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Amstutz F, D'Almeida PG, Wu X, Albertini F, Bachtiary B, Weber DC, Unkelbach J, Lomax AJ, Zhang Y. Quantification of deformable image registration uncertainties for dose accumulation on head and neck cancer proton treatments. Phys Med 2024; 122:103386. [PMID: 38805762 DOI: 10.1016/j.ejmp.2024.103386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 03/11/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
PURPOSE Head and neck cancer (HNC) patients in radiotherapy require adaptive treatment plans due to anatomical changes. Deformable image registration (DIR) is used in adaptive radiotherapy, e.g. for deformable dose accumulation (DDA). However, DIR's ill-posedness necessitates addressing uncertainties, often overlooked in clinical implementations. DIR's further clinical implementation is hindered by missing quantitative commissioning and quality assurance tools. This study evaluates one pathway for more quantitative DDA uncertainties. METHODS For five HNC patients, each with multiple repeated CTs acquired during treatment, a simultaneous-integrated boost (SIB) plan was optimized. Recalculated doses were warped individually using multiple DIRs from repeated to reference CTs, and voxel-by-voxel dose ranges determined an error-bar for DDA. Followed by evaluating, a previously proposed early-stage DDA uncertainty estimation method tested for lung cancer, which combines geometric DIR uncertainties, dose gradients and their directional dependence, in the context of HNC. RESULTS Applying multiple DIRs show dose differences, pronounced in high dose gradient regions. The patient with largest anatomical changes (-13.1 % in ROI body volume), exhibited 33 % maximum uncertainty in contralateral parotid, with 54 % of voxels presenting an uncertainty >5 %. Accumulation over multiple CTs partially mitigated uncertainties. The estimation approach predicted 92.6 % of voxels within ±5 % to the reference dose uncertainty across all patients. CONCLUSIONS DIR variations impact accumulated doses, emphasizing DDA uncertainty quantification's importance for HNC patients. Multiple DIR dose warping aids in quantifying DDA uncertainties. An estimation approach previously described for lung cancer was successfully validated for HNC, for SIB plans, presenting different dose gradients, and for accumulated treatments.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Peter G D'Almeida
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Information Technology & Electrical Engineering, ETH Zurich, Switzerland
| | - Xin Wu
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Information Technology & Electrical Engineering, ETH Zurich, Switzerland
| | | | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland; Department of Radiation Oncology, University Hospital Bern, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland.
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Kraan AC, Moglioni M, Battistoni G, Bersani D, Berti A, Carra P, Cerello P, Ciocca M, Ferrero V, Fiorina E, Mazzoni E, Morrocchi M, Muraro S, Orlandi E, Pennazio F, Retico A, Rosso V, Sportelli G, Vischioni B, Vitolo V, Bisogni MG. Using the gamma-index analysis for inter-fractional comparison of in-beam PET images for head-and-neck treatment monitoring in proton therapy: A Monte Carlo simulation study. Phys Med 2024; 120:103329. [PMID: 38492331 DOI: 10.1016/j.ejmp.2024.103329] [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: 05/15/2023] [Revised: 02/13/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
GOAL In-beam Positron Emission Tomography (PET) is a technique for in-vivo non-invasive treatment monitoring for proton therapy. To detect anatomical changes in patients with PET, various analysis methods exist, but their clinical interpretation is problematic. The goal of this work is to investigate whether the gamma-index analysis, widely used for dose comparisons, is an appropriate tool for comparing in-beam PET distributions. Focusing on a head-and-neck patient, we investigate whether the gamma-index map and the passing rate are sensitive to progressive anatomical changes. METHODS/MATERIALS We simulated a treatment course of a proton therapy patient using FLUKA Monte Carlo simulations. Gradual emptying of the sinonasal cavity was modeled through a series of artificially modified CT scans. The in-beam PET activity distributions from three fields were evaluated, simulating a planar dual head geometry. We applied the 3D-gamma evaluation method to compare the PET images with a reference image without changes. Various tolerance criteria and parameters were tested, and results were compared to the CT-scans. RESULTS Based on 210 MC simulations we identified appropriate parameters for the gamma-index analysis. Tolerance values of 3 mm/3% and 2 mm/2% were suited for comparison of simulated in-beam PET distributions. The gamma passing rate decreased with increasing volume change for all fields. CONCLUSION The gamma-index analysis was found to be a useful tool for comparing simulated in-beam PET images, sensitive to sinonasal cavity emptying. Monitoring the gamma passing rate behavior over the treatment course is useful to detect anatomical changes occurring during the treatment course.
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Affiliation(s)
- Aafke Christine Kraan
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Martina Moglioni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy.
| | - Giuseppe Battistoni
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Via Giovanni Celoria 16, Milano, 20133, Italy
| | - Davide Bersani
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Via Pietro Giuria 1, Torino, 10125, Italy
| | - Andrea Berti
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Pietro Carra
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Piergiorgio Cerello
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Via Pietro Giuria 1, Torino, 10125, Italy
| | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica, Strada Privata Campeggi 53, Pavia, 27100, Italy
| | - Veronica Ferrero
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Via Pietro Giuria 1, Torino, 10125, Italy
| | - Elisa Fiorina
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Via Pietro Giuria 1, Torino, 10125, Italy
| | - Enrico Mazzoni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Matteo Morrocchi
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Silvia Muraro
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Via Giovanni Celoria 16, Milano, 20133, Italy
| | - Ester Orlandi
- Centro Nazionale di Adroterapia Oncologica, Strada Privata Campeggi 53, Pavia, 27100, Italy
| | - Francesco Pennazio
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Via Pietro Giuria 1, Torino, 10125, Italy
| | - Alessandra Retico
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Valeria Rosso
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Giancarlo Sportelli
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
| | - Barbara Vischioni
- Centro Nazionale di Adroterapia Oncologica, Strada Privata Campeggi 53, Pavia, 27100, Italy
| | - Viviana Vitolo
- Centro Nazionale di Adroterapia Oncologica, Strada Privata Campeggi 53, Pavia, 27100, Italy
| | - Maria Giuseppina Bisogni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy; Dipartimento di Fisica, Università di Pisa, Largo Bruno Pontecorvo 3, Pisa, 56127, Italy
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Moglioni M, Carra P, Arezzini S, Belcari N, Bersani D, Berti A, Bisogni MG, Calderisi M, Ceppa I, Cerello P, Ciocca M, Ferrero V, Fiorina E, Kraan AC, Mazzoni E, Morrocchi M, Pennazio F, Retico A, Rosso V, Sbolgi F, Vitolo V, Sportelli G. Synthetic CT imaging for PET monitoring in proton therapy: a simulation study. Phys Med Biol 2024; 69:065011. [PMID: 38373343 DOI: 10.1088/1361-6560/ad2a99] [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: 09/26/2023] [Accepted: 02/19/2024] [Indexed: 02/21/2024]
Abstract
Objective.This study addresses a fundamental limitation of in-beam positron emission tomography (IB-PET) in proton therapy: the lack of direct anatomical representation in the images it produces. We aim to overcome this shortcoming by pioneering the application of deep learning techniques to create synthetic control CT images (sCT) from combining IB-PET and planning CT scan data.Approach.We conducted simulations involving six patients who underwent irradiation with proton beams. Leveraging the architecture of a visual transformer (ViT) neural network, we developed a model to generate sCT images of these patients using the planning CT scans and the inter-fractional simulated PET activity maps during irradiation. To evaluate the model's performance, a comparison was conducted between the sCT images produced by the ViT model and the authentic control CT images-serving as the benchmark.Main results.The structural similarity index was computed at a mean value across all patients of 0.91, while the mean absolute error measured 22 Hounsfield Units (HU). Root mean squared error and peak signal-to-noise ratio values were 56 HU and 30 dB, respectively. The Dice similarity coefficient exhibited a value of 0.98. These values are comparable to or exceed those found in the literature. More than 70% of the synthetic morphological changes were found to be geometrically compatible with the ones reported in the real control CT scan.Significance.Our study presents an innovative approach to surface the hidden anatomical information of IB-PET in proton therapy. Our ViT-based model successfully generates sCT images from inter-fractional PET data and planning CT scans. Our model's performance stands on par with existing models relying on input from cone beam CT or magnetic resonance imaging, which contain more anatomical information than activity maps.
