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Pollul G, Grossmann S, Karle H, Bostel T, Schmidberger H. Improving organ dose sparing in left-sided breast cancer with yaw-limited volumetric modulated arc therapy: A dosimetric comparison to conventional and intensity modulated radiation therapy approaches. J Appl Clin Med Phys 2025; 26:e70041. [PMID: 40022457 PMCID: PMC12059266 DOI: 10.1002/acm2.70041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 11/12/2024] [Accepted: 01/05/2025] [Indexed: 03/03/2025] Open
Abstract
BACKGROUND To assess the dose-sparing capabilities of a yaw-limited volumetric modulated arc therapy (YL_VMAT) beam setup for adjacent organs at risk (OAR) in comparison with 3D-conventional radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT) and conventional VMAT for radiation therapy in left-sided breast cancer patients. METHODS In total, 80 treatment plans for 20 patients, of which 10 patients underwent CT-scans in deep inspiration breath-hold (DIBH) and 10 patients in free-breathing (FB) technique. Besides generally tangential-weighted static and IMRT beams, VMAT treatment plans with approximately 270° arc length have been compared and analyzed to a multi-field, yaw-adapted, unconventional partial VMAT technique retrospectively. The prescription dose was set to 40.05 Gy in 15 fractions. RESULTS We achieved a more pronounced steeper dose falloff directed from the thoracic wall to the adjacent lung tissue resulting in a significantly better ipsilateral lung and considerably cardiac dose sparing using the YL_VMAT method in general. Compared with standard techniques (IMRT, VMAT, 3D-CRT), YL-VMAT in combination with DIBH can achieve lower mean doses for the heart (1.05 Gy vs. 1.73 Gy, 2.16 Gy and 1.44 Gy), the left anterior descending (LAD) artery (3.68 Gy vs. 6.53 Gy, 5.13 Gy and 8.64 Gy) and the left lung (3.59 Gy vs. 5.39 Gy, 4.79 Gy and 5.87 Gy), respectively. Also with FB, the corresponding mean doses for the left lung and cardiac structures were lower with the YL-VMAT method than with IMRT (heart: 1.70 Gy vs. 2.44 Gy; LAD: 6.50 Gy vs. 11.97 Gy; left lung: 3.10 Gy vs. 4.72 Gy), VMAT (heart: 1.70 Gy vs. 2.52 Gy; LAD: 6.50 Gy vs. 9.06 Gy; left lung: 3.10 Gy vs. 4.46 Gy) and 3D-CRT (heart: 1.70 Gy vs. 2.78 Gy; LAD: 6.50 Gy vs. 15.09 Gy; left lung: 3.10 Gy vs. 5.77 Gy). In addition, we found out superiority of YL_VMAT for the V5, V10, and V20 Gy to the left lung. For DIBH and FB, all differences for the left lung were significant, with p < 0.05. CONCLUSIONS With the YL_VMAT technique, dose exposures to radiosensitive OARs like the lung, heart and LAD artery can be reduced considerably to very low values in comparison to already established planning methods. The benefits must be weighed against the potential risks induced by an increased dose exposure to the contralateral breast.
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Affiliation(s)
- Gerhard Pollul
- Department of Radiation OncologyUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Sascha Grossmann
- Department of Radiation OncologyUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Heiko Karle
- Department of Radiation OncologyUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Tilman Bostel
- Department of Radiation OncologyUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Heinz Schmidberger
- Department of Radiation OncologyUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
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Loebner HA, Bertholet J, Mackeprang PH, Volken W, Fix MK, Manser P. Robustness assessment of radiotherapy treatment plans in Switzerland. Z Med Phys 2025:S0939-3889(25)00037-6. [PMID: 40263012 DOI: 10.1016/j.zemedi.2025.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Revised: 01/24/2025] [Accepted: 03/21/2025] [Indexed: 04/24/2025]
Abstract
PURPOSE Robustness assessment is an essential part of radiotherapy plan quality assessment. However, it is often not evaluated in photon-based radiotherapy. This study aims to conduct a robustness audit to establish a baseline for the role of plan robustness in Switzerland by assessing and comparing robustness across plans from and clinical workflows in multiple institutions. MATERIALS AND METHODS A multi-institutional study involving 11 Swiss institutions was conducted. Each institution provided treatment plans for three cases and completed a questionnaire on treatment planning and assessment of robustness in their clinical practice. The plans were planned using the Eclipse treatment planning system and utilized intensity-modulated techniques using a 6 MV flattened photon beam for one brain case, and one unilateral and one bilateral head and neck cases, prescribed 60.0 Gy (one phase), 70.0 Gy (two phases) and 70.0 Gy (three phases) to 95% of the target volume, respectively. Institutions used their standard institutional protocols for the provided CT, structures and prescription. Dose distributions were subsequently recalculated in an in-house Monte Carlo (MC) framework incorporating clinically motivated uncertainties associated to patient setup and multi-leaf collimator (MLC) positions. The uncertainties' impact on the dosimetric plan quality was assessed by evaluating representative target and organ-at-risk (OAR) dose-volume endpoints (e.g. D98% and D2% of the target, mean dose of parallel OARs and near max dose of serial OARs). RESULTS Differences in target and OAR dose-volume endpoints in the presence of random patient setup uncertainties (Gaussian distributed with σ = 0.2 cm in the three translational and σ = 0.5° in the three rotational axes) were smaller than ±0.5 Gy. Exceptions were the near max dose-volume endpoints of structures near the target with differences up to ±2.2 Gy for the optic nerve in the brain case. Systematic rotational patient setup uncertainties of ≤3° in either pitch, yaw or roll had similar impact as translational uncertainties ≤0.3 cm in either left-right, superior inferior or anterior-posterior direction with maximal differences in most investigated dose-volume endpoints of 9.0 Gy. Systematic MLC uncertainties of +0.5 mm of all leaves led to an average increase of up to 3.0 Gy in the dose-volume endpoints. The questionnaire revealed diverse practices in terms of planning and assessment for robustness: all institutions use target and OAR margins, 2/11 use robust optimization and 5/11 regularly perform robustness assessments of treatment plans by recalculating the dose distribution including uncertainties. The importance of robustness in treatment planning was rated ≥8 out of 10 (10 as most important) by 6/11 institutions. The need for better commercial tools to assess or integrate robustness into treatment planning was expressed by 9/11 institutions. CONCLUSION This study presents the first multi-institutional inter-comparison of treatment plan robustness in Switzerland, establishing a robustness baseline for intensity-modulated plans. Despite diverse practices to assess plan robustness and to mitigate the impact of uncertainties on dosimetric plan quality, the robustness to the investigated uncertainties was similar across the plans and cases from all institutes. To foster standardization, we recommend to regularly conduct audits focusing on plan robustness to monitor and reduce inter-institutional variability in handling and assessing plan robustness.
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Affiliation(s)
- Hannes A Loebner
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Paul-Henry Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Werner Volken
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Michael K Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Costin IC, Marcu LG. Patient and treatment-related factors that influence dose to heart and heart substructures in left-sided breast cancer radiotherapy. Phys Med 2024; 128:104851. [PMID: 39504787 DOI: 10.1016/j.ejmp.2024.104851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 10/22/2024] [Accepted: 10/24/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND Cardiac substructures are critical organs at risk in left-sided breast cancer radiotherapy being often overlooked during treatment planning. The treatment technique plays an important role in diminishing dose to critical structures. This review aims to analyze the impact of treatment- and patient-related factors on heart substructure dosimetry and to identify the gaps in literature regarding dosimetric reporting of cardiac substructures. METHODS A systematic search of the literature was conducted in Medline/Pubmed database incorporating data published over the past 10 years, leading to 81 eligible studies. Treatment-related factors analyzed for their impact on patient outcome included the number of treatment fields, field geometry, treatment time and monitor units. Additionally, patient-related parameters such as breast size and tumor shape were considered for cardiac dosimetry evaluation. RESULTS Limited number of fields appeared to be an advantage for mean heart dose reduction when tangential IMRT versus multiple fields IMRT was evaluated. Larger breast size (910.20 ± 439.80 cm3) is linked to larger treatment fields and higher heart doses. Internal mammary node irradiation further escalates cardiac substructures dosimetry treated with 3DCRT and IMRT/VMAT. Proton therapy delivers lower mean heart dose regardless of breathing condition (free or respiratory-gated). CONCLUSION The management of treatment- and patient-related factors must be taken into account regardless of the treatment technique when evaluating cardiac dose. Furthermore, the gap found in the literature regarding heart toxicity assessment in left-sided breast cancer patients emphasizes the need for cardiac substructure contouring to better manage and control radiation-induced cardiac toxicities in this patient group.
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Affiliation(s)
- Ioana-Claudia Costin
- West University of Timisoara, Faculty of Physics, 300223, Timisoara, Romania; Emergency County Hospital, Oradea 410167, Romania
| | - Loredana G Marcu
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA 5001, Australia; Faculty of Informatics & Science, University of Oradea, Oradea 410087, Romania.
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Wang SJ, Zhai YR, Zhang WW, Chen SY, Qin SR, Fang H, Tang Y, Song YW, Liu YP, Chen B, Qi SN, Tang Y, Lu NN, Li YX, Jing H, Wang SL. Dosimetric benefit and clinical feasibility of deep inspiration breath-hold and volumetric modulated arc therapy-based postmastectomy radiotherapy for left-sided breast cancer. Sci Rep 2024; 14:24638. [PMID: 39428424 PMCID: PMC11491445 DOI: 10.1038/s41598-024-75560-5] [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: 05/15/2024] [Accepted: 10/07/2024] [Indexed: 10/22/2024] Open
Abstract
To evaluate the dosimetric benefits and clinical feasibility of deep inspiratory breath-hold (DIBH) combined with volumetric modulated arc therapy (VMAT) in left-sided postmastectomy radiotherapy (PMRT). Eligible patients with left-sided breast cancer undergoing DIBH-based PMRT were prospectively included. Chest wall, supra/infraclavicular fossa, and/or internal mammary node irradiation (IMNI) were planned with a prescription dose of 43.5 Gy in 15 fractions. VMAT plans were designed on free breathing (FB)-and DIBH-CT to compare dosimetric parameters in heart, left anterior descending artery (LAD) and lung. Cone-beam computed tomography (CBCT) was performed before and after treatment to evaluate inter- and intra-fractional setup errors. Heart position and dose variations during treatment were estimated by fusing CBCT with DIBH-CT scans.Twenty patients were included with 10 receiving IMNI. In total, 193 pre-treatment and 39 pairs pre- and post-treatment CBCT scans were analyzed. The Dmean, Dmax, and V5-40 of the heart, LAD, and left lung were significantly lower in DIBH than FB (p < 0.05 for all), except for V5 of LAD (p = 0.167). The cardiopulmonary dosimetric benefits were maintained regardless of IMNI. The inter- and intra-fractional setup errors were < 0.3 cm; and the overall estimated PTV margins were < 1.0 cm. During treatment, the mean dice similarity coefficient of heart position and the mean ratio of heart Dmean between CBCT and DIBH-CT plans was 0.95 (0.88-1.00) and 100% (70.6-119.5%), respectively. DIBH-VMAT could effectively reduce the cardiopulmonary doses with acceptable reproducibility and stability in left-sided PMRT regardless of IMNI.
