomes were evaluated by neurological examination and brain MRI performed 1 month after re-RT and then every 2–3 months. Results: From November 2019 to September 2021, 30 patients presenting recurrent HGG underwent re-RT. Median dose was 24 Gy (range 15–36 Gy), and median fractions was 5 (range 1–6). Twenty-one patients (70%) had RPA class ≤ IV. One patient had a histological diagnosis of anaplastic oligodendroglioma, 24 patients (80%) were affected by glioblastoma (GBM) including 3 cases of multifocal form, and 5 patients (17%) by anaplastic astrocytoma. Median time between primary/adjuvant RT and disease recurrence was 8 months. In six cases (20%) re-operation was performed, and in most cases (87%), a second line of systemic therapy was administrated. At a median follow-up time from recurrence of 13 months (range 6–56 months), 10 patients (33%) were alive: 2 patients with partial response disease, 7 patients with stable disease, and 1 patient with out-field progression disease. Of the 20 patients who died (67%), 15 (75%) died for progression disease and 5 (25%) for other causes (3 due to septic event, 1 due to thrombo-embolic event, and 1 due to car accident). Median OS and PFS after recurrence were 12.1 and 11.2 months. Six-month and one-year OS were, respectively, 81% and 51%. No acute or late neurological side effects grade ≥ 2 and no case of radio-necrosis were reported. One patient experienced, after reintervention and during Regorafenib treatment (administered 40 days after surgery), dehiscence of the surgical wound. In three cases, grade 2 distal paresthesia was reported. Grade 3–4 hematologic toxicity occurred in seven cases. Three case of grade 5 toxicities during chemotherapy were reported: three septic events and one thrombo-embolic event. Conclusion. Re-RT with SRT/FSRT in association with second-line systemic therapy is a safe and feasible treatment for patients with HGG recurrence. Validation of these results by prospective studies is needed.
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Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Letizia Laera
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Maria Annunziata Gentile
- Department of Radiology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Nicola Sasso
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Vincenzo Fanelli
- Department of Neurosurgery, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Romina Tortora
- Centro Orientamento Oncologico, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Eleonora Paulicelli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giammarco Surico
- Department of Medical Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
| | - Giuseppe Lombardi
- Department of Medical Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Division of Neurosurgery, University “Aldo Moro”, 70124 Bari, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Acquaviva delle Fonti (BA), Italy
- Correspondence: ; Tel.: +39-080-3054608
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13
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Zirone L, Bonanno E, Borzì GR, Cavalli N, D’Anna A, Galvagno R, Girlando A, Gueli AM, Pace M, Stella G, Marino C. HyperArc TM Dosimetric Validation for Multiple Targets Using Ionization Chamber and RT-100 Polymer Gel. Gels 2022; 8:gels8080481. [PMID: 36005082 PMCID: PMC9407338 DOI: 10.3390/gels8080481] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Multiple brain metastases single-isocenter stereotactic radiosurgery (SRS) treatment is increasingly employed in radiotherapy department. Before its use in clinical routine, it is recommended to perform end-to-end tests. In this work, we report the results of five HyperArcTM treatment plans obtained by both ionization chamber (IC) and polymer gel. The end-to-end tests were performed using a water equivalent Mobius Verification PhantomTM (MVP) and a 3D-printed anthropomorphic head phantom PseudoPatient® (PP) (RTsafe P.C., Athens, Greece); 2D and 3D dose distributions were evaluated on the PP phantom using polymer gel (RTsafe). Gels were read by 1.5T magnetic resonance imaging (MRI). Comparison between calculated and measured distributions was performed using gamma index passing rate evaluation by different criteria (5% 2 mm, 3% 2 mm, 5% 1 mm). Mean point dose differences of 1.01% [min −0.77%−max 2.89%] and 0.23% [min 0.01%−max 2.81%] were found in MVP and PP phantoms, respectively. For each target volume, the obtained results in terms of gamma index passing rate show an agreement >95% with 5% 2 mm and 3% 2 mm criteria for both 2D and 3D distributions. The obtained results confirmed that the use of a single isocenter for multiple lesions reduces the treatment time without compromising accuracy, even in the case of target volumes that are quite distant from the isocenter.
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Affiliation(s)
- Lucia Zirone
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Elisa Bonanno
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Giuseppina Rita Borzì
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Nina Cavalli
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Alessia D’Anna
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Rosaria Galvagno
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Andrea Girlando
- Radiotherapy Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy;
| | - Anna Maria Gueli
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Martina Pace
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Giuseppe Stella
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
- Correspondence: ; Tel.: +39-328-1847570
| | - Carmelo Marino
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
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14
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Pokhrel D, Mallory R, Bush M, St Clair W, Bernard ME. Feasibility Study of Stereotactic Radiosurgery Treatment of Glomus Jugulare Tumors via HyperArc VMAT. Med Dosim 2022; 47:307-311. [PMID: 35717426 DOI: 10.1016/j.meddos.2022.05.002] [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: 09/02/2021] [Revised: 03/08/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
This study aims to report on the clinical validation and feasibility of utilizing a novel fully automated treatment planning and delivery system, HyperArc VMAT stereotactic radiosurgery (SRS) for glomus jugulare tumors (GJT). Independent dose verification of the HyperArc module via the MD Anderson's SRS head phantom irradiation and credentialing results showed compliance with the SRS treatment requirements per IROC MD Anderson's standard. Following the Alliance clinical trial, AAPM, RTOG protocols, and QUENTAC requirements, utilizing selected three-partial arc geometry of HyperArc module on TrueBeam Linac with 6MV-FFF beam, GJT SRS plans were generated for nine previously treated Gamma Knife (GK) radiosurgery patients using advanced Acuros-based algorithm to account for tissue inhomogeneity corrections and frameless immobilization with Q-fix mask and Encompass device insert. HyperArc VMAT produced highly conformal SRS dose distributions to GJT, a steep dose gradient around the GJT, and spared adjacent critical organs including the spinal cord (< 3.0 Gy). Due to faster patient setup and less MLC modulation through the target (average beam-on time, 6.2 minutes), the HyperArc VMAT plan can deliver a single high-dose of 18 Gy to the GJT in less than 15 minutes overall treatment time, significantly improving patient comfort and clinic workflow. Pretreatment portal dosimetry quality assurance results and independent dose verification via Monte Carlo-based physics second check met our clinical SRS protocol's requirements for treatment. Due to the highly conformal dose distribution, rapid dose fall-off, excellent sparing of adjacent critical organs, and highly precise and accurate treatment, clinical implementation of frameless HyperArc VMAT for GJT patients who may not have access to nor tolerate frame-based GK SRS treatment are underway.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, Lexington KY, 40536, USA.
| | - Richard Mallory
- Department of Radiation Medicine, University of Kentucky, Lexington KY, 40536, USA
| | - Matthew Bush
- Department of Otolaryngology - Head and Neck Surgery, University of Kentucky, Lexington KY, 40536, USA
| | - William St Clair
- Department of Radiation Medicine, University of Kentucky, Lexington KY, 40536, USA
| | - Mark E Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington KY, 40536, USA
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15
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Brenner AW, Patel AJ. Review of Current Principles of the Diagnosis and Management of Brain Metastases. Front Oncol 2022; 12:857622. [PMID: 35686091 PMCID: PMC9171239 DOI: 10.3389/fonc.2022.857622] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/25/2022] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are the most common intracranial tumors and are increasing in incidence as overall cancer survival improves. Diagnosis of brain metastases involves both clinical examination and magnetic resonance imaging. Treatment may involve a combination of surgery, radiotherapy, and systemic medical therapy depending on the patient’s neurologic status, performance status, and overall oncologic burden. Advances in these domains have substantially impacted the management of brain metastases and improved performance status and survival for some patients. Indications for surgery have expanded with improved patient selection, imaging, and intraoperative monitoring. Robust evidence supports the use of whole brain radiotherapy and stereotactic radiosurgery, for both standalone and adjuvant indications, in almost all patients. Lastly, while systemic medical therapy has historically provided little benefit, modern immunotherapeutic agents have demonstrated promise. Current investigation seeks to determine the utility of neoadjuvant radiotherapy and laser interstitial thermal therapy, which have shown benefit in limited studies to date. This article provides a review of the epidemiology, pathology, diagnosis, and treatment of brain metastases and the corresponding supporting evidence.
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Affiliation(s)
- Alex W Brenner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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16
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Rydelius A, Lampinen B, Rundcrantz A, Bengzon J, Engelholm S, van Westen D, Kinhult S, Knutsson L, Lätt J, Nilsson M, Sundgren PC. Diffusion tensor imaging in glioblastoma patients treated with volumetric modulated arc radiotherapy: a longitudinal study. Acta Oncol 2022; 61:680-687. [PMID: 35275512 DOI: 10.1080/0284186x.2022.2045036] [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: 11/01/2022]
Abstract
BACKGROUND Chemo- and radiotherapy (RT) is standard treatment for patients with high-grade glioma, but may cause side-effects on the patient's cognitive function. AIM Use of diffusion tensor imaging (DTI) to investigate the longitudinal changes in normal-appearing brain tissue in glioblastoma patients undergoing modern arc-based RT with volumetric modulated arc therapy (VMAT) or helical tomotherapy. MATERIALS AND METHODS The study included 27 patients newly diagnosed with glioblastoma and planned for VMAT or tomotherapy. All subjects underwent magnetic resonance imaging at the start of RT and at week 3, 6, 15, and 26. Fourteen subjects were additionally imaged at week 52. The DTI data were co-registered to the dose distribution maps. Longitudinal changes in fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were assessed in the corpus callosum, the centrum semiovale, the hippocampus, and the amygdala. RESULTS Significant longitudinal changes in FA, MD, and RD were mainly found in the corpus callosum. In the other examined brain structures, only sparse and transient changes were seen. No consistent correlations were found between biodose, age, or gender and changes in DTI parameters. CONCLUSION Longitudinal changes in MD, FA, and RD were observed but only in a limited number of brain structures and the changes were smaller than expected from literature. The results suggest that modern, arc-based RT may have less negative effect on normal-appearing parts of the brain tissue up to 12 months after radiotherapy.