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Affiliation(s)
- Martina Moglioni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Pietro Carra
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Silvia Arezzini
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Nicola Belcari
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Davide Bersani
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
| | - Andrea Berti
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Maria Giuseppina Bisogni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | | | | | - Piergiorgio Cerello
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, I-10125 Torino, Italy
| | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica, I-27100 Pavia, Italy
| | - Veronica Ferrero
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, I-10125 Torino, Italy
| | - Elisa Fiorina
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, I-10125 Torino, Italy
| | | | - Enrico Mazzoni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
| | - Matteo Morrocchi
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | - Francesco Pennazio
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, I-10125 Torino, Italy
| | - Alessandra Retico
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
| | - Valeria Rosso
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
| | | | - Viviana Vitolo
- Centro Nazionale di Adroterapia Oncologica, I-27100 Pavia, Italy
| | - Giancarlo Sportelli
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, I-56127 Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, I-56127 Pisa, Italy
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Zhang L, Holmes JM, Liu Z, Vora SA, Sio TT, Vargas CE, Yu NY, Keole SR, Schild SE, Bues M, Li S, Liu T, Shen J, Wong WW, Liu W. Beam mask and sliding window-facilitated deep learning-based accurate and efficient dose prediction for pencil beam scanning proton therapy. Med Phys 2024; 51:1484-1498. [PMID: 37748037 DOI: 10.1002/mp.16758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Accurate and efficient dose calculation is essential for on-line adaptive planning in proton therapy. Deep learning (DL) has shown promising dose prediction results in photon therapy. However, there is a scarcity of DL-based dose prediction methods specifically designed for proton therapy. Successful dose prediction method for proton therapy should account for more challenging dose prediction problems in pencil beam scanning proton therapy (PBSPT) due to its sensitivity to heterogeneities. PURPOSE To develop a DL-based PBSPT dose prediction workflow with high accuracy and balanced complexity to support on-line adaptive proton therapy clinical decision and subsequent replanning. METHODS PBSPT plans of 103 prostate cancer patients (93 for training and the other 10 for independent testing) and 83 lung cancer patients (73 for training and the other 10 for independent testing) previously treated at our institution were included in the study, each with computed tomography scans (CTs), structure sets, and plan doses calculated by the in-house developed Monte-Carlo dose engine (considered as the ground truth in the model training and testing). For the ablation study, we designed three experiments corresponding to the following three methods: (1) Experiment 1, the conventional region of interest (ROI) (composed of targets and organs-at-risk [OARs]) method. (2) Experiment 2, the beam mask (generated by raytracing of proton beams) method to improve proton dose prediction. (3) Experiment 3, the sliding window method for the model to focus on local details to further improve proton dose prediction. A fully connected 3D-Unet was adopted as the backbone. Dose volume histogram (DVH) indices, 3D Gamma passing rates with a criterion of 3%/3 mm/10%, and dice coefficients for the structures enclosed by the iso-dose lines between the predicted and the ground truth doses were used as the evaluation metrics. The calculation time for each proton dose prediction was recorded to evaluate the method's efficiency. RESULTS Compared to the conventional ROI method, the beam mask method improved the agreement of DVH indices for both targets and OARs and the sliding window method further improved the agreement of the DVH indices (for lung cancer, CTV D98 absolute deviation: 0.74 ± 0.18 vs. 0.57 ± 0.21 vs. 0.54 ± 0.15 Gy[RBE], ROI vs. beam mask vs. sliding window methods, respectively). For the 3D Gamma passing rates in the target, OARs, and BODY (outside target and OARs), the beam mask method improved the passing rates in these regions and the sliding window method further improved them (for prostate cancer, targets: 96.93% ± 0.53% vs. 98.88% ± 0.49% vs. 99.97% ± 0.07%, BODY: 86.88% ± 0.74% vs. 93.21% ± 0.56% vs. 95.17% ± 0.59%). A similar trend was also observed for the dice coefficients. This trend was especially remarkable for relatively low prescription isodose lines (for lung cancer, 10% isodose line dice: 0.871 ± 0.027 vs. 0.911 ± 0.023 vs. 0.927 ± 0.017). The dose predictions for all the testing cases were completed within 0.25 s. CONCLUSIONS An accurate and efficient deep learning-augmented proton dose prediction framework has been developed for PBSPT, which can predict accurate dose distributions not only inside but also outside ROI efficiently. The framework can potentially further reduce the initial planning and adaptive replanning workload in PBSPT.
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Affiliation(s)
- Lian Zhang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Jason M Holmes
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Zhengliang Liu
- School of Computing, University of Georgia, Athens, Georgia, USA
| | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Sheng Li
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
| | - Tianming Liu
- School of Computing, University of Georgia, Athens, Georgia, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Trnkova P, Zhang Y, Toshito T, Heijmen B, Richter C, Aznar MC, Albertini F, Bolsi A, Daartz J, Knopf AC, Bertholet J. A survey of practice patterns for adaptive particle therapy for interfractional changes. Phys Imaging Radiat Oncol 2023; 26:100442. [PMID: 37197154 PMCID: PMC10183663 DOI: 10.1016/j.phro.2023.100442] [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: 01/25/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Background and purpose Anatomical changes may compromise the planned target coverage and organs-at-risk dose in particle therapy. This study reports on the practice patterns for adaptive particle therapy (APT) to evaluate current clinical practice and wishes and barriers to further implementation. Materials and methods An institutional questionnaire was distributed to PT centres worldwide (7/2020-6/2021) asking which type of APT was used, details of the workflow, and what the wishes and barriers to implementation were. Seventy centres from 17 countries participated. A three-round Delphi consensus analysis (10/2022) among the authors followed to define recommendations on required actions and future vision. Results Out of the 68 clinically operational centres, 84% were users of APT for at least one treatment site with head and neck being most common. APT was mostly performed offline with only two online APT users (plan-library). No centre used online daily re-planning. Daily 3D imaging was used for APT by 19% of users. Sixty-eight percent of users had plans to increase their use or change their technique for APT. The main barrier was "lack of integrated and efficient workflows". Automation and speed, reliable dose deformation for dose accumulation and higher quality of in-room volumetric imaging were identified as the most urgent task for clinical implementation of online daily APT. Conclusion Offline APT was implemented by the majority of PT centres. Joint efforts between industry research and clinics are needed to translate innovations into efficient and clinically feasible workflows for broad-scale implementation of online APT.
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Affiliation(s)
- Petra Trnkova
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Corresponding author.
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Toshiyuki Toshito
- Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Marianne C. Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| | - Antje C. Knopf
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Institute for Medical Engineering and Medical Informatics, School of Life Science FHNW, Muttenz, Switzerland
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
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Bobić M, Lalonde A, Nesteruk KP, Lee H, Nenoff L, Gorissen BL, Bertolet A, Busse PM, Chan AW, Winey BA, Sharp GC, Verburg JM, Lomax AJ, Paganetti H. Large anatomical changes in head-and-neck cancers – a dosimetric comparison of online and offline adaptive proton therapy. Clin Transl Radiat Oncol 2023; 40:100625. [PMID: 37090849 PMCID: PMC10120292 DOI: 10.1016/j.ctro.2023.100625] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Purpose This work evaluates an online adaptive (OA) workflow for head-and-neck (H&N) intensity-modulated proton therapy (IMPT) and compares it with full offline replanning (FOR) in patients with large anatomical changes. Methods IMPT treatment plans are created retrospectively for a cohort of eight H&N cancer patients that previously required replanning during the course of treatment due to large anatomical changes. Daily cone-beam CTs (CBCT) are acquired and corrected for scatter, resulting in 253 analyzed fractions. To simulate the FOR workflow, nominal plans are created on the planning-CT and delivered until a repeated-CT is acquired; at this point, a new plan is created on the repeated-CT. To simulate the OA workflow, nominal plans are created on the planning-CT and adapted at each fraction using a simple beamlet weight-tuning technique. Dose distributions are calculated on the CBCTs with Monte Carlo for both delivery methods. The total treatment dose is accumulated on the planning-CT. Results Daily OA improved target coverage compared to FOR despite using smaller target margins. In the high-risk CTV, the median D98 degradation was 1.1 % and 2.1 % for OA and FOR, respectively. In the low-risk CTV, the same metrics yield 1.3 % and 5.2 % for OA and FOR, respectively. Smaller setup margins of OA reduced the dose to all OARs, which was most relevant for the parotid glands. Conclusion Daily OA can maintain prescription doses and constraints over the course of fractionated treatment, even in cases of large anatomical changes, reducing the necessity for manual replanning in H&N IMPT.
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Elhamiasl M, Salvo K, Poels K, Defraene G, Lambrecht M, Geets X, Sterpin E, Nuyts J. Low-dose CT allows for accurate proton therapy dose calculation and plan optimization. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8dde] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. Protons offer a more conformal dose delivery compared to photons, yet they are sensitive to anatomical changes over the course of treatment. To minimize range uncertainties due to anatomical variations, a new CT acquisition at every treatment session would be paramount to enable daily dose calculation and subsequent plan adaptation. However, the series of CT scans results in an additional accumulated patient dose. Reducing CT radiation dose and thereby decreasing the potential risk of radiation exposure to patients is desirable, however, lowering the CT dose results in a lower signal-to-noise ratio and therefore in a reduced quality image. We hypothesized that the signal-to-noise ratio provided by conventional CT protocols is higher than needed for proton dose distribution estimation. In this study, we aim to investigate the effect of CT imaging dose reduction on proton therapy dose calculations and plan optimization. Approach. To verify our hypothesis, a CT dose reduction simulation tool has been developed and validated to simulate lower-dose CT scans from an existing standard-dose scan. The simulated lower-dose CTs were then used for proton dose calculation and plan optimization and the results were compared with those of the standard-dose scan. The same strategy was adopted to investigate the effect of CT dose reduction on water equivalent thickness (WET) calculation to quantify CT noise accumulation during integration along the beam. Main results. The similarity between the dose distributions acquired from the low-dose and standard-dose CTs was evaluated by the dose-volume histogram and the 3D Gamma analysis. The results on an anthropomorphic head phantom and three patient cases indicate that CT imaging dose reduction up to 90% does not have a significant effect on proton dose calculation and plan optimization. The relative error was employed to evaluate the similarity between WET maps and was found to be less than 1% after reducing the CT imaging dose by 90%. Significance. The results suggest the possibility of using low-dose CT for proton therapy dose estimation, since the dose distributions acquired from the standard-dose and low-dose CTs are clinically equivalent.