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Affiliation(s)
- Shi-Jia Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yi-Rui Zhai
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wen-Wen Zhang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Si-Ye Chen
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shi-Rui Qin
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hui Fang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yu Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yong-Wen Song
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yue-Ping Liu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Bo Chen
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shu-Nan Qi
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yuan Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ning-Ning Lu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ye-Xiong Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Hao Jing
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Shu-Lian Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Costin IC, Cinezan C, Marcu LG. Cardio-oncology concerns in radiotherapy: Heart and cardiac substructure toxicities from modern delivery techniques. Crit Rev Oncol Hematol 2024; 204:104538. [PMID: 39427839 DOI: 10.1016/j.critrevonc.2024.104538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 10/12/2024] [Accepted: 10/15/2024] [Indexed: 10/22/2024] Open
Abstract
Cardio-oncology is lately gaining more attention due to radiation-induced cardiac events reported by a very large number of studies. In view of this, the current overview of the literature aimed to encompass all studies from the past 15 years to assess changes in cardiac dose due to treatment evolution, as well as the changes in treatment planning customs to incorporate not only the heart as a whole but also cardiac substructures. Modern treatment techniques, particularly proton therapy, offers superior cardiac sparing compared to more established radiotherapy, for all evaluated tumor sites. Intensity modulation, particularly coupled with respiratory gating shows significant improvement in dose-volume parameters pertaining to the heart. While past studies considered mean heart dose as the only reference for cardiac toxicities, recommendations for the other cardiac substructures to be dosimetrically assessed during planning are becoming more common.
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Affiliation(s)
- Ioana-Claudia Costin
- West University of Timisoara, Faculty of Physics, Timisoara 300223, Romania; Clinical Emergency County Hospital Bihor, Oradea 410169, Romania
| | - Corina Cinezan
- Clinical Emergency County Hospital Bihor, Oradea 410169, Romania; Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410087, Romania
| | - Loredana G Marcu
- Faculty of Informatics & Science, University of Oradea, Oradea 410087, Romania; UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA 5001, Australia.
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Huijskens S, Granton P, Fremeijer K, van Wanrooij C, Offereins-van Harten K, Schouwenaars-van den Beemd S, Hoogeman MS, Sattler MGA, Penninkhof J. Clinical practicality and patient performance for surface-guided automated VMAT gating for DIBH breast cancer radiotherapy. Radiother Oncol 2024; 195:110229. [PMID: 38492672 DOI: 10.1016/j.radonc.2024.110229] [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: 12/22/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE To evaluate the performance of automated surface-guided gating for left-sided breast cancer with DIBH and VMAT. MATERIALS AND METHODS Patients treated in the first year after introduction of DIBH with VMAT were retrospectively considered for analysis. With automated surface-guided gating the beam automatically switches on/off, if the surface region of interest moved in/out the gating tolerance (±3 mm, ±3°). Patients were coached to hold their breath as long as comfortably possible. Depending on the patient's preference, patients received audio instructions during treatment delivery. Real-time positional variations of the breast/chest wall surface with respect to the reference surface were collected, for all three orthogonal directions. The durations and number of DIBHs needed to complete dose delivery, and DIBH position variations were determined. To evaluate an optimal gating window threshold, smaller tolerances of ±2.5 mm, ±2.0 mm, and ±1.5 mm were simulated. RESULTS 525 fractions from 33 patients showed that median DIBH duration was 51 s (range: 30-121 s), and median 4 DIBHs per fraction were needed to complete VMAT dose delivery. Median intra-DIBH stability and intrafractional DIBH reproducibility approximated 1.0 mm in each direction. No large differences were found between patients who preferred to perform the DIBH procedure with (n = 21) and without audio-coaching (n = 12). Simulations demonstrated that gating window tolerances could be reduced from ±3.0 mm to ±2.0 mm, without affecting beam-on status. CONCLUSION Independent of the use of audio-coaching, this study demonstrates that automated surface-guided gating with DIBH and VMAT proved highly efficient. Patients' DIBH performance far exceeded our expectations compared to earlier experiences and literature. Furthermore, gating window tolerances could be reduced.
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Affiliation(s)
- Sophie Huijskens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands.
| | - Patrick Granton
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kimm Fremeijer
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Cynthia van Wanrooij
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kirsten Offereins-van Harten
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | | | - Mischa S Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Margriet G A Sattler
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Joan Penninkhof
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
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Nowicka Z, Kuna K, Łaszczych M, Łazar-Poniatowska M, Sobocki BK, Stawiski K, Dąbrowski M, Bruski K, Zięba A, Pajdziński M, Staniewska E, Miszczyk M, Paganetti H, Fendler W, Tomasik B. Dose-volume metric-based prediction of radiotherapy-induced lymphocyte loss in patients with non-small-cell lung cancer treated with modern radiotherapy techniques. Phys Imaging Radiat Oncol 2024; 30:100593. [PMID: 38912008 PMCID: PMC11190719 DOI: 10.1016/j.phro.2024.100593] [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: 01/02/2024] [Revised: 05/12/2024] [Accepted: 05/25/2024] [Indexed: 06/25/2024] Open
Abstract
Background and Purpose Radiation-induced lymphopenia (RIL) is a common side effect of radiotherapy (RT) that may negatively impact survival. We aimed to identify RIL predictors in patients with non-small-cell lung cancer (NSCLC) treated intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). Materials and Methods We retrospectively analysed data of 306 patients who underwent radical RT for NSCLC. Absolute lymphocyte count (ALC) loss was evaluated for each patient by fitting an exponential decay curve to data from first 45 days since treatment start, and percentage ALC loss relative to baseline was calculated based on area under the decay curve and baseline ALC. We compared IMRT and VMAT treatment plans and used linear regression to predict ALC loss. Results ALC decreased during RT in the whole patient group, while neutrophil counts remained stable and decreased only in those treated with concurrent chemoradiotherapy (CRT). Percentage ALC loss ranged between 11 and 78 % and was more strongly than lymphocyte nadir correlated with dose-volume metrics for relevant normal structures. We found evidence for the association of high radiation dose to the lungs, heart and body with percentage ALC loss, with lung volume exposed to 20-30 Gy being most important predictors in patients treated with IMRT. A multivariable model based on CRT use, baseline ALC and first principal component (PC1) of the dose-volume predictors showed good predictive performance (bias-corrected R2 of 0.40). Conclusion Percentage lymphocyte loss is a robust measure of RIL that is predicted by baseline ALC, CRT use and dose-volume parameters to the lungs, heart and body.
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Affiliation(s)
- Zuzanna Nowicka
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, Łódź, Poland
| | - Kasper Kuna
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, Łódź, Poland
| | - Mateusz Łaszczych
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, Łódź, Poland
| | | | - Bartosz Kamil Sobocki
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, Łódź, Poland
| | - Michał Dąbrowski
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Konrad Bruski
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Adam Zięba
- Department of Radiotherapy, Medical University of Łódź, Łódź, Poland
| | | | - Emilia Staniewska
- 3 Radiotherapy and Chemotherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Marcin Miszczyk
- 3 Radiotherapy and Chemotherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
- Collegium Medicum, Faculty of Medicine, WSB University, Dąbrowa Górnicza, Poland
| | - Harald Paganetti
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, Łódź, Poland
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Bartłomiej Tomasik
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
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Mankinen M, Virén T, Seppälä J, Koivumäki T. Interfractional variation in whole-breast VMAT irradiation: a dosimetric study with complementary SGRT and CBCT patient setup. Radiat Oncol 2024; 19:21. [PMID: 38347554 PMCID: PMC10863193 DOI: 10.1186/s13014-024-02418-5] [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: 09/04/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The dosimetric effect of setup uncertainty and tissue deformations in left-sided whole-breast irradiation with complementary surface-guided radiotherapy (SGRT) and cone-beam computed tomography (CBCT) setup was evaluated. METHOD Treatment courses of 40.05 Gy prescribed dose in 15 fractions were simulated for 29 patients by calculating the dose on deformed CT images, that were based on daily CBCT images, and deforming and accumulating the dose onto the planning CT image. Variability in clinical target volume (CTV) position and shape was assessed as the 95% Hausdorff distance (HD95) between the planning CTV and deformed CTV structures. DVH metrics were evaluated between the planned and simulated cumulative dose distributions using two treatment techniques: tangential volumetric modulated arc therapy (tVMAT) and conventional 3D-conformal radiotherapy (3D-CRT). RESULTS Based on the HD95 values, the variations in CTV shape and position were enclosed by the 5 mm CTV-PTV margin in 85% of treatment fractions using complementary CBCT and SGRT setup. A residual error of 8.6 mm was observed between the initial SGRT setup and CBCT setup. The median CTV V95% coverage was 98.1% (range 93.1-99.8%) with tVMAT and 98.2% (range 84.5-99.7%) with 3D-CRT techniques with CBCT setup. With the initial SGRT-only setup, the corresponding coverages were 96.3% (range 92.6-99.4%) and 96.6% (range 84.2-99.4%), respectively. However, a considerable bias in vertical residual error between initial SGRT setup and CBCT setup was observed. Clinically relevant changes between the planned and cumulative doses to organs-at-risk (OARs) were not observed. CONCLUSIONS The CTV-to-PTV margin should not be reduced below 5 mm even with daily CBCT setup. Both tVMAT and 3D-CRT techniques were robust in terms of dose coverage to the target and OARs. Based on the shifts between setup methods, CBCT setup is recommended as a complementary method with SGRT.
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Affiliation(s)
- M Mankinen
- Deparment of Physics, University of Jyväskylä (JYU), Survontie 9 C, 40014, Jyväskylä, Finland.
- Deparment of Medical Physics, Hospital Nova of Central Finland, Wellbeing Services County of Central Finland, Jyväskylä, Finland.
| | - T Virén
- Center of Oncology, Kuopio University Hospital (KUH), The Wellbeing Services Country of North Savo, Kuopio, Finland
| | - J Seppälä
- Center of Oncology, Kuopio University Hospital (KUH), The Wellbeing Services Country of North Savo, Kuopio, Finland
| | - T Koivumäki
- Deparment of Physics, University of Jyväskylä (JYU), Survontie 9 C, 40014, Jyväskylä, Finland
- Deparment of Medical Physics, Hospital Nova of Central Finland, Wellbeing Services County of Central Finland, Jyväskylä, Finland
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Gnerucci A, Esposito M, Ghirelli A, Pini S, Paoletti L, Barca R, Fondelli S, Alpi P, Grilli B, Rossi F, Scoccianti S, Russo S. Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds. Strahlenther Onkol 2024; 200:71-82. [PMID: 37380796 DOI: 10.1007/s00066-023-02102-9] [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: 11/19/2022] [Accepted: 05/16/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE The robustness of surface-guided (SG) deep-inspiration breath-hold (DIBH) radiotherapy (RT) for left breast cancer was evaluated by investigating any potential dosimetric effects due to the residual intrafractional motion allowed by the selected beam gating thresholds. The potential reduction of DIBH benefits in terms of organs at risk (OARs) sparing and target coverage was evaluated for conformational (3DCRT) and intensity-modulated radiation therapy (IMRT) techniques. METHODS A total of 192 fractions of SGRT DIBH left breast 3DCRT treatment for 12 patients were analyzed. For each fraction, the average of the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift") during beam-on was evaluated and applied to the original plan isocenter. The dose distribution for the treatment beams with the new isocenter point was then calculated and the total plan dose distribution was obtained by summing the estimated perturbed dose for each fraction. Then, for each patient, the original plan and the perturbed one were compared by means of Wilcoxon test for target coverage and OAR dose-volume histogram (DVH) metrics. A global plan quality score was calculated to assess the overall plan robustness against intrafractional motion of both 3DCRT and IMRT techniques. RESULTS Target coverage and OAR DVH metrics did not show significant variations between the original and the perturbed plan for the IMRT techniques. 3DCRT plans showed significant variations for the left descending coronary artery (LAD) and the humerus only. However, none of the dose metrics exceeded the mandatory dose constraints for any of the analyzed plans. The global plan quality analysis indicated that both 3DCRT and IMRT techniques were affected by the isocenter shifts in the same way and, generally, the residual isocenter shifts more likely tend to worsen the plan in all cases. CONCLUSION The DIBH technique proved to be robust against residual intrafractional isocenter shifts allowed by the selected SGRT beam-hold thresholds. Small-volume OARs located near high dose gradients showed significant marginal deteriorations in the perturbed plans with the 3DCRT technique only. Global plan quality was mainly influenced by patient anatomy and treatment beam geometry rather than the technique adopted.
