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Westerhoff JM, Daamen LA, Christodouleas JP, Blezer ELA, Choudhury A, Westley RL, Erickson BA, Fuller CD, Hafeez S, van der Heide UA, Intven MPW, Kirby AM, Lalondrelle S, Minsky BD, Mook S, Nowee ME, Marijnen CAM, Orrling KM, Sahgal A, Schultz CJ, Faivre-Finn C, Tersteeg RJHA, Tree AC, Tseng CL, Schytte T, Silk DM, Eggert D, Luzzara M, van der Voort van Zyp JRN, Verkooijen HM, Hall WA. Safety and Tolerability of Online Adaptive High-Field Magnetic Resonance-Guided Radiotherapy. JAMA Netw Open 2024; 7:e2410819. [PMID: 38691356 PMCID: PMC11063805 DOI: 10.1001/jamanetworkopen.2024.10819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/06/2024] [Indexed: 05/03/2024] Open
Abstract
Importance In 2018, the first online adaptive magnetic resonance (MR)-guided radiotherapy (MRgRT) system using a 1.5-T MR-equipped linear accelerator (1.5-T MR-Linac) was clinically introduced. This system enables online adaptive radiotherapy, in which the radiation plan is adapted to size and shape changes of targets at each treatment session based on daily MR-visualized anatomy. Objective To evaluate safety, tolerability, and technical feasibility of treatment with a 1.5-T MR-Linac, specifically focusing on the subset of patients treated with an online adaptive strategy (ie, the adapt-to-shape [ATS] approach). Design, Setting, and Participants This cohort study included adults with solid tumors treated with a 1.5-T MR-Linac enrolled in Multi Outcome Evaluation for Radiation Therapy Using the MR-Linac (MOMENTUM), a large prospective international study of MRgRT between February 2019 and October 2021. Included were adults with solid tumors treated with a 1.5-T MR-Linac. Data were collected in Canada, Denmark, The Netherlands, United Kingdom, and the US. Data were analyzed in August 2023. Exposure All patients underwent MRgRT using a 1.5-T MR-Linac. Radiation prescriptions were consistent with institutional standards of care. Main Outcomes and Measures Patterns of care, tolerability, and technical feasibility (ie, treatment completed as planned). Acute high-grade radiotherapy-related toxic effects (ie, grade 3 or higher toxic effects according to Common Terminology Criteria for Adverse Events version 5.0) occurring within the first 3 months after treatment delivery. Results In total, 1793 treatment courses (1772 patients) were included (median patient age, 69 years [range, 22-91 years]; 1384 male [77.2%]). Among 41 different treatment sites, common sites were prostate (745 [41.6%]), metastatic lymph nodes (233 [13.0%]), and brain (189 [10.5%]). ATS was used in 1050 courses (58.6%). MRgRT was completed as planned in 1720 treatment courses (95.9%). Patient withdrawal caused 5 patients (0.3%) to discontinue treatment. The incidence of radiotherapy-related grade 3 toxic effects was 1.4% (95% CI, 0.9%-2.0%) in the entire cohort and 0.4% (95% CI, 0.1%-1.0%) in the subset of patients treated with ATS. There were no radiotherapy-related grade 4 or 5 toxic effects. Conclusions and Relevance In this cohort study of patients treated on a 1.5-T MR-Linac, radiotherapy was safe and well tolerated. Online adaptation of the radiation plan at each treatment session to account for anatomic variations was associated with a low risk of acute grade 3 toxic effects.
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Affiliation(s)
- Jasmijn M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - Lois A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - John P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Erwin L. A. Blezer
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - Ananya Choudhury
- Department of Clinical Oncology, The University of Manchester, Manchester, United Kingdom
| | - Rosalyne L. Westley
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Clifton D. Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Shaista Hafeez
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Uulke A. van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anna M. Kirby
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Bruce D. Minsky
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marlies E. Nowee
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Arjun Sahgal
- Sunnybrook Health Sciences Centre-Odette Cancer Centre, Department of Radiation Oncology, Toronto, Ontario, Canada
| | | | - Corinne Faivre-Finn
- Department of Clinical Oncology, The University of Manchester, Manchester, United Kingdom
- The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | | | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Chia-Lin Tseng
- Sunnybrook Health Sciences Centre-Odette Cancer Centre, Department of Radiation Oncology, Toronto, Ontario, Canada
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Dustin M. Silk
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | | | | | | | - Helena M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
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Sritharan K, Daamen L, Pathmanathan A, Schytte T, Pos F, Choudhury A, van der Voort van Zyp JR, Kerkmeijer LG, Hall W, Hall E, Verkooijen HM, Herbert T, Hafeez S, Mitchell A, Tree AC. MRI-guided radiotherapy in twenty fractions for localised prostate cancer; results from the MOMENTUM study. Clin Transl Radiat Oncol 2024; 46:100742. [PMID: 38440792 PMCID: PMC10909700 DOI: 10.1016/j.ctro.2024.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
Background and purpose MRI-guided radiotherapy (MRIgRT) offers multiple potential advantages over CT-guidance. This study examines the potential clinical benefits of MRIgRT for men with localised prostate cancer, in the setting of moderately hypofractionated radiotherapy. We evaluate two-year toxicity outcomes, early biochemical response and patient-reported outcomes (PRO), using data obtained from a multicentre international registry study, for the first group of patients with prostate cancer who underwent treatment on a 1.5 T MR-Linac. Materials and methods Patients who were enrolled within the MOMENTUM study and received radical treatment with 60 Gy in 20 fractions were identified. PSA levels and CTCAE version 5.0 toxicity data were measured at follow-up visits. Those patients who consented to PRO data collection also completed EQ-5D-5L, EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires. Results Between November 2018 and June 2022, 146 patients who had MRIgRT for localised prostate cancer on the 1.5 T MR-Linac were eligible for this study. Grade 2 and worse gastro-intestinal (GI) toxicity was reported in 3 % of patients at three months whilst grade 2 and worse genitourinary (GU) toxicity was 7 % at three months. There was a significant decrease in the median PSA at 12 months. The results from both the EQ-5D-5L data and EORTC global health status scale indicate a decline in the quality of life (QoL) during the first six months. The mean change in score for the EORTC scale showed a decrease of 11.4 points, which is considered clinically important. QoL improved back to baseline by 24 months. Worsening of hormonal symptoms in the first six months was reported with a return to baseline by 24 months and sexual activity in all men worsened in the first three months and returned to baseline at 12 months. Conclusion This study establishes the feasibility of online-MRIgRT for localised prostate on a 1.5 T MR-Linac with low rates of toxicity, similar to that published in the literature. However, the clinical benefits of MRIgRT over conventional radiotherapy in the setting of moderate hypofractionation is not evident. Further research will focus on the delivery of ultrahypofractionated regimens, where the potential advantages of MRIgRT for prostate cancer may become more discernible.