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Moglioni M, Kraan AC, Baroni G, Battistoni G, Belcari N, Berti A, Carra P, Cerello P, Ciocca M, De Gregorio A, De Simoni M, Del Sarto D, Donetti M, Dong Y, Embriaco A, Fantacci ME, Ferrero V, Fiorina E, Fischetti M, Franciosini G, Giraudo G, Laruina F, Maestri D, Magi M, Magro G, Malekzadeh E, Marafini M, Mattei I, Mazzoni E, Mereu P, Mirandola A, Morrocchi M, Muraro S, Orlandi E, Patera V, Pennazio F, Pullia M, Retico A, Rivetti A, Da Rocha Rolo MD, Rosso V, Sarti A, Schiavi A, Sciubba A, Sportelli G, Tampellini S, Toppi M, Traini G, Trigilio A, Valle SM, Valvo F, Vischioni B, Vitolo V, Wheadon R, Bisogni MG. In-vivo range verification analysis with in-beam PET data for patients treated with proton therapy at CNAO. Front Oncol 2022; 12:929949. [PMID: 36226070 PMCID: PMC9549776 DOI: 10.3389/fonc.2022.929949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Morphological changes that may arise through a treatment course are probably one of the most significant sources of range uncertainty in proton therapy. Non-invasive in-vivo treatment monitoring is useful to increase treatment quality. The INSIDE in-beam Positron Emission Tomography (PET) scanner performs in-vivo range monitoring in proton and carbon therapy treatments at the National Center of Oncological Hadrontherapy (CNAO). It is currently in a clinical trial (ID: NCT03662373) and has acquired in-beam PET data during the treatment of various patients. In this work we analyze the in-beam PET (IB-PET) data of eight patients treated with proton therapy at CNAO. The goal of the analysis is twofold. First, we assess the level of experimental fluctuations in inter-fractional range differences (sensitivity) of the INSIDE PET system by studying patients without morphological changes. Second, we use the obtained results to see whether we can observe anomalously large range variations in patients where morphological changes have occurred. The sensitivity of the INSIDE IB-PET scanner was quantified as the standard deviation of the range difference distributions observed for six patients that did not show morphological changes. Inter-fractional range variations with respect to a reference distribution were estimated using the Most-Likely-Shift (MLS) method. To establish the efficacy of this method, we made a comparison with the Beam’s Eye View (BEV) method. For patients showing no morphological changes in the control CT the average range variation standard deviation was found to be 2.5 mm with the MLS method and 2.3 mm with the BEV method. On the other hand, for patients where some small anatomical changes occurred, we found larger standard deviation values. In these patients we evaluated where anomalous range differences were found and compared them with the CT. We found that the identified regions were mostly in agreement with the morphological changes seen in the CT scan.
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Affiliation(s)
- Martina Moglioni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Aafke Christine Kraan
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- *Correspondence: Aafke Christine Kraan,
| | - Guido Baroni
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
- Politecnico di Milano, Milano, Italy
| | | | - Nicola Belcari
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Andrea Berti
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
- Istituto di Scienza e Tecnologie dell’Informazione, Consiglio Nazionale delle Ricerche, Pisa, Italy
| | - Pietro Carra
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | | | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Angelica De Gregorio
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Micol De Simoni
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Damiano Del Sarto
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Marco Donetti
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Yunsheng Dong
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
- Dipartimento di Fisica, Università di Milano, Milano, Italy
| | - Alessia Embriaco
- Istituto Nazionale di Fisica Nucleare, Sezione di Pavia, Pavia, Italy
| | - Maria Evelina Fantacci
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Veronica Ferrero
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Elisa Fiorina
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Marta Fischetti
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
| | - Gaia Franciosini
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Giuseppe Giraudo
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Francesco Laruina
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Davide Maestri
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Marco Magi
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
| | - Giuseppe Magro
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Etesam Malekzadeh
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
- Department of Medical Physics, Tarbiat Modares University, Teheran, Iran
| | - Michela Marafini
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Museo Storico della Fisica e Centro Studi e Ricerche “E. Fermi”, Roma, Italy
| | - Ilaria Mattei
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
| | - Enrico Mazzoni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
| | - Paolo Mereu
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | | | - Matteo Morrocchi
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Silvia Muraro
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
| | - Ester Orlandi
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Vincenzo Patera
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
| | | | - Marco Pullia
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | | | - Angelo Rivetti
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | | | - Valeria Rosso
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Alessio Sarti
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
| | - Angelo Schiavi
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
| | - Adalberto Sciubba
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione dei Laboratori di Frascati, Frascati, Italy
| | - Giancarlo Sportelli
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | | | - Marco Toppi
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza Universit `a di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione dei Laboratori di Frascati, Frascati, Italy
| | - Giacomo Traini
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
- Museo Storico della Fisica e Centro Studi e Ricerche “E. Fermi”, Roma, Italy
| | - Antonio Trigilio
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | | | | | | | - Viviana Vitolo
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Richard Wheadon
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Maria Giuseppina Bisogni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy
- Dipartimento di Fisica, Università di Pisa, Pisa, Italy
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9
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Cao W, Rocha H, Mohan R, Lim G, Goudarzi HM, Ferreira BC, Dias JM. Reflections on beam configuration optimization for intensity-modulated proton therapy. Phys Med Biol 2022; 67. [PMID: 35561700 DOI: 10.1088/1361-6560/ac6fac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
Abstract
Presumably, intensity-modulated proton radiotherapy (IMPT) is the most powerful form of proton radiotherapy. In the current state of the art, IMPT beam configurations (i.e. the number of beams and their directions) are, in general, chosen subjectively based on prior experience and practicality. Beam configuration optimization (BCO) for IMPT could, in theory, significantly enhance IMPT’s therapeutic potential. However, BCO is complex and highly computer resource-intensive. Some algorithms for BCO have been developed for intensity-modulated photon therapy (IMRT). They are rarely used clinically mainly because the large number of beams typically employed in IMRT renders BCO essentially unnecessary. Moreover, in the newer form of IMRT, volumetric modulated arc therapy, there are no individual static beams. BCO is of greater importance for IMPT because it typically employs a very small number of beams (2-4) and, when the number of beams is small, BCO is critical for improving plan quality. However, the unique properties and requirements of protons, particularly in IMPT, make BCO challenging. Protons are more sensitive than photons to anatomic changes, exhibit variable relative biological effectiveness along their paths, and, as recently discovered, may spare the immune system. Such factors must be considered in IMPT BCO, though doing so would make BCO more resource intensive and make it more challenging to extend BCO algorithms developed for IMRT to IMPT. A limited amount of research in IMPT BCO has been conducted; however, considerable additional work is needed for its further development to make it truly effective and computationally practical. This article aims to provide a review of existing BCO algorithms, most of which were developed for IMRT, and addresses important requirements specific to BCO for IMPT optimization that necessitate the modification of existing approaches or the development of new effective and efficient ones.
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10
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Possibilities and challenges when using synthetic computed tomography in an adaptive carbon-ion treatment workflow. Z Med Phys 2022:S0939-3889(22)00064-2. [PMID: 35764469 DOI: 10.1016/j.zemedi.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Anatomical surveillance during ion-beam therapy is the basis for an effective tumor treatment and optimal organ at risk (OAR) sparing. Synthetic computed tomography (sCT) based on magnetic resonance imaging (MRI) can replace the X-ray based planning CT (X-rayCT) in photon radiotherapy and improve the workflow efficiency without additional imaging dose. The extension to carbon-ion radiotherapy is highly challenging; complex patient positioning, unique anatomical situations, distinct horizontal and vertical beam incidence directions, and limited training data are only few problems. This study gives insight into the possibilities and challenges of using sCTs in carbon-ion therapy. MATERIALS AND METHODS For head and neck patients immobilised with thermoplastic masks 30 clinically applied actively scanned carbon-ion treatment plans on 15 CTs comprising 60 beams were analyzed. Those treatment plans were re-calculated on MRI based sCTs which were created employing a 3D U-Net. Dose differences and carbon-ion spot displacements between sCT and X-rayCT were evaluated on a patient specific basis. RESULTS Spot displacement analysis showed a peak displacement by 0.2 cm caused by the immobilisation mask not measurable with the MRI. 95.7% of all spot displacements were located within 1 cm. For the clinical target volume (CTV) the median D50% agreed within -0.2% (-1.3 to 1.4%), while the median D0.01cc differed up to 4.2% (-1.3 to 25.3%) comparing the dose distribution on the X-rayCT and the sCT. OAR deviations depended strongly on the position and the dose gradient. For three patients no deterioration of the OAR parameters was observed. Other patients showed large deteriorations, e.g. for one patient D2% of the chiasm differed by 28.1%. CONCLUSION The usage of sCTs opens several new questions, concluding that we are not ready yet for an MR-only workflow in carbon-ion therapy, as envisaged in photon therapy. Although omitting the X-rayCT seems unfavourable in the case of carbon-ion therapy, an sCT could be advantageous for monitoring, re-planning, and adaptation.
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11
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Argota-Perez R, Sharma MB, Elstrøm UV, Møller DS, Grau C, Jensen K, Holm AIS, Korreman SS. Dose and robustness comparison of nominal, daily and accumulated doses for photon and proton treatment of sinonasal cancer. Radiother Oncol 2022; 173:102-108. [PMID: 35667574 DOI: 10.1016/j.radonc.2022.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The aim was to evaluate and compare the dosimetric effect and robustness towards day-to-day anatomical and setup variations in the delivered dose for photon and proton treatments of sinonasal cancer (SNC) patients. MATERIALS AND METHODS Photon (VMAT) and proton (IMPT) plans were optimized retrospectively for 24 SNC patients. Synthetic CTs (synCT) were obtained by deforming the planning CT (pCT) to the anatomy of every daily cone-beam CT. Both VMAT and IMPT plans were recalculated on the synCTs. The recalculated daily dose was accumulated over the whole treatment on the pCT. Target coverage and dose to organs and risk (OARs) were evaluated for all patients for the nominal, daily and accumulated dose distribution. RESULTS In general, dose to OARs farther away from the target, including brain, chiasm and contralateral optic nerve, was lower for proton plans than photon plans. Whereas, OARs in proximity of the target received a lower dose for photon plans. For proton plans, the target coverage (volume of CTV receiving 95% of prescribed dose), V95%, fell below 99% for 9/24 patients in one or more fractions. For photon plans, 4/24 patients had one or more fractions where V95% fell below 99%. For accumulated doses, V95% was below 99% only in two cases, but above 98% for all patients. CONCLUSION Photon and proton treatment have different strengths regarding OAR sparing. The robustness was high for both treatment modalities. Patient selection for either proton or photon radiation therapy of SNC patients should be based on a case-by-case comparison.