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Affiliation(s)
- Anna Rydelius
- Department of Radiology, Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skane University Hospital, Lund, Sweden
| | - Björn Lampinen
- Department of Medical Radiation Physics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Andreas Rundcrantz
- Department of Radiology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Johan Bengzon
- Department of Neurosurgery, Clinical Sciences Lund, Lund University and Skane University Hospital, Lund, Sweden
| | - Silke Engelholm
- Deptarments of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Danielle van Westen
- Department of Radiology, Clinical Sciences Lund, Lund University, Lund, Sweden
- Department for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Sara Kinhult
- Department of Oncology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Linda Knutsson
- Department of Medical Radiation Physics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jimmy Lätt
- Lund University BioImaging Centre (LBIC), Lund University, Lund, Sweden
| | - Markus Nilsson
- Department of Radiology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Pia C. Sundgren
- Department of Radiology, Clinical Sciences Lund, Lund University, Lund, Sweden
- Department for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Lund University BioImaging Centre (LBIC), Lund University, Lund, Sweden
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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17
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Pokhrel D, Bernard ME, Johnson J, Fabian D, Kudrimoti M. HyperArc VMAT stereotactic radiotherapy for locally recurrent previously‐irradiated head and neck cancers: Plan quality, treatment delivery accuracy, and efficiency. J Appl Clin Med Phys 2022; 23:e13561. [PMID: 35253992 PMCID: PMC9121031 DOI: 10.1002/acm2.13561] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose Materials/Methods Results Conclusion
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Affiliation(s)
- Damodar Pokhrel
- Medical Physics Graduate Program Department of Radiation Medicine University of Kentucky Lexington Kentucky USA
| | - Mark E Bernard
- Medical Physics Graduate Program Department of Radiation Medicine University of Kentucky Lexington Kentucky USA
| | - Jeremiah Johnson
- Medical Physics Graduate Program Department of Radiation Medicine University of Kentucky Lexington Kentucky USA
| | - Denise Fabian
- Medical Physics Graduate Program Department of Radiation Medicine University of Kentucky Lexington Kentucky USA
| | - Mahesh Kudrimoti
- Medical Physics Graduate Program Department of Radiation Medicine University of Kentucky Lexington Kentucky USA
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18
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Chow VUY, Cheung MLM, Kan MWK, Chan ATC. Shift detection discrepancy between ExacTrac Dynamic system and cone‐beam computed tomography. J Appl Clin Med Phys 2022; 23:e13567. [PMID: 35188333 PMCID: PMC9121052 DOI: 10.1002/acm2.13567] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/12/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Accurate detection of patient shift is essential during radiation therapy such that optimal dose is delivered to the tumor while minimizing radiation to surrounding normal tissues. The shift detectability of a newly developed optical surface and thermal tracking system, which was known as ExacTrac Dynamic (EXTD), was evaluated by comparing its performance with the image guidance under cone‐beam computed tomography (CBCT). Anthropomorphic cranial and pelvis phantoms with internal bone‐like structures and external heat pad were utilized to study the shift detection discrepancy between EXTD system and CBCT. Random displacements within the range of ± 2 cm for translations and ± 2 degrees for rotations were intentionally applied to the phantom. Positional shifts detected by optical surface and thermal tracking (EXTD_Thml), stereoscopic X‐ray (EXTD_Xray), and CBCT were compared in 6 degrees of freedom. The translational difference between EXTD_Thml and CBCT was 0.57 ± 0.41 mm and 0.66 ± 0.40 mm for cranial and pelvis phantom, respectively, while it was 0.60 ± 0.43 mm and 0.76 ± 0.49 mm between EXTD_Xray and CBCT, respectively. For rotational movement, the difference between EXTD_Thml and CBCT was 0.19 ± 0.16° and 0.19 ± 0.22° for cranial and pelvis phantom, respectively, while it was 0.13 ± 0.18° and 0.65 ± 0.46° between EXTD_Xray and CBCT, respectively. This study demonstrated that the EXTD system with thermal mapping ability could offer comparable accuracy for shift detection with CBCT on both cranial and pelvis phantoms.
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Affiliation(s)
- Vivian U. Y. Chow
- Department of Clinical Oncology Prince of Wales Hospital Hong Kong SAR China
| | | | - Monica W. K. Kan
- Department of Clinical Oncology Prince of Wales Hospital Hong Kong SAR China
- Department of Clinical Oncology The Chinese University of Hong Kong Hong Kong SAR China
| | - Anthony T. C. Chan
- Department of Clinical Oncology Prince of Wales Hospital Hong Kong SAR China
- Department of Clinical Oncology The Chinese University of Hong Kong Hong Kong SAR China
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Zhai X, Li W, Li J, Jia W, Jing W, Tian Y, Xu S, Li Y, Zhu H, Yu J. Therapeutic effect of osimertinib plus cranial radiotherapy compared to osimertinib alone in NSCLC patients with EGFR-activating mutations and brain metastases: a retrospective study. Radiat Oncol 2021; 16:233. [PMID: 34865626 PMCID: PMC8647301 DOI: 10.1186/s13014-021-01955-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The study aimed to compare the efficacy of osimertinib plus cranial radiotherapy (RT) with osimertinib alone in advanced non-small-cell lung cancer (NSCLC) patients harboring epidermal growth factor receptor (EGFR) mutations and brain metastases (BMs). METHODS The clinical data of advanced NSCLC patients with BMs who received osimertinib were retrospectively collected. The patients were assigned to one of the two groups according to the therapeutic modality used: the osimertinib monotherapy group or the osimertinib plus RT group. RESULTS This was a retrospective study and 61 patients were included from December 2015 to August 2020. Forty patients received osimertinib monotherapy, and twenty-one patients received osimertinib plus RT. Radiotherapy included whole-brain radiation therapy (WBRT, n = 14), WBRT with simultaneous integrated boost (WBRT-SIB, n = 5) and stereotactic radiosurgery (SRS, n = 2). The median number of prior systemic therapies in the two groups was one. Intracranial and systemic ORR and DCR were not significantly different between the two groups. No difference in iPFS was observed between the two groups (median iPFS: 16.67 vs. 13.50 months, P = 0.836). The median OS was 29.20 months in the osimertinib plus RT group compared with 26.13 months in the osimertinib group (HR = 0.895, P = 0.826). In the L858R mutational subgroup of 31 patients, the osimertinib plus RT group had a longer OS (P = 0.046). In the exon 19 deletion mutational subgroup of 30 patients, OS in the osimertinib alone group was longer than that in the osimertinib plus RT group (P = 0.011). The incidence of any-grade adverse events was not significantly different between the osimertinib plus RT group and the osimertinib alone group (47.6% vs. 32.5%, P = 0.762). However, six patients (28.5%) experienced leukoencephalopathy in the osimertinib plus RT group, and 50% (3/6) of the leukoencephalopathy was greater than or equal to grade 3. CONCLUSION The therapeutic effect of osimertinib with RT was similar to that of osimertinib alone in EGFR-positive NSCLC patients with BM. However, for patients with the L858R mutation, osimertinib plus RT could provide more benefit than osimertinib alone.
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Affiliation(s)
- Xiaoyang Zhai
- Shantou University Medical College, Shantou, 515041, Guangdong Province, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Wanhu Li
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Ji Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Wenxiao Jia
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Wang Jing
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Yaru Tian
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Shuhui Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Yuying Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong University, Shandong First Medical University, Shandong Academy of Medical Sciences, Shandong Province, 250117, Jinan, China.
| | - Jinming Yu
- Shantou University Medical College, Shantou, 515041, Guangdong Province, China.
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China.
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De Ornelas M, Diwanji T, Monterroso I, Bossart E, Yechieli R, Dogan N, Mellon EA. Assessment of intra-fraction motion during automated linac-based SRS treatment delivery with an open face mask system. Phys Med 2021; 92:69-74. [PMID: 34871889 DOI: 10.1016/j.ejmp.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE/OBJECTIVE To evaluate intra-fraction target shift during automated mono-isocentric linac-based stereotactic radiosurgery with open-face mask system and optical real-time tracking. MATERIALS/METHODS Ninety-five patients were treated using automated linac-based stereotactic radiosurgery in 1-5 fractions with single isocenter for a total of 195 fractions. During treatment, patient positioning was tracked real-time with optical surface guidance and immobilized with a rigid open-face mask. Patients were re-positioned if optical surface guidance error exceeded 1 mm magnitude or 1°. Translational and rotational intra-fractional changes were determined by post-treatment CBCT matched to the planning CT. Target specific error was calculated by translation and rotation matrices applied to isocenter and target spatial coordinates. RESULTS For 132 fractions with isocenter within a single target, the median shift magnitude was 0.40 mm with a maximum shift of 1.17 mm. A total of 398 targets treated for plans having multiple or single targets that lied outside isocenter, resulted in a median shift magnitude of 0.46 mm, with median translational shifts of 0.20 mm and 0.20° rotational shifts. A 1 mm PTV margin was insufficient in 18% of targets at a distance greater than 6 cm away from isocenter, but sufficient for 96% of targets within 6 cm. CONCLUSIONS The findings of this study support 1 mm PTV expansion due to intra-fraction motion to ensure target coverage for plans with isocenter placement less than 6 cm away from the targets.
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Affiliation(s)
- Mariluz De Ornelas
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Irene Monterroso
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Elizabeth Bossart
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Eric A Mellon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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22
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Giaj-Levra N, Figlia V, Cuccia F, Mazzola R, Nicosia L, Ricchetti F, Rigo M, Attinà G, Vitale C, Sicignano G, De Simone A, Naccarato S, Ruggieri R, Alongi F. Reduction of inter-observer differences in the delineation of the target in spinal metastases SBRT using an automatic contouring dedicated system. Radiat Oncol 2021; 16:197. [PMID: 34627313 PMCID: PMC8502264 DOI: 10.1186/s13014-021-01924-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Approximately one third of cancer patients will develop spinal metastases, that can be associated with back pain, neurological symptoms and deterioration in performance status. Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) have been offered in clinical practice mainly for the management of oligometastatic and oligoprogressive patients, allowing the prescription of high total dose delivered in one or few sessions to small target volumes, minimizing the dose exposure of normal tissues. Due to the high delivered doses and the proximity of critical organs at risk (OAR) such as the spinal cord, the correct definition of the treatment volume becomes even more important in SBRT treatment, thus making it necessary to standardize the method of target definition and contouring, through the adoption of specific guidelines and specific automatic contouring tools. An automatic target contouring system for spine SBRT is useful to reduce inter-observer differences in target definition. In this study, an automatic contouring tool was evaluated. METHODS Simulation CT scans and MRI data of 20 patients with spinal metastases were evaluated. To evaluate the advantage of the automatic target contouring tool (Elements SmartBrush Spine), which uses the identification of different densities within the target vertebra, we evaluated the agreement of the contours of 20 spinal target (2 cervical, 9 dorsal and 9 lumbar column), outlined by three independent observers using the automatic tool compared to the contours obtained manually, and measured by DICE similarity coefficient. RESULTS The agreement of GTV contours outlined by independent operators was superior with the use of the automatic contour tool compared to manually outlined contours (mean DICE coefficient 0.75 vs 0.57, p = 0.048). CONCLUSIONS The dedicated contouring tool allows greater precision and reduction of inter-observer differences in the delineation of the target in SBRT spines. Thus, the evaluated system could be useful in the setting of spinal SBRT to reduce uncertainties of contouring increasing the level of precision on target delivered doses.