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Affiliation(s)
- A Gnerucci
- Department of Physics and Astronomy, University of Florence, Florence, Italy.
| | - M Esposito
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - A Ghirelli
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Pini
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - L Paoletti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - R Barca
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Fondelli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - P Alpi
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - B Grilli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - F Rossi
- Radiotherapy Unit, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - S Scoccianti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Russo
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
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10
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Heikkilä A, Boman E, Rossi M, Vanhanen A, Mankinen M, Postema M, Koivumäki T. Dosimetric effect of rotational setup errors in volumetric modulated arc therapy and field-in-field treatment of left-sided breast cancer. Phys Med 2024; 117:103203. [PMID: 38171219 DOI: 10.1016/j.ejmp.2023.103203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/06/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
Setup errors are an important factor in the dosimetric accuracy of radiotherapy delivery. In this study, we investigated how rotational setup errors influence the dose distribution in volumetric modulated arc therapy (VMAT) and tangential field-in-field (FiF) treatment of left-sided breast cancer with supraclavicular lymph node involvement in deep inspiration breath hold. Treatment planning computed tomography images and radiotherapy plans of 20 patients were collected retrospectively for the study. Rotational setup errors up to 3° were simulated by rotating the planning images, and the resulting dosimetric changes were calculated. With rotational setup errors up to 3°, the median decrease of V95% to clinical target volume was less than 0.8 percentage point in both VMAT and FiF plans. The dose distribution of the heart and left anterior descending artery was more stable with respect to rotations in VMAT plans compared to FiF plans. Correction of ≥1° setup errors is recommended due to increased doses to the heart and left anterior descending artery after 1° setup errors.
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Affiliation(s)
- Annele Heikkilä
- BioMediTech, Faculty of Medicine and Health Technology, Tampere University, Korkeakoulunkatu 3, 33720 Tampere, Finland; Department of Medical Physics, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland.
| | - Eeva Boman
- Department of Medical Physics, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland; Department of Oncology, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland
| | - Maija Rossi
- Department of Medical Physics, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland; Department of Oncology, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland
| | - Antti Vanhanen
- Department of Medical Physics, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland; Department of Oncology, Tampere University Hospital, P.O. Box 2000, 33521 Tampere, Finland
| | - Mikko Mankinen
- Department of Medical Physics, Central Finland Health Care District, Hoitajantie 3, 40620, Jyväskylä, Finland
| | - Michiel Postema
- BioMediTech, Faculty of Medicine and Health Technology, Tampere University, Korkeakoulunkatu 3, 33720 Tampere, Finland; School of Electrical and Information Engineering, University of the Witwatersrand, Johannesburg, 1 Jan Smutslaan, 2050 Braamfontein, South Africa
| | - Tuomas Koivumäki
- Department of Medical Physics, Central Finland Health Care District, Hoitajantie 3, 40620, Jyväskylä, Finland
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11
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Mast M, Leong A, Korreman S, Lee G, Probst H, Scherer P, Tsang Y. ESTRO-ACROP guideline for positioning, immobilisation and setup verification for local and loco-regional photon breast cancer irradiation. Tech Innov Patient Support Radiat Oncol 2023; 28:100219. [PMID: 37745181 PMCID: PMC10511493 DOI: 10.1016/j.tipsro.2023.100219] [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: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- M.E. Mast
- Department of Radiation Oncology, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - A. Leong
- Department of Radiation Therapy, University of Otago, Wellington, New Zealand
- Bowen Icon Cancer Centre, Wellington, New Zealand
| | - S.S. Korreman
- Department of Clinical Medicine, Aarhus University, Denmark
- Department of Oncology, Aarhus University Hospital, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
| | - G. Lee
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - H. Probst
- Sheffield Hallam University, Sheffield, United Kingdom
| | - P. Scherer
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, Paracelsus Medical University Clinics, Salzburg, Austria
| | - Y. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
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Sauer TO, Stillkrieg W, Ott OJ, Fietkau R, Bert C. Plan robustness analysis for threshold determination of SGRT-based intrafraction motion control in 3DCRT breast cancer radiation therapy. Radiat Oncol 2023; 18:158. [PMID: 37740237 PMCID: PMC10517562 DOI: 10.1186/s13014-023-02325-1] [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: 04/11/2023] [Accepted: 07/27/2023] [Indexed: 09/24/2023] Open
Abstract
PURPOSE The goal of this study was to obtain maximum allowed shift deviations from planning position in six degrees of freedom (DOF), that can serve as threshold values in surface guided radiation therapy (SGRT) of breast cancer patients. METHODS The robustness of conformal treatment plans of 50 breast cancer patients against 6DOF shifts was investigated. For that, new dose distributions were calculated on shifted computed tomography scans and evaluated with respect to target volume and spinal cord dose. Maximum allowed shift values were identified by imposing dose constraints on the target volume dose coverage for 1DOF, and consecutively, for 6DOF shifts using an iterative approach and random sampling. RESULTS Substantial decreases in target dose coverage and increases of spinal cord dose were observed. Treatment plans showed highly differing robustness for different DOFs or treated area. The sensitivity was particularly high if clavicular lymph nodes were irradiated, for shifts in lateral, vertical, roll or yaw direction, and showed partly pronounced asymmetries. Threshold values showed similar properties with an absolute value range of 0.8 mm to 5 mm and 1.4° to 5°. CONCLUSION The robustness analysis emphasized the necessity of taking differences between DOFs and asymmetrical sensitivities into account when evaluating the dosimetric impact of position deviations. It also highlighted the importance of rotational shifts, especially if clavicular lymph nodes were irradiated. A practical approach of determining 6DOF shift limits was introduced and a set of threshold values applicable for SGRT based patient motion control was identified.
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Affiliation(s)
- Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Wilhelm Stillkrieg
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Oliver J. Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
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Redekopp J, Rivest R, Sasaki D, Pistorius S, Alpuche Aviles JE. Automated review of patient position in DIBH breast hybrid IMRT with EPID images. J Appl Clin Med Phys 2023; 24:e14038. [PMID: 37449391 PMCID: PMC10476989 DOI: 10.1002/acm2.14038] [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: 02/21/2023] [Revised: 04/18/2023] [Accepted: 05/04/2023] [Indexed: 07/18/2023] Open
Abstract
Deep Inspiration Breath Hold (DIBH) is a respiratory-gating technique adopted in radiation therapy to lower cardiac irradiation. When performing DIBH treatments, it is important to have a monitoring system to ensure the patient's breath hold level is stable and reproducible at each fraction. In this retrospective study, we developed a system capable of monitoring DIBH breast treatments by utilizing cine EPID images taken during treatment. Setup error and intrafraction motion were measured for all fractions of 20 left-sided breast patients. All patients were treated with a hybrid static-IMRT technique, with EPID images from the static fields analyzed. Ten patients had open static fields and the other ten patients had static fields partially blocked with the multileaf collimator (MLC). Three image-processing algorithms were evaluated on their ability to accurately measure the chest wall position (CWP) in EPID images. CWP measurements were recorded along a 61-pixel region of interest centered along the midline of the image. The median and standard deviation of the CWP were recorded for each image. The algorithm showing the highest agreement with manual measurements was then used to calculate intrafraction motion and setup error. To measure intrafraction motion, the median CWP of the first EPID frame was compared with that of the subsequent EPID images of the treatment. The maximum difference was recorded as the intrafraction motion. The setup error was calculated as the difference in median CWP between the MV DRR and the first EPID image of the lateral tangential field. The results showed that the most accurate image-processing algorithm can identify the chest wall within 1.2 mm on both EPID and MV DRR images, and measures intrafraction motion and setup errors within 1.4 mm.
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Affiliation(s)
- Jonathan Redekopp
- Department of Physics & AstronomyUniversity of ManitobaManitobaWinnipegCanada
- Medical PhysicsCancer Care ManitobaManitobaWinnipegCanada
| | - Ryan Rivest
- Department of Physics & AstronomyUniversity of ManitobaManitobaWinnipegCanada
- Medical PhysicsCancer Care ManitobaManitobaWinnipegCanada
- Department of RadiologyUniversity of ManitobaManitobaWinnipegCanada
| | - David Sasaki
- Medical PhysicsCancer Care ManitobaManitobaWinnipegCanada
- Department of RadiologyUniversity of ManitobaManitobaWinnipegCanada
| | - Stephen Pistorius
- Department of Physics & AstronomyUniversity of ManitobaManitobaWinnipegCanada
- Department of RadiologyUniversity of ManitobaManitobaWinnipegCanada
- CancerCare Manitoba Research InstituteManitobaWinnipegCanada
| | - Jorge E. Alpuche Aviles
- Department of Physics & AstronomyUniversity of ManitobaManitobaWinnipegCanada
- Medical PhysicsCancer Care ManitobaManitobaWinnipegCanada
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Sarkar B, Pradhan A. Planning System-dependent Recommendations of Intensity-modulated Technique for Breast Radiotherapy: A Literature Review-based Adaptation and Institutional Dosimetric Experience from a Large-volume Tertiary Cancer Care Hospital. J Med Phys 2023; 48:221-229. [PMID: 37969141 PMCID: PMC10642598 DOI: 10.4103/jmp.jmp_51_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/27/2023] [Accepted: 08/08/2023] [Indexed: 11/17/2023] Open
Abstract
This article aims to identify, through a literature review, the best intensity-modulated technique (IMRT)/volumetric-modulated arc therapy (VMAT) for the breast/chest wall (Br/CW) as a function of the treatment planning system (TPS) and present the institutional dosimetric data for the same. A PubMed search was conducted following intensity-modulated irradiation techniques (IMRT) presented in the study: field-in-field (FiF), tangential IMRT (t-IMRT), multi-field IMRT, tangential VMAT (t-VMAT), half-arc VMAT (HA-VMAT), and large arc VMAT (LA-VMAT). The literature with at least one arm VMAT is included in this study. A total of 370 articles were identified between 2010 and 2022, out of which 19 articles were found to be unique. These articles were classified in terms of the TPS used: Eclipse (9), Monaco (6), RayStation (2), Pinnacle (1), and one unidentified TPS. Based on the literature review, dosimetric attributes, and second cancer risk analysis (SCRA), t-IMRT was found to be the most preferable technique in Eclipse, Pinnacle, and RayStation TPS. However, for Monaco TPS, t-VMAT (approximately 30° tangential arc) offers better dose coverage with lower organ-at-risk (OAR) doses. In terms of OAR doses and SCRA, LA-VMAT (≥210°) and HA-VMAT (180°) are avoidable techniques in any TPS, and FiF should be preferred over these two techniques. In our present institution, which uses the Eclipse TPS, data for 300 patients treated with t-IMRT were collected. The data included beam angle, monitor unit [MU], target coverage (D95% and V105% [cc]), and analysis of the maximum (%), and mean dose (%) of the OAR. t-IMRT utilizes two medial and three lateral tangential beams placed at a spread of approximately 10° and 20°, respectively. The results showed a D95% of 96.3 ± 1.2% and a V105% of 4.9 ± 7.0 cc. The mean doses to the heart and ipsilateral lung were 10.1 ± 20.9% and 11.4 ± 10.2%, respectively. The mean MU was 1282.7 ± 453.4. Based on the findings, the most preferred intensity-modulated technique for Eclipse, Pinnacle, and RayStation is t-IMRT, while for Monaco, it is t-VMAT. The data from the Eclipse planning system demonstrate a satisfactory dosimetric outcome for t-IMRT. However, the use of VMAT techniques employing an arc angle between 180° and 210° or higher is strongly discouraged.