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Affiliation(s)
- R Argota-Perez
- Department of Oncology, Aarhus University Hospital, Denmark
| | - M B Sharma
- Department of Oncology, Aarhus University Hospital, Denmark
| | - U V Elstrøm
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Denmark
| | - C Grau
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - K Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
| | - A I S Holm
- Department of Oncology, Aarhus University Hospital, Denmark.
| | - S S Korreman
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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12
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Bäumer C, Frakulli R, Kohl J, Nagaraja S, Steinmeier T, Worawongsakul R, Timmermann B. Adaptive Proton Therapy of Pediatric Head and Neck Cases Using MRI-Based Synthetic CTs: Initial Experience of the Prospective KiAPT Study. Cancers (Basel) 2022; 14:cancers14112616. [PMID: 35681594 PMCID: PMC9179385 DOI: 10.3390/cancers14112616] [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: 03/11/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND AND PURPOSE Interfractional anatomical changes might affect the outcome of proton therapy (PT). We aimed to prospectively evaluate the role of Magnetic Resonance Imaging (MRI) based adaptive PT for children with tumors of the head and neck and base of skull. METHODS MRI verification images were acquired at half of the treatment course. A synthetic computed tomography (CT) image was created using this MRI and a deformable image registration (DIR) to the reference MRI. The methodology was verified with in-silico phantoms and validated using a clinical case with a shrinking cystic hygroma on the basis of dosimetric quantities of contoured structures. The dose distributions on the verification X-ray CT and on the synthetic CT were compared with a gamma-index test using global 2 mm/2% criteria. RESULTS Regarding the clinical validation case, the gamma-index pass rate was 98.3%. Eleven patients were included in the clinical study. The most common diagnosis was rhabdomyosarcoma (73%). Craniofacial tumor site was predominant in 64% of patients, followed by base of skull (18%). For one individual case the synthetic CT showed an increase in the median D2 and Dmax dose on the spinal cord from 20.5 GyRBE to 24.8 GyRBE and 14.7 GyRBE to 25.1 GyRBE, respectively. Otherwise, doses received by OARs remained relatively stable. Similarly, the target volume coverage seen by D95% and V95% remained unchanged. CONCLUSIONS The method of transferring anatomical changes from MRIs to a synthetic CTs was successfully implemented and validated with simple, commonly available tools. In the frame of our early results on a small cohort, no clinical relevant deterioration for neither PTV coverage nor an increased dose burden to OARs occurred. However, the study will be continued to identify a pediatric patient cohort, which benefits from adaptive treatment planning.
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Affiliation(s)
- Christian Bäumer
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
- Department of Physics, Technische Universität Dortmund, 44227 Dortmund, Germany
- Correspondence:
| | - Rezarta Frakulli
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- Department of Particle Therapy, 45147 Essen, Germany
| | - Jessica Kohl
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
| | - Sindhu Nagaraja
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- Department of Particle Therapy, 45147 Essen, Germany
| | - Theresa Steinmeier
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- Department of Particle Therapy, 45147 Essen, Germany
| | - Rasin Worawongsakul
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- Department of Particle Therapy, 45147 Essen, Germany
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Ramathibodi Hospital, Mahidol University, Nakhon 73170, Thailand
| | - Beate Timmermann
- West German Proton Therapy Centre Essen, 45147 Essen, Germany; (R.F.); (J.K.); (S.N.); (T.S.); (R.W.); (B.T.)
- University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
- Department of Particle Therapy, 45147 Essen, Germany
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13
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Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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14
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Penescu L, Stora T, Stegemann S, Pitters J, Fiorina E, Augusto RDS, Schmitzer C, Wenander F, Parodi K, Ferrari A, Cocolios TE. Technical Design Report for a Carbon-11 Treatment Facility. Front Med (Lausanne) 2022; 8:697235. [PMID: 35547661 PMCID: PMC9081534 DOI: 10.3389/fmed.2021.697235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
Particle therapy relies on the advantageous dose deposition which permits to highly conform the dose to the target and better spare the surrounding healthy tissues and organs at risk with respect to conventional radiotherapy. In the case of treatments with heavier ions (like carbon ions already clinically used), another advantage is the enhanced radiobiological effectiveness due to high linear energy transfer radiation. These particle therapy advantages are unfortunately not thoroughly exploited due to particle range uncertainties. The possibility to monitor the compliance between the ongoing and prescribed dose distribution is a crucial step toward new optimizations in treatment planning and adaptive therapy. The Positron Emission Tomography (PET) is an established quantitative 3D imaging technique for particle treatment verification and, among the isotopes used for PET imaging, the 11C has gained more attention from the scientific and clinical communities for its application as new radioactive projectile for particle therapy. This is an interesting option clinically because of an enhanced imaging potential, without dosimetry drawbacks; technically, because the stable isotope 12C is successfully already in use in clinics. The MEDICIS-Promed network led an initiative to study the possible technical solutions for the implementation of 11C radioisotopes in an accelerator-based particle therapy center. We present here the result of this study, consisting in a Technical Design Report for a 11C Treatment Facility. The clinical usefulness is reviewed based on existing experimental data, complemented by Monte Carlo simulations using the FLUKA code. The technical analysis starts from reviewing the layout and results of the facilities which produced 11C beams in the past, for testing purposes. It then focuses on the elaboration of the feasible upgrades of an existing 12C particle therapy center, to accommodate the production of 11C beams for therapy. The analysis covers the options to produce the 11C atoms in sufficient amounts (as required for therapy), to ionize them as required by the existing accelerator layouts, to accelerate and transport them to the irradiation rooms. The results of the analysis and the identified challenges define the possible implementation scenario and timeline.
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Affiliation(s)
| | - Thierry Stora
- European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | - Simon Stegemann
- Department of Physics and Astronomy, KU Leuven, Geel, Belgium
| | - Johanna Pitters
- European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | - Elisa Fiorina
- Istituto Nazionale di Fisica Nucleare (INFN), Sezione di Torino, Torino, Italy
- Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Ricardo Dos Santos Augusto
- European Organization for Nuclear Research (CERN), Geneva, Switzerland
- TRIUMF, Vancouver, BC, Canada
- Ludwig Maximilian University of Munich (LMU), Munich, Germany
| | | | - Fredrik Wenander
- European Organization for Nuclear Research (CERN), Geneva, Switzerland
| | - Katia Parodi
- Ludwig Maximilian University of Munich (LMU), Munich, Germany
| | - Alfredo Ferrari
- European Organization for Nuclear Research (CERN), Geneva, Switzerland
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15
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Pennazio F, Ferrero V, D'Onghia G, Garbolino S, Fiorina E, Marti Villarreal OA, Mas Milian F, Monaco V, Monti V, Patera A, Werner J, Wheadon R, Rafecas M. Proton therapy monitoring: spatiotemporal emission reconstruction with prompt gamma timing and implementation with PET detectors. Phys Med Biol 2022; 67. [PMID: 35193131 DOI: 10.1088/1361-6560/ac5765] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/22/2022] [Indexed: 12/17/2022]
Abstract
Objective. In this study we introduce spatiotemporal emission reconstruction prompt gamma timing (SER-PGT), a new method to directly reconstruct the prompt photon emission in the space and time domains inside the patient in proton therapy.Approach. SER-PGT is based on the numerical optimisation of a multidimensional likelihood function, followed by a post-processing of the results. The current approach relies on a specific implementation of the maximum-likelihood expectation maximisation algorithm. The robustness of the method is guaranteed by the complete absence of any information about the target composition in the algorithm.Main results. Accurate Monte Carlo simulations indicate a range resolution of about 0.5 cm (standard deviation) when considering 107primary protons impinging on an homogeneous phantom. Preliminary results on an anthropomorphic phantom are also reported.Significance. By showing the feasibility for the reconstruction of the primary particle range using PET detectors, this study provides significant basis for the development of an hybrid in-beam PET and prompt photon device.
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Affiliation(s)
| | | | | | | | | | | | - Felix Mas Milian
- INFN, Torino, Italy.,Universitá degli Studi di Torino, Torino, Italy.,Universidade Estadual de Santa Cruz, Ilheus, Brazil
| | - Vincenzo Monaco
- INFN, Torino, Italy.,Universitá degli Studi di Torino, Torino, Italy
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16
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Kraan AC, Berti A, Retico A, Baroni G, Battistoni G, Belcari N, Cerello P, Ciocca M, De Simoni M, Del Sarto D, Donetti M, Dong Y, Embriaco A, Ferrero V, Fiorina E, Fischetti M, Franciosini G, Giraudo G, Laruina F, Maestri D, Magi M, Magro G, Mancini Terracciano C, Marafini M, Mattei I, Mazzoni E, Mereu P, Mirabelli R, Mirandola A, Morrocchi M, Muraro S, Patera A, Patera V, Pennazio F, Rivetti A, Da Rocha Rolo MD, Rosso V, Sarti A, Schiavi A, Sciubba A, Solfaroli Camillocci E, Sportelli G, Tampellini S, Toppi M, Traini G, Valle SM, Valvo F, Vischioni B, Vitolo V, Wheadon R, Bisogni MG. Localization of anatomical changes in patients during proton therapy with in-beam PET monitoring: A voxel-based morphometry approach exploiting Monte Carlo simulations. Med Phys 2021; 49:23-40. [PMID: 34813083 PMCID: PMC9303286 DOI: 10.1002/mp.15336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/30/2021] [Accepted: 10/11/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose In‐beam positron emission tomography (PET) is one of the modalities that can be used for in vivo noninvasive treatment monitoring in proton therapy. Although PET monitoring has been frequently applied for this purpose, there is still no straightforward method to translate the information obtained from the PET images into easy‐to‐interpret information for clinical personnel. The purpose of this work is to propose a statistical method for analyzing in‐beam PET monitoring images that can be used to locate, quantify, and visualize regions with possible morphological changes occurring over the course of treatment. Methods We selected a patient treated for squamous cell carcinoma (SCC) with proton therapy, to perform multiple Monte Carlo (MC) simulations of the expected PET signal at the start of treatment, and to study how the PET signal may change along the treatment course due to morphological changes. We performed voxel‐wise two‐tailed statistical tests of the simulated PET images, resembling the voxel‐based morphometry (VBM) method commonly used in neuroimaging data analysis, to locate regions with significant morphological changes and to quantify the change. Results The VBM resembling method has been successfully applied to the simulated in‐beam PET images, despite the fact that such images suffer from image artifacts and limited statistics. Three dimensional probability maps were obtained, that allowed to identify interfractional morphological changes and to visualize them superimposed on the computed tomography (CT) scan. In particular, the characteristic color patterns resulting from the two‐tailed statistical tests lend themselves to trigger alarms in case of morphological changes along the course of treatment. Conclusions The statistical method presented in this work is a promising method to apply to PET monitoring data to reveal interfractional morphological changes in patients, occurring over the course of treatment. Based on simulated in‐beam PET treatment monitoring images, we showed that with our method it was possible to correctly identify the regions that changed. Moreover we could quantify the changes, and visualize them superimposed on the CT scan. The proposed method can possibly help clinical personnel in the replanning procedure in adaptive proton therapy treatments.