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Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy.
| | - Vanessa Figlia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Luca Nicosia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Francesco Ricchetti
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Michele Rigo
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Giorgio Attinà
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Claudio Vitale
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy.,University of Brescia, Brescia, Italy
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23
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Palmiero AN, Fabian D, Randall ME, Clair W, Pokhrel D. Predicting the effect of indirect cell kill in the treatment of multiple brain metastases via single-isocenter/multitarget volumetric modulated arc therapy stereotactic radiosurgery. J Appl Clin Med Phys 2021; 22:94-103. [PMID: 34498359 PMCID: PMC8504608 DOI: 10.1002/acm2.13400] [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: 02/15/2021] [Revised: 07/11/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose Due to spatial uncertainty, patient setup errors are of major concern for radiosurgery of multiple brain metastases (m‐bm) when using single‐isocenter/multitarget (SIMT) volumetric modulated arc therapy (VMAT) techniques. However, recent clinical outcome studies show high rates of tumor local control for SIMT‐VMAT. In addition to direct cell kill (DCK), another possible explanation includes the effects of indirect cell kill (ICK) via devascularization for a single dose of 15 Gy or more and by inducing a radiation immune intratumor response. This study quantifies the role of indirect cell death in dosimetric errors as a function of spatial patient setup uncertainty for stereotactic treatments of multiple lesions. Material and Methods Nine complex patients with 61 total tumors (2‐16 tumors/patient) were planned using SIMT‐VMAT with geometry similar to HyperArc with a 10MV‐FFF beam (2400 MU/min). Isocenter was placed at the geometric center of all tumors. Average gross tumor volume (GTV) and planning target volume (PTV) were 1.1 cc (0.02–11.5) and 1.9 cc (0.11–18.8) with an average distance to isocenter of 5.4 cm (2.2–8.9). The prescription was 20 Gy to each PTV. Plans were recalculated with induced clinically observable patient setup errors [±2 mm, ±2o] in all six directions. Boolean structures were generated to calculate the effect of DCK via 20 Gy isodose volume (IDV) and ICK via 15 Gy IDV minus the 20 Gy IDV. Contributions of each IDV to the PTV coverage were analyzed along with normal brain toxicity due to the patient setup uncertainty. Induced uncertainty and minimum dose covering the entire PTV were analyzed to determine the maximum tolerable patient setup errors to utilize the ICK effect for radiosurgery of m‐bm via SIMT‐VMAT. Results Patient setup errors of 1.3 mm /1.3° in all six directions must be maintained to achieve PTV coverage of the 15 Gy IDV for ICK. Setup errors of ±2 mm/2° showed clinically unacceptable loss of PTV coverage of 29.4 ± 14.6% even accounting the ICK effect. However, no clinically significant effect on normal brain dosimetry was observed. Conclusions Radiosurgery of m‐bm using SIMT‐VMAT treatments have shown positive clinical outcomes even with small residual patient setup errors. These clinical outcomes, while largely due to DCK, may also potentially be due to the ICK. Potential mechanisms, such as devascularization and/or radiation‐induced intratumor immune enhancement, should be explored to provide a better understanding of the radiobiological response of stereotactic radiosurgery of m‐bm using a SIMT‐VMAT plan.
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Affiliation(s)
- Allison N Palmiero
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Denise Fabian
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Marcus E Randall
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - William Clair
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Damodar Pokhrel
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
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24
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Cullom ET, Xia Y, Chuang KC, Gude ZW, Zlateva Y, Adamson JD, Giles WM. Single isocenter SRS using CAVMAT offers improved robustness to commissioning and treatment delivery uncertainty compared to VMAT. J Appl Clin Med Phys 2021; 22:36-43. [PMID: 34165217 PMCID: PMC8292691 DOI: 10.1002/acm2.13248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose In this study, we evaluate and compare single isocenter multiple target VMAT (SIMT) and Conformal Arc Informed VMAT (CAVMAT) radiosurgery's sensitivity to uncertainties in dosimetric leaf gap (DLG) and treatment delivery. CAVMAT is a novel planning technique that uses multiple target conformal arcs as the starting point for limited inverse VMAT optimization. Methods All VMAT and CAVMAT plans were recalculated with DLG values of 0.4, 0.8, and 1.2 mm. DLG effect on V6Gy[cc], V12Gy[cc], and V16Gy[cc], and target dose was evaluated. Plans were delivered to a Delta4 (ScandiDos, Madison, WI) phantom and gamma analysis performed with varying criteria. Log file analysis was performed to evaluate MLC positional error. Sixteen targets were delivered to a SRS MapCHECK (Sun Nuclear Corp., Melbourne, FL) to evaluate VMAT and CAVMAT's dose difference (DD) as a function of DLG. Results VMAT's average maximum and minimum target dose sensitivity to DLG was 9.08 ±3.50%/mm and 9.50 ± 3.30%/mm, compared to 3.20 ± 1.60%/mm and 4.72 ± 1.60%/mm for CAVMAT. For VMAT, V6Gy[cc], V12Gy[cc], and V16Gy[cc] sensitivity was 35.83 ± 9.50%/mm, 34.12 ± 6.60%/mm, and 39.23 ± 8.40%/mm. In comparison, CAVMAT's sensitivity was 23.19 ± 4.50%/mm, 22.45 ± 4.40%/mm, and 24.88 ± 4.90%/mm, respectively. Upon delivery to the Delta4, CAVMAT offered superior dose agreement compared to VMAT. For a 1%/1 mm gamma analysis, VMAT and CAVMAT had a passing rate of 94.53 ± 4.40% and 99.28 ± 1.70%, respectively. CAVMAT was more robust to DLG variation, with the SRS MapCHECK plans yielding an absolute average DD sensitivity of 2.99 ± 1.30%/mm compared to 5.07 ± 1.10%/mm for VMAT. Log files demonstrated minimal differences in MLC positional error for both techniques. Conclusions CAVMAT remains robust to delivery uncertainties while offering a target dose sensitivity to DLG less than half that of VMAT, and 65% of that of VMAT for V6Gy[cc], V12Gy[cc], and V16Gy[cc]. The superior dose agreement and reduced sensitivity of CAVMAT to DLG uncertainties indicate promise as a robust alternative to VMAT for SIMT SRS.
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Affiliation(s)
- Edward T Cullom
- Medical Physics Graduate Program, Duke University, Durham, North Carolina, USA.,Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Yuqing Xia
- Medical Physics Graduate Program, Duke Kunshan University, Suzhou, China
| | - Kai-Cheng Chuang
- Medical Physics Graduate Program, Duke Kunshan University, Suzhou, China
| | - Zachary W Gude
- Medical Physics Graduate Program, Duke University, Durham, North Carolina, USA
| | - Yana Zlateva
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Justus D Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - William M Giles
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
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25
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Cozzi L, Beriwal S, Kuusela E, Chopra S, Burger H, Joubert N, Fogliata A, Agarwal JP, Kupelian P. A novel external beam radiotherapy method for cervical cancer patients using virtual straight or bending boost areas; an in-silico feasibility study. Radiat Oncol 2021; 16:110. [PMID: 34127013 PMCID: PMC8201836 DOI: 10.1186/s13014-021-01838-x] [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: 04/09/2021] [Accepted: 06/10/2021] [Indexed: 12/09/2022] Open
Abstract
Aim To investigate the potential role of a novel spatially fractionated radiation therapy (SFRT) method where heterogeneous dose patterns are created in target areas with virtual rods, straight or curving, of variable position, diameter, separation and alignment personalised to a patient’s anatomy. The images chosen for this study were CT scans acquired for the external beam part of radiotherapy. Methods Ten patients with locally advanced cervical cancer were retrospectively investigated with SFRT. The dose prescription was 30 Gy in 5 fractions to 90% target volume coverage. Peak-and-valley (SFRT_1) and peak-only (SFRT_2) strategies were applied to generate the heterogeneous dose distributions. The planning objectives for the target (CTV) were D90% ≥ 30 Gy, V45Gy ≥ 50–55% and V60Gy ≥ 30%. The planning objectives for the organs at risk (OAR) were: D2cm3 ≤ 23.75 Gy, 17.0 Gy, 19.5 Gy, 17.0 Gy for the bladder, rectum, sigmoid and bowel, respectively. The plan comparison was performed employing the quantitative analysis of the dose-volume histograms. Results The D2cm3 was 22.4 ± 2.0 (22.6 ± 2.1) and 13.9 ± 2.9 (13.2 ± 3.0) for the bladder and the rectum for SFRT_1 (SFRT_2). The results for the sigmoid and the bowel were 2.6 ± 3.1 (2.8 ± 3.0) and 9.1 ± 5.9 (9.7 ± 7.3), respectively. The hotspots in the target volume were V45Gy = 43.1 ± 7.5% (56.6 ± 5.6%) and V60Gy = 15.4 ± 5.6% (26.8 ± 6.6%) for SFRT_1 (SFRT_2). To account for potential uncertainties in the positioning, the dose prescription could be escalated to D90% = 33–35 Gy to the CTV without compromising any constraints to the OARs Conclusion In this dosimetric study, the proposed novel planning technique for boosting the cervix uteri was associated with high-quality plans, respecting constraints for the organs at risk and approaching the level of dose heterogeneity achieved with routine brachytherapy. Based on a sample of 10 patients, the results are promising and might lead to a phase I clinical trial. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01838-x.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Via Manzoni 56, 20089, Milan-Rozzano, Italy. .,Varian Medical Systems, Palo Alto, USA.
