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Beckert R, Schiff JP, Morris E, Samson P, Kim H, Laugeman E. The impact of an Advanced Practice Radiation Therapist contouring for a CBCT-based adaptive radiotherapy program. Tech Innov Patient Support Radiat Oncol 2024; 30:100242. [PMID: 38495830 PMCID: PMC10940769 DOI: 10.1016/j.tipsro.2024.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/19/2024] Open
Abstract
We successfully implemented an APRT specializing in CBCT-guided online adaptive contouring. These data show statistical improvements in contouring time with APRT-led vs non-APRT led ART contouring, suggesting that an APRT specifically trained to manage the ART process may reduce physician workload and patient treatment time.
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Affiliation(s)
- Robbie Beckert
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
| | - Joshua P Schiff
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
| | - Eric Morris
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
| | - Pamela Samson
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
| | - Hyun Kim
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
| | - Eric Laugeman
- Department of Radiation Oncology Washington University School of Medicine in St. Louis, 4921 Parkview Place, MSC: 35-LL-8224, St. Louis, MO 63110, United States
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Pogue JA, Harms J, Cardenas CE, Ray X, Viscariello N, Popple RA, Stanley DN, Boggs DH. Unlocking the adaptive advantage: correlation and machine learning classification to identify optimal online adaptive stereotactic partial breast candidates. Phys Med Biol 2024; 69:115050. [PMID: 38729212 DOI: 10.1088/1361-6560/ad4a1c] [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: 01/08/2024] [Accepted: 05/10/2024] [Indexed: 05/12/2024]
Abstract
Objective.Online adaptive radiotherapy (OART) is a promising technique for delivering stereotactic accelerated partial breast irradiation (APBI), as lumpectomy cavities vary in location and size between simulation and treatment. However, OART is resource-intensive, increasing planning and treatment times and decreasing machine throughput compared to the standard of care (SOC). Thus, it is pertinent to identify high-yield OART candidates to best allocate resources.Approach.Reference plans (plans based on simulation anatomy), SOC plans (reference plans recalculated onto daily anatomy), and daily adaptive plans were analyzed for 31 sequential APBI targets, resulting in the analysis of 333 treatment plans. Spearman correlations between 22 reference plan metrics and 10 adaptive benefits, defined as the difference between mean SOC and delivered metrics, were analyzed to select a univariate predictor of OART benefit. A multivariate logistic regression model was then trained to stratify high- and low-benefit candidates.Main results.Adaptively delivered plans showed dosimetric benefit as compared to SOC plans for most plan metrics, although the degree of adaptive benefit varied per patient. The univariate model showed high likelihood for dosimetric adaptive benefit when the reference plan ipsilateral breast V15Gy exceeds 23.5%. Recursive feature elimination identified 5 metrics that predict high-dosimetric-benefit adaptive patients. Using leave-one-out cross validation, the univariate and multivariate models classified targets with 74.2% and 83.9% accuracy, resulting in improvement in per-fraction adaptive benefit between targets identified as high- and low-yield for 7/10 and 8/10 plan metrics, respectively.Significance.This retrospective, exploratory study demonstrated that dosimetric benefit can be predicted using only ipsilateral breast V15Gy on the reference treatment plan, allowing for a simple, interpretable model. Using multivariate logistic regression for adaptive benefit prediction led to increased accuracy at the cost of a more complicated model. This work presents a methodology for clinics wishing to triage OART resource allocation.
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Affiliation(s)
- Joel A Pogue
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Carlos E Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Xenia Ray
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA, United States of America
| | - Natalie Viscariello
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Dennis N Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - D Hunter Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
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Bryant JM, Cruz-Chamorro RJ, Gan A, Liveringhouse C, Weygand J, Nguyen A, Keit E, Sandoval ML, Sim AJ, Perez BA, Dilling TJ, Redler G, Andreozzi J, Nardella L, Naghavi AO, Feygelman V, Latifi K, Rosenberg SA. Structure-specific rigid dose accumulation dosimetric analysis of ablative stereotactic MRI-guided adaptive radiation therapy in ultracentral lung lesions. COMMUNICATIONS MEDICINE 2024; 4:96. [PMID: 38778215 PMCID: PMC11111790 DOI: 10.1038/s43856-024-00526-7] [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: 09/05/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Definitive local therapy with stereotactic ablative radiation therapy (SABR) for ultracentral lung lesions is associated with a high risk of toxicity, including treatment related death. Stereotactic MR-guided adaptive radiation therapy (SMART) can overcome many of the challenges associated with SABR treatment of ultracentral lesions. METHODS We retrospectively identified 14 consecutive patients who received SMART to ultracentral lung lesions from 10/2019 to 01/2021. Patients had a median distance from the proximal bronchial tree (PBT) of 0.38 cm. Tumors were most often lung primary (64.3%) and HILUS group A (85.7%). A structure-specific rigid registration approach was used for cumulative dose analysis. Kaplan-Meier log-rank analysis was used for clinical outcome data and the Wilcoxon Signed Rank test was used for dosimetric data. RESULTS Here we show that SMART dosimetric improvements in favor of delivered plans over predicted non-adapted plans for PBT, with improvements in proximal bronchial tree DMax of 5.7 Gy (p = 0.002) and gross tumor 100% prescription coverage of 7.3% (p = 0.002). The mean estimated follow-up is 17.2 months and 2-year local control and local failure free survival rates are 92.9% and 85.7%, respectively. There are no grade ≥ 3 toxicities. CONCLUSIONS SMART has dosimetric advantages and excellent clinical outcomes for ultracentral lung tumors. Daily plan adaptation reliably improves target coverage while simultaneously reducing doses to the proximal airways. These results further characterize the therapeutic window improvements for SMART. Structure-specific rigid dose accumulation dosimetric analysis provides insights that elucidate the dosimetric advantages of SMART more so than per fractional analysis alone.
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Affiliation(s)
- J M Bryant
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
| | - Ruben J Cruz-Chamorro
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alberic Gan
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Casey Liveringhouse
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Joseph Weygand
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ann Nguyen
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Emily Keit
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Maria L Sandoval
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Austin J Sim
- Department of Radiation Oncology; James Cancer Hospital, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Bradford A Perez
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Thomas J Dilling
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Gage Redler
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jacqueline Andreozzi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Louis Nardella
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Arash O Naghavi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Vladimir Feygelman
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Stephen A Rosenberg
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Hering S, Nieto A, Marschner S, Hofmaier J, Schmidt-Hegemann NS, da Silva Mendes V, Landry G, Niyazi M, Manapov F, Belka C, Corradini S, Eze C. The role of online MR-guided multi-fraction stereotactic ablative radiotherapy in lung tumours. Clin Transl Radiat Oncol 2024; 45:100736. [PMID: 38433949 PMCID: PMC10909605 DOI: 10.1016/j.ctro.2024.100736] [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: 09/01/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 03/05/2024] Open
Abstract
Background The aim of this prospective observational study was to evaluate the dosimetry benefits, changes in pulmonary function, and clinical outcome of online adaptive MR-guided SBRT. Methods From 11/2020-07/2022, 45 consecutive patients with 59 lesions underwent multi-fraction SBRT (3-8 fractions) at our institution. Patients were eligible if they had biopsy-proven NSCLC or lung cancer/metastases diagnosed via clinical imaging. Endpoints were local control (LC) and overall survival (OS). We evaluated PTV/GTV dose coverage, organs at risk exposure, and changes in pulmonary function (PF). Acute toxicity was classified per the National Cancer Institute-Common Terminology Criteria for Adverse Events version 5.0. Results The median PTV was 14.4 cm3 (range: 3.4 - 96.5 cm3). In total 195/215 (91%) plans were reoptimised. In the reoptimised vs. predicted plans, PTV coverage by the prescribed dose increased in 94.6% of all fractions with a median increase in PTV VPD of 5.6% (range: -1.8 - 44.6%, p < 0.001), increasing the number of fractions with PTV VPD ≥ 95% from 33% to 98%. The PTV D95% and D98% (BED10) increased in 93% and 95% of all fractions with a median increase of 7.7% (p < 0.001) and 10.6% (p < 0.001). The PTV D95% (BED10) increased by a mean of 9.6 Gy (SD: 10.3 Gy, p < 0.001). At a median follow-up of 21.4 months (95% CI: 12.3-27.0 months), 1- and 2-year LC rates were 94.8% (95% CI: 87.6 - 100.0%) and 91.1% (95% CI: 81.3 - 100%); 1- and 2-year OS rates were 85.6% (95% CI: 75.0 - 96.3%) and 67.1 % (95% CI: 50.3 - 83.8%). One grade ≥ 3 toxicity and no significant reduction in short-term PF parameters were recorded. Conclusions Online adaptive MR-guided SBRT is an effective, safe and generally well tolerated treatment option for lung tumours achieving encouraging local control rates with significantly improved target volume coverage.
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Affiliation(s)
- Svenja Hering
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Alexander Nieto
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Marschner
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | | | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich; and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Chukwuka Eze
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
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Pogue JA, Cardenas CE, Stanley DN, Stanley C, Hotsinpiller W, Veale C, Soike MH, Popple RA, Boggs DH, Harms J. Improved Dosimetry and Plan Quality for Accelerated Partial Breast Irradiation Using Online Adaptive Radiation Therapy: A Single Institutional Study. Adv Radiat Oncol 2024; 9:101414. [PMID: 38292886 PMCID: PMC10823088 DOI: 10.1016/j.adro.2023.101414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/23/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) is an attractive treatment modality for eligible patients as it has been shown to result in similar local control and improved cosmetic outcomes compared with whole breast radiation therapy. The use of online adaptive radiation therapy (OART) for APBI is promising as it allows for a reduction of planning target volume margins because breast motion and lumpectomy cavity volume changes are accounted for in daily imaging. Here we present a retrospective, single-institution evaluation on the adequacy of kV-cone beam computed tomography (CBCT) OART for APBI treatments. Methods and Materials Nineteen patients (21 treatment sites) were treated to 30 Gy in 5 fractions between January of 2022 and May of 2023. Time between simulation and treatment, change in gross tumor (ie, lumpectomy cavity) volume, and differences in dose volume histogram metrics with adaption were analyzed. The Wilcoxon paired, nonparametric test was used to test for dose volume histogram metric differences between the scheduled plans (initial plans recalculated on daily CBCT anatomy) and delivered plans, either the scheduled or adapted plan, which was reoptimized using daily anatomy. Results Median (interquartile range) time from simulation to first treatment was 26 days (21-32 days). During this same time, median gross tumor volume reduction was 16.0% (7.3%-23.9%) relative to simulation volume. Adaptive treatments took 31.3 minutes (27.4-36.6 minutes) from start of CBCT to treatment session end. At treatment, the adaptive plan was selected for 86% (89/103) of evaluable fractions. In evaluating plan quality, 78% of delivered plans met all target, organs at risk, and conformity metrics evaluated, compared with 34% of scheduled plans. Conclusions Use of OART for stereotactic linac-based APBI allowed for safe, high-quality treatments in this cohort of 21 treatment courses. Although treatment delivery times were longer than traditional stereotactic body treatments, there were notable improvements in plan quality for APBI using OART.