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Affiliation(s)
| | - Andrea Berti
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | | | - Guido Baroni
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy.,Politecnico di Milano, Milano, Italy
| | | | - Nicola Belcari
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | | | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Micol De Simoni
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Damiano Del Sarto
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Marco Donetti
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Yunsheng Dong
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy.,Dipartimento di Fisica, Università di Milano, Milano, Italy
| | - Alessia Embriaco
- Istituto Nazionale di Fisica Nucleare, Sezione di Pavia, Pavia, Italy
| | - Veronica Ferrero
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Elisa Fiorina
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Marta Fischetti
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy
| | - Gaia Franciosini
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Giuseppe Giraudo
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Francesco Laruina
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Davide Maestri
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Marco Magi
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy
| | - Giuseppe Magro
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Carlo Mancini Terracciano
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Michela Marafini
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | - Ilaria Mattei
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
| | - Enrico Mazzoni
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
| | - Paolo Mereu
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Riccardo Mirabelli
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | | | - Matteo Morrocchi
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Silvia Muraro
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milano, Italy
| | - Alessandra Patera
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Vincenzo Patera
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | | | - Angelo Rivetti
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | | | - Valeria Rosso
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | - Alessio Sarti
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | - Angelo Schiavi
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy
| | - Adalberto Sciubba
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione dei Laboratori di Frascati, Frascati, RM, Italy
| | - Elena Solfaroli Camillocci
- Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy
| | - Giancarlo Sportelli
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
| | | | - Marco Toppi
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare, Sezione dei Laboratori di Frascati, Frascati, RM, Italy
| | - Giacomo Traini
- Istituto Nazionale di Fisica Nucleare, Sezione di Roma, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | | | | | | | - Viviana Vitolo
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Richard Wheadon
- Istituto Nazionale di Fisica Nucleare, Sezione di Torino, Torino, Italy
| | - Maria Giuseppina Bisogni
- Istituto Nazionale di Fisica Nucleare, Sezione di Pisa, Pisa, Italy.,Dipartimento di Fisica, Università di Pisa, Pisa, Italy
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17
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Paganetti H, Botas P, Sharp GC, Winey B. Adaptive proton therapy. Phys Med Biol 2021; 66:10.1088/1361-6560/ac344f. [PMID: 34710858 PMCID: PMC8628198 DOI: 10.1088/1361-6560/ac344f] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy treatments are typically planned based on a single image set, assuming that the patient's anatomy and its position relative to the delivery system remains constant during the course of treatment. Similarly, the prescription dose assumes constant biological dose-response over the treatment course. However, variations can and do occur on multiple time scales. For treatment sites with significant intra-fractional motion, geometric changes happen over seconds or minutes, while biological considerations change over days or weeks. At an intermediate timescale, geometric changes occur between daily treatment fractions. Adaptive radiation therapy is applied to consider changes in patient anatomy during the course of fractionated treatment delivery. While traditionally adaptation has been done off-line with replanning based on new CT images, online treatment adaptation based on on-board imaging has gained momentum in recent years due to advanced imaging techniques combined with treatment delivery systems. Adaptation is particularly important in proton therapy where small changes in patient anatomy can lead to significant dose perturbations due to the dose conformality and finite range of proton beams. This review summarizes the current state-of-the-art of on-line adaptive proton therapy and identifies areas requiring further research.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pablo Botas
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Foundation 29 of February, Pozuelo de Alarcón, Madrid, Spain
| | - Gregory C Sharp
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian Winey
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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18
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Nenoff L, Matter M, Charmillot M, Krier S, Uher K, Weber DC, Lomax AJ, Albertini F. Experimental validation of daily adaptive proton therapy. Phys Med Biol 2021; 66. [PMID: 34587589 DOI: 10.1088/1361-6560/ac2b84] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/29/2021] [Indexed: 11/12/2022]
Abstract
Anatomical changes during proton therapy require rapid treatment plan adaption to mitigate the associated dosimetric impact. This in turn requires a highly efficient workflow that minimizes the time between imaging and delivery. At the Paul Scherrer Institute, we have developed an online adaptive workflow, which is specifically designed for treatments in the skull-base/cranium, with the focus set on simplicity and minimizing changes to the conventional workflow. The dosimetric and timing performance of this daily adaptive proton therapy (DAPT) workflow has been experimentally investigated using an in-house developed DAPT software and specifically developed anthropomorphic phantom. After a standard treatment preparation, which includes the generation of a template plan, the treatment can then be adapted each day, based on daily imaging acquired on an in-room CT. The template structures are then rigidly propagated to this CT and the daily plan is fully re-optimized using the same field arrangement, DVH constraints and optimization settings of the template plan. After a dedicated plan QA, the daily plan is delivered. To minimize the time between imaging and delivery, clinically integrated software for efficient execution of all online adaption steps, as well as tools for comprehensive and automated QA checks, have been developed. Film measurements of an end-to-end validation of a multi-fraction DAPT treatment showed high agreement to the calculated doses. Gamma pass rates with a 3%/3 mm criteria were >92% when comparing the measured dose to the template plan. Additionally, a gamma pass rate >99% was found comparing measurements to the Monte Carlo dose of the daily plans reconstructed from the logfile, accumulated over the delivered fractions. With this, we experimentally demonstrate that the described adaptive workflow can be delivered accurately in a timescale similar to a standard delivery.
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Affiliation(s)
- Lena Nenoff
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
| | - Michael Matter
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
| | | | - Serge Krier
- Department of Physics, ETH Zurich, Switzerland
| | - Klara Uher
- Department of Physics, ETH Zurich, Switzerland
| | - Damien Charles Weber
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Switzerland.,Department of Radiation Oncology, University Hospital Bern, Switzerland
| | - Antony John Lomax
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
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19
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Ricotti R, Pella A, Mirandola A, Fiore MR, Chalaszczyk A, Paganelli C, Antonioli L, Vai A, Tagaste B, Belotti G, Rossi M, Ciocca M, Orlandi E, Baroni G. Dosimetric effect of variable rectum and sigmoid colon filling during carbon ion radiotherapy to sacral chordoma. Phys Med 2021; 90:123-133. [PMID: 34628271 DOI: 10.1016/j.ejmp.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/13/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Carbon ion radiotherapy (CIRT) is sensitive to anatomical density variations. We examined the dosimetric effect of variable intestinal filling condition during CIRT to ten sacral chordoma patients. METHODS For each patient, eight virtual computed tomography scans (vCTs) were generated by varying the density distribution within the rectum and the sigmoid in the planning computed tomography (pCT) with a density override approach mimicking a heterogeneous combination of gas and feces. Totally full and empty intestinal preparations were modelled. In addition, five different intestinal filling conditions were modelled by a mixed density pattern derived from two combined and weighted Gaussian distributions simulating gas and feces respectively. Finally, a patient-specific mixing proportion was estimated by evaluating the daily amount of gas detected in the cone beam computed tomography (CBCT). Dose distribution was recalculated on each vCT and dose volume histograms (DVHs) were examined. RESULTS No target coverage degradation was observed at different vCTs. Rectum and sigma dose degradation ranged respectively between: [-6.7; 21.6]GyE and [-0.7; 15.4]GyE for D50%; [-377.4; 1197.9] and [-95.2; 1027.5] for AUC; [-1.2; 10.7]GyE and [-2.6; 21.5]GyE for D1%. CONCLUSIONS Variation of intestinal density can greatly influence the penetration depth of charged particle and might compromise dose distribution. In particular cases, with large clinical target volume in very close proximity to rectum and sigmoid colon, it is appropriate to evaluate the amount of gas present in the daily CBCT images even if it is totally included in the reference planning structures.
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Affiliation(s)
- R Ricotti
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy.
| | - A Pella
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - M R Fiore
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Chalaszczyk
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - C Paganelli
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - L Antonioli
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - A Vai
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - B Tagaste
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - G Belotti
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - M Rossi
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - M Ciocca
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - E Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - G Baroni
- Bioengineering Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy; Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, Italy
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20
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Sharma M, Argota Perez R, Holm A, Korreman S, Jensen K, Elstrøm U, Grau C. Air variability in maxillary sinus during radiotherapy for sinonasal carcinoma. Clin Transl Radiat Oncol 2021; 27:36-43. [PMID: 33490653 PMCID: PMC7809099 DOI: 10.1016/j.ctro.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The aim was to characterise patterns and predictability of aeration changes in the ipsilateral maxillary sinus during intensity-modulated radiotherapy (IMRT) for sinonasal cancer (SNC), and in a sample evaluate the dosimetric effects of aeration changes for both photon and proton therapy. MATERIALS AND METHODS The study included patients treated with IMRT for SNC in a single institution in 2009-2017. The volume of air in the ipsilateral maxillary sinus was recorded in 1578 daily cone beam computer tomography (CBCT) from 53 patients. Patterns of changing air volumes were categorised as 'stable', increasing', 'decreasing', or 'erratic'. For the prediction analysis, categorisation was performed based both on the entire treatment course and the first five fractions (F1-5). Photon and proton therapy plans were generated for four patients, the one from each category with the largest aeration variation. Synthetic CT images were generated for each CBCT and all plans were recalculated on the daily synthetic CTs. RESULTS The absolute volume of air varied considerably during the treatment course, ranging from 0 to 25.9 cm3. Changes within a single participant varied in the range of 0-18.7 cm3. In the categorisation of patterns, most patients had increasing aeration of the sinus. Generally, patterns of aeration could not be predicted from F1-5. Patients categorised as increasing in F1-5 had the best prediction, with 78% predicted correctly as increasing for the entire treatment course. The numeric correlation coefficients for target coverage and air volume were low for 3/4 scenarios (photons 0.03-0.23, protons 0.26-0.48). No straightforward correlation between the dosimetric effect and the volume changes could be detected in the sample test of four patients for neither photon nor proton therapy. CONCLUSION The variation of aeration was large and unpredictable. No clear dosimetric consequences of the aeration variation were evident for neither IMRT nor proton therapy for the patients investigated.