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Esa Kuusela
- Varian Medical Systems Finland, Helsinki, Finland
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhaba National Institute, Mumbai, India
| | - Hester Burger
- Division of Medical Physics, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Nanette Joubert
- Division of Medical Physics, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Via Manzoni 56, 20089, Milan-Rozzano, Italy
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhaba National Institute, Mumbai, India
| | - Pat Kupelian
- Varian Medical Systems, Palo Alto, USA.,Radiation Oncology Dept, University of California, Los Angeles, USA
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Kutuzov I, Van Beek T, McCurdy BMC. Verification of the delivered patient radiation dose for non-coplanar beam therapy. J Appl Clin Med Phys 2021; 22:110-120. [PMID: 34021713 PMCID: PMC8292689 DOI: 10.1002/acm2.13280] [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: 11/13/2020] [Revised: 03/09/2021] [Accepted: 04/22/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE There is an increased interest in using non-coplanar beams for radiotherapy, including SBRT and SRS. This approach can significantly reduce doses to organs-at-risk, however, it requires stringent quality assurance, especially when a dynamic treatment couch is used. In this work, new functionality that allows using non-coplanar beam arrangements in addition to conventional coplanar beams was added and validated to the previously developed in vivo dose verification system. METHODS The existing program code was modified to manage the additional treatment couch parameters: angle and positions. Ten non-coplanar test plans that use a static couch were created in the treatment planning system. Also, two plans that use a dynamic treatment couch were created and delivered using Varian Developer mode, since the treatment planning system does not support a dynamic couch. All non-coplanar test trajectories were delivered on a simple geometric phantom, using an Edge linear accelerator (Varian Medical Systems) with the megavoltage imager deployed and acquiring megavoltage transmission images that were used to calculate the delivered 3D dose distributions in the phantom with the updated dose calculation algorithm. The reconstructed dose distributions were compared using the 3D chi-comparison test with 2%/2mm tolerances to the corresponding reference dose distributions obtained from the treatment planning system. RESULTS The chi-comparison test resulted in at least a 97.0% pass rate over the entire 3D volume for all tested trajectories. For static gantry, static couch non-coplanar fields, and non-coplanar arcs using dynamic couch the pass rates observed were at least 98%, while for the static couch, non-transverse coplanar arc fields, pass rates were at least 97%. CONCLUSIONS A model-based 3D dose calculation algorithm has been extended and validated for a variety of non-coplanar beam trajectories of different complexities. This system can potentially be applied for quality assurance of treatment delivery systems that use complex, non-coplanar beam arrangements.
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Affiliation(s)
- Ivan Kutuzov
- Department of Physics and Astronomy, University of Manitoba, Winnipeg, Manitoba, Canada.,Medical Physics Department, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Timothy Van Beek
- Medical Physics Department, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Boyd M C McCurdy
- Department of Physics and Astronomy, University of Manitoba, Winnipeg, Manitoba, Canada.,Medical Physics Department, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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Bodensohn R, Kaempfel AL, Fleischmann DF, Hadi I, Hofmaier J, Garny S, Reiner M, Forbrig R, Corradini S, Thon N, Belka C, Niyazi M. Simultaneous stereotactic radiosurgery of multiple brain metastases using single-isocenter dynamic conformal arc therapy: a prospective monocentric registry trial. Strahlenther Onkol 2021; 197:601-613. [PMID: 33884441 PMCID: PMC8219560 DOI: 10.1007/s00066-021-01773-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/23/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Single-isocenter dynamic conformal arc (SIDCA) therapy is a technically efficient way of delivering stereotactic radiosurgery (SRS) to multiple metastases simultaneously. This study reports on the safety and feasibility of linear accelerator (LINAC) based SRS with SIDCA for patients with multiple brain metastases. METHODS All patients who received SRS with this technique between November 2017 and June 2019 within a prospective registry trial were included. The patients were irradiated with a dedicated planning tool for multiple brain metastases using a LINAC with a 5 mm multileaf collimator. Follow-up was performed every 3 months, including clinical and radiological examination with cranial magnetic resonance imaging (MRI). These early data were analyzed using descriptive statistics and the Kaplan-Meier method. RESULTS A total of 65 patients with 254 lesions (range 2-12) were included in this analysis. Median beam-on time was 23 min. The median follow-up at the time of analysis was 13 months (95% CI 11.1-14.9). Median overall survival and median intracranial progression-free survival was 15 months (95% CI 7.7-22.3) and 7 months (95% CI 3.9-10.0), respectively. Intracranial and local control after 1 year was 64.6 and 97.5%, respectively. During follow-up, CTCAE grade I adverse effects (AE) were experienced by 29 patients (44.6%; 18 of them therapy related, 27.7%), CTCAE grade II AEs by four patients (6.2%; one of them therapy related, 1.5%), and CTCAE grade III by three patients (4.6%; none of them therapy related). Two lesions (0.8%) in two patients (3.1%) were histopathologically proven to be radiation necrosis. CONCLUSION Simultaneous SRS using SIDCA seems to be a feasible and safe treatment for patients with multiple brain metastases.
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Anna-Lena Kaempfel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Daniel Felix Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Munich, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany. .,German Cancer Consortium (DKTK), Munich, Germany.
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Woods K, Chin RK, Cook KA, Sheng K, Kishan AU, Hegde JV, Tenn S, Steinberg ML, Cao M. Automated Non-Coplanar VMAT for Dose Escalation in Recurrent Head and Neck Cancer Patients. Cancers (Basel) 2021; 13:cancers13081910. [PMID: 33921062 PMCID: PMC8071369 DOI: 10.3390/cancers13081910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary The ability to escalate the radiation dose to head and neck tumors has been shown to offer improved local control, and consequently, survival for recurrent head and neck cancer (rHNC) patients. This study evaluates the HyperArc automated non-coplanar planning technique (originally developed for intracranial treatment) for 20 rHNC patients, and compares this technique to conventional planning methods. HyperArc enables significant tumor dose escalation, with average increases in mean target dose of over 11.5 Gy (26%), while maintaining clinically-equivalent doses to nearby organs. Our results show that the average probability of tumor control is 23% higher for HyperArc than conventional techniques. Abstract This study evaluates the potential for tumor dose escalation in recurrent head and neck cancer (rHNC) patients with automated non-coplanar volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) planning (HyperArc). Twenty rHNC patients are planned with conventional VMAT SBRT to 40 Gy while minimizing organ-at-risk (OAR) doses. They are then re-planned with the HyperArc technique to match these minimal OAR doses while escalating the target dose as high as possible. Then, we compare the dosimetry, tumor control probability (TCP), and normal tissue complication probability (NTCP) for the two plan types. Our results show that the HyperArc technique significantly increases the mean planning target volume (PTV) and gross tumor volume (GTV) doses by 10.8 ± 4.4 Gy (25%) and 11.5 ± 5.1 Gy (26%) on average, respectively. There are no clinically significant differences in OAR doses, with maximum dose differences of <2 Gy on average. The average TCP is 23% (± 21%) higher for HyperArc than conventional plans, with no significant differences in NTCP for the brainstem, cord, mandible, or larynx. HyperArc can achieve significant tumor dose escalation while maintaining minimal OAR doses in the head and neck—potentially enabling improved local control for rHNC SBRT patients without increased risk of treatment-related toxicities.
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Affiliation(s)
- Kaley Woods
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Robert K. Chin
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Kiri A. Cook
- Department of Radiation Oncology, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - John V. Hegde
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA; (K.W.); (R.K.C.); (K.S.); (A.U.K.); (J.V.H.); (S.T.); (M.L.S.)
- Correspondence:
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Kraft J, van Timmeren JE, Mayinger M, Frei S, Borsky K, Stark LS, Krayenbuehl J, Zamburlini M, Guckenberger M, Tanadini-Lang S, Andratschke N. Distance to isocenter is not associated with an increased risk for local failure in LINAC-based single-isocenter SRS or SRT for multiple brain metastases. Radiother Oncol 2021; 159:168-175. [PMID: 33798610 DOI: 10.1016/j.radonc.2021.03.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/07/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the impact of the distance between treatment isocenter and brain metastases on local failure in patients treated with a frameless linear-accelerator-based single-isocenter volumetric modulated arc (VMAT) SRS/SRT for multiple brain metastases. METHODS AND MATERIALS Patients treated with SRT for brain metastases (BM) between April 2014 and May 2019 were included in this retrospective study. BM treated with a single-isocenter multiple-target (SIMT) SRT were evaluated for local recurrence-free intervals in dependency to their distance to the treatment isocenter. A Cox-regression model was used to investigate different predictor variables for local failure. Results were compared to patients treated with a single-isocenter-single-target (SIST) approach. RESULTS In total 315 patients with a cumulative number of 1087 BM were analyzed in this study of which 140 patients and 708 BM were treated with SIMT SRS/SRT. Median follow-up after treatment was 13.9 months for SIMT approach and 11.9 months for SIST approach. One-year freedom from local recurrence was 87% and 94% in the SIST and SIMT group, respectively. Median distance to isocenter (DTI) was 4.7 cm (range 0.2-10.5) in the SIMT group. Local recurrence-free interval was not associated with the distance to the isocenter in univariable or multivariable Cox-regression analysis. Multivariable analysis revealed only volume as an independent significant predictor for local failure (p-value <0.05). CONCLUSION SRS/SRT using single-isocenter VMAT for multiple targets achieved high local metastases control rates irrespective of distance to the isocenter, supporting efficacy of single-isocenter stereotactic radiation therapy for multiple brain metastases.