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Affiliation(s)
- Kobika Sritharan
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Lois Daamen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Floris Pos
- The Netherlands Cancer Institute, The Netherlands
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, UK
| | | | | | | | - Emma Hall
- The Institute of Cancer Research, UK
| | - Helena M. Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Adam Mitchell
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
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Rabe M, Dietrich O, Forbrig R, Niyazi M, Belka C, Corradini S, Landry G, Kurz C. Repeatability quantification of brain diffusion-weighted imaging for future clinical implementation at a low-field MR-linac. Radiat Oncol 2024; 19:31. [PMID: 38448888 PMCID: PMC10916154 DOI: 10.1186/s13014-024-02424-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Longitudinal assessments of apparent diffusion coefficients (ADCs) derived from diffusion-weighted imaging (DWI) during intracranial radiotherapy at magnetic resonance imaging-guided linear accelerators (MR-linacs) could enable early response assessment by tracking tumor diffusivity changes. However, DWI pulse sequences are currently unavailable in clinical practice at low-field MR-linacs. Quantifying the in vivo repeatability of ADC measurements is a crucial step towards clinical implementation of DWI sequences but has not yet been reported on for low-field MR-linacs. This study assessed ADC measurement repeatability in a phantom and in vivo at a 0.35 T MR-linac. METHODS Eleven volunteers and a diffusion phantom were imaged on a 0.35 T MR-linac. Two echo-planar imaging DWI sequence variants, emphasizing high spatial resolution ("highRes") and signal-to-noise ratio ("highSNR"), were investigated. A test-retest study with an intermediate outside-scanner-break was performed to assess repeatability in the phantom and volunteers' brains. Mean ADCs within phantom vials, cerebrospinal fluid (CSF), and four brain tissue regions were compared to literature values. Absolute relative differences of mean ADCs in pre- and post-break scans were calculated for the diffusion phantom, and repeatability coefficients (RC) and relative RC (relRC) with 95% confidence intervals were determined for each region-of-interest (ROI) in volunteers. RESULTS Both DWI sequence variants demonstrated high repeatability, with absolute relative deviations below 1% for water, dimethyl sulfoxide, and polyethylene glycol in the diffusion phantom. RelRCs were 7% [5%, 12%] (CSF; highRes), 12% [9%, 22%] (CSF; highSNR), 9% [8%, 12%] (brain tissue ROIs; highRes), and 6% [5%, 7%] (brain tissue ROIs; highSNR), respectively. ADCs measured with the highSNR variant were consistent with literature values for volunteers, while smaller mean values were measured for the diffusion phantom. Conversely, the highRes variant underestimated ADCs compared to literature values, indicating systematic deviations. CONCLUSIONS High repeatability of ADC measurements in a diffusion phantom and volunteers' brains were measured at a low-field MR-linac. The highSNR variant outperformed the highRes variant in accuracy and repeatability, at the expense of an approximately doubled voxel volume. The observed high in vivo repeatability confirms the potential utility of DWI at low-field MR-linacs for early treatment response assessment.
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Affiliation(s)
- Moritz Rabe
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Olaf Dietrich
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a Partnership Between DKFZ and LMU University Hospital Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a Partnership Between DKFZ and LMU University Hospital Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christopher Kurz
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
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de Mol van Otterloo S, Westerhoff J, Leer T, Rutgers R, Meijers L, Daamen L, Intven M, Verkooijen H. Patient expectation and experience of MR-guided radiotherapy using a 1.5T MR-Linac. Tech Innov Patient Support Radiat Oncol 2024; 29:100224. [PMID: 38162695 PMCID: PMC10755768 DOI: 10.1016/j.tipsro.2023.100224] [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: 07/20/2023] [Revised: 10/19/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024] Open
Abstract
Background and Purpose Online adaptive MR-guided radiotherapy (MRgRT) is a relatively new form of radiotherapy treatment, delivered using a MR-Linac. It is unknown what patients expect from this treatment and whether these expectations are met. This study evaluates whether patients' pre-treatment expectations of MRgRT are met and reports patients' on-table experience on a 1.5 T MR-Linac. Materials and methods All patients treated on the MR-Linac from November 2020 until April 2021, were eligible for inclusion. Patient expectation and experience were captured through questionnaires before, during, and three months after treatment. The on-table experience questionnaire included patient' physical and psychological coping. Patient-expected side effects, participation in daily and social activity, disease outcome and, disease related symptoms were compared to post-treatment experience. Results We included 113 patients who were primarily male (n = 100, 89 %), with a median age of 69 years (range 52-90). For on-table experience, ninety percent of patients (strongly) agreed to feeling calm during their treatment. Six and eight percent of patients found the treatment position or bed uncomfortable respectively. Twenty-eight percent of patients felt tingling sensations during treatment. After treatment, 79 % of patients' expectations were met. Most patients experienced an (better than) expected level of side effects (75 %), participation in daily- (83 %) and social activity (86 %) and symptoms (78 %). However, 33 % expected more treatment efficacy than experienced. Conclusion Treatment on the 1.5 T MR-Linac is well tolerated and meets patient expectations. Despite the fact that some patients expected greater treatment efficacy and the frequent occurrence of tingling sensations during treatment, most patient experiences were comparable or better than previously expected.
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Affiliation(s)
- S.R. de Mol van Otterloo
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - J.M. Westerhoff
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - T. Leer
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - R.H.A. Rutgers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.T.C. Meijers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.A. Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - M.P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - H.M. Verkooijen
- Division of Imaging, University Medical Center Utrecht, Utrecht, the Netherlands
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Prime S, Schiff JP, Hosni A, Stanescu T, Dawson LA, Henke LE. The Use of MR-Guided Radiation Therapy for Liver Cancer. Semin Radiat Oncol 2024; 34:36-44. [PMID: 38105091 DOI: 10.1016/j.semradonc.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The role of radiotherapy in the management of primary and metastatic liver malignancies has expanded in recent years due to advances such as IGRT and SBRT. MRI-guided radiotherapy (MRgRT) has arisen as an excellent option for the management of hepatocellular carcinoma, cholangiocarcinoma, and liver metastases due to the ability to combine improved hepatic imaging with conformal treatment planning paradigms like adaptive radiotherapy and advanced motion management techniques. Herein we review the data for MRgRT for liver malignancies, as well as describe workflow and technical considerations for the 2 commercially available MRgRT delivery platforms.
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Affiliation(s)
- Sabrina Prime
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Joshua P Schiff
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Lauren E Henke
- University Hospitals/Case Western Reserve University, Department of Radiation Oncology, Cleveland, OH.
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Fast MF, Cao M, Parikh P, Sonke JJ. Intrafraction Motion Management With MR-Guided Radiation Therapy. Semin Radiat Oncol 2024; 34:92-106. [PMID: 38105098 DOI: 10.1016/j.semradonc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
High quality radiation therapy requires highly accurate and precise dose delivery. MR-guided radiotherapy (MRgRT), integrating an MRI scanner with a linear accelerator, offers excellent quality images in the treatment room without subjecting patient to ionizing radiation. MRgRT therefore provides a powerful tool for intrafraction motion management. This paper summarizes different sources of intrafraction motion for different disease sites and describes the MR imaging techniques available to visualize and quantify intrafraction motion. It provides an overview of MR guided motion management strategies and of the current technical capabilities of the commercially available MRgRT systems. It describes how these motion management capabilities are currently being used in clinical studies, protocols and provides a future outlook.
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Affiliation(s)
- Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Parag Parikh
- Department of Radiation Oncology, Henry Ford Health - Cancer, Detroit, MI
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Wu TC, Smith LM, Woolf D, Faivre-Finn C, Lee P. Exploring the Advantages and Challenges of MR-Guided Radiotherapy in Non-Small-Cell Lung Cancer: Who are the Optimal Candidates? Semin Radiat Oncol 2024; 34:56-63. [PMID: 38105094 DOI: 10.1016/j.semradonc.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The landscape of lung radiotherapy (RT) has rapidly evolved over the past decade with modern RT and surgical techniques, systemic therapies, and expanding indications for RT. To date, 2 MRI-guided RT (MRgRT) units, 1 using a 0.35T magnet and 1 using a 1.5T magnet, are available for commercial use with more systems in the pipeline. MRgRT offers distinct advantages such as real-time target tracking, margin reduction, and on-table treatment adaptation, which may help overcome many of the common challenges associated with thoracic RT. Nonetheless, the use of MRI for image guidance and the current MRgRT units also have intrinsic limitations. In this review article, we will discuss clinical experiences to date, advantages, challenges, and future directions of MRgRT to the lung.