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Affiliation(s)
- Joel A. Pogue
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlos E. Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Courtney Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Whitney Hotsinpiller
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher Veale
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael H. Soike
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard A. Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Drexell H. Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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6
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Csiki E, Simon M, Papp J, Barabás M, Mikáczó J, Gál K, Sipos D, Kovács Á. Stereotactic body radiotherapy in lung cancer: a contemporary review. Pathol Oncol Res 2024; 30:1611709. [PMID: 38476352 PMCID: PMC10928908 DOI: 10.3389/pore.2024.1611709] [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: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
The treatment of early stage non-small cell lung cancer (NSCLC) has improved enormously in the last two decades. Although surgery is not the only choice, lobectomy is still the gold standard treatment type for operable patients. For inoperable patients stereotactic body radiotherapy (SBRT) should be offered, reaching very high local control and overall survival rates. With SBRT we can precisely irradiate small, well-defined lesions with high doses. To select the appropriate fractionation schedule it is important to determine the size, localization and extent of the lung tumor. The introduction of novel and further developed planning (contouring guidelines, diagnostic image application, planning systems) and delivery techniques (motion management, image guided radiotherapy) led to lower rates of side effects and more conformal target volume coverage. The purpose of this study is to summarize the current developments, randomised studies, guidelines about lung SBRT, with emphasis on the possibility of increasing local control and overall rates in "fit," operable patients as well, so SBRT would be eligible in place of surgery.
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Affiliation(s)
- Emese Csiki
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Mihály Simon
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Papp
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márton Barabás
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Johanna Mikáczó
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Kristóf Gál
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - David Sipos
- Faculty of Health Sciences, University of Pécs, Pecs, Hungary
| | - Árpád Kovács
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Chuong MD, Lee P, Low DA, Kim J, Mittauer KE, Bassetti MF, Glide-Hurst CK, Raldow AC, Yang Y, Portelance L, Padgett KR, Zaki B, Zhang R, Kim H, Henke LE, Price AT, Mancias JD, Williams CL, Ng J, Pennell R, Raphael Pfeffer M, Levin D, Mueller AC, Mooney KE, Kelly P, Shah AP, Boldrini L, Placidi L, Fuss M, Jitendra Parikh P. Stereotactic MR-guided on-table adaptive radiation therapy (SMART) for borderline resectable and locally advanced pancreatic cancer: A multi-center, open-label phase 2 study. Radiother Oncol 2024; 191:110064. [PMID: 38135187 DOI: 10.1016/j.radonc.2023.110064] [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: 09/12/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND PURPOSE Radiation dose escalation may improve local control (LC) and overall survival (OS) in select pancreatic ductal adenocarcinoma (PDAC) patients. We prospectively evaluated the safety and efficacy of ablative stereotactic magnetic resonance (MR)-guided adaptive radiation therapy (SMART) for borderline resectable (BRPC) and locally advanced pancreas cancer (LAPC). The primary endpoint of acute grade ≥ 3 gastrointestinal (GI) toxicity definitely related to SMART was previously published with median follow-up (FU) 8.8 months from SMART. We now present more mature outcomes including OS and late toxicity. MATERIALS AND METHODS This prospective, multi-center, single-arm open-label phase 2 trial (NCT03621644) enrolled 136 patients (LAPC 56.6 %; BRPC 43.4 %) after ≥ 3 months of any chemotherapy without distant progression and CA19-9 ≤ 500 U/mL. SMART was delivered on a 0.35 T MR-guided system prescribed to 50 Gy in 5 fractions (biologically effective dose10 [BED10] = 100 Gy). Elective coverage was optional. Surgery and chemotherapy were permitted after SMART. RESULTS Mean age was 65.7 years (range, 36-85), induction FOLFIRINOX was common (81.7 %), most received elective coverage (57.4 %), and 34.6 % had surgery after SMART. Median FU was 22.9 months from diagnosis and 14.2 months from SMART, respectively. 2-year OS from diagnosis and SMART were 53.6 % and 40.5 %, respectively. Late grade ≥ 3 toxicity definitely, probably, or possibly attributed to SMART were observed in 0 %, 4.6 %, and 11.5 % patients, respectively. CONCLUSIONS Long-term outcomes from the phase 2 SMART trial demonstrate encouraging OS and limited severe toxicity. Additional prospective evaluation of this novel strategy is warranted.
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Affiliation(s)
- Michael D Chuong
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States.
| | - Percy Lee
- City of Hope National Medical Center, Los Angeles, CA, United States
| | - Daniel A Low
- UCLA Department of Radiation Oncology, Los Angeles, CA, United States
| | - Joshua Kim
- Henry Ford Health - Cancer, Detroit, MI, United States
| | - Kathryn E Mittauer
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Michael F Bassetti
- University of Wisconsin-Madison, Department of Human Oncology, Madison, WI, United States
| | - Carri K Glide-Hurst
- University of Wisconsin-Madison, Department of Human Oncology, Madison, WI, United States
| | - Ann C Raldow
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Yingli Yang
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Lorraine Portelance
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Kyle R Padgett
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Bassem Zaki
- Section of Radiation Oncology Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Rongxiao Zhang
- Section of Radiation Oncology Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Hyun Kim
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Lauren E Henke
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Alex T Price
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Joseph D Mancias
- Brigham and Women's Hospital, Department of Radiation Oncology, Dana-Farber Cancer Institute, Department of Radiation Oncology, Harvard Medical School, Boston, MA, United States
| | - Christopher L Williams
- Brigham and Women's Hospital, Department of Radiation Oncology, Dana-Farber Cancer Institute, Department of Radiation Oncology, Harvard Medical School, Boston, MA, United States
| | - John Ng
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, NY, United States
| | - Ryan Pennell
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, NY, United States
| | | | - Daphne Levin
- Assuta Medical Center, Tel Aviv, IL, United States
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Kelly
- Orlando Health Cancer Institute, Orlando, FL, United States
| | - Amish P Shah
- Orlando Health Cancer Institute, Orlando, FL, United States
| | - Luca Boldrini
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
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8
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La Rosa A, Mittauer KE, Bassiri N, Rzepczynski AE, Chuong MD, Yarlagadda S, Kutuk T, McAllister NC, Hall MD, Gutierrez AN, Tolakanahalli R, Mehta MP, Kotecha R. Accelerated Hypofractionated Magnetic Resonance Guided Adaptive Radiation Therapy for Ultracentral Lung Tumors. Tomography 2024; 10:169-180. [PMID: 38250959 PMCID: PMC10820032 DOI: 10.3390/tomography10010013] [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: 10/05/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
Radiotherapy for ultracentral lung tumors represents a treatment challenge, considering the high rates of high-grade treatment-related toxicities with stereotactic body radiation therapy (SBRT) or hypofractionated schedules. Accelerated hypofractionated magnetic resonance-guided adaptive radiation therapy (MRgART) emerged as a potential game-changer for tumors in these challenging locations, in close proximity to central organs at risk, such as the trachea, proximal bronchial tree, and esophagus. In this series, 13 consecutive patients, predominantly male (n = 9), with a median age of 71 (range (R): 46-85), underwent 195 MRgART fractions (all 60 Gy in 15 fractions) to metastatic (n = 12) or primary ultra-central lung tumors (n = 1). The median gross tumor volumes (GTVs) and planning target volumes (PTVs) were 20.72 cc (R: 0.54-121.65 cc) and 61.53 cc (R: 3.87-211.81 cc), respectively. The median beam-on time per fraction was 14 min. Adapted treatment plans were generated for all fractions, and indications included GTV/PTV undercoverage, OARs exceeding tolerance doses, or both indications in 46%, 18%, and 36% of fractions, respectively. Eight patients received concurrent systemic therapies, including immunotherapy (four), chemotherapy (two), and targeted therapy (two). The crude in-field loco-regional control rate was 92.3%. No CTCAE grade 3+ toxicities were observed. Our results offer promising insights, suggesting that MRgART has the potential to mitigate toxicities, enhance treatment precision, and improve overall patient care in the context of ultracentral lung tumors.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Kathryn E. Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Amy E. Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Sreenija Yarlagadda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Nicole C. McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Alonso N. Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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9
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Lee G, Han Z, Huynh E, Tjong MC, Cagney DN, Huynh MA, Kann BH, Kozono D, Leeman JE, Singer L, Williams CL, Mak RH. Widening the therapeutic window for central and ultra-central thoracic oligometastatic disease with stereotactic MR-guided adaptive radiation therapy (SMART). Radiother Oncol 2024; 190:110034. [PMID: 38030080 DOI: 10.1016/j.radonc.2023.110034] [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: 08/29/2023] [Revised: 10/13/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND/PURPOSE Central/ultra-central thoracic tumors are challenging to treat with stereotactic radiotherapy due potential high-grade toxicity. Stereotactic MR-guided adaptive radiation therapy (SMART) may improve the therapeutic window through motion control with breath-hold gating and real-time MR-imaging as well as the option for daily online adaptive replanning to account for changes in target and/or organ-at-risk (OAR) location. MATERIALS/METHODS 26 central (19 ultra-central) thoracic oligoprogressive/oligometastatic tumors treated with isotoxic (OAR constraints-driven) 5-fraction SMART (median 50 Gy, range 35-60) between 10/2019-10/2022 were reviewed. Central tumor was defined as tumor within or touching 2 cm around proximal tracheobronchial tree (PBT) or adjacent to mediastinal/pericardial pleura. Ultra-central was defined as tumor abutting the PBT, esophagus, or great vessel. Hard OAR constraints observed were ≤ 0.03 cc for PBT V40, great vessel V52.5, and esophagus V35. Local failure was defined as tumor progression/recurrence within the planning target volume. RESULTS Tumor abutted the PBT in 31 %, esophagus in 31 %, great vessel in 65 %, and heart in 42 % of cases. 96 % of fractions were treated with reoptimized plan, necessary to meet OAR constraints (80 %) and/or target coverage (20 %). Median follow-up was 19 months (27 months among surviving patients). Local control (LC) was 96 % at 1-year and 90 % at 2-years (total 2/26 local failure). 23 % had G2 acute toxicities (esophagitis, dysphagia, anorexia, nausea) and one (4 %) had G3 acute radiation dermatitis. There were no G4-5 acute toxicities. There was no symptomatic pneumonitis and no G2 + late toxicities. CONCLUSION Isotoxic 5-fraction SMART resulted in high rates of LC and minimal toxicity. This approach may widen the therapeutic window for high-risk oligoprogressive/oligometastatic thoracic tumors.