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Affiliation(s)
- Johannes Kraft
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland; Department of Radiation Oncology, University Hospital Wuerzburg, Germany.
| | - Janita E van Timmeren
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Simon Frei
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Kim Borsky
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Luisa Sabrina Stark
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Jerome Krayenbuehl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Mariangela Zamburlini
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
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30
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Alongi F, Nicosia L, Figlia V, Giaj-Levra N, Cuccia F, Mazzola R, Ricchetti F, Rigo M, Vitale C, De Simone A, Naccarato S, Sicignano G, Gurrera D, Corradini S, Ruggeri R. Long-term disease outcome and volume-based decision strategy in a large cohort of multiple brain metastases treated with a mono-isocentric linac-based Stereotactic Radiosurgery technique. Clin Transl Oncol 2021; 23:1561-1570. [PMID: 33570720 DOI: 10.1007/s12094-020-02550-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Radiosurgery (SRS) is an effective treatment option for brain metastases (BMs). Long-term results of the first worldwide experience with a mono-isocentric, non-coplanar, linac-based stereotactic technique in the treatment of multiple BMs are reported. METHODS patients with multiple BMs, life expectancy > 3 months, and good performance status (≤ 2) were treated with simultaneous SRS with volumetric modulated arc technique. Data were retrospectively evaluated. RESULTS 172 patients accounting for 1079 BMs were treated at our institution from 2017 to 2020. The median number of treated metastases was 4 (range 2-22). Primary tumor histology was: lung (44.8%), breast (32%), and melanoma (9.4%). The 2-year LPFS was 71.6%, respectively. A biological effective dose (BED) ≥ 51.3 Gy10 correlated with higher local control. Uncontrolled systemic disease and melanoma histology were independent prognostic factors correlated with decreased iPFS. Patients with > 10 BMs had a trend towards shorter iPFS (p = 0.055). 31 patients received multiple SRS courses (2-7) in case of intracranial progression. The median iOS was 22.4 months. Brainstem metastases and total PTV > 7.1 cc correlated with shorter iOS. The 1- and 2-year WBRT-free survival was 83.2% and 61.1%, respectively. CONCLUSION Long-term results in a large patient population treated with a mono-isocentric, dedicated technique demonstrated its effectiveness and safety also in the case of multiple courses. The shortened treatment time and the possibility to safely spare healthy brain tissue allows the safe treatment of patients with a large number of metastases and to deliver multiple courses of SRS. In selected cases, the administration of WBRT can be delayed.
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Affiliation(s)
- F Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
| | - L Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - V Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - N Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - F Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - R Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - F Ricchetti
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - M Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - C Vitale
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - A De Simone
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - S Naccarato
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - G Sicignano
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - D Gurrera
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - S Corradini
- Radiation Oncology Department, University Hospital, LMU Munich, Munich, Germany
| | - R Ruggeri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
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Bossart E, Mellon EA, Monterroso I, Elsayyad N, Diwanji T, Samuels S, Dogan N. Assessment of single isocenter linear accelerator radiosurgery for metastases and base of skull lesions. Phys Med 2020; 81:1-8. [PMID: 33278764 DOI: 10.1016/j.ejmp.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/22/2020] [Accepted: 11/07/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Newer technology for stereotactic radiosurgery (SRS) should be assessed for different multi-leaf collimators (MLC). OBJECTIVE Assess plan quality of an automated, frameless, linear accelerator based (linac) planning and delivery system (HyperArc) for SRS using both standard MLC (SMLC) and high definition MLC (HDMLC) compared to a cobalt-60 based SRS system (Gamma Knife, GK). METHODS We re-planned twenty GK Perfexion-treated SRS patients (27 lesions) for HyperArc using SMLC and HDMLC. We assessed plan quality using the following metrics: gradient index (GI), Paddick and RTOG conformity indices (CIPaddick, CIRTOG), volume receiving half of prescription isodose (PIVhalf) and maximum dose to 0.03 cc for brainstem, optic chiasm and optic nerves, and V12Gy for brain-GTV. RESULTS Linac plans had better conformity with HDMLC being most conformal. GK exhibited better GI. PIVhalf demonstrated no statistically significant difference between HDMLC and GK, and SMLC was nominally worse than GK. Mean PIVhalf was generally 0.85 cc larger for SMLC than HDMLC. For TV > 1.0 cc, the relative differences in CIRTOG, GI, and PIVhalf for SMLC vs. HDMLC were less than 21%. For TV less than < 1.0 cc, there were more obvious relative differences for SMLC vs. HDMLC in CIRTOG (mean 146%, max 700%), GI (mean 49%, max 162%), and PIVhalf (mean 77%, max 522%). Organ at risk doses were met in all plans. CONCLUSIONS New linac-based plans positively compare to GK plans overall. HDMLC should be strongly considered for treatment of lesions < 1.0 cc given the significant improvements in conformity and PIVhalf over SMLC.
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Affiliation(s)
- Elizabeth Bossart
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irene Monterroso
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nagy Elsayyad
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stuart Samuels
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Parikh NR, Kundu P, Levin-Epstein R, Chang EM, Agazaryan N, Hegde JV, Steinberg ML, Tenn SE, Kaprealian TB. Time-Driven Activity-Based Costing Comparison of Stereotactic Radiosurgery to Multiple Brain Lesions Using Single-Isocenter Versus Multiple-Isocenter Technique. Int J Radiat Oncol Biol Phys 2020; 108:999-1007. [PMID: 32603774 DOI: 10.1016/j.ijrobp.2020.06.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/30/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) historically has been used to treat multiple brain lesions using a multiple-isocenter technique-frequently associated with significant complexity in treatment planning and long treatment times. Recently, given innovations in planning algorithms, patients with multiple brain lesions may now be treated with a single-isocenter technique using fewer total arcs and less time spent during image guidance (though with stricter image guided radiation therapy tolerances). This study used time-driven activity-based costing to determine the difference in cost to a provider for delivering SRS to multiple brain lesions using single-isocenter versus multiple-isocenter techniques. METHODS AND MATERIALS Process maps, consisting of discrete steps, were created for each phase of the SRS care cycle and were based on interviews with department personnel. Actual treatment times (including image guidance) were extracted from treatment record and verify software. Additional sources of data to determine costs included salary/benefit data of personnel and average list price/maintenance costs for equipment. RESULTS Data were collected for 22 patients who underwent single-isocenter SRS (mean lesions treated, 5.2; mean treatment time, 30.2 minutes) and 51 patients who underwent multiple-isocenter SRS (mean lesions treated, 4.4; mean treatment time, 75.2 minutes). Treatment time for multiple-isocenter SRS varied substantially with increasing number of lesions (11.8 minutes/lesion; P < .001), but to a much lesser degree in single-isocenter SRS (1.8 minutes/lesion; P = .029). The resulting cost savings from single-isocenter SRS based on number of lesions treated ranged from $296 to $3878 for 2 to 10 lesions treated. The 2-mm planning treatment volume margin used with single-isocenter SRS resulted in a mean 43% increase of total volume treated compared with a 1-mm planning treatment volume expansion. CONCLUSIONS In a comparison of time-driven activity-based costing assessment of single-isocenter versus multiple-isocenter SRS for multiple brain lesions, single-isocenter SRS appears to save time and resources for as few as 2 lesions, with incremental benefits for additional lesions treated.
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Affiliation(s)
- Neil R Parikh
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Palak Kundu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Eric M Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - John V Hegde
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Stephen E Tenn
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Tania B Kaprealian
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
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Palmiero AN, Critchfield L, St Clair W, Randall M, Pokhrel D. Single-Isocenter Volumetric Modulated Arc Therapy (VMAT) Radiosurgery for Multiple Brain Metastases: Potential Loss of Target(s) Coverage Due to Isocenter Misalignment. Cureus 2020; 12:e11267. [PMID: 33274143 PMCID: PMC7707911 DOI: 10.7759/cureus.11267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/30/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose A single-isocenter volumetric modulated arc therapy (VMAT) treatment to multiple brain metastatic patients is an efficient stereotactic radiosurgery (SRS) option. However, the current clinical practice of single-isocenter SRS does not account for patient setup uncertainty, which degrades treatment delivery accuracy. This study quantifies the loss of target coverage and potential collateral dose to normal tissue due to clinically observable isocenter misalignment. Methods and materials Nine patients with 61 total tumors (2-16 tumors/patient) who underwent Gamma Knife® SRS were replanned in Eclipse™ using 10 megavoltages (MV) flattening-filter-free (FFF) bream (2400 MU/min), using a single-isocenter VMAT plan, similar to HyperArc™ VMAT plan. Isocenter was placed in the geometric center of the tumors. The prescription was 20 Gy to each tumor. Average gross tumor volume (GTV) and planning target volume (PTV) were 1.1 cc (0.02-11.5 cc) and 1.9 cc (0.11-18.8 cc), respectively, derived from MRI images. The average isocenter to tumor distance was 5.5 cm (1.6-10.1 cm). Six-degrees of freedom (6DoF) random and systematic residual set up errors within [±2 mm, ±2o] were generated using an in-house script in Eclipse based on our pre-treatment daily cone-beam CT imaging shifts and recomputed for the simulated VMAT plan. Relative loss of target coverage as a function of tumor size and distance to isocenter were evaluated as well as collateral dose to organs-at risk (OAR). Results The average beam-on time was less than six minutes. However, loss of target coverage for clinically observable setup errors were, on average, 7.9% (up to 73.1%) for the GTV (p < 0.001) and 21.5% for the PTV (up to 93.7%; p < 0.001). The correlation was found for both random and systematic residual setup errors with tumor sizes; there was a greater loss of target coverage for small tumors. Due to isocenter misalignment, OAR doses fluctuated and potentially receive higher doses than the original plan. Conclusion A single-isocenter VMAT SRS treatment (similar to HyperArc™ VMAT) to multiple brain metastases was fast with < 6 min of beam-on time. However, due to small residual set up errors, single-isocenter VMAT, in its current use, is not an accurate SRS treatment modality for multiple brain metastases. Loss of target coverage was statistically significant, especially for smaller lesions, and may not be clinically acceptable if left uncorrected. Further investigation of correction strategies is underway.