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Affiliation(s)
- Biplab Sarkar
- Department of Radiation Oncology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
- Department of Physics, GLA University, Mathura, Uttar Pradesh, India
| | - Anirudh Pradhan
- Director, Centre for Cosmology, Astrophysics and Space Science (CCASS), GLA University, Mathura, Uttar Pradesh, India
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He Y, Chen S, Gao X, Fu L, Kang Z, Liu J, Shi L, Li Y. Robustness of VMAT to setup errors in postmastectomy radiotherapy of left-sided breast cancer: Impact of bolus thickness. PLoS One 2023; 18:e0280456. [PMID: 36693073 PMCID: PMC9873183 DOI: 10.1371/journal.pone.0280456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/30/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Volumetric modulated arc therapy (VMAT) with varied bolus thicknesses has been employed in postmastectomy radiotherapy (PMRT) of breast cancer to improve superficial target coverage. However, impact of bolus thickness on plan robustness remains unclear. METHODS The study enrolled ten patients with left-sided breast cancer who received radiotherapy using VMAT with 5 mm and 10 mm bolus (VMAT-5B and VMAT-10B). Inter-fractional setup errors were simulated by introducing a 3 mm shift to isocenter of the original plans in the anterior-posterior, left-right, and inferior-superior directions. The plans (perturbed plans) were recalculated without changing other parameters. Dose volume histograms (DVH) were collected for plan evaluation. Absolute dose differences in DVH endpoints for the clinical target volume (CTV), heart, and left lung between the perturbed plans and the original ones were used for robustness analysis. RESULTS VMAT-10B showed better target coverage, while VMAT-5B was superior in organs-at-risk (OARs) sparing. As expected, small setup errors of 3 mm could induce dose fluctuations in CTV and OARs. The differences in CTV were small in VMAT-5B, with a maximum difference of -1.05 Gy for the posterior shifts. For VMAT-10B, isocenter shifts in the posterior and right directions significantly decreased CTV coverage. The differences were -1.69 Gy, -1.48 Gy and -1.99 Gy, -1.69 Gy for ΔD95% and ΔD98%, respectively. Regarding the OARs, only isocenter shifts in the posterior, right, and inferior directions increased dose to the left lung and the heart. Differences in VMAT-10B were milder than those in VMAT-5B. Specifically, mean heart dose were increased by 0.42 Gy (range 0.10 ~ 0.95 Gy) and 0.20 Gy (range -0.11 ~ 0.72 Gy), and mean dose for the left lung were increased by 1.02 Gy (range 0.79 ~ 1.18 Gy) and 0.68 Gy (range 0.47 ~ 0.84 Gy) in VMAT-5B and VMAT-10B, respectively. High-dose volumes in the organs were increased by approximate 0 ~ 2 and 1 ~ 3 percentage points, respectively. Nevertheless, most of the dosimetric parameters in the perturbed plans were still clinically acceptable. CONCLUSIONS VMAT-5B appears to be more robust to 3 mm setup errors than VMAT-10B. VMAT-5B also resulted in better OARs sparing with acceptable target coverage and dose homogeneity. Therefore 5 mm bolus is recommended for PMRT of left-sided breast cancer using VMAT.
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Affiliation(s)
- Yipeng He
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Sijia Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Xiang Gao
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Lirong Fu
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zheng Kang
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jun Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Liwan Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yimin Li
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
- * E-mail:
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Stowe HB, Andruska ND, Reynoso F, Thomas M, Bergom C. Heart Sparing Radiotherapy Techniques in Breast Cancer: A Focus on Deep Inspiration Breath Hold. BREAST CANCER: TARGETS AND THERAPY 2022; 14:175-186. [PMID: 35899145 PMCID: PMC9309321 DOI: 10.2147/bctt.s282799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
Adjuvant radiation therapy is a critical component of breast cancer management. However, when breast cancer patients receive incidental radiation to the heart, there is an increased risk of cardiac disease and mortality. This is most common for patients with left-sided breast cancers and those receiving nodal irradiation as part of treatment. The overall risk of cardiac toxicity increases 4–16% with each Gray increase in mean heart radiation dose, with data suggesting that no lower limit exists which would eliminate cardiac risk entirely. Radiation techniques have improved over time, leading to lower cardiac radiation exposure than in the past. This decline is expected to reduce the incidence of radiation-induced heart dysfunction in patients. Deep inspiration breath hold (DIBH) is one such technique that was developed to reduce the risk of cardiac death and coronary events. DIBH is a non-invasive approach that capitalizes on the natural physiology of the respiratory cycle to increase the distance between the heart and the therapeutic target throughout the course of radiation therapy. DIBH has been shown to decrease the mean incidental radiation doses to the heart and left anterior descending coronary artery by approximately 20–70%. In this review, we summarize different techniques for DIBH and discuss recent data on this technique.
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Affiliation(s)
- Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neal D Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Francisco Reynoso
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Maria Thomas
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Alvin J. Siteman Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Correspondence: Carmen Bergom, Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA, Email
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Chau OW, Fakir H, Lock M, Dinniwell R, Perera F, Erickson A, Gaede S. Dosimetric Planning Comparison for Left-Sided Breast Cancer Radiotherapy: The Clinical Feasibility of Four-Dimensional-Computed Tomography-Based Treatment Planning Optimization. Cureus 2022; 14:e24777. [PMID: 35673303 PMCID: PMC9165918 DOI: 10.7759/cureus.24777] [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] [Accepted: 05/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Adjuvant whole-breast radiotherapy (RT) is a significant part of the standard of care treatment after breast cancer (BC) conserving surgery. Modern techniques including intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) have constituted to better target coverage and critical organs sparing. However, BC survivors are at risk of developing radiation-induced cardiac toxicity. Hence, deep-inspiration breath-hold (DIBH) techniques have been implemented at many centers to further reduce cardiac exposure but require compliance. 4D-CT robust optimization can account for heart intrafractional motion per breathing phase. The optimization has been explored in cardiac sparing of breast IMRT compared to DIBH in a small sample size but has not been evaluated in substructures sparing, nor in VMAT. To provide patients who are not compliant to breath-hold with an optimal treatment approach, various heart sparing techniques need to be evaluated for statistical significance and clinical feasibility. Aim: This retrospective study aimed to provide an extensive dosimetric heart sparing comparison of free-breathing, 4D-CT-based treatment planning, including robust optimization with DIBH-based treatment planning. Combinations of forward and inverse IMRT and VMAT are also considered. Methods: Fifteen early stage left-sided BC standard treatment plans were selected. Breast, lung, left anterior descending artery (LAD), left ventricle (LV), and the whole heart were contoured on each 4D-CT phase and DIBH CT dataset. Each treatment plan was optimized using forward/inverse IMRT and VMAT on the following CT datasets: DIBH, average 4D-CT, and the complete 4D-CT dataset needed for robust optimization. Dose-volume histograms were used to compare V5GyHeart, mean heart dose, mean and max LAD dose, mean LV dose, and V50%Lung. Results: All RT techniques assessed including 4D robust optimization were clinically feasible. Statistically significant differences in mean heart, LAD and LV dose, max LAD dose, and V5GyHeart (p < 0.01) but no difference in V50%Lung (p = 0.29) were found between different techniques. IMRT DIBH achieved the optimal cardiac and substructure sparing among treatment plans. 4D robust IMRT had significantly greater mean heart and LV dose than DIBH IMRT (p ≤ 0.01), except LAD dose. Among free-breathing methods, no difference in all cardiac and substructure dose parameters was observed (p > 0.2) in comparing forward and inverse IMRT with average 4D-CT, inverse average 4D-CT, and 4D robust with IMRT, and between average 4D-CT VMAT and 4D robust VMAT. Only V5GyHeart and mean LV dose were significantly greater in 4D robust VMAT (p < 0.01) compared to DIBH VMAT. Mean heart and LV doses were significantly reduced (p < 0.01) in DIBH IMRT compared to DIBH VMAT. Moreover, mean heart and LV dose, V5GyHeart were significantly reduced in inverse IMRT average 4D-CT compared to average 4D-CT VMAT (p < 0.02) and in 4D robust IMRT compared to 4D robust VMAT (p < 0.04). Conclusion: This study demonstrated the clinical feasibility of 4D robust optimization in limiting the cardiac and substructures dose during free-breathing RT with both IMRT/VMAT for patients who are not compliant with breath-hold RT. However, this study also presents that 4D robust optimization can reduce LAD dose but not fully outperform DIBH or conventional 4D-CT-based planning with IMRT/VMAT in heart sparing in treating early staged left-sided BC patients.
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Gleeson I. Comparing the robustness of different skin flash approaches using wide tangents, manual flash VMAT, and simulated organ motion robust optimization VMAT in breast and nodal radiotherapy. Med Dosim 2022; 47:264-272. [DOI: 10.1016/j.meddos.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
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Loebner HA, Volken W, Mueller S, Bertholet J, Mackeprang PH, Guyer G, Aebersold DM, Stampanoni M, Manser P, Fix MK. Development of a Monte Carlo based robustness calculation and evaluation tool. Med Phys 2022; 49:4780-4793. [PMID: 35451087 PMCID: PMC9545707 DOI: 10.1002/mp.15683] [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: 10/27/2021] [Revised: 04/01/2022] [Accepted: 04/03/2022] [Indexed: 11/09/2022] Open
Abstract
Background Evaluating plan robustness is a key step in radiotherapy. Purpose To develop a flexible Monte Carlo (MC)‐based robustness calculation and evaluation tool to assess and quantify dosimetric robustness of intensity‐modulated radiotherapy (IMRT) treatment plans by exploring the impact of systematic and random uncertainties resulting from patient setup, patient anatomy changes, and mechanical limitations of machine components. Methods The robustness tool consists of two parts: the first part includes automated MC dose calculation of multiple user‐defined uncertainty scenarios to populate a robustness space. An uncertainty scenario is defined by a certain combination of uncertainties in patient setup, rigid intrafraction motion and in mechanical steering of the following machine components: angles of gantry, collimator, table‐yaw, table‐pitch, table‐roll, translational positions of jaws, multileaf‐collimator (MLC) banks, and single MLC leaves. The Swiss Monte Carlo Plan (SMCP) is integrated in this tool to serve as the backbone for the MC dose calculations incorporating the uncertainties. The calculated dose distributions serve as input for the second part of the tool, handling the quantitative evaluation of the dosimetric impact of the uncertainties. A graphical user interface (GUI) is developed to simultaneously evaluate the uncertainty scenarios according to user‐specified conditions based on dose‐volume histogram (DVH) parameters, fast and exact gamma analysis, and dose differences. Additionally, a robustness index (RI) is introduced with the aim to simultaneously evaluate and condense dosimetric robustness against multiple uncertainties into one number. The RI is defined as the ratio of scenarios passing the conditions on the dose distributions. Weighting of the scenarios in the robustness space is possible to consider their likelihood of occurrence. The robustness tool is applied on IMRT, a volumetric modulated arc therapy (VMAT), a dynamic trajectory radiotherapy (DTRT), and a dynamic mixed beam radiotherapy (DYMBER) plan for a brain case to evaluate the robustness to uncertainties of gantry‐, table‐, collimator angle, MLC, and intrafraction motion. Additionally, the robustness of the IMRT, VMAT, and DTRT plan against patient setup uncertainties are compared. The robustness tool is validated by Delta4 measurements for scenarios including all uncertainty types available. Results The robustness tool performs simultaneous calculation of uncertainty scenarios, and the GUI enables their fast evaluation. For all evaluated plans and uncertainties, the planning target volume (PTV) margin prevented major clinical target volume (CTV) coverage deterioration (maximum observed standard deviation of D98%CTV was 1.3 Gy). OARs close to the PTV experienced larger dosimetric deviations (maximum observed standard deviation of D2%chiasma was 14.5 Gy). Robustness comparison by RI evaluation against patient setup uncertainties revealed better dosimetric robustness of the VMAT and DTRT plans as compared to the IMRT plan. Delta4 validation measurements agreed with calculations by >96% gamma‐passing rate (3% global/2 mm). Conclusions The robustness tool was successfully implemented. Calculation and evaluation of uncertainty scenarios with the robustness tool were demonstrated on a brain case. Effects of patient and machine‐specific uncertainties and the combination thereof on the dose distribution are evaluated in a user‐friendly GUI to quantitatively assess and compare treatment plans and their robustness.