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Affiliation(s)
- Grace Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Zhaohui Han
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth Huynh
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel N Cagney
- Radiotherapy Department, Mater Private Network, Dublin, Ireland
| | - Mai Anh Huynh
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin H Kann
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Kozono
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lisa Singer
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher L Williams
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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10
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Katano A, Minamitani M, Ohira S, Yamashita H. Recent Advances and Challenges in Stereotactic Body Radiotherapy. Technol Cancer Res Treat 2024; 23:15330338241229363. [PMID: 38321892 PMCID: PMC10851756 DOI: 10.1177/15330338241229363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Affiliation(s)
- Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Masanari Minamitani
- Department of Comprehensive Radiation Oncology, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Shingo Ohira
- Department of Comprehensive Radiation Oncology, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
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11
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Tanaka S, Kadoya N, Ishizawa M, Katsuta Y, Arai K, Takahashi H, Xiao Y, Takahashi N, Sato K, Takeda K, Jingu K. Evaluation of Unity 1.5 T MR-linac plan quality in patients with prostate cancer. J Appl Clin Med Phys 2023; 24:e14122. [PMID: 37559561 PMCID: PMC10691646 DOI: 10.1002/acm2.14122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/26/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023] Open
Abstract
The Unity magnetic resonance (MR) linear accelerator (MRL) with MR-guided adaptive radiotherapy (MRgART) is capable of online MRgART where images are acquired on the treatment day and the radiation treatment plan is immediately replanned and performed. We evaluated the MRgART plan quality and plan reproducibility of the Unity MRL in patients with prostate cancer. There were five low- or moderate-risk and five high-risk patients who received 36.25 Gy or 40 Gy, respectively in five fractions. All patients underwent simulation magnetic resonance imaging (MRI) and five online adaptive MRI. We created plans for 5, 7, 9, 16, and 20 beams and for 60, 100, and 150 segments. We evaluated the target and organ doses for different number of beams and segments, respectively. Variation in dose constraint between the simulation plan and online adaptive plan was measured for each patient to assess plan reproducibility. The plan quality improved with the increasing number of beams. However, the proportion of significantly improved dose constraints decreased as the number of beams increased. For some dose parameters, there were statistically significant differences between 60 and 100 segments, and 100 and 150 segments. The plan of five beams exhibited limited reproducibility. The number of segments had minimal impact on plan reproducibility, but 60 segments sometimes failed to meet dose constraints for online adaptive plan. The optimization and delivery time increased with the number of beams and segments. We do not recommend using five or fewer beams for a reproducible and high-quality plan in the Unity MRL. In addition, many number of segments and beams may help meet dose constraints during online adaptive plan. Treatment with the Unity MRL should be performed with the appropriate number of beams and segments to achieve a good balance among plan quality, delivery time, and optimization time.
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Affiliation(s)
- Shohei Tanaka
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Noriyuki Kadoya
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Miyu Ishizawa
- Department of Radiological TechnologySchool of Health SciencesFaculty of MedicineTohoku UniversitySendaiJapan
| | - Yoshiyuki Katsuta
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Kazuhiro Arai
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Haruna Takahashi
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Yushan Xiao
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Noriyoshi Takahashi
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
| | - Kiyokazu Sato
- Radiation TechnologyTohoku University HospitalSendaiJapan
| | - Ken Takeda
- Department of Radiological TechnologySchool of Health SciencesFaculty of MedicineTohoku UniversitySendaiJapan
| | - Keiichi Jingu
- Department of Radiation OncologyTohoku University Graduate School of MedicineSendaiJapan
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12
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Nasser N, Yang GQ, Koo J, Bowers M, Greco K, Feygelman V, Moros EG, Caudell JJ, Redler G. A head and neck treatment planning strategy for a CBCT-guided ring-gantry online adaptive radiotherapy system. J Appl Clin Med Phys 2023; 24:e14134. [PMID: 37621133 PMCID: PMC10691641 DOI: 10.1002/acm2.14134] [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: 06/16/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE A planning strategy was developed and the utility of online-adaptation with the Ethos CBCT-guided ring-gantry adaptive radiotherapy (ART) system was evaluated using retrospective data from Head-and-neck (H&N) patients that required clinical offline adaptation during treatment. METHODS Clinical data were used to re-plan 20 H&N patients (10 sequential boost (SEQ) with separate base and boost plans plus 10 simultaneous integrated boost (SIB)). An optimal approach, robust to online adaptation, for Ethos-initial plans using clinical goal prioritization was developed. Anatomically-derived isodose-shaping helper structures, air-density override, goals for controlling hotspot location(s), and plan normalization were investigated. Online adaptation was simulated using clinical offline adaptive simulation-CTs to represent an on-treatment CBCT. Dosimetric comparisons were based on institutional guidelines for Clinical-initial versus Ethos-initial plans and Ethos-scheduled versus Ethos-adapted plans. Timing for five components of the online adaptive workflow was analyzed. RESULTS The Ethos H&N planning approach generated Ethos-initial SEQ plans with clinically comparable PTV coverage (average PTVHigh V100% = 98.3%, Dmin,0.03cc = 97.9% and D0.03cc = 105.5%) and OAR sparing. However, Ethos-initial SIB plans were clinically inferior (average PTVHigh V100% = 96.4%, Dmin,0.03cc = 93.7%, D0.03cc = 110.6%). Fixed-field IMRT was superior to VMAT for 93.3% of plans. Online adaptation succeeded in achieving conformal coverage to the new anatomy in both SEQ and SIB plans that was even superior to that achieved in the initial plans (which was due to the changes in anatomy that simplified the optimization). The average adaptive workflow duration for SIB, SEQ base and SEQ boost was 30:14, 22.56, and 14:03 (min: sec), respectively. CONCLUSIONS With an optimal planning approach, Ethos efficiently auto-generated dosimetrically comparable and clinically acceptable initial SEQ plans for H&N patients. Initial SIB plans were inferior and clinically unacceptable, but adapted SIB plans became clinically acceptable. Online adapted plans optimized dose to new anatomy and maintained target coverage/homogeneity with improved OAR sparing in a time-efficient manner.
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Affiliation(s)
- Nour Nasser
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - George Q. Yang
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jihye Koo
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Mark Bowers
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Kevin Greco
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | | | - Eduardo G. Moros
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jimmy J. Caudell
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Gage Redler
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
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13
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Rabe M, Paganelli C, Schmitz H, Meschini G, Riboldi M, Hofmaier J, Nierer-Kohlhase L, Dinkel J, Reiner M, Parodi K, Belka C, Landry G, Kurz C, Kamp F. Continuous time-resolved estimated synthetic 4D-CTs for dose reconstruction of lung tumor treatments at a 0.35 T MR-linac. Phys Med Biol 2023; 68:235008. [PMID: 37669669 DOI: 10.1088/1361-6560/acf6f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/05/2023] [Indexed: 09/07/2023]
Abstract
Objective.To experimentally validate a method to create continuous time-resolved estimated synthetic 4D-computed tomography datasets (tresCTs) based on orthogonal cine MRI data for lung cancer treatments at a magnetic resonance imaging (MRI) guided linear accelerator (MR-linac).Approach.A breathing porcine lung phantom was scanned at a CT scanner and 0.35 T MR-linac. Orthogonal cine MRI series (sagittal/coronal orientation) at 7.3 Hz, intersecting tumor-mimicking gelatin nodules, were deformably registered to mid-exhale 3D-CT and 3D-MRI datasets. The time-resolved deformation vector fields were extrapolated to 3D and applied to a reference synthetic 3D-CT image (sCTref), while accounting for breathing phase-dependent lung density variations, to create 82 s long tresCTs at 3.65 Hz. Ten tresCTs were created for ten tracked nodules with different motion patterns in two lungs. For each dataset, a treatment plan was created on the mid-exhale phase of a measured ground truth (GT) respiratory-correlated 4D-CT dataset with the tracked nodule as gross tumor volume (GTV). Each plan was recalculated on the GT 4D-CT, randomly sampled tresCT, and static sCTrefimages. Dose distributions for corresponding breathing phases were compared in gamma (2%/2 mm) and dose-volume histogram (DVH) parameter analyses.Main results.The mean gamma pass rate between all tresCT and GT 4D-CT dose distributions was 98.6%. The mean absolute relative deviations of the tresCT with respect to GT DVH parameters were 1.9%, 1.0%, and 1.4% for the GTVD98%,D50%, andD2%, respectively, 1.0% for the remaining nodulesD50%, and 1.5% for the lungV20Gy. The gamma pass rate for the tresCTs was significantly larger (p< 0.01), and the GTVD50%deviations with respect to the GT were significantly smaller (p< 0.01) than for the sCTref.Significance.The results suggest that tresCTs could be valuable for time-resolved reconstruction and intrafractional accumulation of the dose to the GTV for lung cancer patients treated at MR-linacs in the future.
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Affiliation(s)
- Moritz Rabe
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Henning Schmitz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Giorgia Meschini
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Marco Riboldi
- Department of Medical Physics, Ludwig-Maximilians-Universität München (LMU Munich), Garching (Munich), Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lukas Nierer-Kohlhase
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center, German Center for Lung Research (DZL), Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Katia Parodi
- Department of Medical Physics, Ludwig-Maximilians-Universität München (LMU Munich), Garching (Munich), Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, a partnership between DKFZ and LMU University Hospital Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Kamp
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Radiation Oncology, University Hospital Cologne, Cologne, Germany
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14
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Liu H, Schaal D, Curry H, Clark R, Magliari A, Kupelian P, Khuntia D, Beriwal S. Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction. Radiat Oncol 2023; 18:144. [PMID: 37660057 PMCID: PMC10475190 DOI: 10.1186/s13014-023-02340-2] [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: 04/10/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Abstract
Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.
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Affiliation(s)
- Hefei Liu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | - Ryan Clark
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc, Palo Alto, CA, USA.
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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15
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Price AT, Schiff JP, Laugeman E, Maraghechi B, Schmidt M, Zhu T, Reynoso F, Hao Y, Kim T, Morris E, Zhao X, Hugo GD, Vlacich G, DeSelm CJ, Samson PP, Baumann BC, Badiyan SN, Robinson CG, Kim H, Henke LE. Initial clinical experience building a dual CT- and MR-guided adaptive radiotherapy program. Clin Transl Radiat Oncol 2023; 42:100661. [PMID: 37529627 PMCID: PMC10388162 DOI: 10.1016/j.ctro.2023.100661] [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: 02/13/2023] [Revised: 06/12/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Our institution was the first in the world to clinically implement MR-guided adaptive radiotherapy (MRgART) in 2014. In 2021, we installed a CT-guided adaptive radiotherapy (CTgART) unit, becoming one of the first clinics in the world to build a dual-modality ART clinic. Herein we review factors that lead to the development of a high-volume dual-modality ART program and treatment census over an initial, one-year period. Materials and Methods The clinical adaptive service at our institution is enabled with both MRgART (MRIdian, ViewRay, Inc, Mountain View, CA) and CTgART (ETHOS, Varian Medical Systems, Palo Alto, CA) platforms. We analyzed patient and treatment information including disease sites treated, radiation dose and fractionation, and treatment times for patients on these two platforms. Additionally, we reviewed our institutional workflow for creating, verifying, and implementing a new adaptive workflow on either platform. Results From October 2021 to September 2022, 256 patients were treated with adaptive intent at our institution, 186 with MRgART and 70 with CTgART. The majority (106/186) of patients treated with MRgART had pancreatic cancer, and the most common sites treated with CTgART were pelvis (23/70) and abdomen (20/70). 93.0% of treatments on the MRgART platform were stereotactic body radiotherapy (SBRT), whereas only 72.9% of treatments on the CTgART platform were SBRT. Abdominal gated cases were allotted a longer time on the CTgART platform compared to the MRgART platform, whereas pelvic cases were allotted a shorter time on the CTgART platform when compared to the MRgART platform. Our adaptive implementation technique has led to six open clinical trials using MRgART and seven using CTgART. Conclusions We demonstrate the successful development of a dual platform ART program in our clinic. Ongoing efforts are needed to continue the development and integration of ART across platforms and disease sites to maximize access and evidence for this technique worldwide.