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Affiliation(s)
| | | | | | - Marcus Randall
- Radiation Medicine, University of Kentucky, Lexington, USA
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Radiosurgery treatment planning using conformal arc informed volumetric modulated arc therapy. Med Dosim 2020; 46:3-12. [PMID: 32807612 DOI: 10.1016/j.meddos.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022]
Abstract
Linac based radiosurgery to multiple metastases is commonly planned with volumetric modulated arc therapy (VMAT) as it effectively achieves high conformality to complex target arrangements. However, as the number of targets increases, VMAT can struggle to block between targets, which can lead to highly modulated and/or nonconformal multi-leaf collimator (MLC) trajectories that unnecessarily irradiation of healthy tissue. In this study we introduce, describe, and evaluate a treatment planning technique called Conformal Arc Informed VMAT (CAVMAT), which aims to reduce the dose to healthy tissue while generating highly conformal treatment plans. CAVMAT is a hybrid technique which combines the conformal MLC trajectories of dynamic conformal arcs with the MLC modulation and versatility of inverse optimization. CAVMAT has 3 main steps. First, targets are assigned to subgroups to maximize MLC blocking between targets. Second, arc weights are optimized to achieve the desired target dose, while minimizing MU variation between arcs. Third, the optimized conformal arc plan serves as the starting point for limited inverse optimization to improve dose conformity to each target. Twenty multifocal VMAT cases were replanned with CAVMAT with 20Gy applied to each target. The total volume receiving 2.5Gy[cm3], 6Gy[cm3], 12Gy[cm3], and 16Gy[cm3], conformity index, treatment delivery time, and the total MU were used to compare the VMAT and CAVMAT plans. In addition, CAVMAT was compared to a broad range of planning strategies from various institutions (108 linear accelerator based plans, 14 plans using other modalities) for a 5-target case utilized in a recent plan challenge. For the linear accelerator-based plans, a plan complexity metric based on aperture opening area and perimeter, total monitor units (MU), and MU for a given aperture opening was utilized in the plan challenge scoring algorithm to compare the submitted plans to CAVMAT. After re-planning the 20 VMAT cases, CAVMAT reduced the average V2.5Gy[cm3] by 25.25 ± 19.23%, V6Gy[cm3] by 13.68 ± 18.97%, V12Gy[cm3] by 11.40 ± 19.44%, and V16Gy[cm3] by 6.38 ± 19.11%. CAVMAT improved conformity by 3.81 ± 7.57%, while maintaining comparable target dose. MU for the CAVMAT plans increased by 24.35 ± 24.66%, leading to an increased treatment time of 2 minutes. For the plan challenge case, CAVMAT was 1 of 12 linac based plans that met all plan challenge scoring criteria. Compared to the average submitted VMAT plan, CAVMAT increased the V10%Gy[%] of healthy tissue (Brain-PTV) by roughly 3.42%, but in doing so was able to reduce the V25%Gy[%] by roughly 3.73%, while also reducing V50%Gy[%], V75%Gy[%], and V100%Gy[%]. The CAVMAT technique successfully eliminated insufficient MLC blocking between targets prior to the inverse optimization, leading to less complex treatment plans and improved tissue sparing. Tissue sparing, improved conformity, and decreased plan complexity at the cost of slight increase in treatment delivery time indicates CAVMAT to be a promising method to treat brain metastases.
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Freislederer P, Kügele M, Öllers M, Swinnen A, Sauer TO, Bert C, Giantsoudi D, Corradini S, Batista V. Recent advanced in Surface Guided Radiation Therapy. Radiat Oncol 2020; 15:187. [PMID: 32736570 PMCID: PMC7393906 DOI: 10.1186/s13014-020-01629-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/21/2020] [Indexed: 01/27/2023] Open
Abstract
The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques.SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments.The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations.Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests.Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition).This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.
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Affiliation(s)
- P. Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M. Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M. Öllers
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - A. Swinnen
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - T.-O. Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - C. Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - D. Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - V. Batista
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
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Remick JS, Kowalski E, Khairnar R, Sun K, Morse E, Cherng HRR, Poirier Y, Lamichhane N, Becker SJ, Chen S, Patel AN, Kwok Y, Nichols E, Mohindra P, Woodworth GF, Regine WF, Mishra MV. A multi-center analysis of single-fraction versus hypofractionated stereotactic radiosurgery for the treatment of brain metastasis. Radiat Oncol 2020; 15:128. [PMID: 32466775 PMCID: PMC7257186 DOI: 10.1186/s13014-020-01522-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypofractionated-SRS (HF-SRS) may allow for improved local control and a reduced risk of radiation necrosis compared to single-fraction-SRS (SF-SRS). However, data comparing these two treatment approaches are limited. The purpose of this study was to compare clinical outcomes between SF-SRS versus HF-SRS across our multi-center academic network. Methods Patients treated with SF-SRS or HF-SRS for brain metastasis from 2013 to 2018 across 5 radiation oncology centers were retrospectively reviewed. SF-SRS dosing was standardized, whereas HF-SRS dosing regimens were variable. The co-primary endpoints of local control and radiation necrosis were estimated using the Kaplan Meier method. Multivariate analysis using Cox proportional hazards modeling was performed to evaluate the impact of select independent variables on the outcomes of interest. Propensity score adjustments were used to reduce the effects confounding variables. To assess dose response for HF-SRS, Biologic Effective Dose (BED) assuming an α/β of 10 (BED10) was used as a surrogate for total dose. Results One-hundred and fifty six patients with 335 brain metastasis treated with SF-SRS (n = 222 lesions) or HF-SRS (n = 113 lesions) were included. Prior whole brain radiation was given in 33% (n = 74) and 34% (n = 38) of lesions treated with SF-SRS and HF-SRS, respectively (p = 0.30). After a median follow up time of 12 months in each cohort, the adjusted 1-year rate of local control and incidence of radiation necrosis was 91% (95% CI 86–96%) and 85% (95% CI 75–95%) (p = 0.26) and 10% (95% CI 5–15%) and 7% (95% CI 0.1–14%) (p = 0.73) for SF-SRS and HF-SRS, respectively. For lesions > 2 cm, the adjusted 1 year local control was 97% (95% CI 84–100%) for SF-SRS and 64% (95% CI 43–85%) for HF-SRS (p = 0.06). On multivariate analysis, SRS fractionation was not associated with local control and only size ≤2 cm was associated with a decreased risk of developing radiation necrosis (HR 0.21; 95% CI 0.07–0.58, p < 0.01). For HF-SRS, 1 year local control was 100% for lesions treated with a BED10 ≥ 50 compared to 77% (95% CI 65–88%) for lesions that received a BED10 < 50 (p = 0.09). Conclusions In this comparison study of dose fractionation for the treatment of brain metastases, there was no difference in local control or radiation necrosis between HF-SRS and SF-SRS. For HF-SRS, a BED10 ≥ 50 may improve local control.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily Kowalski
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Morse
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshar N Patel
- Chesapeake Oncology Hematology Associates, Glen Bernie, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Nicosia L, Figlia V, Giaj-Levra N, Minniti G, Alongi F. Repeated stereotactic radiosurgery for the treatment of relapsed brain metastases: is it time to give up whole-brain radiotherapy? Oncoscience 2020; 7:19-20. [PMID: 32426417 PMCID: PMC7217138 DOI: 10.18632/oncoscience.500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023] Open
Affiliation(s)
- Luca Nicosia
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Vanessa Figlia
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Giuseppe Minniti
- Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy.,University of Brescia, Brescia, Italy
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Swinnen ACC, Öllers MC, Loon Ong C, Verhaegen F. The potential of an optical surface tracking system in non-coplanar single isocenter treatments of multiple brain metastases. J Appl Clin Med Phys 2020; 21:63-72. [PMID: 32237274 PMCID: PMC7324699 DOI: 10.1002/acm2.12866] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/23/2020] [Accepted: 02/24/2020] [Indexed: 12/25/2022] Open
Abstract
To evaluate the accuracy of a commercial optical surface tracking (OST) system and to demonstrate how it can be implemented to monitor patient positioning during non‐coplanar single isocenter stereotactic treatments of brain metastases. A 3‐camera OST system was used (Catalyst HD™, C‐RAD) on a TruebeamSTx with a 6DoF couch. The setup accuracy and agreement between the OST system, and CBCT and kV‐MV imaging at couch angles 0° and 270°, respectively, were examined. Film measurements at 3 depths in the Rando‐Alderson phantom were performed using a single isocenter non‐coplanar VMAT plan containing 4 brain lesions. Setup of the phantom was performed with CBCT at couch 0° and subsequently monitored by OST at other couch angles. Setup data for 7 volunteers were collected to evaluate the accuracy and reproducibility of the OST system at couch angles 0°, 45°, 90°, 315°, and 270°. These results were also correlated to the couch rotation offsets obtained by a Winston‐Lutz (WL) test. The Rando‐Alderson phantom, as well as volunteers, were fixated using open face masks (Orfit). For repeated tests with the Rando‐Alderson phantom, deviations between rotational and translational isocenter corrections for CBCT and OST systems are always within 0.2° (pitch, roll, yaw), and 0.1mm and 0.5mm (longitudinal, lateral, vertical) for couch positions 0° and 270°, respectively. Dose deviations between the film and TPS doses in the center of the 4 lesions were −1.2%, −0.1%, −0.0%, and −1.9%. Local gamma evaluation criteria of 2%/2 mm and 3%/1 mm yielded pass rates of 99.2%, 99.2%, 98.6%, 89.9% and 98.8%, 97.5%, 81.7%, 78.1% for the 4 lesions. Regarding the volunteers, the mean translational and rotational isocenter shift values were (0.24 ± 0.09) mm and (0.15 ± 0.07) degrees. Largest isocenter shifts were found for couch angles 45˚ and 90˚, confirmed by WL couch rotation offsets. Patient monitoring during non‐coplanar VMAT treatments of brain metastases is feasible with submillimeter accuracy.