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Affiliation(s)
- H A Loebner
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - W Volken
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - S Mueller
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - J Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - P-H Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - G Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - D M Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mfm Stampanoni
- Institute for Biomedical Engineering, ETH Zürich and PSI, Villigen, Switzerland
| | - P Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M K Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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20
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Noblet C, Duthy M, Coste F, Saliou M, Samain B, Drouet F, Papazyan T, Moreau M. Implementation of volumetric-modulated arc therapy for locally advanced breast cancer patients: Dosimetric comparison with deliverability consideration of planning techniques and predictions of patient-specific QA results via supervised machine learning. Phys Med 2022; 96:18-31. [DOI: 10.1016/j.ejmp.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 12/21/2022] Open
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21
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Tang L, Ishikawa Y, Ito K, Yamamoto T, Umezawa R, Jingu K. Evaluation of DIBH and VMAT in Hypofractionated Radiotherapy for Left-Sided Breast Cancers After Breast-Conserving Surgery: A Planning Study. Technol Cancer Res Treat 2021; 20:15330338211048706. [PMID: 34657495 PMCID: PMC8521420 DOI: 10.1177/15330338211048706] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Dosimetric parameters of the planning target volume (PTV) and organs at risk (OARs) were compared among 3 different radiotherapy (RT) modalities in left breast cancer patients after breast-conserving surgery (BCS). Methods: Eleven patients with left breast cancer after BCS were enrolled and underwent CT simulation in the free breathing (FB) and deep inspiration breath-hold (DIBH) position. Three-dimensional conformal RT (3DCRT) and volumetric modulated arc therapy (VMAT) plans were generated for each patient in the DIBH positions. A 3DCRT plan was also created in the FB position. A dose-volume histogram (DVH) was used to analyze each evaluation index of PTV and OARs. The principal outcomes were PTV dose, heart dose, right breast dose, left anterior descending coronary artery (LADCA) dose, and left lung dose. Results: For 3DCRT plans, significant dose reductions were demonstrated in all evaluation parameters of the heart, LADCA, and left lung doses in the DIBH position compared with those in the FB position (P < 0.05). In the DIBH position, significant dose reductions were found in the heart and LADCA in VMAT plans compared to those in 3DCRT plans (P < 0.05). For the right breast, VMAT reduced Dmean significantly (0.32 Gy vs 0.08 Gy, P < 0.01). There were no significant differences between 3DCRT and VMAT plans for the left lung dose in the DIBH position. The indicators of PTV had no significant difference between the 3 plans. Conclusion: DIBH and VMAT could reduce dosimetric parameters of the OARs in left breast cancer patients after BCS. RT plans for left breast cancer after BCS can be optimized by DIBH and VMAT techniques to minimize radiation-induced toxicity.
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Affiliation(s)
- Liuwei Tang
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yojiro Ishikawa
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kengo Ito
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rei Umezawa
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Tohoku University Graduate School of Medicine, Sendai, Japan
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22
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Jensen CA, Funderud M, Lervåg C. Free breathing VMAT versus deep inspiration breath-hold 3D conformal radiation therapy for early stage left-sided breast cancer. J Appl Clin Med Phys 2021; 22:44-51. [PMID: 33638600 PMCID: PMC8035549 DOI: 10.1002/acm2.13208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/15/2020] [Accepted: 02/01/2021] [Indexed: 12/25/2022] Open
Abstract
The purpose of the in silico study was to compare free breathing volumetric modulated arc therapy (VMAT) to standard deep inspiration breath‐hold (DIBH) three‐dimensional conformal radiotherapy (3DCRT) and determine whether the former is a viable option for elderly patients with left‐sided early stage breast cancer. Data from 22 patients with early‐stage left breast carcinoma requiring breast‐only radiation therapy were used for this planning study. The robustness of VMAT plans when using the free breathing method was compared to that of standard 3DCRT plans using the DIBH method. The endpoints for evaluation were the target dose coverage as well as doses to the organs‐at‐risk. The free breathing VMAT plans produced a significantly higher mean dose to the heart and right breast than the DIBH‐3DCRT plans. Free breathing VMAT plans resulted in significantly better target coverage than did 3DCRT using DIBH. The external volume that received more than 40 Gy was significantly smaller in the VMAT plans. Free breathing VMAT is a viable alternative to DIBH 3DCRT in elderly patients with a limited life expectancy and in subjects who are unable to perform DIBH. The choice of treatment should be individualized, and all relevant risks ought to be considered.
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Affiliation(s)
- Christer A Jensen
- Department of Medicine and Healthcare, Møre & Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway.,Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
| | - Marit Funderud
- Department of Oncology, Møre & Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway
| | - Christoffer Lervåg
- Department of Oncology, Møre & Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway
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23
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Shang H, Pu Y, Wang Y. Robust Optimization of SBRT Planning for Patients With Early Stage Non-Small Cell Lung Cancer. Technol Cancer Res Treat 2020; 19:1533033820916505. [PMID: 32314663 PMCID: PMC7175055 DOI: 10.1177/1533033820916505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Setup uncertainty is a known challenge for stereotactic body radiotherapy planning. Using the internal target volume-based robust optimization was proposed as a more accurate way than the conventional planning target volume-based optimization when considering the robustness criteria. In this study, we aim to investigate the feasibility of internal target volume-based robust optimization in stereotactic body radiotherapy planning using 4-dimensional computed tomography and develop a novel dose–volume histogram band width metric to quantitatively evaluate robustness. Method and Materials: A total of 50 patients with early stage non-small cell lung cancer, who underwent stereotactic body radiotherapy, were retrospectively selected. Each of the 50 patients had 2 stereotactic body radiotherapy plans: one with the conventional planning target volume-based optimization and the other with patient-specific robustly optimized internal target volume and with a uniform 5 mm setup error. These were compared with the planning target volume-based optimization method based on both plan quality and robustness. The quality was evaluated using dosimetric parameters and radiobiology parameters, such as high-dose spillage (V90%RX, conformity index), intermediate-dose spillage (dose falloff products), low-dose spillage (normal tissue: V50%RX), and lung tissue complication probability. The robustness was evaluated under a uniform 3 to 5 mm setup errors with a novel proposed metric: dose–volume histogram band width. Results: When compared with planning target volume-based optimization plans, the internal target volume-based robust optimization plans have better conformity of internal target volume coverage (conformity index: 1.17 vs 1.27, P < .001), intermediate-dose spillage (dose falloff product: 129 vs 167, P < .001), low-dose spillage in normal tissue (V50%RX: 0.8% vs 1.5%, P < .05), and lower risk of radiation pneumonitis (lung tissue complication probability: 4.2% vs 5.5%, P < .001). For the robustness, dose–volume histogram band width analysis shows that the average values in internal target volume, D95%, D98%, and D99%, of internal target volume-based robust optimization are smaller than that of planning target volume-based optimization (unit cGy) under 3-, 4-, and 5-mm setup uncertainties (3-mm setup uncertainty: 42 vs 73 cGy; 4-mm setup uncertainty: 88 vs 176 cGy; 5-mm setup uncertainty: 229 vs 490 cGy), which might indicate that internal target volume-based robust optimization harbored a greater robustness regardless of the setup errors. Conclusions: Internal target volume-based robust optimization may have clinical potential in offering better plan quality in both target and organs at risk and lower risk of radiation pneumonitis. In addition, the proposed internal target volume-based robust optimization may demonstrate robustness regardless of different setup uncertainties in the stereotactic body radiotherapy planning. Registration: Retrospective study with local ethics committee approval.
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Affiliation(s)
- Haijiao Shang
- Shanghai Institute of Applied Physics, Chinese Academy of Sciences, Shanghai, People's Republic of China.,University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Yuehu Pu
- Shanghai Institute of Applied Physics, Chinese Academy of Sciences, Shanghai, People's Republic of China.,University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Yuenan Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, People's Republic of China
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24
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Zhao Y, Diao P, Zhang D, Wu J, Xin X, Fontanarosa D, Liu M, Li J, Orlandini LC. Impact of Positioning Errors on the Dosimetry of Breath-Hold-Based Volumetric Arc Modulated and Tangential Field-in-Field Left-Sided Breast Treatments. Front Oncol 2020; 10:554131. [PMID: 33194616 PMCID: PMC7658584 DOI: 10.3389/fonc.2020.554131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Heart diseases and cardiovascular events are well-known side effects in left-sided breast irradiation. Deep inspiration breath hold (BH) combined with fast delivery techniques such as volumetric modulated arc therapy (VMAT) or tangential field-in-field (TFiF) can serve as a valuable solution to reduce the dose to the heart. This study aims to compare the impact of positioning errors in VMAT and TFiF plans for BH left-sided breast treatments. Fifteen left-sided breast patients treated in BH with TFiF technique were included in this retrospective study. For each patient, a second plan with VMAT technique was optimized. Eighteen setup variations were introduced in each of these VMAT and TFiF reference plans, shifting the isocenter along six different directions by 3, 5, and 10 mm. A total of 540 perturbed plans, 270 for each technique, were recalculated and analyzed. The dose distributions on the target and organs at risk obtained in the different perturbed scenarios were compared with the reference scenarios, using as dosimetric endpoints the dose-volume histograms (DVH). The results were compared using the Wilcoxon test. Comparable plan quality was obtained for the reference VMAT and TFiF plans, except for low doses to organs at risk for which higher values (p < 0.05) were obtained for VMAT plans. For TFiF plans, perturbations of the isocenter position of 3, 5, or 10 mm produced mean deviations of the target DVH dosimetric parameters up to -0.5, -1.0, and -5.2%, respectively; VMAT plans were more sensitive to positioning errors resulting in mean deviations up to -0.5, -4.9, and -13.9%, respectively, for the same magnitude of the above mentioned perturbations. For organs at risk, only perturbations along the left, posterior, and inferior directions resulted in dose increase with a maximum deviation of +2% in the DVH dosimetric parameters. A notable exception were low doses to the left lung and heart for 10 mm isocenter shifts for which the mean differences ranged between +2.7 and +4.1%. Objective information on how external stresses affect the dosimetry of the treatment is the first step towards personalized radiotherapy.