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Affiliation(s)
- Alex T. Price
- University Hospitals/Case Western Reserve University, Department of Radiation Oncology, Cleveland, OH, USA
| | - Joshua P. Schiff
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Eric Laugeman
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Borna Maraghechi
- City of Hope Orange County, Department of Radiation Oncology, Irvine, CA, USA
| | - Matthew Schmidt
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Tong Zhu
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Francisco Reynoso
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Yao Hao
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Taeho Kim
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Eric Morris
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Xiaodong Zhao
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Geoffrey D. Hugo
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Gregory Vlacich
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Carl J. DeSelm
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Pamela P. Samson
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Brian C. Baumann
- Springfield Clinic, Department of Radiation Oncology, Springfield, IL, USA
| | - Shahed N. Badiyan
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, USA
| | - Clifford G. Robinson
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Hyun Kim
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Lauren E. Henke
- University Hospitals/Case Western Reserve University, Department of Radiation Oncology, Cleveland, OH, USA
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Lavrova E, Garrett MD, Wang YF, Chin C, Elliston C, Savacool M, Price M, Kachnic LA, Horowitz DP. Adaptive Radiation Therapy: A Review of CT-based Techniques. Radiol Imaging Cancer 2023; 5:e230011. [PMID: 37449917 PMCID: PMC10413297 DOI: 10.1148/rycan.230011] [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: 02/09/2023] [Revised: 04/18/2023] [Accepted: 05/10/2023] [Indexed: 07/18/2023]
Abstract
Adaptive radiation therapy is a feedback process by which imaging information acquired over the course of treatment, such as changes in patient anatomy, can be used to reoptimize the treatment plan, with the end goal of improving target coverage and reducing treatment toxicity. This review describes different types of adaptive radiation therapy and their clinical implementation with a focus on CT-guided online adaptive radiation therapy. Depending on local anatomic changes and clinical context, different anatomic sites and/or disease stages and presentations benefit from different adaptation strategies. Online adaptive radiation therapy, where images acquired in-room before each fraction are used to adjust the treatment plan while the patient remains on the treatment table, has emerged to address unpredictable anatomic changes between treatment fractions. Online treatment adaptation places unique pressures on the radiation therapy workflow, requiring high-quality daily imaging and rapid recontouring, replanning, plan review, and quality assurance. Generating a new plan with every fraction is resource intensive and time sensitive, emphasizing the need for workflow efficiency and clinical resource allocation. Cone-beam CT is widely used for image-guided radiation therapy, so implementing cone-beam CT-guided online adaptive radiation therapy can be easily integrated into the radiation therapy workflow and potentially allow for rapid imaging and replanning. The major challenge of this approach is the reduced image quality due to poor resolution, scatter, and artifacts. Keywords: Adaptive Radiation Therapy, Cone-Beam CT, Organs at Risk, Oncology © RSNA, 2023.
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Affiliation(s)
- Elizaveta Lavrova
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Matthew D. Garrett
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Yi-Fang Wang
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Christine Chin
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Carl Elliston
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Michelle Savacool
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Michael Price
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - Lisa A. Kachnic
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
| | - David P. Horowitz
- From the Department of Radiation Oncology, Columbia University Irving
Medical Center, 622 W 168th St, New York, NY 10032 (E.L., M.D.G., Y.F.W., C.C.,
C.E., M.S., M.P., L.A.K., D.P.H.); and Herbert Irving Comprehensive Cancer
Center, New York, NY (C.C., L.A.K., D.P.H.)
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Yan M, Louie AV, Kotecha R, Ashfaq Ahmed M, Zhang Z, Guckenberger M, Kim MS, Lo SS, Scorsetti M, Tree AC, Sahgal A, Slotman BJ. Stereotactic body radiotherapy for Ultra-Central lung Tumors: A systematic review and Meta-Analysis and International Stereotactic Radiosurgery Society practice guidelines. Lung Cancer 2023; 182:107281. [PMID: 37393758 DOI: 10.1016/j.lungcan.2023.107281] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an effective and safe modality for early-stage lung cancer and lung metastases. However, tumors in an ultra-central location pose unique safety considerations. We performed a systematic review and meta-analysis to summarize the current safety and efficacy data and provide practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS We performed a systematic review using PubMed and EMBASE databases of patients with ultra-central lung tumors treated with SBRT. Studies reporting local control (LC) and/or toxicity were included. Studies with <5 treated lesions, non-English language, re-irradiation, nodal tumors, or mixed outcomes in which ultra-central tumors could not be discerned were excluded. Random-effects meta-analysis was performed for studies reporting relevant endpoints. Meta-regression was conducted to determine the effect of various covariates on the primary outcomes. RESULTS 602 unique studies were identified of which 27 (one prospective observational, the remainder retrospective) were included, representing 1183 treated targets. All studies defined ultra-central as the planning target volume (PTV) overlapping the proximal bronchial tree (PBT). The most common dose fractionations were 50 Gy/5, 60 Gy/8, and 60 Gy/12 fractions. The pooled 1- and 2-year LC estimates were 92 % and 89 %, respectively. Meta-regression identified biological effective dose (BED10) as a significant predictor of 1-year LC. A total of 109 grade 3-4 toxicity events, with a pooled incidence of 6 %, were reported, most commonly pneumonitis. There were 73 treatment related deaths, with a pooled incidence of 4 %, with the most common being hemoptysis. Anticoagulation, interstitial lung disease, endobronchial tumor, and concomitant targeted therapies were observed risk factors for fatal toxicity events. CONCLUSION SBRT for ultra-central lung tumors results in acceptable rates of local control, albeit with risks of severe toxicity. Caution should be taken for appropriate patient selection, consideration of concomitant therapies, and radiotherapy plan design.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, USA
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mi-Sook Kim
- Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, IRCCS-Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Ladbury C, Amini A, Schwer A, Liu A, Williams T, Lee P. Clinical Applications of Magnetic Resonance-Guided Radiotherapy: A Narrative Review. Cancers (Basel) 2023; 15:cancers15112916. [PMID: 37296879 DOI: 10.3390/cancers15112916] [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: 04/13/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Magnetic resonance-guided radiotherapy (MRgRT) represents a promising new image guidance technology for radiation treatment delivery combining an onboard MRI scanner with radiation delivery technology. By enabling real-time low-field or high-field MRI acquisition, it facilitates improved soft tissue delineation, adaptive treatment, and motion management. Now that MRgRT has been available for nearly a decade, research has shown the technology can be used to effectively shrink treatment margins to either decrease toxicity (in breast, prostate cancer, and pancreatic cancer) or facilitate dose-escalation and improved oncologic outcomes (in pancreatic and liver cancer), as well as enabling indications that require clear soft tissue delineation and gating (lung and cardiac ablation). In doing so, the use of MRgRT has the potential to significantly improve the outcomes and quality of life of the patients it treats. The present narrative review aims to describe the rationale for MRgRT, the current and forthcoming state of technology, existing studies, and future directions for the advancement of MRgRT, including associated challenges.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Amanda Schwer
- Department of Radiation Oncology, City of Hope Orange County Lennar Foundation Cancer Center, Irvine, CA 92618, USA
| | - An Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Terence Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Percy Lee
- Department of Radiation Oncology, City of Hope Orange County Lennar Foundation Cancer Center, Irvine, CA 92618, USA
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19
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Qiu Z, Olberg S, den Hertog D, Ajdari A, Bortfeld T, Pursley J. Online adaptive planning methods for intensity-modulated radiotherapy. Phys Med Biol 2023; 68:10.1088/1361-6560/accdb2. [PMID: 37068488 PMCID: PMC10637515 DOI: 10.1088/1361-6560/accdb2] [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: 12/29/2022] [Accepted: 04/17/2023] [Indexed: 04/19/2023]
Abstract
Online adaptive radiation therapy aims at adapting a patient's treatment plan to their current anatomy to account for inter-fraction variations before daily treatment delivery. As this process needs to be accomplished while the patient is immobilized on the treatment couch, it requires time-efficient adaptive planning methods to generate a quality daily treatment plan rapidly. The conventional planning methods do not meet the time requirement of online adaptive radiation therapy because they often involve excessive human intervention, significantly prolonging the planning phase. This article reviews the planning strategies employed by current commercial online adaptive radiation therapy systems, research on online adaptive planning, and artificial intelligence's potential application to online adaptive planning.
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Affiliation(s)
- Zihang Qiu
- Department of Business Analytics, University of Amsterdam, The Netherlands
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Sven Olberg
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Dick den Hertog
- Department of Business Analytics, University of Amsterdam, The Netherlands
| | - Ali Ajdari
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Thomas Bortfeld
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, United States of America
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20
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Regnery S, de Colle C, Eze C, Corradini S, Thieke C, Sedlaczek O, Schlemmer HP, Dinkel J, Seith F, Kopp-Schneider A, Gillmann C, Renkamp CK, Landry G, Thorwarth D, Zips D, Belka C, Jäkel O, Debus J, Hörner-Rieber J. Pulmonary magnetic resonance-guided online adaptive radiotherapy of locally advanced: the PUMA trial. Radiat Oncol 2023; 18:74. [PMID: 37143154 PMCID: PMC10161406 DOI: 10.1186/s13014-023-02258-9] [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: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Patients with locally-advanced non-small-cell lung cancer (LA-NSCLC) are often ineligible for surgery, so that definitive chemoradiotherapy (CRT) represents the treatment of choice. Nevertheless, long-term tumor control is often not achieved. Intensification of radiotherapy (RT) to improve locoregional tumor control is limited by the detrimental effect of higher radiation exposure of thoracic organs-at-risk (OAR). This narrow therapeutic ratio may be expanded by exploiting the advantages of magnetic resonance (MR) linear accelerators, mainly the online adaptation of the treatment plan to the current anatomy based on daily acquired MR images. However, MR-guidance is both labor-intensive and increases treatment times, which raises the question of its clinical feasibility to treat LA-NSCLC. Therefore, the PUMA trial was designed as a prospective, multicenter phase I trial to demonstrate the clinical feasibility of MR-guided online adaptive RT in LA-NSCLC. METHODS Thirty patients with LA-NSCLC in stage III A-C will be accrued at three German university hospitals to receive MR-guided online adaptive RT at two different MR-linac systems (MRIdian Linac®, View Ray Inc. and Elekta Unity®, Elekta AB) with concurrent chemotherapy. Conventionally fractioned RT with isotoxic dose escalation up to 70 Gy is applied. Online plan adaptation is performed once weekly or in case of major anatomical changes. Patients are followed-up by thoracic CT- and MR-imaging for 24 months after treatment. The primary endpoint is twofold: (1) successfully completed online adapted fractions, (2) on-table time. Main secondary endpoints include adaptation frequency, toxicity, local tumor control, progression-free and overall survival. DISCUSSION PUMA aims to demonstrate the clinical feasibility of MR-guided online adaptive RT of LA-NSCLC. If successful, PUMA will be followed by a clinical phase II trial that further investigates the clinical benefits of this approach. Moreover, PUMA is part of a large multidisciplinary project to develop MR-guidance techniques. TRIAL REGISTRATION ClinicalTrials.gov: NCT05237453 .
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Affiliation(s)
- Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Chiara de Colle
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Thieke
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Sedlaczek
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Julien Dinkel
- Department of Radiology, LMU Munich, Munich, Germany
| | - Ferdinand Seith
- Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | | | - Clarissa Gillmann
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Jäkel
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.
- National Center for Tumor diseases (NCT), Heidelberg, Germany.