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Affiliation(s)
- Trudy C Wu
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Lauren M Smith
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - David Woolf
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.; Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.; Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA..
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de Leon J, Twentyman T, Carr M, Jameson M, Batumalai V. Optimising the MR-Linac as a standard treatment modality. J Med Radiat Sci 2023; 70:491-497. [PMID: 37540059 PMCID: PMC10715353 DOI: 10.1002/jmrs.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
The magnetic resonance linear accelerator (MR-Linac) offers a new treatment paradigm, providing improved visualisation of targets and organs at risk while allowing for daily adaptation of treatment plans in real time. Online MR-guided adaptive treatment has reduced treatment uncertainties; however, the additional treatment time and resource requirements may be a concern. We present our experience of integrating an MR-Linac into a busy department and provide recommendations for improved clinical and resource efficiency. Furthermore, we discuss potential future technological innovations that can further optimise clinical productivity in a busy department.
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Affiliation(s)
| | | | - Madeline Carr
- GenesisCareAlexandriaNew South WalesAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongWollongongNew South WalesAustralia
| | - Michael Jameson
- GenesisCareAlexandriaNew South WalesAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongWollongongNew South WalesAustralia
- School of Clinical Medicine, Faculty of Medicine and HealthUNSW SydneySydneyNew South WalesAustralia
| | - Vikneswary Batumalai
- GenesisCareAlexandriaNew South WalesAustralia
- School of Clinical Medicine, Faculty of Medicine and HealthUNSW SydneySydneyNew South WalesAustralia
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Uno T, Tsuneda M, Abe K, Fujita Y, Harada R, Saito M, Kanazawa A, Kodate A, Abe Y, Ikeda Y, Nemoto MW, Yokota H. A new workflow of the on-line 1.5-T MR-guided adaptive radiation therapy. Jpn J Radiol 2023; 41:1316-1322. [PMID: 37354344 PMCID: PMC10613593 DOI: 10.1007/s11604-023-01457-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE The aim of this study was to develop a new workflow for 1.5-T magnetic resonance (MR)-guided on-line adaptive radiation therapy (MRgART) and assess its feasibility in achieving dose constraints. MATERIALS AND METHODS We retrospectively evaluated the clinical data of patients who underwent on-line adaptive radiation therapy using a 1.5-T MR linear accelerator (MR-Linac). The workflow in MRgART was established by reviewing the disease site, number of fractions, and re-planning procedures. Five cases of prostate cancer were selected to evaluate the feasibility of the new workflow with respect to achieving dose constraints. RESULTS Between December 2021 and September 2022, 50 consecutive patients underwent MRgART using a 1.5-T MR-Linac. Of these, 20 had prostate cancer, 10 had hepatocellular carcinoma, 6 had pancreatic cancer, 5 had lymph node oligo-metastasis, 3 had renal cancer, 3 had bone metastasis, 2 had liver metastasis from colon cancer, and 1 had a mediastinal tumor. Among a total of 247 fractions, 235 (95%) were adapt-to-shape (ATS)-based re-planning. The median ATS re-planning time in all 50 cases was 17 min. In the feasibility study, all dose constraint sets were met in all 5 patients by ATS re-planning. Conversely, a total of 14 dose constraints in 5 patients could not be achieved by virtual plan without using adaptive re-planning. These dose constraints included the minimum dose received by the highest irradiated volume of 1 cc in the planning target volume and the maximum dose of the rectal/bladder wall. CONCLUSION A new workflow of 1.5-T MRgART was established and found to be feasible. Our evaluation of the dose constraint achievement demonstrated the effectiveness of the workflow.
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Affiliation(s)
- Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan.
| | - Masato Tsuneda
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Kota Abe
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Yukio Fujita
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Rintaro Harada
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Makoto Saito
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Aki Kanazawa
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Asuka Kodate
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Yukinao Abe
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Yohei Ikeda
- Department of Radiology, Chiba University Hospital, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Miho Watanabe Nemoto
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
| | - Hajime Yokota
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuou-ku, Chiba City, Chiba, 260-8670, Japan
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11
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Eijkelenkamp H, Grimbergen G, Daamen LA, Heerkens HD, van de Ven S, Mook S, Meijer GJ, Molenaar IQ, van Santvoort HC, Paulson E, Erickson BA, Verkooijen HM, Hall WA, Intven MPW. Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac. Front Oncol 2023; 13:1040673. [PMID: 37854684 PMCID: PMC10579578 DOI: 10.3389/fonc.2023.1040673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT. Methods We evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3-12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan-Meier analysis to calculate the cumulative overall survival. Results A total of 80 patients were assessed with a median FU of 8 months (range 1-39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3-4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3-4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%. Conclusion Online adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3-4 toxicity and a stable QoL at 3 months of FU.
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Affiliation(s)
- Hidde Eijkelenkamp
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Guus Grimbergen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A. Daamen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia van de Ven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Stella Mook
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J. Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Izaak Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, Netherlands
| | | | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Ann Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - William Adrian Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Martijn P. W. Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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12
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Leeman JE, Shin KY, Chen YH, Mak RH, Nguyen PL, D'Amico AV, Martin NE. Acute toxicity comparison of magnetic resonance-guided adaptive versus fiducial or computed tomography-guided non-adaptive prostate stereotactic body radiotherapy: A systematic review and meta-analysis. Cancer 2023; 129:3044-3052. [PMID: 37485697 DOI: 10.1002/cncr.34836] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is gaining wider adoption for prostate cancer management but there remain significant toxicity risks when delivering prostate SBRT with standard techniques. Magnetic resonance-guided daily adaptive SBRT (MRg-A-SBRT) offers technological advantages in precision of radiation dose delivery, but the toxicity profile associated with MRg-A-SBRT compared to more standardly used fiducial or computed tomography-guided non-adaptive prostate SBRT (CT-SBRT) remains unknown. METHODS A meta-analysis to compare acute toxicity rates associated with MRg-A-SBRT and CT-SBRT for prostate cancer was performed in compliance with PRISMA guidelines. MEDLINE (PubMed) and Google Scholar were searched for prospective studies of prostate SBRT that were published between January 1, 2018 and August 31, 2022. Random effects and fixed effects models were used to estimate pooled toxicity rates, and meta-regression was performed to compare toxicity between MRg-A-SBRT and CT-SBRT study groups. RESULTS Twenty-nine prospective studies were identified that met the inclusion criteria and included a total of 2547 patients. The pooled estimates for acute grade 2 or higher (G2+) genitourinary (GU) and gastrointestinal (GI) toxicity for MRg-A-SBRT were 16% (95% confidence interval [CI], 10%-24%) and 4% (95% CI, 2%-7%) and for CT-SBRT they were 28% (95% CI, 23%-33%) and 9% (95% CI, 6%-12%), respectively. On meta-regression, the odds ratios for acute G2+ GU and GI toxicities comparing MRg-A-SBRT and CT-SBRT were 0.56 (95% CI, 0.33-0.97, p = .04) and 0.40 (95% CI, 0.17-0.96, p = .04), respectively. CONCLUSION MRg-A-SBRT is associated with a significantly reduced risk of acute G2+ GU or GI toxicity compared to CT-SBRT. Longer follow-up will be needed to evaluate late toxicity and disease control outcomes. PLAIN LANGUAGE SUMMARY Magnetic resonance imaging-guided daily adaptive prostate stereotactic radiation (MRg-A-SBRT) is a treatment that may allow for delivery of prostate radiation more precisely than other radiotherapy techniques, but it is unknown whether this reduces side effects compared to standardly used computed tomography-guided SBRT (CT-SBRT). In this systematic review and meta-analysis combining data from 29 clinical trials including 2547 patients, it was found that the risk of short-term urinary side effects was reduced by 44% and the risk of short-term bowel side effects was reduced by 60% with MRg-A-SBRT compared to CT-SBRT.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee-Young Shin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Yu-Hui Chen
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil E Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Hooshangnejad H, Miles D, Hill C, Narang A, Ding K, Han-Oh S. Inter-Breath-Hold Geometric and Dosimetric Variations in Organs at Risk during Pancreatic Stereotactic Body Radiotherapy: Implications for Adaptive Radiation Therapy. Cancers (Basel) 2023; 15:4332. [PMID: 37686608 PMCID: PMC10486406 DOI: 10.3390/cancers15174332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/27/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer-related death, with nearly 60,000 cases each year and less than a 10% 5-year overall survival rate. Radiation therapy (RT) is highly beneficial as a local-regional anticancer treatment. As anatomical variation is of great concern, motion management techniques, such as DIBH, are commonly used to minimize OARs toxicities; however, the variability between DIBHs has not been well studied. Here, we present an unprecedented systematic analysis of patients' anatomical reproducibility over multiple DIBH motion-management technique uses for pancreatic cancer RT. We used data from 20 patients; four DIBH scans were available for each patient to design 80 SBRT plans. Our results demonstrated that (i) there is considerable variation in OAR geometry and dose between same-subject DIBH scans; (ii) the RT plan designed for one scan may not be directly applicable to another scan; (iii) the RT treatment designed using a DIBH simulation CT results in different dosimetry in the DIBH treatment delivery; and (iv) this confirms the importance of adaptive radiation therapy (ART), such as MR-Linacs, for pancreatic RT delivery. The ART treatment delivery technique can account for anatomical variation between referenced and scheduled plans, and thus avoid toxicities of OARs because of anatomical variations between DIBH patient setups.