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Affiliation(s)
- M.B. Sharma
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R. Argota Perez
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - A.I.S. Holm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - S.S. Korreman
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - K. Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - U.V. Elstrøm
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - C. Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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21
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Lowe M, Gosling A, Nicholas O, Underwood T, Miles E, Chang YC, Amos RA, Burnet NG, Clark CH, Patel I, Tsang Y, Sisson N, Gulliford S. Comparing Proton to Photon Radiotherapy Plans: UK Consensus Guidance for Reporting Under Uncertainty for Clinical Trials. Clin Oncol (R Coll Radiol) 2020; 32:459-466. [PMID: 32307206 DOI: 10.1016/j.clon.2020.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
In the UK, the recent introduction of high-energy proton beam therapy into national clinical practice provides an opportunity for new clinical trials, particularly those comparing proton and photon treatments. However, comparing these different modalities can present many challenges. Although protons may confer an advantage in terms of reduced normal tissue dose, they can also be more sensitive to uncertainty. Uncertainty analysis is fundamental in ensuring that proton plans are both safe and effective in the event of unavoidable discrepancies, such as variations in patient setup and proton beam range. Methods of evaluating and mitigating the effect of these uncertainties can differ from those approaches established for photon therapy treatments, such as the use of expansion margins to assure safety. These differences should be considered when comparing protons and photons. An overview of the effect of uncertainties on proton plans is presented together with an introduction to some of the concepts and terms that should become familiar to those involved in proton therapy trials. This report aims to provide guidance for those engaged in UK clinical trials comparing protons and photons. This guidance is intended to take a pragmatic approach considering the tools that are available to practising centres and represents a consensus across multidisciplinary groups involved in proton therapy in the UK.
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Affiliation(s)
- M Lowe
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK.
| | - A Gosling
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - O Nicholas
- South West Wales Cancer Centre, Swansea Bay NHS Trust, Swansea, UK; Swansea University Medical School, Swansea University, Swansea, UK; National Radiotherapy Trials Quality Assurance Group, Velindre Cancer Centre, Cardiff, UK
| | - T Underwood
- Division of Cancer Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - E Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, Middlesex, UK
| | - Y-C Chang
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
| | - R A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - N G Burnet
- Division of Cancer Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - C H Clark
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, Middlesex, UK
| | - I Patel
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Y Tsang
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, Northwood, Middlesex, UK
| | - N Sisson
- National Radiotherapy Trials Quality Assurance Group, The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, Wirral, UK
| | - S Gulliford
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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22
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Colloca G, Tagliaferri L, Capua BD, Gambacorta MA, Lanzotti V, Bellieni A, Monfardini S, Balducci L, Bernabei R, Cho WC, Valentini V. Management of The Elderly Cancer Patients Complexity: The Radiation Oncology Potential. Aging Dis 2020; 11:649-657. [PMID: 32489709 PMCID: PMC7220284 DOI: 10.14336/ad.2019.0616] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 06/16/2019] [Indexed: 12/30/2022] Open
Abstract
Radiation oncology has the potential to be an excellent option for the frail elderly cancer patients because of its limited systemic toxicities. It can be effective for curative, prophylactic, disease control or palliative purposes. Currently about 60% of all cancer patients undergoing active treatment at some point receive radiation treatment. However, though widely used, there are limited clinical trials strictly designed for the elderly. This paper will review the key points in the assessment and treatment of elderly cancer patient including quality of life, active life expectancy, cognitive performance, frailty, sarcopenia and how the new technologies can help to reach the key goal of maintaining autonomy and independence for the elderly cancer patient.
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Affiliation(s)
- Giuseppe Colloca
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy.,3GIOGER Gruppo italiano di Oncologia Geriatrica, Italy
| | - Luca Tagliaferri
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
| | - Beatrice Di Capua
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy.,3GIOGER Gruppo italiano di Oncologia Geriatrica, Italy
| | - Maria Antonietta Gambacorta
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
| | - Vito Lanzotti
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
| | - Andrea Bellieni
- 2Istituto di Medicina Interna e Geriatria, Università Cattolica Sacro Cuore, Roma, Italy.,3GIOGER Gruppo italiano di Oncologia Geriatrica, Italy
| | | | | | - Roberto Bernabei
- 2Istituto di Medicina Interna e Geriatria, Università Cattolica Sacro Cuore, Roma, Italy
| | - William C Cho
- 6Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong
| | - Vincenzo Valentini
- 1Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
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23
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Burnet NG, Mackay RI, Smith E, Chadwick AL, Whitfield GA, Thomson DJ, Lowe M, Kirkby NF, Crellin AM, Kirkby KJ. Proton beam therapy: perspectives on the National Health Service England clinical service and research programme. Br J Radiol 2020; 93:20190873. [PMID: 31860337 PMCID: PMC7066938 DOI: 10.1259/bjr.20190873] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/05/2019] [Accepted: 12/16/2019] [Indexed: 12/19/2022] Open
Abstract
The UK has an important role in the evaluation of proton beam therapy (PBT) and takes its place on the world stage with the opening of the first National Health Service (NHS) PBT centre in Manchester in 2018, and the second in London coming in 2020. Systematic evaluation of the role of PBT is a key objective. By September 2019, 108 patients had started treatment, 60 paediatric, 19 teenagers and young adults and 29 adults. Obtaining robust outcome data is vital, if we are to understand the strengths and weaknesses of current treatment approaches. This is important in demonstrating when PBT will provide an advantage and when it will not, and in quantifying the magnitude of benefit.The UK also has an important part to play in translational PBT research, and building a research capability has always been the vision. We are perfectly placed to perform translational pre-clinical biological and physical experiments in the dedicated research room in Manchester. The nature of DNA damage from proton irradiation is considerably different from X-rays and this needs to be more fully explored. A better understanding is needed of the relative biological effectiveness (RBE) of protons, especially at the end of the Bragg peak, and of the effects on tumour and normal tissue of PBT combined with conventional chemotherapy, targeted drugs and immunomodulatory agents. These experiments can be enhanced by deterministic mathematical models of the molecular and cellular processes of DNA damage response. The fashion of ultra-high dose rate FLASH irradiation also needs to be explored.
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Affiliation(s)
| | | | - Ed Smith
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | - Amy L Chadwick
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Gillian A Whitfield
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | - David J Thomson
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | | | - Norman F Kirkby
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | | | - Karen J Kirkby
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
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24
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Albertini F, Matter M, Nenoff L, Zhang Y, Lomax A. Online daily adaptive proton therapy. Br J Radiol 2020; 93:20190594. [PMID: 31647313 PMCID: PMC7066958 DOI: 10.1259/bjr.20190594] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
It is recognized that the use of a single plan calculated on an image acquired some time before the treatment is generally insufficient to accurately represent the daily dose to the target and to the organs at risk. This is particularly true for protons, due to the physical finite range. Although this characteristic enables the generation of steep dose gradients, which is essential for highly conformal radiotherapy, it also tightens the dependency of the delivered dose to the range accuracy. In particular, the use of an outdated patient anatomy is one of the most significant sources of range inaccuracy, thus affecting the quality of the planned dose distribution. A plan should be ideally adapted as soon as anatomical variations occur, ideally online. In this review, we describe in detail the different steps of the adaptive workflow and discuss the challenges and corresponding state-of-the art developments in particular for an online adaptive strategy.
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Affiliation(s)
| | | | | | - Ye Zhang
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
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25
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Nomura Y, Xu Q, Peng H, Takao S, Shimizu S, Xing L, Shirato H. Modified fast adaptive scatter kernel superposition (mfASKS) correction and its dosimetric impact on CBCT‐based proton therapy dose calculation. Med Phys 2019; 47:190-200. [DOI: 10.1002/mp.13878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/11/2019] [Accepted: 10/12/2019] [Indexed: 12/27/2022] Open
Affiliation(s)
- Yusuke Nomura
- Department of Radiation Oncology Graduate School of Medicine Hokkaido University Sapporo 060‐8638 Japan
| | - Qiong Xu
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
| | - Hao Peng
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
- Department of Radiation Oncology Stanford University Stanford CA 94305‐5847 USA
| | - Seishin Takao
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
- Department of Radiation Oncology Hokkaido University Hospital Sapporo 060‐8648 Japan
| | - Shinichi Shimizu
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
- Department of Radiation Medical Science and Engineering Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo 060‐8638 Japan
| | - Lei Xing
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
- Department of Radiation Oncology Stanford University Stanford CA 94305‐5847 USA
| | - Hiroki Shirato
- Global Station for Quantum Medical Science and Engineering Global Institution for Collaborative Research and Education (GI‐CoRE) Hokkaido University Sapporo 060‐8648 Japan
- Department of Proton Beam Therapy Research Center for Cooperative Projects Faculty of Medicine Hokkaido University Sapporo 060‐8638 Japan
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26
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Ricotti R, Pella A, Tagaste B, Elisei G, Fontana G, Bonora M, Ciocca M, Valvo F, Orecchia R, Baroni G. Long-time clinical experience in patient setup for several particle therapy clinical indications: management of patient positioning and evaluation of setup reproducibility and stability. Br J Radiol 2019; 93:20190595. [PMID: 31687833 DOI: 10.1259/bjr.20190595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Accurate patient positioning is crucial in particle therapy due to the geometrical selectivity of particles. We report and discuss the National Center for Oncological Hadrontherapy (CNAO) experience in positioning accuracy and stability achieved with solid thermoplastic masks fixed on index base plates and assessed by daily orthogonal X-ray imaging. METHODS Positioning data were retrospectively collected (between 2012 and 2018) and grouped according to the treated anatomical site. 19696 fractions of 1325 patients were evaluated.The study was designed to assess:(i) the number of fractions in which a single correction vector was applied(SCV);(ii) the number of fractions in which further setup verification was performed (SV);(iii) the number of fractions in which SV lead to an additional correction within (MCV<5min) or after (MCV>5min) 5 minutes from the first setup correction;(iv) the systematic (Σ) and random (σ) error components of the correction vectors applied. RESULTS A SCV was applied in 71.5% of fractions, otherwise SV was required. In 30.6% of fractions with SV, patient position was not further revised. In the remaining fractions, MCV<5min and MCV>5min were applied mainly in extracranial and cranial sites respectively.Interfraction Σ was ≤ 1.7 mm/0.7° and σ was ≤ 1.2 mm/0.6° in cranial sites while in extracranial sites Σ was ≤ 5.5 mm/0.9° and σ was ≤4.4 mm/0.9°. Setup residuals were submillimetric in all sites. In cranial patients, maximum intrafractional Σ was 0.8 mm/0.4°. CONCLUSION This report extensively quantifies inter- and intrafraction setup accuracy on an institutional basis and confirms the need of image guidance to fully benefit from the geometrical selectivity of particles. ADVANCES IN KNOWLEDGE The reported analysis provides a board institutional data set on the evaluation of patient immobilization and bony anatomy alignment for several particle therapy clinical indications.