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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21
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Chiloiro G, Boldrini L, Romano A, Placidi L, Tran HE, Nardini M, Massaccesi M, Cellini F, Indovina L, Gambacorta MA. Magnetic resonance-guided stereotactic body radiation therapy (MRgSBRT) for oligometastatic patients: a single-center experience. LA RADIOLOGIA MEDICA 2023; 128:619-627. [PMID: 37079221 PMCID: PMC10116467 DOI: 10.1007/s11547-023-01627-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Stereotactic body radiotherapy is increasingly used for the treatment of oligometastatic disease. Magnetic resonance-guided stereotactic radiotherapy (MRgSBRT) offers the opportunity to perform dose escalation protocols while reducing the unnecessary irradiation of the surrounding organs at risk. The aim of this retrospective, monoinstitutional study is to evaluate the feasibility and clinical benefit (CB) of MRgSBRT in the setting of oligometastatic patients. MATERIALS AND METHODS Data from oligometastatic patients treated with MRgSBRT were collected. The primary objectives were to define the 12-month progression-free survival (PFS) and local progression-free survival (LPFS) and 24-month overall survival (OS) rate. The objective response rate (ORR) included complete response (CR) and partial response (PR). CB was defined as the achievement of ORR and stable disease (SD). Toxicities were also assessed according to the CTCAE version 5.0 scale. RESULTS From February 2017 to March 2021, 59 consecutive patients with a total of 80 lesions were treated by MRgSBRT on a 0.35 T hybrid unit. CR and PR as well as SD were observed in 30 (37.5%), 7 (8.75%), and 17 (21.25%) lesions, respectively. Furthermore, CB was evaluated at a rate of 67.5% with an ORR of 46.25%. Median follow-up time was 14 months (range: 3-46 months). The 12-month LPFS and PFS rates were 70% and 23%, while 24-month OS rate was 93%. No acute toxicity was reported, whereas late pulmonary fibrosis G1 was observed in 9 patients (15.25%). CONCLUSION MRgSBRT was well tolerated by patients with reported low toxicity levels and a satisfying CB.
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Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Huong Elena Tran
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Mariangela Massaccesi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Francesco Cellini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
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22
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Chuong MD, Palm RF, Tjong MC, Hyer DE, Kishan AU. Advances in MRI-Guided Radiation Therapy. Surg Oncol Clin N Am 2023; 32:599-615. [PMID: 37182995 DOI: 10.1016/j.soc.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Image guidance for radiation therapy (RT) has evolved over the last few decades and now is routinely performed using cone-beam computerized tomography (CBCT). Conventional linear accelerators (LINACs) that use CBCT have limited soft tissue contrast, are not able to image the patient's internal anatomy during treatment delivery, and most are not capable of online adaptive replanning. RT delivery systems that use MRI have become available within the last several years and address many of the imaging limitations of conventional LINACs. Herein, the authors review the technical characteristics and advantages of MRI-guided RT as well as emerging clinical outcomes.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, 8900 North Kendall Drive, Miami, FL 33176, USA.
| | - Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Daniel E Hyer
- Department of Radiation Oncology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, 1338 S Hope Street, Los Angeles, CA 90015, USA
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23
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Cuneo KC, Herr DJ. Advances in Radiation Therapy for Primary Liver Cancer. Surg Oncol Clin N Am 2023; 32:415-432. [PMID: 37182985 DOI: 10.1016/j.soc.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
During the past 30 years, several advances have been made allowing for safer and more effective treatment of patients with liver cancer. This report reviews recent advances in radiation therapy for primary liver cancers including hepatocellular carcinoma and intrahepatic cholangiocarcinoma. First, studies focusing on liver stereotactic body radiation therapy (SBRT) are reviewed focusing on lessons learned and knowledge gained from early pioneering trials. Then, new technologies to enhance SBRT treatments are explored including adaptive therapy and MRI-guided and biology-guided radiation therapy. Finally, treatment with Y-90 transarterial radioembolization is reviewed with a focus on novel approaches focused on personalized therapy.
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24
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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Regnery S, Katsigiannopulos E, Hoegen P, Weykamp F, Sandrini E, Held T, Deng M, Eichkorn T, Buchele C, Rippke C, Renkamp CK, König L, Lang K, Thomas M, Winter H, Adeberg S, Klüter S, Debus J, Hörner-Rieber J. To fly or not to fly: Stereotactic MR-guided adaptive radiotherapy effectively treats ultracentral lung tumors with favorable long-term outcomes. Lung Cancer 2023; 179:107175. [PMID: 36965207 DOI: 10.1016/j.lungcan.2023.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Stereotactic radiotherapy of ultracentral lung tumors (ULT) is challenging as it may cause overdoses to sensitive mediastinal organs with severe complications. We aimed to describe long-term outcomes after stereotactic magnetic resonance (MR)-guided online adaptive radiotherapy (SMART) as an innovative treatment of ULT. PATIENTS & METHODS We analyzed 36 patients that received SMART to 40 tumors between 02/2020 - 08/2021 inside prospective databases. ULT were defined by planning target volume (PTV) overlap with the proximal bronchial tree or esophagus. We calculated Kaplan Meier estimates for overall survival (OS) and progression-free survival (PFS), and competing risk estimates for the incidence of tumor progression and treatment-related toxicities. ULT patients (N = 16) were compared to non-ULT patients (N = 20). RESULTS Baseline characteristics were similar between ULT and non-ULT, but ULT were larger (median PTV: ULT 54.7 cm3, non-ULT 19.2 cm3). Median follow-up was 23.6 months. ULT and non-ULT showed a similar OS (2-years: ULT 67%, non-ULT 60%, p = 0.7) and PFS (2-years: ULT 37%, non-ULT 34%, p = 0.73). Progressions occurred mainly at distant sites (2-year incidence of distant progression: ULT 63%, non-ULT 61%, p = 0.77), while local tumor control was favorable (2-year incidence of local progression: ULT 7%, non-ULT 0%, p = 0.22). Treatment of ULT led to significantly more toxicities ≥ grade (G) 2 (ULT: 9 (56%), non-ULT: 1 (5%), p = 0.002). Most toxicities were moderate (G2). Two ULT patients developed high-grade toxicities: 1) esophagitis G3 and bronchial bleeding G4 after VEGF treatment, 2) bronchial bleeding G3. Estimated incidence of high-grade toxicities was 19% (3-48%) in ULT, and no treatment-related death occurred. CONCLUSION Our small series supports SMART as potentially effective treatment of ULT. SMART with careful fractionation could reduce severe complications, but treatment of ULT remains a high-risk procedure and needs careful benefit-risk-assessment.
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Affiliation(s)
- Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Efthimios Katsigiannopulos
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Elisabetta Sandrini
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tanja Eichkorn
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Carolin Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Carolin Rippke
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Michael Thomas
- National Center for Tumor Diseases (NCT), Heidelberg, Germany; Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Hauke Winter
- National Center for Tumor Diseases (NCT), Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Stanley DN, Harms J, Pogue JA, Belliveau JG, Marcrom SR, McDonald AM, Dobelbower MC, Boggs DH, Soike MH, Fiveash JA, Popple RA, Cardenas CE. A roadmap for implementation of kV-CBCT online adaptive radiation therapy and initial first year experiences. J Appl Clin Med Phys 2023:e13961. [PMID: 36920871 DOI: 10.1002/acm2.13961] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/12/2023] [Accepted: 02/23/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Online Adaptive Radiation Therapy (oART) follows a different treatment paradigm than conventional radiotherapy, and because of this, the resources, implementation, and workflows needed are unique. The purpose of this report is to outline our institution's experience establishing, organizing, and implementing an oART program using the Ethos therapy system. METHODS We include resources used, operational models utilized, program creation timelines, and our institutional experiences with the implementation and operation of an oART program. Additionally, we provide a detailed summary of our first year's clinical experience where we delivered over 1000 daily adaptive fractions. For all treatments, the different stages of online adaption, primary patient set-up, initial kV-CBCT acquisition, contouring review and edit of influencer structures, target review and edits, plan evaluation and selection, Mobius3D 2nd check and adaptive QA, 2nd kV-CBCT for positional verification, treatment delivery, and patient leaving the room, were analyzed. RESULTS We retrospectively analyzed data from 97 patients treated from August 2021-August 2022. One thousand six hundred seventy seven individual fractions were treated and analyzed, 632(38%) were non-adaptive and 1045(62%) were adaptive. Seventy four of the 97 patients (76%) were treated with standard fractionation and 23 (24%) received stereotactic treatments. For the adaptive treatments, the generated adaptive plan was selected in 92% of treatments. On average(±std), adaptive sessions took 34.52 ± 11.42 min from start to finish. The entire adaptive process (from start of contour generation to verification CBCT), performed by the physicist (and physician on select days), was 19.84 ± 8.21 min. CONCLUSION We present our institution's experience commissioning an oART program using the Ethos therapy system. It took us 12 months from project inception to the treatment of our first patient and 12 months to treat 1000 adaptive fractions. Retrospective analysis of delivered fractions showed that the average overall treatment time was approximately 35 min and the average time for the adaptive component of treatment was approximately 20 min.
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Affiliation(s)
- Dennis N Stanley
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Joel A Pogue
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Jean-Guy Belliveau
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Samuel R Marcrom
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Andrew M McDonald
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Michael C Dobelbower
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Michael H Soike
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - John A Fiveash
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Carlos E Cardenas
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama, USA
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Forghani F, Ginn JS, Schiff JP, Zhu T, Marut L, Laugeman E, Maraghechi B, Badiyan SN, Samson PP, Kim H, Robinson CG, Hugo GD, Henke LE, Price AT. Knowledge-based adaptive planning quality assurance using dosimetric indicators for stereotactic adaptive radiotherapy for pancreatic cancer. Radiother Oncol 2023; 182:109603. [PMID: 36889595 DOI: 10.1016/j.radonc.2023.109603] [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: 11/30/2022] [Revised: 02/26/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION We aimed to develop knowledge-based tools for robust adaptive radiotherapy (ART) planning to determine on-table adaptive DVH metric variations or planning process errors for stereotactic pancreatic ART. We developed volume-based dosimetric identifiers to identify deviations of ART plans from simulation plans. MATERIALS AND METHODS Two patient cohorts who were treated on MR-Linac for pancreas cancer were included in this retrospective study; a training cohort and a validation cohort. All patients received 50 Gy in 5 fractions. PTV-OPT was generated by subtracting the critical organs plus a 5 mm-margin from PTV. Several metrics that potentially can identify failure-modes were calculated including PTV & PTV_OPT V95% and PTV & PTV_OPT D95%/D5%. The difference between each DVH metric in each adaptive plan with the DVH metric in simulation plan was calculated. The 95% confidence interval (CI) of the variations in each DVH metric was calculated for the patient training cohort. Variations in DVH metrics that exceeded the 95% CI for all fractions in training and validation cohort were flagged for retrospective investigation for root-cause analysis to determine their predictive power for identifying failure-modes. RESULTS The CIs for the PTV & PTV_OPT V95% and PTV & PTV_OPT D95%/D5% were ± 13%, ± 5%, ± 0.1, ± 0.03, respectively. We estimated the positive predictive value and negative predictive value of our method to be 77% and 89%, respectively, for the training cohort, and 80% for both in the validation cohort. DISCUSSION We developed dosimetric indicators for ART planning QA to identify population-based deviations or planning errors during online adaptive process for stereotactic pancreatic ART. This technology may be useful as an ART clinical trial QA tool and improve overall ART quality at an institution.
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Affiliation(s)
- Farnoush Forghani
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA.
| | - John S Ginn
- Department of Radiation Oncology, Duke University, USA
| | - Joshua P Schiff
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Tong Zhu
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Luke Marut
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Borna Maraghechi
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA
| | - Alex T Price
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, USA.