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Affiliation(s)
- Yanqun Zhao
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Peng Diao
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Da Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Juxiang Wu
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Xin Xin
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Davide Fontanarosa
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Min Liu
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Jie Li
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Lucia Clara Orlandini
- Department of Radiation Oncology, Sichuan Cancer Hospital and Research Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
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25
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Zhang W, Li R, You D, Su Y, Dong W, Ma Z. Dosimetry and Feasibility Studies of Volumetric Modulated Arc Therapy With Deep Inspiration Breath-Hold Using Optical Surface Management System for Left-Sided Breast Cancer Patients. Front Oncol 2020; 10:1711. [PMID: 33014848 PMCID: PMC7494967 DOI: 10.3389/fonc.2020.01711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/31/2020] [Indexed: 01/29/2023] Open
Abstract
Background During radiotherapy (RT) procedure of breast cancer, portions of the heart and lung will receive some radiation dose, which may result in acute and late toxicities. In the current study, we report the experience of our single institution with organs at risk (OARs)–sparing RT with deep inspiration breath hold (DIBH) using an Optical Surface Management System (OSMS) and compare the dosimetric parameters with that of free breathing (FB). Patients and Methods Forty-eight cases diagnosed as early stage left-sided breast cancer scheduled for postoperative RT were enrolled. The OSMS was used to monitor the breathing magnitude and track the real-time respiratory status, which can control a stable lung and heart volume during RT delivery under DIBH. We did the dosimetric analysis of the heart, left anterior descending (LAD) coronary artery, lungs, and contralateral breast under FB and DIBH plans. Results Compared with FB–volumetric-modulated arc therapy (FB-VMAT), DIBH-VMAT resulted in significantly changed volumes to the heart and lungs receiving irradiation dose. The average mean heart dose and average D2%, V5, and V10 showed significant differences between the DIBH and FB techniques. For the LAD coronary artery, we found significantly reduced average mean dose, D2%, and V10 with DIBH. Similar results were also found in the lungs and contralateral breast. The use of flattening-filter–free decreased treatment time compared with the flat beam mode in our VMAT (p < 0.05). For the 48 patients, there were no significant differences in the lateral, longitudinal, and vertical directions between OSMS and cone beam CT. Conclusions DIBH-VMAT with OSMS is very feasible in daily practice with excellent patient compliance in our single-center experience. Note that OSMS is an effective tool that may allow easier-to-achieve precise positioning and better and shorter position-verify time. Meanwhile, compared with FB, DIBH was characterized by lower doses to OARs, which may reduce the probability of cardiac and pulmonary complications in the future.
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Affiliation(s)
- Wei Zhang
- Department of Radiation Oncology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Ruisheng Li
- Department of Medical Imaging, Yantai Yuhuangding Hospital, Yantai, China
| | - Dong You
- Department of Radiation Oncology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Yi Su
- Department of Radiation Oncology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Wei Dong
- Department of Radiation Oncology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Zhao Ma
- Department of Radiation Oncology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
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26
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Noufal MP, Widesott L, Sharma SD, Righetto R, Cianchetti M, Schwarz M. The Role of Plan Robustness Evaluation in Comparing Protons and Photons Plans - An Application on IMPT and IMRT Plans in Skull Base Chordomas. J Med Phys 2020; 45:206-214. [PMID: 33953495 PMCID: PMC8074721 DOI: 10.4103/jmp.jmp_45_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/17/2020] [Accepted: 10/30/2020] [Indexed: 12/03/2022] Open
Abstract
PURPOSE To analyze robustness of treatment plans optimized using different approaches in intensity modulated proton therapy (IMPT) and investigate the necessity of robust optimization and evaluation in intensity modulated radiotherapy (IMRT) plans for skull base chordomas. MATERIALS AND METHODS Two photon plans, standard IMRT and robustly optimized IMRT (RB-IMRT), and two IMPT plans, robustly optimized multi field optimization (MFO) and hybrid-MFO (HB-MFO), were created in RayStation TPS for five patients previously treated using single field uniform optimization (SFO). Both set-up and range uncertainties were incorporated during robust optimization of IMPT plans whereas only set-up uncertainty was used in RB-IMRT. The dosimetric outcomes from the five planning techniques were compared for every patient using standard dose volume indices and integral dose (ID) estimated for target and organs at risk (OARs). Robustness of each treatment plan was assessed by introducing set-up uncertainties of ±3 mm along the three translational axes and, only in protons, an additional range uncertainty of ±3.5%. RESULTS All the five nominal plans provided comparable and clinically acceptable target coverage. In comparison to nominal plans, worst case decrease in D95% of clinical target volume-high risk (CTV-HR) were 11.1%, 13.5%, and 13.6% for SFO, MFO, and HB-MFO plans respectively. The corresponding values were 13.7% for standard IMRT which improved to 11.5% for RB-IMRT. The worst case increased in high dose (D1%) to CTV-HR was highest in IMRT (2.1%) and lowest in SFO (0.7%) plans. Moreover, IMRT showed worst case increases in D1% for all neurological OARs and were lowest for SFO plans. The worst case D1% for brainstem, chiasm, spinal cord, optic nerves, and temporal lobes were increased by 29%, 41%, 30%, 41% and 14% for IMRT and 18%, 21%, 21%, 24%, and 7% for SFO plans, respectively. In comparison to IMRT, RB-IMRT improved D1% of all neurological OARs ranging from 5% to 14% in worst case scenarios. CONCLUSION Based on the five cases presented in the current study, all proton planning techniques (SFO, MFO and HB-MFO) were robust both for target coverage and OARs sparing. Standard IMRT plans were less robust than proton plans in regards to high doses to neurological OARs. However, robust optimization applied to IMRT resulted in improved robustness in both target coverage and high doses to OARs. Robustness evaluation may be considered as a part of plan evaluation procedure even in IMRT.
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Affiliation(s)
| | - Lamberto Widesott
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | | | - Roberto Righetto
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | - Marco Cianchetti
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
| | - Marco Schwarz
- Department of Proton Therapy, Azienda Provinciale Per I Servizi Sanitari, Trento, Italy
- TIFPA - INFN, Trento, Italy
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27
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Takakura T, Koubuchi S, Uehara A, Tashima A, Hirose T, Kimura H, Tachiiri S, Koizumi M. Evaluation of beam-on time and number of breath-holds using a flattening-filter-free beam with the deep inspiration breath-hold method in left-sided breast cancer. Med Dosim 2020; 45:359-362. [PMID: 32546372 DOI: 10.1016/j.meddos.2020.05.002] [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: 11/28/2019] [Revised: 03/03/2020] [Accepted: 05/10/2020] [Indexed: 11/18/2022]
Abstract
We performed a dosimetric study to evaluate the benefits of using a flattening-filter-free (FFF) beam with the deep inspiration breath-hold (DIBH) method for left-breast cancer. We used data from 30 previous patients with treatment plans that included DIBH for left-breast cancer with a flattened beam. FFF beam plans were calculated from previous treatment plan images and compared to the original plans in terms of monitor units (MU), number of segments, beam-on time, and breath-holds. Beam-on time was calculated by adding the traveling time of 1.5 second between segments to the time calculated from the MU and dose rate. Breath-holds were calculated based on the beam-on time, assuming 15 s per hold. The FFF beam had increased MU in all cases (mean ± SD: flattened beam, 122.4 ± 9.8 MU; FFF beam, 160.2 ± 17.5 MU). Furthermore, the number of segments increased with the FFF beam in all cases (median [range]: flattened beam, 2 [1 to 3]; FFF beam, 5 [3 to 7]). However, in most cases, the beam-on time was reduced using the FFF beam (mean ± SD: flattened beam, 27.8 ± 7.4 seconds; FFF beam, 13.2 ± 1.7 seconds), although when a 6 MV flattened beam was used there was not a large increase. There were fewer breath-holds in most cases with the FFF beam. Cases using a 4 MV flattened beam also had fewer breath-holds; however, the number of breath-holds was consistent or increased in cases that used a 6 MV flattened beam (median [range]: flattened beam, 3 [1 to 3]; FFF beam, 1 [1 to 2]).
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Affiliation(s)
- Toru Takakura
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan; Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Satoshi Koubuchi
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Aiki Uehara
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Ayano Tashima
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Tomoyo Hirose
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Hiroto Kimura
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Seiji Tachiiri
- Department of Radiation Therapeutic Radiology, Uji Tokushukai Medical Center, Kyoto, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
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28
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Rafic KM, Patricia S, Timothy Peace B, Sujith CJ, Selvamani B, Ravindran PB. Dosimetric and clinical advantages of adapting the DIBH technique to hybrid solitary dynamic portal radiotherapy for left-sided chest-wall plus regional nodal irradiation. Med Dosim 2020; 45:256-263. [PMID: 32362370 DOI: 10.1016/j.meddos.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/10/2020] [Indexed: 11/15/2022]
Abstract
To evaluate the dosimetric and clinical advantages of using deep-inspiration breath-hold (DIBH) technique in hybrid solitary dynamic portal radiotherapy (hSDPRT) for left-sided chest-wall plus regional nodal irradiation and to demonstrate a simplified strategy for preclinical commissioning and calibration of DIBH-gating technique. Fifteen patients with left-sided breast cancer who underwent postmastectomy radiotherapy using hSDPRT were retrospectively evaluated. Two sets of planning-CT images were acquired for each patient, one with free/normal breathing and the other with DIBH. The hSDPRT plans were computed to deliver about 85% of the prescribed dose using static open fields and 15% of dose using a less complex solitary dynamic field. The dosimetric differences between the paired samples were compared using the Wilcoxon signed-rank test. For clinical commissioning of gated treatments, a respiratory simulator equipped with a microcontroller was programmed to simulate free-breathing and DIBH-patterns using a custom-developed android application. While both the hSDPRT plans displayed identical target coverage on both the image-sets, the DIBH technique resulted in statistically significant differences in various dose-volume metrics of heart, left-anterior-descending artery, and ipsilateral-lung structures. The hSDPRT plan with DIBH entails reduced total monitor unit (354.9 ± 13.6 MU) and breath-hold time ranging from 2.9 ± 0.3 to 13.7 ± 0.8 seconds/field, along with an acceptable impact on overall machine throughput. DIBH is a feasible method to effectively address the delivery uncertainty and produce substantial sparing of heart and lung when combined with hSDPRT. Streamlined procedures for commissioning and calibration of DIBH-gating technique are essential for more efficient clinical practice.
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Affiliation(s)
- Kather Mohamathu Rafic
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
| | - Solomon Patricia
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India
| | - Balasingh Timothy Peace
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
| | - Christopher J Sujith
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India
| | - Backianathan Selvamani
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
| | - Paul B Ravindran
- Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India; Dosimetry and Medical Radiation Physics Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, Vienna 1400, Austria.
