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Zheng D, Yoon J, Jung H, Lemus OMD, Gou L, Zhou Y, Usuki KY, Hardy S, Milano MT. How Does the Number of Brain Metastases Correlate With Normal Brain Exposure in Single-Isocenter Multitarget Multifraction Stereotactic Radiosurgery. Adv Radiat Oncol 2024; 9:101499. [PMID: 38681891 PMCID: PMC11047183 DOI: 10.1016/j.adro.2024.101499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/11/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose To investigate the relationship between normal brain exposure in LINAC-based single-isocenter multitarget multifraction stereotactic radiosurgery or stereotactic radiation therapy (SRT) and the number or volume of treated brain metastases, especially for high numbers of metastases. Methods and Materials A cohort of 44 SRT patients with 709 brain metastases was studied. Renormalizing to a uniform prescription of 27 Gy in 3 fractions, normal brain dose volume indices, including V23 Gy (volume receiving >23 Gy), V18 Gy (volume receiving >18 Gy), and mean dose, were evaluated on these plans against the number and the total volume of targets for each plan. To compare with exposures from whole-brain radiation therapy (WBRT), the SRT dose distributions were converted to equivalent dose in 3 Gy fractions (EQD3) using an alpha-beta ratio of 2 Gy. Results With increasing number of targets and increasing total target volume, normal brain exposures to dose ≥18 Gy increases, and so does the mean normal brain dose. The factors of the number of targets and the total target volume are both significant, although the number of targets has a larger effect on the mean normal brain dose and the total target volume has a larger effect on V23 Gy and V18 Gy. The EQD3 mean normal brain dose with SRT planning is lower than conventional WBRT. On the other hand, SRT results in higher hot spot (ie, maximum dose outside of tumor) EQD3 dose than WBRT. Conclusions Based on clinical SRT plans, our study provides information on correlations between normal brain exposure and the number and total volume of targets. As SRT becomes more greatly used for patients with increasingly extensive brain metastases, more clinical data on outcomes and toxicities is necessary to better define the normal brain dose constraints for high-exposure cases and to optimize the SRT management for those patients.
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Affiliation(s)
- Dandan Zheng
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Jihyung Yoon
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Hyunuk Jung
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Olga Maria Dona Lemus
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Lang Gou
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Yuwei Zhou
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Kenneth Y. Usuki
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Sara Hardy
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michael T. Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
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Zhang L, Cheng H, Du F, Shao K, Zheng S, Yang Y, Shan G. Single isocenter versus dual isocenter treatment using flattening filter-free and jaw-tracking volumetrically modulated arc therapy for boot-shaped lung cancer: Evaluation of dosimetric and feasibility. J Appl Clin Med Phys 2024:e14292. [PMID: 38286001 DOI: 10.1002/acm2.14292] [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: 10/22/2023] [Revised: 12/23/2023] [Accepted: 01/16/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND To determine whether a dual-isocenter volumetrically modulated arc therapy (VMAT) technique results in lower normal pulmonary dosage compared to a traditional single isocenter technique for boot-shaped lung cancer. METHODS A cohort of 15 patients with advanced peripheral or central lung cancer who had metastases in the mediastinum and supraclavicular lymph nodes was randomly selected for this retrospective study. VMAT plans were generated for each patient using two different beam alignment techniques with the 6-MV flattening filter-free (FFF) photon beam: single-isocenter jaw-tracking VMAT based on the Varian TrueBeam linear accelerator (S-TV), and dual-isocenter VMAT based on both TrueBeam (D-TV) and Halcyon linear accelerator (D-HV). For all 45 treatment plans, planning target volume (PTV) dose coverage, conformity/homogeneity index (CI/HI), mean heart dose (MHD), mean lung dose (MLD) and the total lung tissue receiving 5, 20, 30 Gy (V5 , V20 , V30 ) were evaluated. The monitor units (MUs), delivery time, and plan quality assurance (QA) results were recorded. RESULTS The quality of the objectives of the three plans was comparable to each other. In comparison with S-TV, D-TV and D-HV improved the CI and HI of the PTV (p < 0.05). The MLD was 13.84 ± 1.44 Gy (mean ± SD) for D-TV, 14.22 ± 1.30 Gy and 14.16 ± 1.42 Gy for S-TV and D-HV, respectively. Lungs-V5Gy was 50.78 ± 6.24%, 52.00 ± 7.32% and 53.36 ± 8.48%, Lungs-V20Gy was 23.72 ± 2.27%, 26.18 ± 2.86% and 24.96 ± 3.09%, Lungs-V30Gy was 15.69 ± 1.76%, 17.20 ± 1.72% and 16.52 ± 2.07%. Compared to S-TV, D-TV provided statistically significant better protection for the total lung, with the exception of the lungs-V5 . All plans passed QA according the gamma criteria of 3%/3 mm. CONCLUSIONS Taking into account the dosimetric results and published clinical data on radiation-induced pulmonary injury, dual-isocenter jaw-tracking VMAT may be the optimal choice for treating boot-shaped lung cancer.