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Hoppen L, Sarria GR, Kwok CS, Boda-Heggemann J, Buergy D, Ehmann M, Giordano FA, Fleckenstein J. Dosimetric benefits of adaptive radiation therapy for patients with stage III non-small cell lung cancer. Radiat Oncol 2023; 18:34. [PMID: 36814271 PMCID: PMC9945670 DOI: 10.1186/s13014-023-02222-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Daily adaptive radiation therapy (ART) of patients with non-small cell lung cancer (NSCLC) lowers organs at risk exposure while maintaining the planning target volume (PTV) coverage. Thus, ART allows an isotoxic approach with increased doses to the PTV that could improve local tumor control. Herein we evaluate daily online ART strategies regarding their impact on relevant dose-volume metrics. METHODS Daily cone-beam CTs (1 × n = 28, 1 × n = 29, 11 × n = 30) of 13 stage III NSCLC patients were converted into synthetic CTs (sCTs). Treatment plans (TPs) were created retrospectively on the first-fraction sCTs (sCT1) and subsequently transferred unaltered to the sCTs of the remaining fractions of each patient (sCT2-n) (IGRT scenario). Two additional TPs were generated on sCT2-n: one minimizing the lung-dose while preserving the D95%(PTV) (isoeffective scenario), the other escalating the D95%(PTV) with a constant V20Gy(lungipsilateral) (isotoxic scenario). RESULTS Compared to the original TPs predicted dose, the median D95%(PTV) in the IGRT scenario decreased by 1.6 Gy ± 4.2 Gy while the V20Gy(lungipsilateral) increased in median by 1.1% ± 4.4%. The isoeffective scenario preserved the PTV coverage and reduced the median V20Gy(lungipsilateral) by 3.1% ± 3.6%. Furthermore, the median V5%(heart) decreased by 2.9% ± 6.4%. With an isotoxic prescription, a median dose-escalation to the gross target volume of 10.0 Gy ± 8.1 Gy without increasing the V20Gy(lungipsilateral) and V5%(heart) was feasible. CONCLUSIONS We demonstrated that even without reducing safety margins, ART can reduce lung-doses, while still reaching adequate target coverage or escalate target doses without increasing ipsilateral lung exposure. Clinical benefits by means of toxicity and local control of both strategies should be evaluated in prospective clinical trials.
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Affiliation(s)
- Lea Hoppen
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Gustavo R. Sarria
- grid.10388.320000 0001 2240 3300Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Chung S. Kwok
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Judit Boda-Heggemann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Daniel Buergy
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Michael Ehmann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Frank A. Giordano
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Jens Fleckenstein
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Ng J, Gregucci F, Pennell RT, Nagar H, Golden EB, Knisely JPS, Sanfilippo NJ, Formenti SC. MRI-LINAC: A transformative technology in radiation oncology. Front Oncol 2023; 13:1117874. [PMID: 36776309 PMCID: PMC9911688 DOI: 10.3389/fonc.2023.1117874] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
Advances in radiotherapy technologies have enabled more precise target guidance, improved treatment verification, and greater control and versatility in radiation delivery. Amongst the recent novel technologies, Magnetic Resonance Imaging (MRI) guided radiotherapy (MRgRT) may hold the greatest potential to improve the therapeutic gains of image-guided delivery of radiation dose. The ability of the MRI linear accelerator (LINAC) to image tumors and organs with on-table MRI, to manage organ motion and dose delivery in real-time, and to adapt the radiotherapy plan on the day of treatment while the patient is on the table are major advances relative to current conventional radiation treatments. These advanced techniques demand efficient coordination and communication between members of the treatment team. MRgRT could fundamentally transform the radiotherapy delivery process within radiation oncology centers through the reorganization of the patient and treatment team workflow process. However, the MRgRT technology currently is limited by accessibility due to the cost of capital investment and the time and personnel allocation needed for each fractional treatment and the unclear clinical benefit compared to conventional radiotherapy platforms. As the technology evolves and becomes more widely available, we present the case that MRgRT has the potential to become a widely utilized treatment platform and transform the radiation oncology treatment process just as earlier disruptive radiation therapy technologies have done.
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Affiliation(s)
- John Ng
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States,*Correspondence: John Ng,
| | - Fabiana Gregucci
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States,Department of Radiation Oncology, Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Ryan T. Pennell
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States
| | - Encouse B. Golden
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States
| | | | | | - Silvia C. Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, United States
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McDonald BA, Zachiu C, Christodouleas J, Naser MA, Ruschin M, Sonke JJ, Thorwarth D, Létourneau D, Tyagi N, Tadic T, Yang J, Li XA, Bernchou U, Hyer DE, Snyder JE, Bubula-Rehm E, Fuller CD, Brock KK. Dose accumulation for MR-guided adaptive radiotherapy: From practical considerations to state-of-the-art clinical implementation. Front Oncol 2023; 12:1086258. [PMID: 36776378 PMCID: PMC9909539 DOI: 10.3389/fonc.2022.1086258] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/27/2023] Open
Abstract
MRI-linear accelerator (MR-linac) devices have been introduced into clinical practice in recent years and have enabled MR-guided adaptive radiation therapy (MRgART). However, by accounting for anatomical changes throughout radiation therapy (RT) and delivering different treatment plans at each fraction, adaptive radiation therapy (ART) highlights several challenges in terms of calculating the total delivered dose. Dose accumulation strategies-which typically involve deformable image registration between planning images, deformable dose mapping, and voxel-wise dose summation-can be employed for ART to estimate the delivered dose. In MRgART, plan adaptation on MRI instead of CT necessitates additional considerations in the dose accumulation process because MRI pixel values do not contain the quantitative information used for dose calculation. In this review, we discuss considerations for dose accumulation specific to MRgART and in relation to current MR-linac clinical workflows. We present a general dose accumulation framework for MRgART and discuss relevant quality assurance criteria. Finally, we highlight the clinical importance of dose accumulation in the ART era as well as the possible ways in which dose accumulation can transform clinical practice and improve our ability to deliver personalized RT.
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Affiliation(s)
- Brigid A. McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cornel Zachiu
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Mohamed A. Naser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tuebingen, Tuebingen, Germany
| | - Daniel Létourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Daniel E. Hyer
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Jeffrey E. Snyder
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | | | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kristy K. Brock
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Maraghechi B, Mazur T, Lam D, Price A, Henke L, Kim H, Hugo GD, Cai B. Phantom-based Quality Assurance of a Clinical Dose Accumulation Technique Used in an Online Adaptive Radiation Therapy Platform. Adv Radiat Oncol 2022; 8:101138. [PMID: 36691450 PMCID: PMC9860416 DOI: 10.1016/j.adro.2022.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/01/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose This study aimed to develop a routine quality assurance method for a dose accumulation technique provided by a radiation therapy platform for online treatment adaptation. Methods and Materials Two commonly used phantoms were selected for the dose accumulation QA: Electron density and anthropomorphic pelvis. On a computed tomography (CT) scan of the electron density phantom, 1 target (gross tumor volume [GTV]; insert at 6 o'clock), a subvolume within this target, and 7 organs at risk (OARs; other inserts) were contoured in the treatment planning system (TPS). Two adaptation sessions were performed in which the GTV was recontoured, first at 7 o'clock and then at 5 o'clock. The accumulated dose was exported from the TPS after delivery. Deformable vector fields were also exported to manually accumulate doses for comparison. For the pelvis phantom, synthetic Gaussian deformations were applied to the planning CT image to simulate organ changes. Two single-fraction adaptive plans were created based on the deformed planning CT and cone beam CT images acquired onboard the radiation therapy platform. A manual dose accumulation was performed after delivery using the exported deformable vector fields for comparison with the system-generated result. Results All plans were successfully delivered, and the accumulated dose was both manually calculated and derived from the TPS. For the electron density phantom, the average mean dose differences in the GTV, boost volume, and OARs 1 to 7 were 0.0%, -0.2%, 92.0%, 78.4%, 1.8%, 1.9%, 0.0%, 0.0%, and 2.3%, respectively, between the manually summed and platform-accumulated doses. The gamma passing rates for the 3-dimensional dose comparison between the manually generated and TPS-provided dose accumulations were >99% for both phantoms. Conclusions This study demonstrated agreement between manually obtained and TPS-generated accumulated doses in terms of both mean structure doses and local 3-dimensional dose distributions. Large disagreements were observed for OAR1 and OAR2 defined on the electron density phantom due to OARs having lower deformation priority over the target in addition to artificially large changes in position induced for these structures fraction-by-fraction. The tests applied in this study to a commercial platform provide a straightforward approach toward the development of routine quality assurance of dose accumulation in online adaptation.
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Affiliation(s)
- Borna Maraghechi
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Thomas Mazur
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Dao Lam
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Alex Price
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Lauren Henke
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Geoffrey D. Hugo
- Department of Radiation Oncology, Washington University, St Louis, Missouri,Corresponding author: Geoffrey Hugo, PhD
| | - Bin Cai
- Department of Radiation Oncology, Washington University, St Louis, Missouri,Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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Singer L, Scholey J. Finding Resonance: Using MRI to Improve the Care of Oligometastatic Disease. Int J Radiat Oncol Biol Phys 2022; 114:936-940. [DOI: 10.1016/j.ijrobp.2022.06.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022]
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Nasief HG, Parchur AK, Omari E, Zhang Y, Chen X, Paulson E, Hall WA, Erickson B, Li XA. Predicting necessity of daily online adaptive replanning based on wavelet image features for MRI guided adaptive radiation therapy. Radiother Oncol 2022; 176:165-171. [PMID: 36216299 PMCID: PMC9838213 DOI: 10.1016/j.radonc.2022.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE Online adaptive replanning (OLAR) is generally labor-intensive and time-consuming during MRI-guided adaptive radiation therapy (MRgART). This work aims to develop a method to determine OLAR necessity during MRgART. METHODS A machine learning classifier was developed to predict OLAR necessity based on wavelet multiscale texture features extracted from daily MRIs and was trained and tested with data from 119 daily MRI datasets acquired during MRgART for 24 pancreatic cancer patients treated on a 1.5 T MR-Linac. Spearman correlations, interclass correlation (ICC), coefficient of variance (COV), t-test (p < 0.05), self-organized map (SOM) and maximum stable extremal region (MSER) algorithm were used to determine candidate features, which were used to build the prediction models using Bayesian classifiers. The model performance was judged using the AUC of the ROC curve. RESULTS Spearman correlation identified 123 features that were not redundant (r < 0.9). Of them 82 showed high ICC for repositioning > 0.6, 67 had a COV greater than 9% for OLAR. Among the 38 features passed the t-test, 25 passed the SOM and 12 passed the MSER. These final 12 features were used to build the classifier model. The combination of 2-3 features at a time was used to build the classifier models. The best performing model was a 3-feature combination, which can predict OLAR necessity with a CV-AUC of 0.98. CONCLUSIONS A machine learning classifier model based on the wavelet features extracted from daily MRI for pancreatic cancer was developed to automatically and objectively determine if OLAR is necessary for a treatment fraction avoiding unnecessary effort during MRgART.