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Miura H, Ozawa S, Kusaba H, Doi Y, Kenjo M, Yamada K, Nagata Y. Characterization of robust optimization for VMAT plan for liver cancer. Rep Pract Oncol Radiother 2020; 25:376-381. [PMID: 32322176 DOI: 10.1016/j.rpor.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 01/21/2020] [Accepted: 03/16/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose We investigated the feasibility of robust optimization for volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) for liver cancer in comparison with planning target volume (PTV)-based optimized plans. Treatment plan quality, robustness, complexity, and accuracy of dose delivery were assessed. Methods Ten liver cancer patients were selected for this study. PTV-based optimized plans with an 8-mm PTV margin and robust optimized plans with an 8-mm setup uncertainty were generated. Plan perturbed doses were evaluated using a setup error of 8 mm in all directions from the isocenter. The dosimetric comparison parameters were clinical target volume (CTV) doses (D98%, D50%, and D2%), liver doses, and monitor unit (MU). Plan complexity was evaluated using the modulation complexity score for VMAT (MCSv). Results There was no significant difference between the two optimizations with respect to CTV doses and MUs. Robust optimized plans had a higher liver dose than did PTV-based optimized plans. Plan perturbed dose evaluations showed that doses to the CTV for the robust optimized plans had small variations. Robust optimized plans were less complex than PTV-based optimized plans. Robust optimized plans had statistically significant fewer leaf position errors than did PTV-based optimized plans. Conclusions Comparison of treatment plan quality, robustness, and plan complexity of both optimizations showed that robust optimization could be feasibile for VMAT of liver cancer.
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Affiliation(s)
- Hideharu Miura
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan.,Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, Japan
| | - Shuichi Ozawa
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan.,Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, Japan
| | - Hayate Kusaba
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan
| | - Yoshiko Doi
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan.,Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, Japan
| | - Masahiko Kenjo
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan.,Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, Japan
| | - Kiyoshi Yamada
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan
| | - Yasushi Nagata
- Hiroshima High-Precision Radiotherapy Cancer Center, Japan.,Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, Japan
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Cao N, Kalet AM, Young LA, Fang LC, Kim JN, Mayr NA, Meyer J. Predictors of cardiac and lung dose sparing in DIBH for left breast treatment. Phys Med 2019; 67:27-33. [PMID: 31629280 DOI: 10.1016/j.ejmp.2019.09.240] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/10/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023] Open
Abstract
This retrospective study of left breast radiation therapy (RT) investigates the correlation between anatomical parameters and dose to heart or/and left lung in deep inspiration breath-hold (DIBH) compared to free-breathing (FB) technique. Anatomical parameters of sixty-seven patients, treated with a step-and-shoot technique to 50 Gy or 50.4 Gy were included. They consisted of the cardiac contact distances in axial (CCDax) and parasagittal (CCDps) planes, and the lateral heart-to-chest distance (HCD). Correlation analysis was performed to identify predictors for heart and lung dose sparing. Paired t-test and linear regression were used for data analysis with significance level of p = 0.05. All dose metrics for heart and lung were significantly reduced with DIBH, however 21% of patients analyzed had less than 1.0 Gy mean heart dose reduction. Both FB-CCDpsdistance and FB-HCD correlated with FB mean heart dose and mean DIBH heart dose reduction. The strongest correlation was observed for the ratio of FB-CCDpsand FB-HCD with heart dose sparing. A FB-CCDps and FB-HCD model was developed to predict DIBH induced mean heart dose reduction, with 1.04 Gy per unit of FB-CCDps/FB-HCD. Variation between predicted and actual mean heart dose reduction ranged from -0.6 Gy to 0.6 Gy. In this study, FB-CCDps and FB-HCD distance served as predictors for heart dose reduction with DIBH equally, with FB-CCDps/FB-HCD as a stronger predictor. These parameters and the prediction model could be further investigated for use as a tool to better select patients who will benefit from DIBH.
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Affiliation(s)
- Ning Cao
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA.
| | - Alan M Kalet
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Lori A Young
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - L Christine Fang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Janice N Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
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Korevaar EW, Habraken SJM, Scandurra D, Kierkels RGJ, Unipan M, Eenink MGC, Steenbakkers RJHM, Peeters SG, Zindler JD, Hoogeman M, Langendijk JA. Practical robustness evaluation in radiotherapy - A photon and proton-proof alternative to PTV-based plan evaluation. Radiother Oncol 2019; 141:267-274. [PMID: 31492443 DOI: 10.1016/j.radonc.2019.08.005] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/23/2019] [Accepted: 08/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE A planning target volume (PTV) in photon treatments aims to ensure that the clinical target volume (CTV) receives adequate dose despite treatment uncertainties. The underlying static dose cloud approximation (the assumption that the dose distribution is invariant to errors) is problematic in intensity modulated proton treatments where range errors should be taken into account as well. The purpose of this work is to introduce a robustness evaluation method that is applicable to photon and proton treatments and is consistent with (historic) PTV-based treatment plan evaluations. MATERIALS AND METHODS The limitation of the static dose cloud approximation was solved in a multi-scenario simulation by explicitly calculating doses for various treatment scenarios that describe possible errors in the treatment course. Setup errors were the same as the CTV-PTV margin and the underlying theory of 3D probability density distributions was extended to 4D to include range errors, maintaining a 90% confidence level. Scenario dose distributions were reduced to voxel-wise minimum and maximum dose distributions; the first to evaluate CTV coverage and the second for hot spots. Acceptance criteria for CTV D98 and D2 were calibrated against PTV-based criteria from historic photon treatment plans. RESULTS CTV D98 in worst case scenario dose and voxel-wise minimum dose showed a very strong correlation with scenario average D98 (R2 > 0.99). The voxel-wise minimum dose visualised CTV dose conformity and coverage in 3D in agreement with PTV-based evaluation in photon therapy. Criteria for CTV D98 and D2 of the voxel-wise minimum and maximum dose showed very strong correlations to PTV D98 and D2 (R2 > 0.99) and on average needed corrections of -0.9% and +2.3%, respectively. CONCLUSIONS A practical approach to robustness evaluation was provided and clinically implemented for PTV-less photon and proton treatment planning, consistent with PTV evaluations but without its static dose cloud approximation.
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Affiliation(s)
- Erik W Korevaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Steven J M Habraken
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Daniel Scandurra
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Roel G J Kierkels
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Mirko Unipan
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | | | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Stephanie G Peeters
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | - Jaap D Zindler
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
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Seppälä J, Vuolukka K, Virén T, Heikkilä J, Honkanen JTJ, Pandey A, Al-Gburi A, Shah M, Sefa S, Koivumäki T. Breast deformation during the course of radiotherapy: The need for an additional outer margin. Phys Med 2019; 65:1-5. [PMID: 31430580 DOI: 10.1016/j.ejmp.2019.07.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/18/2019] [Accepted: 07/25/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The aim of this retrospective study was to investigate and quantify the extent of breast deformation during the course of breast cancer (BC) radiotherapy (RT). The magnitude of breast deformation determines the additional outer margin needed for treatment planning to deliver a full dose to the target volume. This is especially important when using inverse planning techniques. METHODS A total of 93 BC patients treated with RT and with daily CBCT image guidance were selected for this study. Patients underwent either only breast-conserving surgery (BCS) (n = 5), BCS with sentinel node biopsy (n = 57) or BCS with radical axillary node dissection (n = 31). The treatment area included the whole breast and chest wall (54%) or also the axillary lymph nodes (46%). 3D-registration was conducted between 1731 CBCT images and the respective planning CT images to assess the difference in breast surface. RESULTS The largest maximum breast surface expansion (MBSE) was 15 mm; the average was 2.4 ± 2.1 mm. In 294 fractions (17%), the MBSE was ≥5 mm. An outer margin of 8 mm would have been required to cover the whole breast in 95% of the treated fractions. There was a statistically significant correlation between the MBSE and body mass index (r = 0.38, p = 0.001). CONCLUSIONS Significant changes in the breast surface occur during the course of BC RT which should be considered in treatment planning. An additional margin outside the breast surface of at least 8 mm is required to take into account the anatomical changes occurring during BC RT.
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Affiliation(s)
- J Seppälä
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland.
| | - K Vuolukka
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - T Virén
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - J Heikkilä
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - J T J Honkanen
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - A Pandey
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - A Al-Gburi
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - M Shah
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - S Sefa
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - T Koivumäki
- Department of Medical Physics, Central Finland Central Hospital, Jyväskylä, Finland
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Hamming VC, Visser C, Batin E, McDermott LN, Busz DM, Both S, Langendijk JA, Sijtsema NM. Evaluation of a 3D surface imaging system for deep inspiration breath-hold patient positioning and intra-fraction monitoring. Radiat Oncol 2019; 14:125. [PMID: 31296245 PMCID: PMC6624957 DOI: 10.1186/s13014-019-1329-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine the accuracy of a surface guided radiotherapy (SGRT) system for positioning of breast cancer patients in breath-hold (BH) with respect to cone-beam computed tomography (CBCT). Secondly, to evaluate the thorax position stability during BHs with SGRT, when using an air-volume guidance system. METHODS AND MATERIALS Eighteen left-sided breast cancer patients were monitored with SGRT during CBCT and treatment, both in BH. CBCT scans were matched on the target volume and the patient surface. The setup error differences were evaluated, including with linear regression analysis. The intra-fraction variability and stability of the air-volume guided BHs were determined from SGRT measurements. The variability was determined from the maximum difference between the different BH levels within one treatment fraction. The stability was determined from the difference between the start and end position of each BH. RESULTS SGRT data correlated well with CBCT data. The correlation was stronger for surface-to-CBCT (0.61) than target volume-to-CBCT (0.44) matches. Systematic and random setup error differences were ≤ 2 mm in all directions. The 95% limits of agreement (mean ± 2SD) were 0.1 ± 3.0, 0.6 ± 4.1 and 0.4 ± 3.4 mm in the three orthogonal directions, for the surface-to-CBCT matches. For air-volume guided BHs, the variability detected with SGRT was 2.2, 2.8 and 2.3 mm, and the stability - 1.0, 2.1 and 1.5 mm, in three orthogonal directions. Furthermore, the SGRT system could detect unexpected patient movement, undetectable by the air-volume BH system. CONCLUSION With SGRT, left-sided breast cancer patients can be positioned and monitored continuously to maintain position errors within 5 mm. Low intra-fraction variability and good stability can be achieved with the air-volume BH system, however, additional patient position information is available with SGRT, that cannot be detected with air-volume BH systems.
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Affiliation(s)
- Vincent C. Hamming
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Christa Visser
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Estelle Batin
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Leah N. McDermott
- Department of Radiation Oncology, Northwest Clinics, Alkmaar, The Netherlands
| | - Dianne M. Busz
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Stefan Both
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes A. Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nanna M. Sijtsema
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Composite minimax robust optimization of VMAT improves target coverage and reduces non-target dose in head and neck cancer patients. Radiother Oncol 2019; 136:71-77. [DOI: 10.1016/j.radonc.2019.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/15/2019] [Accepted: 03/20/2019] [Indexed: 11/21/2022]
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Svensson H, Lundstedt D, Hällje M, Gustafsson M, Chakarova R, Karlsson P. Integration of biological factors in the treatment plan evaluation in breast cancer radiotherapy. Phys Imaging Radiat Oncol 2019; 11:54-60. [PMID: 33458278 PMCID: PMC7807607 DOI: 10.1016/j.phro.2019.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 12/25/2022] Open
Abstract
This study suggests a PQM methodology for breast cancer radiotherapy evaluation. The risk/benefit balance estimation includes tumor biology and smoking status. Smoking status influenced risk/benefit balance for different treatment techniques. Survival benefit dominated for all patients with high-risk breast cancer. Survival benefit for smokers with low- or intermediate- risk cancer was not seen.