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Affiliation(s)
- Hamed Hooshangnejad
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
| | - Devin Miles
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
| | - Colin Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA; (D.M.); (C.H.); (A.N.); (K.D.)
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14
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Zhou Y, Yuan J, Xue C, Poon DMC, Yang B, Yu SK, Cheung KY. A pilot study of MRI radiomics for high-risk prostate cancer stratification in 1.5 T MR-guided radiotherapy. Magn Reson Med 2023; 89:2088-2099. [PMID: 36572990 DOI: 10.1002/mrm.29564] [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: 08/30/2022] [Revised: 11/09/2022] [Accepted: 12/09/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate the potential value of MRI radiomics obtained from a 1.5 T MRI-guided linear accelerator (MR-LINAC) for D'Amico high-risk prostate cancer (PC) classification in MR-guided radiotherapy (MRgRT). METHODS One hundred seventy-six consecutive PC patients underwent 1.5 T MRgRT treatment were retrospectively enrolled. Each patient received one or two pretreatment T2 -weighted MRI scans on a 1.5 T MR-LINAC. The endpoint was to differentiate high-risk from low/intermediate-risk PC based on D'Amico criteria using MRI-radiomics. Totally 1023 features were extracted from clinical target volume (CTV) and planning target volume (PTV). Intraclass correlation coefficient of scan-rescan repeatability, feature correlation, and recursive feature elimination were used for feature dimension reduction. Least absolute shrinkage and selection operator regression was employed for model construction. Receiver operating characteristic area under the curve (AUC) analysis was used for model performance assessment in both training and testing data. RESULTS One hundred and eleven patients fulfilled all criteria were finally included: 76 for training and 35 for testing. The constructed MRI-radiomics models extracted from CTV and PTV achieved the AUC of 0.812 and 0.867 in the training data, without significant difference (P = 0.083). The model performances remained in the testing. The sensitivity, specificity, and accuracy were 85.71%, 64.29%, and 77.14% for the PTV-based model; and 71.43%, 71.43%, and 71.43% for the CTV-based model. The corresponding AUCs were 0.718 and 0.750 (P = 0.091) for CTV- and PTV-based models. CONCLUSION MRI-radiomics obtained from a 1.5 T MR-LINAC showed promising results in D'Amico high-risk PC stratification, potentially helpful for the future PC MRgRT. Prospective studies with larger sample sizes and external validation are warranted for further verification.
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Affiliation(s)
- Yihang Zhou
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Jing Yuan
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Cindy Xue
- Research Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Darren M C Poon
- Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Bin Yang
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Siu Ki Yu
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
| | - Kin Yin Cheung
- Medical Physics Department, Hong Kong Sanatorium & Hospital, Hong Kong, People's Republic of China
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15
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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16
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Liu X, Li Z, Yin Y. Clinical application of MR-Linac in tumor radiotherapy: a systematic review. Radiat Oncol 2023; 18:52. [PMID: 36918884 PMCID: PMC10015924 DOI: 10.1186/s13014-023-02221-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/01/2023] [Indexed: 03/15/2023] Open
Abstract
Recent years have seen both a fresh knowledge of cancer and impressive advancements in its treatment. However, the clinical treatment paradigm of cancer is still difficult to implement in the twenty-first century due to the rise in its prevalence. Radiotherapy (RT) is a crucial component of cancer treatment that is helpful for almost all cancer types. The accuracy of RT dosage delivery is increasing as a result of the quick development of computer and imaging technology. The use of image-guided radiation (IGRT) has improved cancer outcomes and decreased toxicity. Online adaptive radiotherapy will be made possible by magnetic resonance imaging-guided radiotherapy (MRgRT) using a magnetic resonance linear accelerator (MR-Linac), which will enhance the visibility of malignancies. This review's objectives are to examine the benefits of MR-Linac as a treatment approach from the perspective of various cancer patients' prognoses and to suggest prospective development areas for additional study.
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Affiliation(s)
- Xin Liu
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.,Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Zhenjiang Li
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China.
| | - Yong Yin
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China. .,Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China.
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17
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Hall MD, Mittauer KE, Herrera R, Von Werne K, Kotecha R, Kalman NS, McCulloch J, Alvarez D, McAllister NC, Doty DG, Rzepczynski AE, Deere W, Gutierrez AN, Chuong MD. Initial clinical experience with magnetic resonance-guided radiotherapy in pediatric patients: Lessons learned from a single institution with proton therapy. Front Oncol 2023; 12:1037674. [PMID: 36713501 PMCID: PMC9875284 DOI: 10.3389/fonc.2022.1037674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Purpose/Objectives Magnetic resonance-guided radiotherapy (MRgRT) is increasingly used in a variety of adult cancers. To date, published experience regarding the use of MRgRT in pediatric patients is limited to two case reports. We report on the use of MRgRT for pediatric patients at our institution during a four-year period and describe important considerations in the selection and application of this technology in children. Materials/Methods All patients treated with MRgRT since inception at our institution between 4/2018 and 4/2022 were retrospectively reviewed. We also evaluated all pediatric patients treated at our institution during the same period who received either imaging or treatment using our magnetic resonance-guided linear accelerator (MR Linac). We summarize four clinical cases where MRgRT was selected for treatment in our clinic, including disease outcomes and toxicities and describe our experience using the MR Linac for imaging before and during treatment for image fusion and tumor assessments. Results Between 4/2018 and 4/2022, 535 patients received MRgRT at our center, including 405 (75.7%) with stereotactic ablative radiotherapy (SABR). During this period, 347 distinct radiotherapy courses were delivered to pediatric patients, including 217 (62.5%) with proton therapy. Four pediatric patients received MRgRT. One received SABR for lung metastasis with daily adaptive replanning and a second was treated for liver metastasis using a non-adaptive workflow. Two patients received fractionated MRgRT for an ALK-rearranged non-small cell lung cancer and neuroblastoma. No Grade 2 or higher toxicities were observed or reported during MRgRT or subsequent follow-up. Twelve patients underwent MR imaging without contrast during treatment for brain tumors to assess for tumor/cystic changes. Two patients treated with other modalities underwent MR simulation for target volume delineation and organ at risk sparing due to anatomic changes during treatment or unexpected delays in obtaining diagnostic MR appointments. Conclusions In four pediatric patients treated with MRgRT, treatment was well tolerated with no severe acute effects. At our center, most pediatric patients are treated with proton therapy, but the cases selected for MRgRT demonstrated significant organ at risk sparing compared to alternative modalities. In particular, MRgRT may provide advantages for thoracic/abdominal/pelvic targets using gated delivery and adaptive replanning, but selected patients treated with fractionated radiotherapy may also benefit MRgRT through superior organ at risk sparing.