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Affiliation(s)
- Rosalinda Ricotti
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Andrea Pella
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Barbara Tagaste
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Giovanni Elisei
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Giulia Fontana
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Maria Bonora
- Radiotherapy Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Mario Ciocca
- Medical Physics Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Francesca Valvo
- Radiotherapy Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Roberto Orecchia
- CNAO National Center for Oncological Hadrontherapy, Pavia, Italy.,European Institute of Oncology, Milan, Italy
| | - Guido Baroni
- Bioengineering Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy
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27
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Nenoff L, Matter M, Hedlund Lindmar J, Weber DC, Lomax AJ, Albertini F. Daily adaptive proton therapy - the key to innovative planning approaches for paranasal cancer treatments. Acta Oncol 2019; 58:1423-1428. [PMID: 31364904 DOI: 10.1080/0284186x.2019.1641217] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: For proton therapy of paranasal tumors, field directions avoiding volumes that might change during therapy are typically used. If the plan is optimized on the daily anatomy using daily adapted proton therapy (DAPT) however, field directions crossing the nasal cavities might be feasible. In this study, we investigated the effectiveness of DAPT for enabling narrow-field treatment approaches. Material and methods: For five paranasal tumor patients, representing a wide patient spectrum, anatomically robust 4-field-star and narrow-field plans were calculated and their robustness to anatomical and setup uncertainties was compared with and without DAPT. Based on the nominal planning CTs, per patient up to 125 simulated CTs (simCTs) with different nasal cavity fillings were created and random translations and rotations due to patient setup uncertainties were further simulated. Plans were recalculated or re-optimized on all error scenarios, representing non-adapted and DAPT fractions, respectively. From these, 100 possible treatments (60 GyRBE, 30 fx) were simulated and changes in integral dose, target and organs at risk (OARs) doses evaluated. Results: In comparison to the 4-field-star approach, the use of narrow-fields reduced integral dose between 29% and 56%. If OARs did not overlap with the target, OAR doses were also reduced. Finally, the significantly reduced target coverage in non-adapted treatments (mean V95 reductions of up to 34%) could be almost fully restored with DAPT in all cases (differences <1%). Conclusions: DAPT was found to be not only an effective way to increase plan robustness to anatomical and positional uncertainties, but also opened the possibility to use improved and more conformal field arrangements.
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Affiliation(s)
- Lena Nenoff
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Michael Matter
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Johanna Hedlund Lindmar
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Antony John Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
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28
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Vyfhuis MAL, Fellows Z, McGovern N, Zhu M, Mohindra P, Wong J, Nichols EM. Preserving Endocrine Function in Premenopausal Women Undergoing Whole Pelvis Radiation for Cervical Cancer. Int J Part Ther 2019; 6:10-17. [PMID: 31773044 DOI: 10.14338/ijpt-d-19-00061.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/16/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose Whole pelvis radiation therapy (WPRT) in premenopausal women with cervical cancer can cause permanent ovarian damage, resulting in premature menopause. Oophoropexy, often considered as an initial step, demonstrates safety of sparing 1 ovary at the cost of delay in initiating WPRT. Therefore, we dosimetrically compared volumetric modulated arc radiotherapy (VMAT) and intensity modulated proton therapy (IMPT) techniques to allow for ovarian-sparing WPRT. Materials and Methods Ten patients previously treated for cervical cancer at our institution were included in this institutional review board-approved analysis. A modified clinical treatment volume (CTV) was designed, sparing 1 ovary (left or right), as determined by the physician (ovarian-sparing CTV) and disease extent, including physical exam, positron emission tomography/computed tomography and magnetic resonance imaging. An ovarian-sparing planning target volume was determined as the ovarian-sparing CTV+5 mm for patients who were supine and 7 mm for those who were prone. All plans were calculated to a dose of 45 Gy with specific optimization goals for target volumes, while attempting to maintain a mean ovary dose (Dmean) < 15 Gy. Dosimetric goals were compared across the 2 modalities using the Mann-Whitney U test. Results Both treatment modalities were able to achieve primary clinical goal coverage to the uterus/cervix (P = .529, comparing VMAT versus IMPT), ovarian-sparing CTV (P = .796) and ovarian-sparing planning target volume (P = .004). All 10 IMPT plans were able to accomplish the ovary objective (14.0 ± 1.66 Gy). However, only 4 of the 10 VMAT plans were able to achieve a Dmean < 15 Gy to the prioritized ovary, with an average dose of 15.3 ± 4.10 Gy. Conclusion Sparing an ovary in women undergoing WPRT for cervical cancer is dosimetrically feasible with IMPT without sacrificing coverage to important clinical targets. Future work will incorporate the brachytherapy dose to the ovarian-sparing CTV and assess the clinical response of this technique as a means to preserve ovarian endocrine function.
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Affiliation(s)
- Melissa A L Vyfhuis
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Zachary Fellows
- Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nathaniel McGovern
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jade Wong
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
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29
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Kountouri M, Pica A, Walser M, Albertini F, Bolsi A, Kliebsch U, Bachtiary B, Combescure C, Lomax AJ, Schneider R, Weber DC. Radiation-induced optic neuropathy after pencil beam scanning proton therapy for skull-base and head and neck tumours. Br J Radiol 2019; 93:20190028. [PMID: 31322969 DOI: 10.1259/bjr.20190028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To assess the radiation-induced optic neuropathy (RION) prevalence, following high dose pencil beam scanning proton therapy (PBSPT) to skull base and head and neck (H&N) tumours. METHODS Between 1999 and 2014, 216 adult patients, median age 47 years (range, 18-77), were treated with PBS PT for skull base or H&N malignancies, delivering ≥45 GyRBE to the optic nerve(s) (ON) and/or optic chiasma (OC). The median administered dose to the planning target volume was 74.0 GyRBE (range, 54.0-77.4). The median follow-up was 5.3 years (range, 0.8-15.9). RESULTS RION was observed in 14 (6.5%) patients at a median time of 13.2 months (range, 4.8-42.6) following PBSPT. Most (92.9%) of RION were symptomatic. Most affected patients (11/14; 79%) developed unilateral toxicity. Grade 4, 3, 2 and 1 toxicity was observed in 10, 2, 1 and 1 patients, respectively. On univariate analyses, age (<70 vs ≥70 years; p < 0.0001), hypertension (p = 0.0007) and tumour abutting the optic apparatus (p = 0.012) were associated with RION. OC's V60 GyRBE was of border line significance (p = 0.06). None of the other evaluated OC-ON dose/volume metrics (Dmax, Dmean, V40-60) were significantly associated with this complication. CONCLUSION These data suggest that high-dose PBS PT for skull base and H&N tumours is associated with a low prevalence of RION. Caution should be however exercised when treating elderly/hypertensive patients with tumours abutting the optic apparatus. ADVANCES IN KNOWLEDGE This is the first study reporting the risk of developing RION following proton therapy with PBS technique, demonstrating the safety of this treatment.
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Affiliation(s)
- Melpomeni Kountouri
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Francesca Albertini
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Ulrike Kliebsch
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Christophe Combescure
- Service d'Epidemiologie Clinique, Hôpitaux Universitaire de Genève, CH 12011 Geneva, Geneva, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland.,Department of Physics, ETH, Zürich, Switzerland
| | - Ralf Schneider
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, CH-5232, Villigen, Switzerland.,University of Bern, Bern, Switzerland.,University of Zürich, Zürich, Switzerland
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30
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Intensity modulated proton therapy (IMPT) - The future of IMRT for head and neck cancer. Oral Oncol 2018; 88:66-74. [PMID: 30616799 DOI: 10.1016/j.oraloncology.2018.11.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022]
Abstract
Radiation therapy plays an integral role in the management of head and neck cancers (HNCs). While most HNC patients have historically been treated with photon-based radiation techniques such as intensity modulated radiation therapy (IMRT), there is a growing awareness of the potential clinical benefits of proton therapy over IMRT in the definitive, postoperative and reirradiation settings given the unique physical properties of protons. Intensity modulated proton therapy (IMPT), also known as "pencil beam proton therapy," is a sophisticated mode of proton therapy that is analogous to IMRT and an active area of investigation in cancer care. Multifield optimization IMPT allows for high quality plans that can target superficially located HNCs as well as large neck volumes while significantly reducing integral doses. Several dosimetric studies have demonstrated the superiority of IMPT over IMRT to improve dose sparing of nearby organs such as the larynx, salivary glands, and esophagus. Evidence of the clinical translation of these dosimetric advantages has been demonstrated with documented toxicity reductions (such as decreased feeding tube dependency) after IMPT for patients with HNCs. While there are relative challenges to IMPT planning that exist today such as particle range uncertainties and high sensitivity to anatomical changes, ongoing investigations in image-guidance techniques and robust optimization methods are promising. A systematic approach towards utilizing IMPT and additional prospective studies are necessary in order to more accurately estimate the clinical benefit of IMPT over IMRT and passive proton therapy on a case-by-case basis for patients with sub-site specific HNCs.