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Affiliation(s)
| | | | - Chin Loon Ong
- Department of Radiation Oncology, HagaZiekenhuis, Den Haag, the Netherlands
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Zhang S, Yang R, Shi C, Li J, Zhuang H, Tian S, Wang J. Noncoplanar VMAT for Brain Metastases: A Plan Quality and Delivery Efficiency Comparison With Coplanar VMAT, IMRT, and CyberKnife. Technol Cancer Res Treat 2020; 18:1533033819871621. [PMID: 31451059 PMCID: PMC6710677 DOI: 10.1177/1533033819871621] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: To compare plan quality and delivery efficiency of noncoplanar volumetric modulated arc therapy with coplanar volumetric modulated arc therapy, intensity-modulated radiation therapy, and CyberKnife for multiple brain metastases. Methods: For 15 patients with multiple brain metastases, noncoplanar volumetric modulated arc therapy, coplanar volumetric modulated arc therapy, intensity-modulated radiation therapy, and CyberKnife plans with a prescription dose of 30 Gy in 3 fractions were generated. Noncoplanar volumetric modulated arc therapy and coplanar volumetric modulated arc therapy plans consisted of 4 noncoplanar arcs and 2 full coplanar arcs, respectively. Intensity-modulated radiation therapy plans consisted of 7 coplanar fields. CyberKnife plans used skull tracking to ensure accurate position. All plans were generated to cover 95% target volume with prescription dose. Gradient index, conformity index, normal brain tissue volume (V3Gy − V24Gy), monitor units, and beam on time were evaluated. Results: Gradient index was the lowest for CyberKnife (3.49 ± 0.65), followed by noncoplanar volumetric modulated arc therapy (4.21 ± 1.38), coplanar volumetric modulated arc therapy (4.87 ± 1.35), and intensity-modulated radiation therapy (5.36 ± 1.98). Conformity index was the largest for noncoplanar volumetric modulated arc therapy (0.87 ± 0.03), followed by coplanar volumetric modulated arc therapy (0.86 ± 0.04), CyberKnife (0.86 ± 0.07), and intensity-modulated radiation therapy (0.85 ± 0.05). Normal brain tissue volume at high-to-moderate dose spreads (V24Gy − V9Gy) was significantly reduced in noncoplanar volumetric modulated arc therapy over that of intensity-modulated radiation therapy and coplanar volumetric modulated arc therapy. Normal brain tissue volume for noncoplanar volumetric modulated arc therapy was comparable with noncoplanar volumetric modulated arc therapy at high-dose level (V24Gy − V15Gy) and larger than CyberKnife at moderate-to-low dose level (V12Gy − V3Gy). Monitor units was highest for CyberKnife (28 733.59 ± 7197.85), followed by intensity-modulated radiation therapy (4128.40 ± 1185.38), noncoplanar volumetric modulated arc therapy (3105.20 ± 371.23), and coplanar volumetric modulated arc therapy (2997.27 ± 446.84). Beam on time was longest for CyberKnife (30.25 ± 7.32 minutes), followed by intensity-modulated radiation therapy (2.95 ± 0.85 minutes), noncoplanar volumetric modulated arc therapy (2.61 ± 0.07 minutes), and coplanar volumetric modulated arc therapy (2.30 ± 0.23 minutes). Conclusion: For brain metastases far away from organs-at-risk, noncoplanar volumetric modulated arc therapy generated more rapid dose falloff and higher conformity compared to intensity-modulated radiation therapy and coplanar volumetric modulated arc therapy. Noncoplanar volumetric modulated arc therapy provided a comparable dose falloff with CyberKnife at high-dose level and a slower dose falloff than CyberKnife at moderate-to-low dose level. Noncoplanar volumetric modulated arc therapy plans had less monitor units and shorter beam on time than CyberKnife plans.
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Affiliation(s)
- Shuming Zhang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruijie Yang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Chengyu Shi
- 2 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jiaqi Li
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Hongqing Zhuang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Suqing Tian
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Junjie Wang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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Wang C, Zhu X, Hong JC, Zheng D. Artificial Intelligence in Radiotherapy Treatment Planning: Present and Future. Technol Cancer Res Treat 2020; 18:1533033819873922. [PMID: 31495281 PMCID: PMC6732844 DOI: 10.1177/1533033819873922] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Treatment planning is an essential step of the radiotherapy workflow. It has become more sophisticated over the past couple of decades with the help of computer science, enabling planners to design highly complex radiotherapy plans to minimize the normal tissue damage while persevering sufficient tumor control. As a result, treatment planning has become more labor intensive, requiring hours or even days of planner effort to optimize an individual patient case in a trial-and-error fashion. More recently, artificial intelligence has been utilized to automate and improve various aspects of medical science. For radiotherapy treatment planning, many algorithms have been developed to better support planners. These algorithms focus on automating the planning process and/or optimizing dosimetric trade-offs, and they have already made great impact on improving treatment planning efficiency and plan quality consistency. In this review, the smart planning tools in current clinical use are summarized in 3 main categories: automated rule implementation and reasoning, modeling of prior knowledge in clinical practice, and multicriteria optimization. Novel artificial intelligence-based treatment planning applications, such as deep learning-based algorithms and emerging research directions, are also reviewed. Finally, the challenges of artificial intelligence-based treatment planning are discussed for future works.
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Affiliation(s)
- Chunhao Wang
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Xiaofeng Zhu
- 2 Department of Radiation Oncology, Georgetown University Hospital, Rockville, MD, USA
| | - Julian C Hong
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,3 Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Dandan Zheng
- 4 Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Volume de-escalation in radiation therapy: state of the art and new perspectives. J Cancer Res Clin Oncol 2020; 146:909-924. [PMID: 32072318 DOI: 10.1007/s00432-020-03152-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT. METHOD The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic. RESULTS In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases. CONCLUSION Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.
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Nicosia L, Figlia V, Mazzola R, Napoli G, Giaj-Levra N, Ricchetti F, Rigo M, Lunardi G, Tomasini D, Bonù ML, Corradini S, Ruggieri R, Alongi F. Repeated stereotactic radiosurgery (SRS) using a non-coplanar mono-isocenter (HyperArc™) technique versus upfront whole-brain radiotherapy (WBRT): a matched-pair analysis. Clin Exp Metastasis 2020; 37:77-83. [PMID: 31691873 DOI: 10.1007/s10585-019-10004-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022]
Abstract
Stereotactic radiosurgery (SRS) is an effective treatment option for multiple brain metastases (BMs). Modern mono-isocentric techniques allow the delivery of multiple stereotactic courses, in the event of intracranial failure. Nevertheless, limited data on effectiveness and toxicity have been reported in comparison to WBRT. Aim of this retrospective matched-pair analysis was to compare patients affected by limited BMs treated with multiple SRS courses using a mono-isocentric, non-coplanar technique (HyperArc™, Varian Medical System) to upfront WBRT. One hundred and two patients accounting for 677 BMs were treated with HyperArc™. In case of further intracranial progression, 44 treatment courses of 201 metastases in 19 patients, were treated by subsequent HyperArc™ courses. This population was matched with 38 patients treated with WBRT. The median BMs number was 4 (range 2-10) for HyperArc™ and 5 (range 2-10) for WBRT. Overall survival (OS) and toxicity were evaluated. The median follow-up was 9 months (range 3-40 months). The median OS was not reached (range 5-22 months) for HyperArc™ patients and 8 months (range 3-40 months) for WBRT patients, while the 1-year OS was 77% and 34.6% for HyperArc™ and WBRT, respectively (p = 0.001; HR 4.77, 95% CI 1.62-14.00). There was one case of radionecrosis. HyperArc™ is an effective and safe technique for the treatment of multiple BMs. In selected cases of intracranial oligorecurrence, further subsequent courses can be safely delivered with the same technical approach. Moreover, in patients with a limited number of BMs, SRS showed an improved survival outcome when compared to WBRT.
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Affiliation(s)
- Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Vanessa Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Giuseppe Napoli
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Francesco Ricchetti
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Gianluigi Lunardi
- Medical Analysis Laboratory, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Negrar, Italy
| | - Davide Tomasini
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
| | - Marco L Bonù
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
| | - Stefanie Corradini
- Radiation Oncology Department, University Hospital, LMU Munich, Munich, Germany
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
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Khattab MH, Sherry AD, Cmelak AJ, Attia A. In Reply: A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma. Neurosurgery 2019; 85:E1127-E1129. [PMID: 31529045 DOI: 10.1093/neuros/nyz373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | | | - Anthony J Cmelak
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee.,Department of Neurological Surgery Vanderbilt University Medical Center Nashville, Tennessee
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Feasibility and preliminary clinical results of linac-based Stereotactic Body Radiotherapy for spinal metastases using a dedicated contouring and planning system. Radiat Oncol 2019; 14:184. [PMID: 31655620 PMCID: PMC6815388 DOI: 10.1186/s13014-019-1379-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/10/2019] [Indexed: 12/25/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are well established local treatment approaches in several cancer settings. Although SBRT is still under investigation for spinal metastases, promising results in terms of a high effectiveness and optimal tolerability have been recently published on this topic. For spinal SBRT, one of the most relevant issues is represented by the inter-observer variability in target definition. Recently, several technological innovations, including specific tools such as multimodality-imaging (computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET-CT), automated volumes contouring and planning, could allow clinicians to minimize the uncertainties related to spinal SBRT workflow. Aim of this study is to report the feasibility of the clinical application of a dedicated software (Element®, Brainlab™ Germany) for spinal metastases SBRT. Material and method The patient selection criteria for SBRT in spinal metastases were the following: age > 18 years, diagnosis of spinal metastases (n ≤ 3), life expectancy > 3 months, controlled primary tumor or synchronous diagnosis and Spinal Instability Neoplastic Score (SINS) ≤ 12 points. All radiation target volumes were defined and planned with the support of the dedicated software Elements® (Brainlab™ Germany). Different dose prescription have been used: 12 Gy in single fraction, 12 Gy, 18 Gy, 21 Gy and 24 Gy in 3 fractions. Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. SPSS version 20 was used for statistical analysis. Results From April 2018 to April 2019, 54 spinal metastases in 32 recruited patients were treated with Linac-based SBRT. With a median follow-up of 6 months (range 3–12), local control rates at 6 months and 9 months were 86 and 86%, respectively. No adverse events ≥3 grade were observed. Conclusions This preliminary experience shows that with respect to acute toxicity and early clinical response, linac-based using Elements® Spine SRS is a feasible and effective approach.
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Hartgerink D, Swinnen A, Roberge D, Nichol A, Zygmanski P, Yin FF, Deblois F, Hurkmans C, Ong CL, Bruynzeel A, Aizer A, Fiveash J, Kirckpatrick J, Guckenberger M, Andratschke N, de Ruysscher D, Popple R, Zindler J. LINAC based stereotactic radiosurgery for multiple brain metastases: guidance for clinical implementation. Acta Oncol 2019; 58:1275-1282. [PMID: 31257960 DOI: 10.1080/0284186x.2019.1633016] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Stereotactic radiosurgery (SRS) is a promising treatment option for patients with multiple brain metastases (BM). Recent technical advances have made LINAC based SRS a patient friendly technique, allowing for accurate patient positioning and a short treatment time. Since SRS is increasingly being used for patients with multiple BM, it remains essential that SRS be performed with the highest achievable quality in order to prevent unnecessary complications such as radionecrosis. The purpose of this article is to provide guidance for high-quality LINAC based SRS for patients with BM, with a focus on single isocenter non-coplanar volumetric modulated arc therapy (VMAT). Methods: The article is based on a consensus statement by the study coordinators and medical physicists of four trials which investigated whether patients with multiple BM are better palliated with SRS instead of whole brain radiotherapy (WBRT): A European trial (NCT02353000), two American trials and a Canadian CCTG lead intergroup trial (CE.7). This manuscript summarizes the quality assurance measures concerning imaging, planning and delivery. Results: To optimize the treatment, the interval between the planning-MRI (gadolinium contrast-enhanced, maximum slice thickness of 1.5 mm) and treatment should be kept as short as possible (< two weeks). The BM are contoured based on the planning-MRI, fused with the planning-CT. GTV-PTV margins are minimized or even avoided when possible. To maximize efficiency, the preferable technique is single isocenter (non-)coplanar VMAT, which delivers high doses to the target with maximal sparing of the organs at risk. The use of flattening filter free photon beams ensures a lower peripheral dose and shortens the treatment time. To bench mark SRS treatment plan quality, it is advisable to compare treatment plans between hospitals. Conclusion: This paper provides guidance for quality assurance and optimization of treatment delivery for LINAC-based radiosurgery for patients with multiple BM.