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Affiliation(s)
- Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States,*Correspondence: Matthew D. Hall,
| | - Kathryn E. Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Katherine Von Werne
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
| | - Noah S. Kalman
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
| | - James McCulloch
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Diane Alvarez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
| | - Nicole C. McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Delia G. Doty
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Amy E. Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Will Deere
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Alonso N. Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States,Herbert Wertheim College of Medicine, Department of Radiation Oncology, Florida International University, Miami, FL, United States
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18
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Poon DMC, Yang B, Geng H, Wong OL, Chiu ST, Cheung KY, Yu SK, Chiu G, Yuan J. Analysis of online plan adaptation for 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer. J Cancer Res Clin Oncol 2023; 149:841-850. [PMID: 35199189 PMCID: PMC8866042 DOI: 10.1007/s00432-022-03950-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To analyze and characterize the online plan adaptation of 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer (PC). METHODS PC patients (n = 107) who received adaptive 1.5 Tesla MRgSBRT were included. Online plan adaptation was implemented by either the adapt-to-position (ATP) or adapt-to-shape (ATS) methods. Patients were assigned to the ATS group if they underwent ≥ 1 ATS fraction (n = 51); the remainder were assigned to the ATP group (n = 56). The online plan adaptation records of 535 (107 × 5) fractions were retrospectively reviewed. Rationales for ATS decision-making were determined and analyzed using predefined criteria. Statistics of ATS fractions were summarized. Associations of patient characteristics and clinical factors with ATS utilization were investigated. RESULTS There were 87 (16.3%) ATS fractions and 448 ATP fractions (83.7%). The numbers of ATS adoptions in fractions 1-5 were 29 (29/107, 27.1%), 18 (16.8%), 15 (14.0%), 16 (15.0%), and 9 (8.4%), respectively, with significant differences in adoption frequency between fractions (p = 0.007). Other baseline patient characteristics and clinical factors were not significantly associated with ATS classification (all p > 0.05). Underlying criteria for the determination of ATS implementation comprised anatomical changes (77 fractions in 50 patients) and discrete multiple targets (15 fractions in 3 patients). No ATS utilization was determined using dosimetric or online quality assurance criteria. CONCLUSIONS This study contributes to facilitating the establishment of a standardized protocol for online MR-guided adaptive radiotherapy in PC.
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Affiliation(s)
- Darren M. C. Poon
- grid.414329.90000 0004 1764 7097Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Bin Yang
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Hui Geng
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Oi Lei Wong
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Sin Ting Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Kin Yin Cheung
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Siu Ki Yu
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - George Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Jing Yuan
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
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Gelbart Pridan O, Ben David MA, Zalmanov S, Lipski Y, Grinberg V, Levin D, Apter S, Guindi M, Epstein D, Radus R, Arsenault O, Hod K, Tamami Q, Pfeffer R. Outcome of the first 200 patients with prostate cancer treated with MRI-Linac at Assuta MC. Front Oncol 2023; 13:1151256. [PMID: 37035136 PMCID: PMC10076851 DOI: 10.3389/fonc.2023.1151256] [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] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Background We present our experience with MR-guided stereotactic body radiotherapy (SBRT) for 200 consecutive patients with prostate cancer with minimum 3-month follow-up. Methods Treatment planning included fusion of the 0.35-Tesla planning MRI with multiparametric MRI and PET-PSMA for Group Grade (GG) 2 or higher and contour review with an expert MRI radiologist. No fiducials or rectal spacers were used. Prescription dose was 36.25 Gy in 5 fractions over 2 weeks to the entire prostate with 3-mm margins. Daily plan was adapted if tumor and organs at risk (OAR) doses differed significantly from the original plan. The prostate was monitored during treatment that was automatically interrupted if the target moved out of the PTV range. Results Mean age was 72 years. Clinical stage was T1c, 85.5%; T2, 13%; and T3, 1.5%. In addition, 20% were GG1, 50% were GG2, 14.5% were GG3, 13% were GG4, and one patient was GG5. PSA ranged from 1 to 77 (median, 6.2). Median prostate volume was 57cc, and 888/1000 (88%) fractions required plan adaptation. The most common acute GU toxicity was Grade I, 31%; dysuria and acute gastrointestinal toxicity were rare. Three patients required temporary catheterization. Prostate size of over 100cc was associated with acute fatigue, urinary hesitance, and catheter insertion. Prostate Specific Antigen (PSA) decreased in 99% of patients, and one patient had regional recurrence. Conclusion MR-guided prostate SBRT shows low acute toxicity and excellent short-term outcomes. Real-time MRI ensures accurate positioning and SBRT delivery.
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Affiliation(s)
| | - Merav Akiva Ben David
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- *Correspondence: Merav Akiva Ben David,
| | - Svetlana Zalmanov
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Yoav Lipski
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | | | - Daphne Levin
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Sara Apter
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Guindi
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Innovation Division, Assuta Medical Center, Tel Aviv, Israel
| | - Dan Epstein
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Roman Radus
- Radiation Oncology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Orit Arsenault
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Keren Hod
- Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel
| | - Qusai Tamami
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
| | - Raphael Pfeffer
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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20
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Teunissen FR, Willigenburg T, Tree AC, Hall WA, Choi SL, Choudhury A, Christodouleas JP, de Boer JCJ, de Groot-van Breugel EN, Kerkmeijer LGW, Pos FJ, Schytte T, Vesprini D, Verkooijen HM, van der Voort van Zyp JRN. Magnetic Resonance-Guided Adaptive Radiation therapy for Prostate Cancer: The First Results from the MOMENTUM study-An International Registry for the Evidence-Based Introduction of Magnetic Resonance-Guided Adaptive Radiation Therapy. Pract Radiat Oncol 2022; 13:e261-e269. [PMID: 36462619 DOI: 10.1016/j.prro.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Magnetic resonance (MR)-guided radiation therapy (MRgRT) is a new technique for treatment of localized prostate cancer (PCa). We report the 12-month outcomes for the first PCa patients treated within an international consortium (the MOMENTUM study) on a 1.5T MR-Linac system with ultrahypofractionated radiation therapy. METHODS AND MATERIALS Patients treated with 5 × 7.25 Gy were identified. Prostate specific antigen-level, physician-reported toxicity (Common Terminology Criteria for Adverse Events [CTCAE]), and patient-reported outcomes (Quality of Life Questionnaire PR25 and Quality of Life Questionnaire C30 questionnaires) were recorded at baseline and at 3, 6, and 12 months of follow-up (FU). Pairwise comparative statistics were conducted to compare outcomes between baseline and FU. RESULTS The study included 425 patients with localized PCa (11.4% low, 82.0% intermediate, and 6.6% high-risk), and 365, 313, and 186 patients reached 3-, 6-, and 12-months FU, respectively. Median prostate specific antigen level declined significantly to 1.2 ng/mL and 0.1 ng/mL at 12 months FU for the nonandrogen deprivation therapy (ADT) and ADT group, respectively. The peak of genitourinary and gastrointestinal CTCAE toxicity was reported at 3 months FU, with 18.7% and 1.7% grade ≥2, respectively. The QLQ-PR25 questionnaire outcomes showed significant deterioration in urinary domain score at all FU moments, from 8.3 (interquartile range [IQR], 4.1-16.6) at baseline to 12.4 (IQR, 8.3-24.8; P = .005) at 3 months, 12.4 (IQR, 8.3-20.8; P = .018;) at 6 months, and 12.4 (IQR, 8.3-20.8; P = .001) at 12 months. For the non-ADT group, physician- and patient-reported erectile function worsened significantly between baseline and 12 months FU. CONCLUSIONS Ultrahypofractionated MR-guided radiation therapy for localized PCa using a 1.5T MR-Linac is effective and safe. The peak of CTCAE genitourinary and gastrointestinal toxicity was reported at 3 months FU. Furthermore, for patients without ADT, a significant increase in CTCAE erectile dysfunction was reported at 12 months FU. These data are useful for educating patients on expected outcomes and informing study design of future comparative-effectiveness studies.