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Affiliation(s)
- Haidy G Nasief
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Abdul K Parchur
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Eenas Omari
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ying Zhang
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Xinfeng Chen
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Chuong MD, Ann Clark M, Henke LE, Kishan AU, Portelance L, Parikh PJ, Bassetti MF, Nagar H, Rosenberg SA, Mehta MP, Refaat T, Rineer JM, Smith A, Seung S, Zaki BI, Fuss M, Mak RH. Patterns of Utilization and Clinical Adoption of 0.35 Tesla MR-guided Radiation Therapy in the United States - Understanding the Transition to Adaptive, Ultra-Hypofractionated Treatments. Clin Transl Radiat Oncol 2022; 38:161-168. [DOI: 10.1016/j.ctro.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
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Kisling K, Keiper TD, Branco D, Kim GG, Moore KL, Ray X. Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations. J Appl Clin Med Phys 2022; 23:e13801. [PMID: 36316805 PMCID: PMC9797177 DOI: 10.1002/acm2.13801] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 12/29/2022] Open
Abstract
Online adaptive radiotherapy platforms present a unique challenge for commissioning as guidance is lacking and specialized adaptive equipment, such as deformable phantoms, are rare. We designed a novel adaptive commissioning process consisting of end-to-end tests using standard clinical resources. These tests were designed to simulate anatomical changes regularly observed at patient treatments. The test results will inform users of the magnitude of uncertainty from on-treatment changes during the adaptive workflow and the limitations of their systems. We implemented these tests for the cone-beam computed tomography (CT)-based Varian Ethos online adaptive platform. Many adaptive platforms perform online dose calculation on a synthetic CT (synCT). To assess the impact of the synCT generation and online dose calculation on dosimetric accuracy, we conducted end-to-end tests using commonly available equipment: a CIRS IMRT Thorax phantom, PinPoint ionization chamber, Gafchromic film, and bolus. Four clinical scenarios were evaluated: weight gain and weight loss were simulated by adding and removing bolus, internal target shifts were simulated by editing the CTV during the adaptive workflow to displace it, and changes in gas were simulated by removing and reinserting rods in varying phantom locations. The effect of overriding gas pockets during planning was also assessed. All point dose measurements agreed within 2.7% of the calculated dose, with one exception: a scenario simulating gas present in the planning CT, not overridden during planning, and dissipating at treatment. Relative film measurements passed gamma analysis (3%/3 mm criteria) for all scenarios. Our process validated the Ethos dose calculation for online adapted treatment plans. Based on our results, we made several recommendations for our clinical adaptive workflow. This commissioning process used commonly available equipment and, therefore, can be applied in other clinics for their respective online adaptive platforms.
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Affiliation(s)
- Kelly Kisling
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Timothy D. Keiper
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Daniela Branco
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Grace Gwe‐Ya Kim
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Kevin L Moore
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Xenia Ray
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
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Palacios MA, Verheijen S, Schneiders FL, Bohoudi O, Slotman BJ, Lagerwaard FJ, Senan S. Same-day consultation, simulation and lung Stereotactic Ablative Radiotherapy delivery on a Magnetic Resonance-linac. Phys Imaging Radiat Oncol 2022; 24:76-81. [PMID: 36217429 PMCID: PMC9547277 DOI: 10.1016/j.phro.2022.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/09/2022] Open
Abstract
A same-day consultation and lung SABR workflow was introduced, and experience in 10 patients reported. A detailed simulation procedure and the use of real-time cine magnetic resonance imaging enabled accurate treatment delivery. All patients reported satisfaction with the procedure, which improved patient convenience. On average, at least 94.4% (5th percentile) of the GTV was always located inside the PTV during beam-on. System-latency for triggering a beam-off event comprised 5.3% of the delivery time.
Background and Purpose Magnetic resonance-guided radiotherapy (MRgRT) with real-time intra-fraction tumor motion monitoring allows for high precision Stereotactic Ablative Radiotherapy (SABR). This study aimed to investigate the clinical feasibility, patient satisfaction and delivery accuracy of single-fraction MR-guided SABR in a single day (one-stop-shop, OSS). Methods and Materials Ten patients with small lung tumors eligible for single fraction treatments were included. The OSS procedure consisted of consultation, treatment simulation, treatment planning and delivery. Following SABR delivery, patients completed a reported experience measure (PREM) questionnaire. Prescribed doses ranged 28–34 Gy. Median GTV was 2.2 cm3 (range 1.3–22.9 cm3). A gating boundary of 3 mm, and PTV margin of 5 mm around the GTV, were used with auto-beam delivery control. Accuracy of SABR delivery was studied by analyzing delivered MR-cines reconstructed from machine log files. Results All 10 patients completed the OSS procedure in a single day, and all reported satisfaction with the process. Median time for the treatment planning step and the whole procedure were 2.8 h and 6.6 h, respectively. With optimization of the procedure, treatment could be completed in half a day. During beam-on, the 3 mm tracking boundary encompassed between 78.0 and 100 % of the GTV across all patients, with corresponding PTV values being 94.4–100 % (5th-95th percentiles). On average, system-latency for triggering a beam-off event comprised 5.3 % of the delivery time. Latency reduced GTV coverage by an average of −0.3 %. Duty-cycles during treatment delivery ranged from 26.1 to 64.7 %. Conclusions An OSS procedure with MR-guided SABR for lung cancer led to good patient satisfaction. Gated treatment delivery was highly accurate with little impact of system-latency.
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McComas KN, Yock A, Darrow K, Shinohara ET. Online Adaptive Radiation Therapy and Opportunity Cost. Adv Radiat Oncol 2022. [DOI: 10.1016/j.adro.2022.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Zhou S, Meng Y, Sun X, Jin Z, Feng W, Yang H. The critical components for effective adaptive radiotherapy in patients with unresectable non-small-cell lung cancer: who, when and how. Future Oncol 2022; 18:3551-3562. [PMID: 36189758 DOI: 10.2217/fon-2022-0291] [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: 12/15/2022] Open
Abstract
Adaptive radiotherapy (ART) is a new radiotherapy technology based on image-guided radiation therapy technology, used to avoid radiation overexposure to residual tumors and the surrounding normal tissues. Tumors undergoing the same radiation doses and modes can occur unequal shrinkage due to the variation of response times to radiation doses in different patients. To perform ART effectively, eligible patients with a high probability of benefits from ART need to be identified. Confirming the precise timetable for ART in every patient is another urgent problem to be resolved. Moreover, the outcomes of ART are different depending on the various image guidance used. This review discusses 'who, when and how' as the three key factors involved in the most effective implementation for the management of ART.
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Affiliation(s)
- Suna Zhou
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shanxi, 710018, PR China
| | - Yinnan Meng
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Xuefeng Sun
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Zhicheng Jin
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
| | - Wei Feng
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, PR China
| | - Haihua Yang
- Key Laboratory of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China.,Department of Radiation Oncology, The Affiliated Taizhou Hospital, Wenzhou Medical University, Taizhou, 317000, Zhejiang, PR China
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Schiff JP, Price AT, Stowe HB, Laugeman E, Chin RI, Hatscher C, Pryser E, Cai B, Hugo GD, Kim H, Badiyan SN, Robinson CG, Henke LE. Simulated computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR) for the treatment of locally advanced pancreatic cancer. Radiother Oncol 2022; 175:144-151. [PMID: 36063981 DOI: 10.1016/j.radonc.2022.08.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE We conducted a prospective, in silico imaging clinical trial to evaluate the feasibility and potential dosimetric benefits of computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR) for the treatment of locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Eight patients with LAPC received five additional CBCTs on the ETHOS system before or after their standard of care radiotherapy treatment. Initial plans were created based on their initial simulation anatomy (PI) and emulated adaptive plans were created based on their anatomy-of-the-day (PA). The prescription was 50 Gy/5 fractions. Plans were created under a strict isotoxicity approach, in which organ-at-risk (OAR) constraints were prioritized over planning target volume coverage. The PI was evaluated on the patient's anatomy-of-the-day, compared to the daily PA, and the superior plan was selected. Feasibility was defined as successful completion of the workflow in compliance with strict OAR constraints in ≥80% of fractions. RESULTS CT-STAR was feasible in silico for LAPC and improved OAR and/or target dosimetry in 100% of fractions. Use of the PI based on the patient's anatomy-of-the-day would have yielded a total of 94 OAR constraint violations and ≥1 hard constraint violation in 40/40 fractions. In contrast, 39/40 PA met all OAR constraints. In one fraction, the PA minimally exceeded the large bowel constraint, although dosimetrically improved compared to the PI. Total workflow time per fraction was 36.28 minutes (27.57-55.86). CONCLUSION CT-STAR for the treatment of LAPC cancer proved feasible and was dosimetrically superior to non-adapted CT-stereotactic body radiotherapy.
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Affiliation(s)
- Joshua P Schiff
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Casey Hatscher
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Eleanor Pryser
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390, USA.
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
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Delpon G, Barateau A, Beneux A, Bessières I, Latorzeff I, Welmant J, Tallet A. [What do we need to deliver "online" adapted radiotherapy treatment plans?]. Cancer Radiother 2022; 26:794-802. [PMID: 36028418 DOI: 10.1016/j.canrad.2022.06.024] [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: 06/22/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
During the joint SFRO/SFPM session of the 2019 congress, a state of the art of adaptive radiotherapy announced a strong impact in our clinical practice, in particular with the availability of treatment devices coupled to an MRI system. Three years later, it seems relevant to take stock of adaptive radiotherapy in practice, and especially the "online" strategy because it is indeed more and more accessible with recent hardware and software developments, such as coupled accelerators to a three-dimensional imaging device and algorithms based on artificial intelligence. However, the deployment of this promising strategy is complex because it contracts the usual time scale and upsets the usual organizations. So what do we need to deliver adapted treatment plans with an "online" strategy?
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Affiliation(s)
- G Delpon
- Institut de cancérologie de l'Ouest, Saint-Herblain et IMT Atlantique, Nantes université, CNRS/IN2P3, Subatech, Nantes, France.
| | - A Barateau
- Université Rennes, CLCC Eugène-Marquis, Inserm, LTSI-UMR 1099, Rennes, France
| | - A Beneux
- Hospices Civils de Lyon, Lyon, France
| | - I Bessières
- Centre Georges-François Leclerc, Dijon, France
| | | | - J Welmant
- Institut du cancer de Montpellier, Montpellier, France
| | - A Tallet
- Institut Paoli-Calmettes, Marseille, France
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Slotman BJ, Clark MA, Özyar E, Kim M, Itami J, Tallet A, Debus J, Pfeffer R, Gentile P, Hama Y, Andratschke N, Riou O, Camilleri P, Belka C, Quivrin M, Kim B, Pedersen A, van Overeem Felter M, Kim YI, Kim JH, Fuss M, Valentini V. Clinical adoption patterns of 0.35 Tesla MR-guided radiation therapy in Europe and Asia. Radiat Oncol 2022; 17:146. [PMID: 35996192 PMCID: PMC9396857 DOI: 10.1186/s13014-022-02114-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Magnetic resonance-guided radiotherapy (MRgRT) utilization is rapidly expanding, driven by advanced capabilities including better soft tissue imaging, continuous intrafraction target visualization, automatic triggered beam delivery, and the availability of on-table adaptive replanning. Our objective was to describe patterns of 0.35 Tesla (T)-MRgRT utilization in Europe and Asia among early adopters of this novel technology.
Methods Anonymized administrative data from all 0.35T-MRgRT treatment systems in Europe and Asia were extracted for patients who completed treatment from 2015 to 2020. Detailed treatment information was analyzed for all MR-linear accelerators (linac) and -cobalt systems.