Background/purpose Tumor biology and patient smoking status have clear effects on the benefit of breast radiotherapy. This study developed treatment evaluation strategies that integrated dosimetry, tumor aggressiveness and smoking status for patients undergoing hypo-fractionated whole breast irradiation with simultaneous integrated boost. Materials/methods The evaluation method Plan Quality Metrics (PQM) was adapted for breast cancer. Radiotherapy (RT) benefit was assessed for three levels of tumor aggressiveness; RT risk was estimated using mean dose to organs at risk and published Excess Relative Risk per Gy data for lung cancer and cardiac mortality for smokers and non-smokers. Risk for contralateral breast cancer was also evaluated. PQM and benefit/risk was applied to four patient groups (n = 10 each). Plans using 3D conformal radiotherapy (3DCRT), 3DCRT plus intensity-modulated radiation therapy (IMRT), 3DCRT plus volumetric modulated arc therapy (VMAT) and VMAT were evaluated for each patient. Results 3DCRT-IMRT hybrid planning resulted in higher PQM score (median 87.0 vs. 3DCRT 82.4, p < 0.01), better dose conformity, lower doses to the heart, lungs and contralateral breast. Survival benefit was most predominant for patients with high-risk breast cancer (>7% and >4.5% gain for non-smokers and smokers). For smokers with intermediate- or low-risk breast cancer, RT induced mortality risk dominated for all techniques. When considering the risk of local recurrence, RT benefitted also smokers (>5% and >2% for intermediate- and low-risk cancer). Conclusions PQM methodology was suggested for breast cancer radiotherapy evaluation. Further validation is needed. RT was beneficial for all patients with high risk of recurrence. A survival benefit for smokers with low or intermediate risk of recurrence could not be confirmed.
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Affiliation(s)
- Henrik Svensson
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
- Corresponding author at: Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gula stråket 2B, 413 45 Gothenburg, Sweden.
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Hällje
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Gustafsson
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roumiana Chakarova
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Dunlop A, Colgan R, Kirby A, Ranger A, Blasiak-Wal I. Evaluation of organ motion-based robust optimisation for VMAT planning for breast and internal mammary chain radiotherapy. Clin Transl Radiat Oncol 2019; 16:60-66. [PMID: 31032432 PMCID: PMC6479013 DOI: 10.1016/j.ctro.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 11/23/2022] Open
Abstract
AIMS In patients undergoing locoregional radiotherapy (RT) for breast cancer including the internal mammary chain (IMC), VMAT has been shown to be superior to tangential-field radiotherapy in terms of target coverage and minimising dose to heart and lungs. In this study we describe and validate organ motion-based robust optimisation for generating breast and locoregional lymph node VMAT plans that are robust to inter-fractional changes. MATERIALS AND METHODS In this retrospective study of five patients with left-sided breast cancer requiring locoregional breast radiotherapy including the IMC, non-robust plans were generated in the nominal scenario (planning-CT) and corresponding robust plans were created by optimising over a range of simulated CTs representing worst-case scenario shape changes to the breast. Both plans were re-calculated on CBCT images (n = 67) acquired prior to RT to generate estimates of delivered fractional dose. Plan robustness to inter-fractional changes was assessed in terms of the estimated target coverage and OAR dose. RESULTS Organ motion-based robust optimisation was able to generate clinically acceptable treatment plans in the nominal scenario on the planning CT with no significant differences to OAR dose between the robust and non-robust planning techniques. All plans (robust and non-robust) achieved the mandatory target coverage requirements. Estimates of delivered dose demonstrated a significant improvement in breast target coverage for the robust plans compared to non-robust plans. For the breast CTV, 92% of the robust plans achieved the optimal D98% > 95% clinical goal as compared to 71% of the non-robust plans (p < 0.01). 94% of robust plans achieved acceptable superficial breast coverage, as compared to 55% for the non-robust technique. CONCLUSIONS Organ motion-based robust optimisation VMAT is able to produce clinically acceptable organ-at-risk sparing plans for locoregional breast radiotherapy (including the IMC) that are robust to inter-fractional changes, therefore reducing the likelihood of reactive adaptive re-planning.
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Affiliation(s)
- Alex Dunlop
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
| | - Ruth Colgan
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
| | - Anna Kirby
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Alison Ranger
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Irena Blasiak-Wal
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
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Kalet AM, Cao N, Smith WP, Young L, Wootton L, Stewart RD, Fang LC, Kim J, Horton T, Meyer J. Accuracy and stability of deep inspiration breath hold in gated breast radiotherapy – A comparison of two tracking and guidance systems. Phys Med 2019; 60:174-181. [DOI: 10.1016/j.ejmp.2019.03.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 03/14/2019] [Accepted: 03/24/2019] [Indexed: 01/22/2023] Open
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Miura H, Doi Y, Ozawa S, Nakao M, Ohnishi K, Kenjo M, Nagata Y. Volumetric modulated arc therapy with robust optimization for larynx cancer. Phys Med 2019; 58:54-58. [PMID: 30824150 DOI: 10.1016/j.ejmp.2019.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The aim of this study was to perform a comparison between robust optimization and planning target volume (PTV)-based optimization plans using volumetric modulated arc-therapy (VMAT) by evaluating perturbed doses induced by localization offsets for setup uncertainties in larynx cancer radiation therapy. METHODS Ten patients with early-stage (T1-2N0) glottis carcinoma were selected. The clinical target volume (CTV), carotid arteries, and spinal cord were contoured by a radiation oncologist. PTV-based and robust optimization plans were normalized at D50% to the PTV and D98% to the CTV, respectively. Both optimization plans were evaluated using perturbed doses by specifying user defined shifted values from the isocenter. CTV dose (D98%, D50%, and D2%), homogeneity index (HI) and conformity index (CI95%, CI80%, and CI50%), as well as doses to the carotid arteries and spinal cord were compared between PTV-based and robust optimization plans. RESULTS The robust optimization plans exhibited superior CTV coverage and a reduced dose to the carotid arteries compared to the PTV-based optimization plans (p < 0.05). HI, CI95% and the dose to the spinal cord did not significantly differ between the PTV-based and robust optimization plans (p > 0.05). The robust optimization plans showed better CI80% and CI50% compared to the PTV-based optimization plans (p < 0.05). Plan perturbed evaluations showed that the robust optimization plan has small variations in the doses to the CTV, carotid arteries, and spinal cord compared to the PTV-based optimization plan. CONCLUSIONS The robust optimization plan may be a suitable treatment method in radiotherapy for larynx cancer patient.
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Affiliation(s)
- Hideharu Miura
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan.
| | - Yoshiko Doi
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Shuichi Ozawa
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Minoru Nakao
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Keiichi Ohnishi
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan
| | - Masahiko Kenjo
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Yasushi Nagata
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Claridge Mackonis ER, Estoesta RP, Carroll S. In-vivo dosimetry comparison of supraclavicular junction dose for breast and chest-wall patients with and without deep inspiration breath hold (DIBH). Phys Med 2018; 54:15-20. [DOI: 10.1016/j.ejmp.2018.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/14/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022] Open
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Balaji K, Yadav P, BalajiSubramanian S, Anu Radha C, Ramasubramanian V. Hybrid volumetric modulated arc therapy for chest wall irradiation: For a good plan, get the right mixture. Phys Med 2018; 52:86-92. [PMID: 30139614 DOI: 10.1016/j.ejmp.2018.06.641] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 06/29/2018] [Accepted: 06/30/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To find the optimal dose weighting for hybrid volumetric modulated arc therapy (H-VMAT), a combination of conventional 3DCRT and VMAT plans for left sided chest wall and supraclavicular radiation therapy. METHODS & MATERIALS 20 left-sided breast cancer patients who received adjuvant radiotherapy were considered for this study. To find the optimal weighting, 5 H-VMAT plans were generated for each study case by combining different dose proportions of 3DCRT and VMAT plans including: 90% 3DCRT/10% VMAT, 80% 3DCRT/20% VMAT, 70% 3DCRT/30% VMAT, 60% 3DCRT/40% VMAT, 50% 3DCRT/50% VMAT. Further field-in-field, optimal H-VMAT and VMAT alone plans were compared. RESULTS All H-VMAT plans achieved the expected target coverage. A higher conformity index was achieved for 50% 3DCRT/50% VMAT plan, while better homogeneity index was achieved for 80% 3DCRT/20% VMAT plan. Mean and low doses were less in 90% 3DCRT/10% VMAT plan. Compared with other proportions, 80% 3DCRT/20% VMAT and 70% 3DCRT/30% VMAT weighted H-VMAT plans achieved balanced results for PTVs and OARs. CONCLUSION The optimal dose mixture for H-VMAT technique is 70% to 80% for 3DCRT and 20% to 30% for VMAT. The optimal H-VMAT achieved balanced results for the PTVs and OARs compared with field-in-field and VMAT alone plans.
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Affiliation(s)
- Karunakaran Balaji
- Department of Radiation Oncology, Gleneagles Global Hospitals, Chennai, India; School of Advanced Sciences, Vellore Institute of Technology, Vellore, India.
| | - Poonam Yadav
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
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Tyran M, Tallet A, Resbeut M, Ferre M, Favrel V, Fau P, Moureau-Zabotto L, Darreon J, Gonzague L, Benkemouche A, Varela-Cagetti L, Salem N, Farnault B, Acquaviva MA, Mailleux H. Safety and benefit of using a virtual bolus during treatment planning for breast cancer treated with arc therapy. J Appl Clin Med Phys 2018; 19:463-472. [PMID: 29959819 PMCID: PMC6123145 DOI: 10.1002/acm2.12398] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose This study evaluates the benefit of a virtual bolus method for volumetric modulated arc therapy (VMAT) plan optimization to compensate breast modifications that may occur during breast treatment. Methods Ten files were replanned with VMAT giving 50 Gy to the breast and 47 Gy to the nodes within 25 fractions. The planning process used a virtual bolus for the first optimization, then the monitors units were reoptimized without bolus, after fixing the segments shapes. Structures and treatment planning were exported on a second scanner (CT) performed during treatment as a consequence to modifications in patient's anatomy. The comparative end‐point was clinical target volume's coverage. The first analysis compared the VMAT plans made using the virtual bolus method (VB‐VMAT) to the plans without using it (NoVB‐VMAT) on the first simulation CT. Then, the same analysis was performed on the second CT. Finally, the level of degradation of target volume coverage between the two CT using VB‐VMAT was compared to results using a standard technique of forward‐planned multisegment technique (Tan‐IMRT). Results Using a virtual bolus for VMAT does not degrade dosimetric results on the first CT. No significant result in favor of the NoVB‐VMAT plans was noted. The VB‐VMAT method led to significant better dose distribution on a second CT with modified anatomies compared to NoVB‐VMAT. The clinical target volume's coverage by 95% (V95%) of the prescribed dose was 98.9% [96.1–99.6] on the second CT for VB‐VMAT compared to 92.6% [85.2–97.7] for NoVB‐VMAT (P = 0.0002). The degradation of the target volume coverage for VB‐VMAT is not worse than for Tan‐IMRT: the median differential of V95% between the two CT was 0.9% for VMAT and 0.7% for Tan‐IMRT (P = 1). Conclusion This study confirms the safety and benefit of using a virtual bolus during the VMAT planning process to compensate potential breast shape modifications.
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Affiliation(s)
- Marguerite Tyran
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Agnes Tallet
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Michel Resbeut
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Marjorie Ferre
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Veronique Favrel
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Pierre Fau
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Julien Darreon
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurence Gonzague
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ahcene Benkemouche
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Naji Salem
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Bertrand Farnault
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Hugues Mailleux
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
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