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Affiliation(s)
- Frederik R Teunissen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas Willigenburg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison C Tree
- Department of Urological Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seungtaek L Choi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - John P Christodouleas
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Elekta AB, Stockholm, Sweden
| | - Johannes C J de Boer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Helena M Verkooijen
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht University, Utrecht, The Netherlands
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21
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Tseng CL, Chen H, Stewart J, Lau AZ, Chan RW, Lawrence LSP, Myrehaug S, Soliman H, Detsky J, Lim-Fat MJ, Lipsman N, Das S, Heyn C, Maralani PJ, Binda S, Perry J, Keller B, Stanisz GJ, Ruschin M, Sahgal A. High grade glioma radiation therapy on a high field 1.5 Tesla MR-Linac - workflow and initial experience with daily adapt-to-position (ATP) MR guidance: A first report. Front Oncol 2022; 12:1060098. [PMID: 36518316 PMCID: PMC9742425 DOI: 10.3389/fonc.2022.1060098] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/10/2022] [Indexed: 07/30/2023] Open
Abstract
PURPOSE This study reports the workflow and initial clinical experience of high grade glioma (HGG) radiotherapy on the 1.5 T MR-Linac (MRL), with a focus on the temporal variations of the tumor and feasibility of multi-parametric image (mpMRI) acquisition during routine treatment workflow. MATERIALS AND METHODS Ten HGG patients treated with radiation within the first year of the MRL's clinical operation, between October 2019 and August 2020, were identified from a prospective database. Workflow timings were recorded and online adaptive plans were generated using the Adapt-To-Position (ATP) workflow. Temporal variation within the FLAIR hyperintense region (FHR) was assessed by the relative FHR volumes (n = 281 contours) and migration distances (maximum linear displacement of the volume). Research mpMRIs were acquired on the MRL during radiation and changes in selected functional parameters were investigated within the FHR. RESULTS All patients completed radiotherapy to a median dose of 60 Gy (range, 54-60 Gy) in 30 fractions (range, 30-33), receiving a total of 287 fractions on the MRL. The mean in-room time per fraction with or without post-beam research imaging was 42.9 minutes (range, 25.0-69.0 minutes) and 37.3 minutes (range, 24.0-51.0 minutes), respectively. Three patients (30%) required re-planning between fractions 9 to 12 due to progression of tumor and/or edema identified on daily MRL imaging. At the 10, 20, and 30-day post-first fraction time points 3, 3, and 4 patients, respectively, had a FHR volume that changed by at least 20% relative to the first fraction. Research mpMRIs were successfully acquired on the MRL. The median apparent diffusion coefficient (ADC) within the FHR and the volumes of FLAIR were significantly correlated when data from all patients and time points were pooled (R=0.68, p<.001). CONCLUSION We report the first clinical series of HGG patients treated with radiotherapy on the MRL. The ATP workflow and treatment times were clinically acceptable, and daily online MRL imaging triggered adaptive re-planning for selected patients. Acquisition of mpMRIs was feasible on the MRL during routine treatment workflow. Prospective clinical outcomes data is anticipated from the ongoing UNITED phase 2 trial to further refine the role of MR-guided adaptive radiotherapy.
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Affiliation(s)
- Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Angus Z. Lau
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
- Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Rachel W. Chan
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mary Jane Lim-Fat
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Chinthaka Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman J. Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Brian Keller
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Greg J. Stanisz
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
- Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University, Lublin, Poland
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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22
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Lagendijk JJW, Raaymakers BW, Intven MPW, van der Voort van Zyp JRN. ESTRO Breur lecture 2022: Real-time MRI-guided radiotherapy: The next generation standard? Radiother Oncol 2022; 176:244-248. [PMID: 36446518 DOI: 10.1016/j.radonc.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jan J W Lagendijk
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands
| | - Bas W Raaymakers
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands
| | - Martijn P W Intven
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands.
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23
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Hall WA, Kishan AU, Hall E, Nagar H, Vesprini D, Paulson E, Van der Heide UA, Lawton CAF, Kerkmeijer LGW, Tree AC. Adaptive magnetic resonance image guided radiation for intact localized prostate cancer how to optimally test a rapidly emerging technology. Front Oncol 2022; 12:962897. [PMID: 36132128 PMCID: PMC9484536 DOI: 10.3389/fonc.2022.962897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Prostate cancer is a common malignancy for which radiation therapy (RT) provides an excellent management option with high rates of control and low toxicity. Historically RT has been given with CT based image guidance. Recently, magnetic resonance (MR) imaging capabilities have been successfully integrated with RT delivery platforms, presenting an appealing, yet complex, expensive, and time-consuming method of adapting and guiding RT. The precise benefits of MR guidance for localized prostate cancer are unclear. We sought to summarize optimal strategies to test the benefits of MR guidance specifically in localized prostate cancer. Methods A group of radiation oncologists, physicists, and statisticians were identified to collectively address this topic. Participants had a history of treating prostate cancer patients with the two commercially available MRI-guided RT devices. Participants also had a clinical focus on randomized trials in localized prostate cancer. The goal was to review both ongoing trials and present a conceptual focus on MRI-guided RT specifically in the definitive treatment of prostate cancer, along with developing and proposing novel trials for future consideration. Trial hypotheses, endpoints, and areas for improvement in localized prostate cancer that specifically leverage MR guided technology are presented. Results Multiple prospective trials were found that explored the potential of adaptive MRI-guided radiotherapy in the definitive treatment of prostate cancer. Different primary areas of improvement that MR guidance may offer in prostate cancer were summarized. Eight clinical trial design strategies are presented that summarize options for clinical trials testing the potential benefits of MRI-guided RT. Conclusions The number and scope of trials evaluating MRI-guided RT for localized prostate cancer is limited. Yet multiple promising opportunities to test this technology and potentially improve outcomes for men with prostate cancer undergoing definitive RT exist. Attention, in the form of multi-institutional randomized trials, is needed.