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Affiliation(s)
- Lei Zhang
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
- Radiotherapy Technology Department, Yuyao People's Hospital of Zhejiang Province, NingBo, Zhejiang, China
| | - Hang Cheng
- Radiotherapy Technology Department, Yuyao People's Hospital of Zhejiang Province, NingBo, Zhejiang, China
| | - Fenglei Du
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Kainan Shao
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Shiming Zheng
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Yiwei Yang
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Guoping Shan
- Department of Radiation Physics, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
- Hangzhou Institute of Medicine(HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
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Tang C, Gong C, Liu B, Guo H, Dai Z, Yuan J, Wang X, Zhang Y. Feasibility and dosimetric evaluation of single- and multi-isocentre stereotactic body radiation therapy for multiple liver metastases. Front Oncol 2023; 13:1144784. [PMID: 37188200 PMCID: PMC10175834 DOI: 10.3389/fonc.2023.1144784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Objectives Single-isocentre volumetric-modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) improves treatment efficiency and patient compliance for patients with multiple liver metastases (MLM). However, the potential increase in dose spillage to normal liver tissue using a single-isocentre technique has not yet been studied. We comprehensively evaluated the quality of single- and multi-isocentre VMAT-SBRT for MLM and propose a RapidPlan-based automatic planning (AP) approach for MLM SBRT. Methods A total of 30 patients with MLM (two or three lesions) were selected for this retrospective study. We manually replanned all patients treated with MLM SBRT by using the single-isocentre (MUS) and multi-isocentre (MUM) techniques. Then, we randomly selected 20 MUS and MUM plans for training to generate the single-isocentre RapidPlan model (RPS) and the multi-isocentre RapidPlan model (RPM). Finally, we used data from the remaining 10 patients to validate RPS and RPM. Results Compared with MUS, MUM reduced the mean dose delivered to the right kidney by 0.3 Gy. The mean liver dose (MLD) was 2.3 Gy higher for MUS compared with MUM. However, the monitor units, delivery time, and V20Gy of normal liver (liver-gross tumour volume) for MUM were significantly higher than for MUS. Based on validation, RPS and RPM slightly improved the MLD, V20Gy, normal tissue complications, and dose sparing to the right and left kidneys and spinal cord compared with manual plans (MUS vs RPS and MUM vs RPM), but RPS and RPM significantly increased monitor units and delivery time. Conclusions The single-isocentre VMAT-SBRT approach could be used for MLM to reduce treatment time and patient comfort at the cost of a small increase in the MLD. Compared with the manual plans, RapidPlan-based plans, especially RPS, have slightly improved quality.
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Affiliation(s)
- Chunbo Tang
- Department of Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Changfei Gong
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
- *Correspondence: Changfei Gong, ; Yun Zhang,
| | - Biaoshui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hailiang Guo
- Department of Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zhongyang Dai
- Department of Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jun Yuan
- Department of Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xiaoping Wang
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Yun Zhang
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
- *Correspondence: Changfei Gong, ; Yun Zhang,
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Palmiero AN, Fabian D, Randall ME, Clair W, Pokhrel D. Predicting the effect of indirect cell kill in the treatment of multiple brain metastases via single-isocenter/multitarget volumetric modulated arc therapy stereotactic radiosurgery. J Appl Clin Med Phys 2021; 22:94-103. [PMID: 34498359 PMCID: PMC8504608 DOI: 10.1002/acm2.13400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/11/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose Due to spatial uncertainty, patient setup errors are of major concern for radiosurgery of multiple brain metastases (m‐bm) when using single‐isocenter/multitarget (SIMT) volumetric modulated arc therapy (VMAT) techniques. However, recent clinical outcome studies show high rates of tumor local control for SIMT‐VMAT. In addition to direct cell kill (DCK), another possible explanation includes the effects of indirect cell kill (ICK) via devascularization for a single dose of 15 Gy or more and by inducing a radiation immune intratumor response. This study quantifies the role of indirect cell death in dosimetric errors as a function of spatial patient setup uncertainty for stereotactic treatments of multiple lesions. Material and Methods Nine complex patients with 61 total tumors (2‐16 tumors/patient) were planned using SIMT‐VMAT with geometry similar to HyperArc with a 10MV‐FFF beam (2400 MU/min). Isocenter was placed at the geometric center of all tumors. Average gross tumor volume (GTV) and planning target volume (PTV) were 1.1 cc (0.02–11.5) and 1.9 cc (0.11–18.8) with an average distance to isocenter of 5.4 cm (2.2–8.9). The prescription was 20 Gy to each PTV. Plans were recalculated with induced clinically observable patient setup errors [±2 mm, ±2o] in all six directions. Boolean structures were generated to calculate the effect of DCK via 20 Gy isodose volume (IDV) and ICK via 15 Gy IDV minus the 20 Gy IDV. Contributions of each IDV to the PTV coverage were analyzed along with normal brain toxicity due to the patient setup uncertainty. Induced uncertainty and minimum dose covering the entire PTV were analyzed to determine the maximum tolerable patient setup errors to utilize the ICK effect for radiosurgery of m‐bm via SIMT‐VMAT. Results Patient setup errors of 1.3 mm /1.3° in all six directions must be maintained to achieve PTV coverage of the 15 Gy IDV for ICK. Setup errors of ±2 mm/2° showed clinically unacceptable loss of PTV coverage of 29.4 ± 14.6% even accounting the ICK effect. However, no clinically significant effect on normal brain dosimetry was observed. Conclusions Radiosurgery of m‐bm using SIMT‐VMAT treatments have shown positive clinical outcomes even with small residual patient setup errors. These clinical outcomes, while largely due to DCK, may also potentially be due to the ICK. Potential mechanisms, such as devascularization and/or radiation‐induced intratumor immune enhancement, should be explored to provide a better understanding of the radiobiological response of stereotactic radiosurgery of m‐bm using a SIMT‐VMAT plan.
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Affiliation(s)
- Allison N Palmiero
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Denise Fabian
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Marcus E Randall
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - William Clair
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Damodar Pokhrel
- Medical Physics Graduate Program, Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
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