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Affiliation(s)
- Dianne Hartgerink
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ans Swinnen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - David Roberge
- Department of Radiation Oncology, CHUM, Montreal, QC, Canada
| | - Alan Nichol
- Department of Radiation Oncology, CHUM, Montreal, QC, Canada
| | - Piotr Zygmanski
- Brigham and Women’s Hospital, Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Chin Loon Ong
- Department of Radiation Oncology, HagaZiekenhuis, Den Haag, The Netherlands
| | - Anna Bruynzeel
- Department of Radiotherapy, Cancer Center Amsterdam, VU University medical center, Amsterdam, The Netherlands
| | - Ayal Aizer
- Brigham and Women’s Hospital, Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John Kirckpatrick
- Brigham and Women’s Hospital, Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zürich, Zürich, Switzerland
| | - Dirk de Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Richard Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jaap Zindler
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Radiation Oncology, Erasmus MC, Rotterdam, The Netherlands
- Holland Proton Therapy Center, Delft, The Netherlands
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Hofmaier J, Bodensohn R, Garny S, Hadi I, Fleischmann DF, Eder M, Dinc Y, Reiner M, Corradini S, Parodi K, Belka C, Niyazi M. Single isocenter stereotactic radiosurgery for patients with multiple brain metastases: dosimetric comparison of VMAT and a dedicated DCAT planning tool. Radiat Oncol 2019; 14:103. [PMID: 31186023 PMCID: PMC6560766 DOI: 10.1186/s13014-019-1315-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/31/2019] [Indexed: 12/02/2022] Open
Abstract
Background In this dosimetric study, a dedicated planning tool for single isocenter stereotactic radiosurgery for multiple brain metastases using dynamic conformal arc therapy (DCAT) was compared to standard volumetric modulated arc therapy (VMAT). Methods Twenty patients with a total of 66 lesions who were treated with the DCAT tool were included in this study. Single fraction doses of 15–20 Gy were prescribed to each lesion. Patients were re-planned using non-coplanar VMAT. Number of monitor units as well as V4Gy, V5Gy and V8Gy were extracted for every plan. Using a density-based clustering algorithm, V10Gy and V12Gy and the volume receiving half of the prescribed dose were extracted for every lesion. Gradient indices and conformity indices were calculated. The correlation of the target sphericity, a measure of how closely the shape of the target PTV resembles a sphere, to the difference in V10Gy and V12Gy between the two techniques was assessed using Spearman’s correlation coefficient. Results The automated DCAT planning tool performed significantly better in terms of all investigated metrics (p < 0.05), in particular healthy brain sparing (V10Gy: median 3.2 cm3 vs. 4.9 cm3), gradient indices (median 5.99 vs. 7.17) and number of monitor units (median 4569 vs. 5840 MU). Differences in conformity indices were minimal (median 0.75 vs. 0.73) but still significant (p < 0.05). A moderate correlation between PTV sphericity and the difference of V10Gy and V12Gy between the two techniques was found (Spearman’s rho = 0.27 and 0.30 for V10Gy and V12Gy, respectively, p < 0.05). Conclusions The dedicated DCAT planning tool performed better than VMAT in terms of healthy brain sparing and treatment efficiency, in particular for nearly spherical lesions. In contrast, VMAT can be superior in cases with irregularly shaped lesions.
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Affiliation(s)
- Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany.
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Daniel F Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany.,German Cancer Consortium (DKTK), Munich, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Eder
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Yavuz Dinc
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany.,German Cancer Consortium (DKTK), Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, DE, Germany.,German Cancer Consortium (DKTK), Munich, Germany
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Vergalasova I, Liu H, Alonso-Basanta M, Dong L, Li J, Nie K, Shi W, Teo BKK, Yu Y, Yue NJ, Zou W, Li T. Multi-Institutional Dosimetric Evaluation of Modern Day Stereotactic Radiosurgery (SRS) Treatment Options for Multiple Brain Metastases. Front Oncol 2019; 9:483. [PMID: 31231614 PMCID: PMC6568036 DOI: 10.3389/fonc.2019.00483] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/21/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose/Objectives: There are several popular treatment options currently available for stereotactic radiosurgery (SRS) of multiple brain metastases: 60Co sources and cone collimators around a spherical geometry (GammaKnife), multi-aperture dynamic conformal arcs on a linac (BrainLab Elements™ v1.5), and volumetric arc therapy on a linac (VMAT) calculated with either the conventional optimizer or with the Varian HyperArc™ solution. This study aimed to dosimetrically compare and evaluate the differences among these treatment options in terms of dose conformity to the tumor as well as dose sparing to the surrounding normal tissues. Methods and Materials: Sixteen patients and a total of 112 metastases were analyzed. Five plans were generated per patient: GammaKnife, Elements, HyperArc-VMAT, and two Manual-VMAT plans to evaluate different treatment planning styles. Manual-VMAT plans were generated by different institutions according to their own clinical planning standards. The following dosimetric parameters were extracted: RTOG and Paddick conformity indices, gradient index, total volume of brain receiving 12Gy, 6Gy, and 3Gy, and maximum doses to surrounding organs. The Wilcoxon signed rank test was applied to evaluate statistically significant differences (p < 0.05). Results: For targets ≤ 1 cm, GammaKnife, HyperArc-VMAT and both Manual-VMAT plans achieved comparable conformity indices, all superior to Elements. However, GammaKnife resulted in the lowest gradient indices at these target sizes. HyperArc-VMAT performed similarly to GammaKnife for V12Gy parameters. For targets ≥ 1 cm, HyperArc-VMAT and Manual-VMAT plans resulted in superior conformity vs. GammaKnife and Elements. All SRS plans achieved clinically acceptable organs-at-risk dose constraints. Beam-on times were significantly longer for GammaKnife. Manual-VMATA and Elements resulted in shorter delivery times relative to Manual-VMATB and HyperArc-VMAT. Conclusion: The study revealed that Manual-VMAT and HyperArc-VMAT are capable of achieving similar low dose brain spillage and conformity as GammaKnife, while significantly minimizing beam-on time. For targets smaller than 1 cm in diameter, GammaKnife still resulted in superior gradient indices. The quality of the two sets of Manual-VMAT plans varied greatly based on planner and optimization constraint settings, whereas HyperArc-VMAT performed dosimetrically superior to the two Manual-VMAT plans.
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Affiliation(s)
- Irina Vergalasova
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Haisong Liu
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Jun Li
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Ke Nie
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Yan Yu
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Ning Jeff Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Taoran Li
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
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Mazzola R, Corradini S, Gregucci F, Figlia V, Fiorentino A, Alongi F. Role of Radiosurgery/Stereotactic Radiotherapy in Oligometastatic Disease: Brain Oligometastases. Front Oncol 2019; 9:206. [PMID: 31019891 PMCID: PMC6458247 DOI: 10.3389/fonc.2019.00206] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/11/2019] [Indexed: 12/25/2022] Open
Abstract
During the natural history of oncologic diseases, approximately 20-40% of patients affected by cancer will develop brain metastases. Non-small lung cancer, breast cancer, and melanoma are the primaries that are most likely to metastasize into the brain. To date, the role of Radiosurgery/Stereotactic Radiotherapy (SRS/SRT) without Whole brain irradiation (WBRT) is a well-recognized treatment option for patients with limited intracranial disease (1-4 BMs) and a life-expectancy of more than 3-6 months. In the current review, we focused on randomized studies that evaluate the potential benefit of radiosurgery/stereotactic radiotherapy for brain oligometastases. To date, no difference in overall survival has been observed between SRS/SRT alone compared to WBRT plus SRS. Notably, SRS alone achieved higher local control rates compared to WBRT. A possible strength of SRS adoption is the potential decreased neurocognitive impairment.
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Affiliation(s)
- Rosario Mazzola
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Stefanie Corradini
- Radiation Oncology Department, LMU Munich University Hospital, Munich, Germany
| | - Fabiana Gregucci
- Radiation Oncology Department, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Italy
| | - Vanessa Figlia
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Italy
| | - Filippo Alongi
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
- Radiation Oncology Department, University of Brescia, Brescia, Italy
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Linac-based radiosurgery or fractionated stereotactic radiotherapy with flattening filter-free volumetric modulated arc therapy in elderly patients : A mono-institutional experience on 110 brain metastases. Strahlenther Onkol 2018; 195:218-225. [PMID: 30478669 DOI: 10.1007/s00066-018-1405-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/15/2018] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to analyze the feasibility and clinical results of linear accelerator (linac-)based stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SFRT) with flattening filter-free (FFF) volumetric modulated arc therapy (VMAT) in elderly patients affected by brain metastases (BMs). PATIENTS AND METHODS Patients selected for the present analysis were ≥65 years old with a life expectancy of >3 months, a controlled or synchronous primary tumor, and <10 BMs with a diameter <3 cm. All patients were treated with FFF linac-based SRS/SFRT. The prescribed total dose (15-30 Gy/1-5 fractions) was based on BM size and proximity to organs at risk (OAR). Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. MedCalc v18.2 (MedCalc Software, Ostend, Belgium) was used for statistical analysis. RESULTS From April 2014 to December 2017, 40 elderly patients with 110 BMs were treated by FFF linac-based SRS/SFRT. With a median follow-up of 28 months (range 6-50 months), median and 1‑year overall survival were 9 months and 39%, respectively; median intracranial progression-free survival was 6 months. At the time of the analysis, local control was reported in 109/110 BMs (99.1%): 12 BMs had a complete response; 51 a partial response; 46 showed stable disease. One BM (0.9%) progressed after 2 months. BM volume (<1 cc) and higher SRS/SFRT dose correlated to treatment response (p = 0.01 and p = 0.0017, respectively). No adverse events higher than grade 2 were observed. CONCLUSION The present findings highlight the feasibility, safety, and effectiveness of FFF linac-based SRS/SFRT in elderly patients with BMs.
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