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Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Emma Hall
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Himanshu Nagar
- Depart of Radiation Oncology, Weill Cornell Medicine, Department of Radiation Oncology, New York, NY, United States
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uulke A. Van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Colleen A. F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Linda G. W. Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, and the Institute of Cancer Research, Sutton, United Kingdom
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24
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Slotman BJ, Clark MA, Özyar E, Kim M, Itami J, Tallet A, Debus J, Pfeffer R, Gentile P, Hama Y, Andratschke N, Riou O, Camilleri P, Belka C, Quivrin M, Kim B, Pedersen A, van Overeem Felter M, Kim YI, Kim JH, Fuss M, Valentini V. Clinical adoption patterns of 0.35 Tesla MR-guided radiation therapy in Europe and Asia. Radiat Oncol 2022; 17:146. [PMID: 35996192 PMCID: PMC9396857 DOI: 10.1186/s13014-022-02114-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Magnetic resonance-guided radiotherapy (MRgRT) utilization is rapidly expanding, driven by advanced capabilities including better soft tissue imaging, continuous intrafraction target visualization, automatic triggered beam delivery, and the availability of on-table adaptive replanning. Our objective was to describe patterns of 0.35 Tesla (T)-MRgRT utilization in Europe and Asia among early adopters of this novel technology.
Methods Anonymized administrative data from all 0.35T-MRgRT treatment systems in Europe and Asia were extracted for patients who completed treatment from 2015 to 2020. Detailed treatment information was analyzed for all MR-linear accelerators (linac) and -cobalt systems.
Results From 2015 through the end of 2020, there were 5796 completed treatment courses delivered in 46,389 individual fractions. 23.5% of fractions were adapted. Ultra-hypofractionated (UHfx) dose schedules (1–5 fractions) were delivered for 63.5% of courses, with 57.8% of UHfx fractions adapted on-table. The most commonly treated tumor types were prostate (23.5%), liver (14.5%), lung (12.3%), pancreas (11.2%), and breast (8.0%), with increasing compound annual growth rates (CAGRs) in numbers of courses from 2015 through 2020 (pancreas: 157.1%; prostate: 120.9%; lung: 136.0%; liver: 134.2%). Conclusions This is the first comprehensive study reporting patterns of utilization among early adopters of a 0.35T-MRgRT system in Europe and Asia. Intrafraction MR image-guidance, advanced motion management, and increasing adoption of on-table adaptive RT have accelerated a transition to UHfx regimens. MRgRT has been predominantly used to treat tumors in the upper abdomen, pelvis and lungs, and increasingly with adaptive replanning, which is a radical departure from legacy radiotherapy practices.
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Affiliation(s)
| | - Mary Ann Clark
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA.
| | - Enis Özyar
- Department of Radiation Oncology, School of Medicine, Acibadem MAA University, Istanbul, Turkey
| | - Myungsoo Kim
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Itami
- Radiation Oncology, National Cancer Center Japan, Tokyo, Japan
| | - Agnès Tallet
- Radiation Therapy Department, Institut Paoli-Calmettes, Marseille, France.,CRCM Inserm UMR1068, Marseille, France
| | - Jürgen Debus
- Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centers, Tel Aviv, Israel
| | - PierCarlo Gentile
- Radiation Oncology, Ospedale San Pietro Fatebenefratelli di Roma, Rome, Italy
| | | | | | - Olivier Riou
- Montpellier Cancer Institute (ICM), University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier University, INSERM U1194 IRCM, 34298, Montpellier, France
| | | | - Claus Belka
- Radiation Oncology, Klinikum der Universität München, Munich, Germany
| | - Magali Quivrin
- Radiation Oncology, Centre Georges-Francois Leclerc, Dijon, France
| | - BoKyong Kim
- Department of Radiation Oncology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | | | | | - Young Il Kim
- Radiation Oncology, Chungnam National University Sejong Hospital, Daejeon, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Martin Fuss
- ViewRay, Inc., Suite 3000, 1099 18th Street, Denver, CO, 80202, USA
| | - Vincenzo Valentini
- Radiology, Radiation Oncology and Hematology Dept., Università Cattolica S.Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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25
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Kerkmeijer LGW, Kishan AU, Tree AC. Magnetic Resonance Imaging-guided Adaptive Radiotherapy for Urological Cancers: What Urologists Should Know. Eur Urol 2022; 82:149-151. [PMID: 35031164 DOI: 10.1016/j.eururo.2021.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 12/24/2021] [Indexed: 01/06/2023]
Abstract
Magnetic resonance imaging (MRI)-guided radiotherapy allows for online adaptation of the radiation plan on the basis of anatomical and functional changes during treatment. MRI-guided radiotherapy holds significant promise for broadening the therapeutic window for multiple urological cancers.
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Affiliation(s)
- Linda G W Kerkmeijer
- Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Amar U Kishan
- Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Alison C Tree
- Uro-Oncology, The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
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26
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MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges. Int J Radiat Oncol Biol Phys 2022; 114:950-967. [PMID: 35901978 DOI: 10.1016/j.ijrobp.2022.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting. METHODS AND MATERIALS We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT. RESULTS Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered. CONCLUSIONS The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.
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27
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Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
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Kutuk T, Herrera R, Mustafayev TZ, Gungor G, Ugurluer G, Atalar B, Kotecha R, Hall MD, Rubens M, Mittauer KE, Contreras JA, McCulloch J, Kalman NS, Alvarez D, Romaguera T, Gutierrez AN, Garcia J, Kaiser A, Mehta MP, Ozyar E, Chuong MD. Multi-Institutional Outcomes of Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (SMART) with a Median Biologically Effective Dose of 100 Gy10 for Non-Bone Oligometastases. Adv Radiat Oncol 2022; 7:100978. [PMID: 35647412 PMCID: PMC9130084 DOI: 10.1016/j.adro.2022.100978] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/16/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Randomized data show a survival benefit of stereotactic ablative body radiation therapy in selected patients with oligometastases (OM). Stereotactic magnetic resonance guided adaptive radiation therapy (SMART) may facilitate the delivery of ablative dose for OM lesions, especially those adjacent to historically dose-limiting organs at risk, where conventional approaches preclude ablative dosing. Methods and Materials The RSSearch Registry was queried for OM patients (1-5 metastatic lesions) treated with SMART. Freedom from local progression (FFLP), freedom from distant progression (FFDP), progression-free survival (PFS), and overall survival (LS) were estimated using the Kaplan-Meier method. FFLP was evaluated using RECIST 1.1 criteria. Toxicity was evaluated using Common Terminology Criteria for Adverse Events version 4 criteria. Results Ninety-six patients with 108 OM lesions were treated on a 0.35 T MR Linac at 2 institutions between 2018 and 2020. SMART was delivered to mostly abdominal or pelvic lymph nodes (48.1%), lung (18.5%), liver and intrahepatic bile ducts (16.7%), and adrenal gland (11.1%). The median prescribed radiation therapy dose was 48.5 Gy (range, 30-60 Gy) in 5 fractions (range, 3-15). The median biologically effective dose corrected using an alpha/beta value of 10 was 100 Gy10 (range, 48-180). No acute or late grade 3+ toxicities were observed with median 10 months (range, 3-25) follow-up. Estimated 1-year FFLP, FFDP, PFS, and OS were 92.3%, 41.1%, 39.3%, and 89.6%, respectively. Median FFDP and PFS were 8.9 months (95% confidence interval, 5.2-12.6 months) and 7.6 months (95% confidence interval, 4.5-10.6 months), respectively. Conclusions To our knowledge, this represents the largest analysis of SMART using ablative dosing for non-bone OM. A median prescribed biologically effective dose of 100 Gy10 resulted in excellent early FFLP and no significant toxicity, likely facilitated by continuous intrafraction MR visualization, breath hold delivery, and online adaptive replanning. Additional prospective evaluation of dose-escalated SMART for OM is warranted.
