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Grimbergen G, Eijkelenkamp H, Snoeren LM, Bahij R, Bernchou U, van der Bijl E, Heerkens HD, Binda S, Ng SS, Bouchart C, Paquier Z, Brown K, Khor R, Chuter R, Freear L, Dunlop A, Mitchell RA, Erickson BA, Hall WA, Godoy Scripes P, Tyagi N, de Leon J, Tran C, Oh S, Renz P, Shessel A, Taylor E, Intven MP, Meijer GJ. Treatment planning for MR-guided SBRT of pancreatic tumors on a 1.5 T MR-Linac: A global consensus protocol. Clin Transl Radiat Oncol 2024; 47:100797. [PMID: 38831754 PMCID: PMC11145226 DOI: 10.1016/j.ctro.2024.100797] [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: 04/22/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Background and purpose Treatment planning for MR-guided stereotactic body radiotherapy (SBRT) for pancreatic tumors can be challenging, leading to a wide variation of protocols and practices. This study aimed to harmonize treatment planning by developing a consensus planning protocol for MR-guided pancreas SBRT on a 1.5 T MR-Linac. Materials and methods A consortium was founded of thirteen centers that treat pancreatic tumors on a 1.5 T MR-Linac. A phased planning exercise was conducted in which centers iteratively created treatment plans for two cases of pancreatic cancer. Each phase was followed by a meeting where the instructions for the next phase were determined. After three phases, a consensus protocol was reached. Results In the benchmarking phase (phase I), substantial variation between the SBRT protocols became apparent (for example, the gross tumor volume (GTV) D99% ranged between 36.8 - 53.7 Gy for case 1, 22.6 - 35.5 Gy for case 2). The next phase involved planning according to the same basic dosimetric objectives, constraints, and planning margins (phase II), which led to a large degree of harmonization (GTV D99% range: 47.9-53.6 Gy for case 1, 33.9-36.6 Gy for case 2). In phase III, the final consensus protocol was formulated in a treatment planning system template and again used for treatment planning. This not only resulted in further dosimetric harmonization (GTV D99% range: 48.2-50.9 Gy for case 1, 33.5-36.0 Gy for case 2) but also in less variation of estimated treatment delivery times. Conclusion A global consensus protocol has been developed for treatment planning for MR-guided pancreatic SBRT on a 1.5 T MR-Linac. Aside from harmonizing the large variation in the current clinical practice, this protocol can provide a starting point for centers that are planning to treat pancreatic tumors on MR-Linac systems.
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Affiliation(s)
- Guus Grimbergen
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Louk M.W. Snoeren
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, Denmark
| | - Uffe Bernchou
- Department of Oncology, Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Denmark
| | - Erik van der Bijl
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Hanne D. Heerkens
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Shawn Binda
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia S.W. Ng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Christelle Bouchart
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Zelda Paquier
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Kerryn Brown
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Richard Khor
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | | | | | - Alex Dunlop
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Robert Adam Mitchell
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Charles Tran
- GenesisCare, Darlinghurst, New South Wales, Australia
| | - Seungjong Oh
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul Renz
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Andrea Shessel
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Edward Taylor
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Martijn P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
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Wang K, Karalis JD, Elamir A, Bifolco A, Wachsmann M, Capretti G, Spaggiari P, Enrico S, Balasubramanian K, Fatimah N, Pontecorvi G, Nebbia M, Yopp A, Kaza R, Pedrosa I, Zeh H, Polanco P, Zerbi A, Wang J, Aguilera T, Ligorio M. Delta Radiomic Features Predict Resection Margin Status and Overall Survival in Neoadjuvant-Treated Pancreatic Cancer Patients. Ann Surg Oncol 2024; 31:2608-2620. [PMID: 38151623 PMCID: PMC10908610 DOI: 10.1245/s10434-023-14805-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) emerged as the standard of care for patients with pancreatic ductal adenocarcinoma (PDAC) who undergo surgery; however, surgery is morbid, and tools to predict resection margin status (RMS) and prognosis in the preoperative setting are needed. Radiomic models, specifically delta radiomic features (DRFs), may provide insight into treatment dynamics to improve preoperative predictions. METHODS We retrospectively collected clinical, pathological, and surgical data (patients with resectable, borderline, locally advanced, and metastatic disease), and pre/post-NAT contrast-enhanced computed tomography (CT) scans from PDAC patients at the University of Texas Southwestern Medical Center (UTSW; discovery) and Humanitas Hospital (validation cohort). Gross tumor volume was contoured from CT scans, and 257 radiomics features were extracted. DRFs were calculated by direct subtraction of pre/post-NAT radiomic features. Cox proportional models and binary prediction models, including/excluding clinical variables, were constructed to predict overall survival (OS), disease-free survival (DFS), and RMS. RESULTS The discovery and validation cohorts comprised 58 and 31 patients, respectively. Both cohorts had similar clinical characteristics, apart from differences in NAT (FOLFIRINOX vs. gemcitabine/nab-paclitaxel; p < 0.05) and type of surgery resections (pancreatoduodenectomy, distal or total pancreatectomy; p < 0.05). The model that combined clinical variables (pre-NAT carbohydrate antigen (CA) 19-9, the change in CA19-9 after NAT (∆CA19-9), and resectability status) and DRFs outperformed the clinical feature-based models and other radiomics feature-based models in predicting OS (UTSW: 0.73; Humanitas: 0.66), DFS (UTSW: 0.75; Humanitas: 0.64), and RMS (UTSW 0.73; Humanitas: 0.69). CONCLUSIONS Our externally validated, predictive/prognostic delta-radiomics models, which incorporate clinical variables, show promise in predicting the risk of predicting RMS in NAT-treated PDAC patients and their OS or DFS.