Results From 2015 through the end of 2020, there were 5796 completed treatment courses delivered in 46,389 individual fractions. 23.5% of fractions were adapted. Ultra-hypofractionated (UHfx) dose schedules (1–5 fractions) were delivered for 63.5% of courses, with 57.8% of UHfx fractions adapted on-table. The most commonly treated tumor types were prostate (23.5%), liver (14.5%), lung (12.3%), pancreas (11.2%), and breast (8.0%), with increasing compound annual growth rates (CAGRs) in numbers of courses from 2015 through 2020 (pancreas: 157.1%; prostate: 120.9%; lung: 136.0%; liver: 134.2%). Conclusions This is the first comprehensive study reporting patterns of utilization among early adopters of a 0.35T-MRgRT system in Europe and Asia. Intrafraction MR image-guidance, advanced motion management, and increasing adoption of on-table adaptive RT have accelerated a transition to UHfx regimens. MRgRT has been predominantly used to treat tumors in the upper abdomen, pelvis and lungs, and increasingly with adaptive replanning, which is a radical departure from legacy radiotherapy practices.
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Affiliation(s)
| | - Mary Ann Clark
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA.
| | - Enis Özyar
- Department of Radiation Oncology, School of Medicine, Acibadem MAA University, Istanbul, Turkey
| | - Myungsoo Kim
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Itami
- Radiation Oncology, National Cancer Center Japan, Tokyo, Japan
| | - Agnès Tallet
- Radiation Therapy Department, Institut Paoli-Calmettes, Marseille, France.,CRCM Inserm UMR1068, Marseille, France
| | - Jürgen Debus
- Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centers, Tel Aviv, Israel
| | - PierCarlo Gentile
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | | | | | - Olivier Riou
- Montpellier Cancer Institute (ICM), University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier University, INSERM U1194 IRCM, 34298, Montpellier, France
| | | | - Claus Belka
- Radiation Oncology, Klinikum der Universität München, Munich, Germany
| | - Magali Quivrin
- Radiation Oncology, Centre Georges-Francois Leclerc, Dijon, France
| | - BoKyong Kim
- Department of Radiation Oncology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | | | | | - Young Il Kim
- Radiation Oncology, Chungnam National University Sejong Hospital, Daejeon, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Martin Fuss
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA
| | - Vincenzo Valentini
- Radiology, Radiation Oncology and Hematology Dept., Università Cattolica S.Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Rammohan N, Randall JW, Yadav P. History of Technological Advancements towards MR-Linac: The Future of Image-Guided Radiotherapy. J Clin Med 2022; 11:jcm11164730. [PMID: 36012969 PMCID: PMC9409689 DOI: 10.3390/jcm11164730] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/27/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Image-guided radiotherapy (IGRT) enables optimal tumor targeting and sparing of organs-at-risk, which ultimately results in improved outcomes for patients. Magnetic resonance imaging (MRI) revolutionized diagnostic imaging with its superior soft tissue contrast, high spatiotemporal resolution, and freedom from ionizing radiation exposure. Over the past few years there has been burgeoning interest in MR-guided radiotherapy (MRgRT) to overcome current challenges in X-ray-based IGRT, including but not limited to, suboptimal soft tissue contrast, lack of efficient daily adaptation, and incremental exposure to ionizing radiation. In this review, we present an overview of the technologic advancements in IGRT that led to MRI-linear accelerator (MRL) integration. Our report is organized in three parts: (1) a historical timeline tracing the origins of radiotherapy and evolution of IGRT, (2) currently available MRL technology, and (3) future directions and aspirations for MRL applications.
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MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges. Int J Radiat Oncol Biol Phys 2022; 114:950-967. [PMID: 35901978 DOI: 10.1016/j.ijrobp.2022.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting. METHODS AND MATERIALS We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT. RESULTS Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered. CONCLUSIONS The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.
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Towards Accurate and Precise Image-Guided Radiotherapy: Clinical Applications of the MR-Linac. J Clin Med 2022; 11:jcm11144044. [PMID: 35887808 PMCID: PMC9324978 DOI: 10.3390/jcm11144044] [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: 04/13/2022] [Revised: 06/24/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Advances in image-guided radiotherapy have brought about improved oncologic outcomes and reduced toxicity. The next generation of image guidance in the form of magnetic resonance imaging (MRI) will improve visualization of tumors and make radiation treatment adaptation possible. In this review, we discuss the role that MRI plays in radiotherapy, with a focus on the integration of MRI with the linear accelerator. The MR linear accelerator (MR-Linac) will provide real-time imaging, help assess motion management, and provide online adaptive therapy. Potential advantages and the current state of these MR-Linacs are highlighted, with a discussion of six different clinical scenarios, leading into a discussion on the future role of these machines in clinical workflows.
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Werensteijn-Honingh AM, Kroon PS, Winkel D, van Gaal JC, Hes J, Snoeren LM, Timmer JK, Mout CC, Bol GH, Kotte AN, Eppinga WS, Intven M, Raaymakers BW, Jürgenliemk-Schulz IM. Impact of magnetic resonance-guided versus conventional radiotherapy workflows on organ at risk doses in stereotactic body radiotherapy for lymph node oligometastases. Phys Imaging Radiat Oncol 2022; 23:66-73. [PMID: 35814260 PMCID: PMC9263510 DOI: 10.1016/j.phro.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/10/2022] [Accepted: 06/27/2022] [Indexed: 10/29/2022] Open
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Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
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Pedersen LN, Khoobchandani M, Brenneman R, Mitchell JD, Bergom C. Radiation-Induced Cardiac Dysfunction: Optimizing Radiation Delivery and Postradiation Care. Heart Fail Clin 2022; 18:403-413. [PMID: 35718415 DOI: 10.1016/j.hfc.2022.02.012] [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] [Indexed: 11/29/2022]
Abstract
Radiation therapy (RT) is part of standard-of-care treatment of many thoracic cancers. More than 60% of patients receiving thoracic RT may eventually develop radiation-induced cardiac dysfunction (RICD) secondary to collateral heart dose. This article reviews factors contributing to a thoracic cancer patient's risk for RICD, including RT dose to the heart and/or cardiac substructures, other anticancer treatments, and a patient's cardiometabolic health. It is also discussed how automated tracking of these factors within electronic medical record environments may aid radiation oncologists and other treating physicians in their ability to prevent, detect, and/or treat RICD in this expanding patient population.
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Affiliation(s)
- Lauren N Pedersen
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, St. Louis, MO 63110, USA
| | - Menka Khoobchandani
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, St. Louis, MO 63110, USA
| | - Randall Brenneman
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, St. Louis, MO 63110, USA; Alvin J. Siteman Center, Washington University in St. Louis, St Louis, MO, USA
| | - Joshua D Mitchell
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St Louis, MO, USA; Alvin J. Siteman Center, Washington University in St. Louis, St Louis, MO, USA; Division of Cardiology, Department of Medicine, Washington University in St. Louis, St Louis, MO, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, St. Louis, MO 63110, USA; Cardio-Oncology Center of Excellence, Washington University in St. Louis, St Louis, MO, USA; Alvin J. Siteman Center, Washington University in St. Louis, St Louis, MO, USA.
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Breto AL, Spieler B, Zavala-Romero O, Alhusseini M, Patel NV, Asher DA, Xu IR, Baikovitz JB, Mellon EA, Ford JC, Stoyanova R, Portelance L. Deep Learning for Per-Fraction Automatic Segmentation of Gross Tumor Volume (GTV) and Organs at Risk (OARs) in Adaptive Radiotherapy of Cervical Cancer. Front Oncol 2022; 12:854349. [PMID: 35664789 PMCID: PMC9159296 DOI: 10.3389/fonc.2022.854349] [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: 01/13/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background/Hypothesis MRI-guided online adaptive radiotherapy (MRI-g-OART) improves target coverage and organs-at-risk (OARs) sparing in radiation therapy (RT). For patients with locally advanced cervical cancer (LACC) undergoing RT, changes in bladder and rectal filling contribute to large inter-fraction target volume motion. We hypothesized that deep learning (DL) convolutional neural networks (CNN) can be trained to accurately segment gross tumor volume (GTV) and OARs both in planning and daily fractions' MRI scans. Materials/Methods We utilized planning and daily treatment fraction setup (RT-Fr) MRIs from LACC patients, treated with stereotactic body RT to a dose of 45-54 Gy in 25 fractions. Nine structures were manually contoured. MASK R-CNN network was trained and tested under three scenarios: (i) Leave-one-out (LOO), using the planning images of N- 1 patients for training; (ii) the same network, tested on the RT-Fr MRIs of the "left-out" patient, (iii) including the planning MRI of the "left-out" patient as an additional training sample, and tested on RT-Fr MRIs. The network performance was evaluated using the Dice Similarity Coefficient (DSC) and Hausdorff distances. The association between the structures' volume and corresponding DSCs was investigated using Pearson's Correlation Coefficient, r. Results MRIs from fifteen LACC patients were analyzed. In the LOO scenario the DSC for Rectum, Femur, and Bladder was >0.8, followed by the GTV, Uterus, Mesorectum and Parametrium (0.6-0.7). The results for Vagina and Sigmoid were suboptimal. The performance of the network was similar for most organs when tested on RT-Fr MRI. Including the planning MRI in the training did not improve the segmentation of the RT-Fr MRI. There was a significant correlation between the average organ volume and the corresponding DSC (r = 0.759, p = 0.018). Conclusion We have established a robust workflow for training MASK R-CNN to automatically segment GTV and OARs in MRI-g-OART of LACC. Albeit the small number of patients in this pilot project, the network was trained to successfully identify several structures while challenges remain, especially in relatively small organs. With the increase of the LACC cases, the performance of the network will improve. A robust auto-contouring tool would improve workflow efficiency and patient tolerance of the OART process.
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Affiliation(s)
- Adrian L Breto
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Benjamin Spieler
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Olmo Zavala-Romero
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Mohammad Alhusseini
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Nirav V Patel
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - David A Asher
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Isaac R Xu
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jacqueline B Baikovitz
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - John C Ford
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Radka Stoyanova
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Lorraine Portelance
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
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Lay LM, Chuang K, Wu Y, Giles W, Adamson J. Virtual patient‐specific QA with DVH‐based metrics. J Appl Clin Med Phys 2022; 23:e13639. [DOI: 10.1002/acm2.13639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/15/2022] [Accepted: 04/25/2022] [Indexed: 12/11/2022] Open
Affiliation(s)
- Lam M. Lay
- Medical Physics Graduate Program Duke University Durham North Carolina USA
| | - Kai‐Cheng Chuang
- Medical Physics Graduate Program Duke Kunshan University Kunshan China
| | - Yuyao Wu
- Medical Physics Graduate Program Duke Kunshan University Kunshan China
| | - William Giles
- Department of Radiation Oncology Duke University Medical Center Durham North Carolina USA
| | - Justus Adamson
- Department of Radiation Oncology Duke University Medical Center Durham North Carolina USA
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Kim H, Lee P, Tree AC, Chuong MD, Raldow AC, Kishan AU, Fuller CD, Rosenberg SA, Hall WA, Chie EK, Portelance L. Adaptive radiation therapy physician guidelines: Recommendations from an expert users’ panel. Pract Radiat Oncol 2022; 12:e355-e362. [DOI: 10.1016/j.prro.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
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