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31
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van de Water S, Albertini F, Weber DC, Heijmen BJM, Hoogeman MS, Lomax AJ. Anatomical robust optimization to account for nasal cavity filling variation during intensity-modulated proton therapy: a comparison with conventional and adaptive planning strategies. Phys Med Biol 2018; 63:025020. [PMID: 29160775 DOI: 10.1088/1361-6560/aa9c1c] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this study is to develop an anatomical robust optimization method for intensity-modulated proton therapy (IMPT) that accounts for interfraction variations in nasal cavity filling, and to compare it with conventional single-field uniform dose (SFUD) optimization and online plan adaptation. We included CT data of five patients with tumors in the sinonasal region. Using the planning CT, we generated for each patient 25 'synthetic' CTs with varying nasal cavity filling. The robust optimization method available in our treatment planning system 'Erasmus-iCycle' was extended to also account for anatomical uncertainties by including (synthetic) CTs with varying patient anatomy as error scenarios in the inverse optimization. For each patient, we generated treatment plans using anatomical robust optimization and, for benchmarking, using SFUD optimization and online plan adaptation. Clinical target volume (CTV) and organ-at-risk (OAR) doses were assessed by recalculating the treatment plans on the synthetic CTs, evaluating dose distributions individually and accumulated over an entire fractionated 50 GyRBE treatment, assuming each synthetic CT to correspond to a 2 GyRBE fraction. Treatment plans were also evaluated using actual repeat CTs. Anatomical robust optimization resulted in adequate CTV doses (V95% ⩾ 98% and V107% ⩽ 2%) if at least three synthetic CTs were included in addition to the planning CT. These CTV requirements were also fulfilled for online plan adaptation, but not for the SFUD approach, even when applying a margin of 5 mm. Compared with anatomical robust optimization, OAR dose parameters for the accumulated dose distributions were on average 5.9 GyRBE (20%) higher when using SFUD optimization and on average 3.6 GyRBE (18%) lower for online plan adaptation. In conclusion, anatomical robust optimization effectively accounted for changes in nasal cavity filling during IMPT, providing substantially improved CTV and OAR doses compared with conventional SFUD optimization. OAR doses can be further reduced by using online plan adaptation.
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Affiliation(s)
- Steven van de Water
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA Rotterdam, Netherlands. Author to whom any correspondence should be addressed
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32
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Hammi A, Placidi L, Weber DC, Lomax AJ. Positioning of head and neck patients for proton therapy using proton range probes: a proof of concept study. ACTA ACUST UNITED AC 2017; 63:015025. [DOI: 10.1088/1361-6560/aa9cff] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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33
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Cubillos-Mesías M, Baumann M, Troost EGC, Lohaus F, Löck S, Richter C, Stützer K. Impact of robust treatment planning on single- and multi-field optimized plans for proton beam therapy of unilateral head and neck target volumes. Radiat Oncol 2017; 12:190. [PMID: 29183377 PMCID: PMC5706329 DOI: 10.1186/s13014-017-0931-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proton beam therapy is promising for the treatment of head and neck cancer (HNC), but it is sensitive to uncertainties in patient positioning and particle range. Studies have shown that the planning target volume (PTV) concept may not be sufficient to ensure robustness of the target coverage. A few planning studies have considered irradiation of unilateral HNC targets with protons, but they have only taken into account the dose on the nominal plan, without considering anatomy changes occurring during the treatment course. METHODS Four pencil beam scanning (PBS) proton therapy plans were calculated for 8 HNC patients with unilateral target volumes: single-field (SFO) and multi-field optimized (MFO) plans, either using the PTV concept or clinical target volume (CTV)-based robust optimization. The dose was recalculated on computed tomography (CT) scans acquired during the treatment course. Doses to target volumes and organs at risk (OARs) were compared for the nominal plans, cumulative doses considering anatomical changes, and additional setup and range errors in each fraction. If required, the treatment plan was adapted, and the dose was compared with the non-adapted plan. RESULTS All nominal plans fulfilled the clinical specifications for target coverage, but significantly higher doses on the ipsilateral parotid gland were found for both SFO approaches. MFO PTV-based plans had the lowest robustness against range and setup errors. During the treatment course, the influence of the anatomical variation on the dose has shown to be patient specific, mostly independent of the chosen planning approach. Nine plans in four patients required adaptation, which led to a significant improvement of the target coverage and a slight reduction in the OAR dose in comparison to the cumulative dose without adaptation. CONCLUSIONS The use of robust MFO optimization is recommended for ensuring plan robustness and reduced doses in the ipsilateral parotid gland. Anatomical changes occurring during the treatment course might degrade the target coverage and increase the dose in the OARs, independent of the chosen planning approach. For some patients, a plan adaptation may be required.
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Affiliation(s)
- Macarena Cubillos-Mesías
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Michael Baumann
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Esther G. C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases (NCT), partner site Dresden, Dresden, Germany
| | - Fabian Lohaus
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Kristin Stützer
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
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Stützer K, Jakobi A, Bandurska-Luque A, Barczyk S, Arnsmeyer C, Löck S, Richter C. Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes. J Appl Clin Med Phys 2017; 18:104-113. [PMID: 28921843 PMCID: PMC5689930 DOI: 10.1002/acm2.12189] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose Evaluation of dose degradation by anatomic changes for head‐and‐neck cancer (HNC) intensity‐modulated proton therapy (IMPT) relative to intensity‐modulated photon therapy (IMRT) and identification of potential indicators for IMPT treatment plan adaptation. Methods For 31 advanced HNC datasets, IMPT and IMRT plans were recalculated on a computed tomography scan (CT) taken after about 4 weeks of therapy. Dose parameter changes were determined for the organs at risk (OARs) spinal cord, brain stem, parotid glands, brachial plexus, and mandible, for the clinical target volume (CTV) and the healthy tissue outside planning target volume (PTV). Correlation of dose degradation with target volume changes and quality of rigid CT matching was investigated. Results Recalculated IMPT dose distributions showed stronger degradation than the IMRT doses. OAR analysis revealed significant changes in parotid median dose (IMPT) and near maximum dose (D1ml) of spinal cord (IMPT, IMRT) and mandible (IMPT). OAR dose parameters remained lower in IMPT cases. CTV coverage (V95%) and overdose (V107%) deteriorated for IMPT plans to (93.4 ± 5.4)% and (10.6 ± 12.5)%, while those for IMRT plans remained acceptable. Recalculated plans showed similarly decreased PTV conformity, but considerable hotspots, also outside the PTV, emerged in IMPT cases. Lower CT matching quality was significantly correlated with loss of PTV conformity (IMPT, IMRT), CTV homogeneity and coverage (IMPT). Target shrinkage correlated with increased dose in brachial plexus (IMRT, IMPT), hotspot generation outside the PTV (IMPT) and lower PTV conformity (IMRT). Conclusions The study underlines the necessity of precise positioning and monitoring of anatomy changes, especially in IMPT which might require adaptation more often. Since OAR doses remained typically below constraints, IMPT plan adaptation will be indicated by target dose degradations.
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Affiliation(s)
- Kristin Stützer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany
| | - Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Anna Bandurska-Luque
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Steffen Barczyk
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Carolin Arnsmeyer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.,German Cancer Consortium (DKTK), partner site Dresden, Germany and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69192, Heidelberg, Germany
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Gorgisyan J, Perrin R, Lomax AJ, Persson GF, Josipovic M, Engelholm SA, Weber DC, Munck af Rosenschold P. Impact of beam angle choice on pencil beam scanning breath-hold proton therapy for lung lesions. Acta Oncol 2017; 56:853-859. [PMID: 28464744 DOI: 10.1080/0284186x.2017.1287950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The breath-hold technique inter alia has been suggested to mitigate the detrimental effect of motion on pencil beam scanned (PBS) proton therapy dose distributions. The aim of this study was to evaluate the robustness of incident proton beam angles to day-to-day anatomical variations in breath-hold. MATERIALS AND METHODS Single field PBS plans at five degrees increments in the transversal plane were made and water-equivalent path lengths (WEPLs) were derived on the planning breath-hold CT (BHCT) for 30 patients diagnosed with locally-advanced non-small cell lung cancer (NSCLC), early stage NSCLC or lung metastasis. Our treatment planning system was subsequently used to recalculate the plans and derive WEPL on a BHCT scan acquired at the end of the treatment. Changes to the V95%, D95 and mean target dose were evaluated. RESULTS The difference in WEPL as a function of the beam angle was highly patient specific, with a median of 3.3 mm (range: 0.0-41.1 mm). Slightly larger WEPL differences were located around the lateral or lateral anterior/posterior beam angles. Linear models revealed that changes in dose were associated to the changes in WEPL and the tumor baseline shift (p < 0.05). CONCLUSIONS WEPL changes and tumor baseline shift can serve as reasonable surrogates for dosimetric uncertainty of the target coverage and are well-suited for routine evaluation of plan robustness. The two lateral beam angles are not recommended to use for PBS proton therapy of lung cancer patients treated in breath-hold, due to the poor robustness for several of the patients evaluated.
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Affiliation(s)
- Jenny Gorgisyan
- Paul Scherrer Institute, Villigen PSI, Switzerland
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | | | - Antony J. Lomax
- Paul Scherrer Institute, Villigen PSI, Switzerland
- Physics Department, ETH Zurich, Zurich, Switzerland
| | - Gitte F. Persson
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mirjana Josipovic
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | - Svend Aage Engelholm
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Damien C. Weber
- Paul Scherrer Institute, Villigen PSI, Switzerland
- Radiation Oncology Department, University Hospital of Zurich, Zurich, Switzerland
| | - Per Munck af Rosenschold
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
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