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Magnetic Resonance Guided Radiotherapy for Head and Neck Cancers. J Clin Med 2022; 11:jcm11051388. [PMID: 35268479 PMCID: PMC8911481 DOI: 10.3390/jcm11051388] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022] Open
Abstract
Radiotherapy is an integral component of head/neck squamous cell carcinomas (HNSCCs) treatment, and technological developments including advances in image-guided radiotherapy over the past decades have offered improvements in the technical treatment of these cancers. Integration of magnetic resonance imaging (MRI) into image guidance through the development of MR-guided radiotherapy (MRgRT) offers further potential for refinement of the techniques by which HNSCCs are treated. This article provides an overview of the literature supporting the current use of MRgRT for HNSCC, challenges with its use, and developing research areas.
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Tan H, Stewart J, Ruschin M, Wang MH, Myrehaug S, Tseng CL, Detsky J, Husain Z, Chen H, Sahgal A, Soliman H. Inter-fraction dynamics during post-operative 5 fraction cavity hypofractionated stereotactic radiotherapy with a MR LINAC: a prospective serial imaging study. J Neurooncol 2022; 156:569-577. [PMID: 34981300 DOI: 10.1007/s11060-021-03938-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE/OBJECTIVE(S) This study examined changes in the clinical target volume (CTV) and associated clinical implications on a magnetic resonance imaging linear accelerator (MR LINAC) during hypofractionated stereotactic radiotherapy (HSRT) to resected brain metastases. In addition, the suitability of using T2/FLAIR (T2f) sequence to define CTV was explored by assessing contouring variability between gadolinium-enhanced T1 (T1c) and T2f sequences. MATERIALS/METHODS Fifteen patients treated to either 27.5 or 30 Gy with five fraction HSRT were imaged with T1c and T2f sequences during treatment; T1c was acquired at planning (FxSim), and fraction 3 (Fx3), and T2f was acquired at FxSim and all five fractions. The CTV were contoured on all acquired images. Inter-fraction cavity dynamics and CTV contouring variability were quantified using absolute volume, Dice similarity coefficient (DSC), and Hausdorff distance (HD) metrics. RESULTS The median CTV on T1c and T2f sequences at FxSim were 12.0cm3 (range, 1.2-30.1) and 10.2cm3 (range, 2.9-27.9), respectively. At Fx3, the median CTV decreased in both sequences to 9.3cm3 (range, 3.7-25.9) and 8.6cm3 (range, 3.3-22.5), translating to a median % relative reduction of - 11.4% on T1c (p = 0.009) and - 8.4% on T2f (p = 0.032). We observed a median % relative reduction in CTV between T1c and T2f at FxSim of - 6.0% (p = 0.040). The mean DSC was 0.85 ± 0.10, and the mean HD was 5.3 ± 2.7 mm when comparing CTV on T1c and T2f at FxSim. CONCLUSION Statistically significant reductions in cavity CTV was observed during HSRT, supporting the use of MR image guided radiation therapy and treatment adaptation to mitigate toxicity. Significant CTV contouring variability was seen between T1c and T2f sequences. Trial registration NCT04075305 - August 30, 2019.
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Affiliation(s)
- Hendrick Tan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- GenesisCare, Perth, WA, Australia
| | - James Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Michael H Wang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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Hall WA, Paulson E, Li XA, Erickson B, Schultz C, Tree A, Awan M, Low DA, McDonald BA, Salzillo T, Glide-Hurst CK, Kishan AU, Fuller CD. Magnetic resonance linear accelerator technology and adaptive radiation therapy: An overview for clinicians. CA Cancer J Clin 2022; 72:34-56. [PMID: 34792808 PMCID: PMC8985054 DOI: 10.3322/caac.21707] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) continues to play an important role in the treatment of cancer. Adaptive RT (ART) is a novel method through which RT treatments are evolving. With the ART approach, computed tomography or magnetic resonance (MR) images are obtained as part of the treatment delivery process. This enables the adaptation of the irradiated volume to account for changes in organ and/or tumor position, movement, size, or shape that may occur over the course of treatment. The advantages and challenges of ART maybe somewhat abstract to oncologists and clinicians outside of the specialty of radiation oncology. ART is positioned to affect many different types of cancer. There is a wide spectrum of hypothesized benefits, from small toxicity improvements to meaningful gains in overall survival. The use and application of this novel technology should be understood by the oncologic community at large, such that it can be appropriately contextualized within the landscape of cancer therapies. Likewise, the need to test these advances is pressing. MR-guided ART (MRgART) is an emerging, extended modality of ART that expands upon and further advances the capabilities of ART. MRgART presents unique opportunities to iteratively improve adaptive image guidance. However, although the MRgART adaptive process advances ART to previously unattained levels, it can be more expensive, time-consuming, and complex. In this review, the authors present an overview for clinicians describing the process of ART and specifically MRgART.
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MESH Headings
- History, 20th Century
- History, 21st Century
- Humans
- Magnetic Resonance Imaging, Interventional/history
- Magnetic Resonance Imaging, Interventional/instrumentation
- Magnetic Resonance Imaging, Interventional/methods
- Magnetic Resonance Imaging, Interventional/trends
- Neoplasms/diagnostic imaging
- Neoplasms/radiotherapy
- Particle Accelerators
- Radiation Oncology/history
- Radiation Oncology/instrumentation
- Radiation Oncology/methods
- Radiation Oncology/trends
- Radiotherapy Planning, Computer-Assisted/history
- Radiotherapy Planning, Computer-Assisted/instrumentation
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy Planning, Computer-Assisted/trends
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Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alison Tree
- The Royal Marsden National Health Service Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel A. Low
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Brigid A. McDonald
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Travis Salzillo
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Carri K. Glide-Hurst
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
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1.5T Magnetic Resonance-Guided Stereotactic Body Radiotherapy for Localized Prostate Cancer: Preliminary Clinical Results of Clinician- and Patient-Reported Outcomes. Cancers (Basel) 2021; 13:cancers13194866. [PMID: 34638348 PMCID: PMC8508440 DOI: 10.3390/cancers13194866] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) offers the potential for achieving better prostate cancer (PC) treatment outcomes. This study reports the preliminary clinical results of 1.5T MRgSBRT in localized PC, based on both clinician-reported outcome measurement (CROM) and patient-reported outcome measurement (PROM). METHODS Fifty-one consecutive localized PC patients were prospectively enrolled with a median follow-up of 199 days. MRgSBRT was delivered in five fractions of 7.25-8 Gy with daily online adaptation. Clinician-reported gastrointestinal (GI) and genitourinary (GU) adverse events based on the Common Terminology Criteria for Adverse Events (CTCAE) Scale v. 5.0 were assessed. The Expanded Prostate Cancer Index Composite Questionnaire was collected at baseline, 1 month, and every 3 months thereafter. Serial prostate-specific antigen measurements were longitudinally recorded. RESULTS The maximum cumulative clinician-reported grade ≥ 2 acute GU and GI toxicities were 11.8% (6/51) and 2.0% (1/51), respectively, while grade ≥ 2 subacute GU and GI toxicities were 2.3% (1/43) each. Patient-reported urinary, bowel, and hormonal domain summary scores were reduced at 1 month, then gradually returned to baseline levels, with the exception of the sexual domain. Domain-specific subscale scores showed similar longitudinal changes. All patients had early post-MRgSBRT biochemical responses. CONCLUSIONS The finding of low toxicity supports the accumulation of clinical evidence for 1.5T MRgSBRT in localized PC.
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