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Affiliation(s)
- Kai Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John D Karalis
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ahmed Elamir
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alessandro Bifolco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Megan Wachsmann
- Department of Pathology, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Giovanni Capretti
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Paola Spaggiari
- Department of Pathology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Sebastian Enrico
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Nafeesah Fatimah
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Giada Pontecorvi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Martina Nebbia
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Kaza
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ivan Pedrosa
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio Polanco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Jing Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Todd Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Matteo Ligorio
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Nenoff L, Amstutz F, Murr M, Archibald-Heeren B, Fusella M, Hussein M, Lechner W, Zhang Y, Sharp G, Vasquez Osorio E. Review and recommendations on deformable image registration uncertainties for radiotherapy applications. Phys Med Biol 2023; 68:24TR01. [PMID: 37972540 PMCID: PMC10725576 DOI: 10.1088/1361-6560/ad0d8a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 11/19/2023]
Abstract
Deformable image registration (DIR) is a versatile tool used in many applications in radiotherapy (RT). DIR algorithms have been implemented in many commercial treatment planning systems providing accessible and easy-to-use solutions. However, the geometric uncertainty of DIR can be large and difficult to quantify, resulting in barriers to clinical practice. Currently, there is no agreement in the RT community on how to quantify these uncertainties and determine thresholds that distinguish a good DIR result from a poor one. This review summarises the current literature on sources of DIR uncertainties and their impact on RT applications. Recommendations are provided on how to handle these uncertainties for patient-specific use, commissioning, and research. Recommendations are also provided for developers and vendors to help users to understand DIR uncertainties and make the application of DIR in RT safer and more reliable.
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Affiliation(s)
- Lena Nenoff
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, Dresden Germany
- Helmholtz-Zentrum Dresden—Rossendorf, Institute of Radiooncology—OncoRay, Dresden, Germany
| | - Florian Amstutz
- Department of Physics, ETH Zurich, Switzerland
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martina Murr
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | | | - Marco Fusella
- Department of Radiation Oncology, Abano Terme Hospital, Italy
| | - Mohammad Hussein
- Metrology for Medical Physics, National Physical Laboratory, Teddington, United Kingdom
| | - Wolfgang Lechner
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
| | - Greg Sharp
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Eliana Vasquez Osorio
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
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Lee D, Renz P, Oh S, Hwang MS, Pavord D, Yun KL, Collura C, McCauley M, Colonias A(T, Trombetta M, Kirichenko A. Online Adaptive MRI-Guided Stereotactic Body Radiotherapy for Pancreatic and Other Intra-Abdominal Cancers. Cancers (Basel) 2023; 15:5272. [PMID: 37958447 PMCID: PMC10648954 DOI: 10.3390/cancers15215272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
A 1.5T MRI combined with a linear accelerator (Unity®, Elekta; Stockholm, Sweden) is a device that shows promise in MRI-guided stereotactic body radiation treatment (SBRT). Previous studies utilized the manufacturer's pre-set MRI sequences (i.e., T2 Weighted (T2W)), which limited the visualization of pancreatic and intra-abdominal tumors and organs at risk (OAR). Here, a T1 Weighted (T1W) sequence was utilized to improve the visualization of tumors and OAR for online adapted-to-position (ATP) and adapted-to-shape (ATS) during MRI-guided SBRT. Twenty-six patients, 19 with pancreatic and 7 with intra-abdominal cancers, underwent CT and MRI simulations for SBRT planning before being treated with multi-fractionated MRI-guided SBRT. The boundary of tumors and OAR was more clearly seen on T1W image sets, resulting in fast and accurate contouring during online ATP/ATS planning. Plan quality in 26 patients was dependent on OAR proximity to the target tumor and achieved 96 ± 5% and 92 ± 9% in gross tumor volume D90% and planning target volume D90%. We utilized T1W imaging (about 120 s) to shorten imaging time by 67% compared to T2W imaging (about 360 s) and improve tumor visualization, minimizing target/OAR delineation uncertainty and the treatment margin for sparing OAR. The average time-consumption of MRI-guided SBRT for the first 21 patients was 55 ± 15 min for ATP and 79 ± 20 min for ATS.
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Affiliation(s)
- Danny Lee
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
| | - Paul Renz
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
| | - Seungjong Oh
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
| | - Min-Sig Hwang
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
| | - Daniel Pavord
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
| | - Kyung Lim Yun
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
| | - Colleen Collura
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
| | - Mary McCauley
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
| | - Athanasios (Tom) Colonias
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
| | - Mark Trombetta
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
| | - Alexander Kirichenko
- Radiation Oncology, Allegheny Health Network, Pittsburgh, PA 15012, USA; (P.R.); (S.O.); (M.-S.H.); (D.P.); (K.L.Y.); (C.C.); (M.M.); (M.T.); (A.K.)
- College of Medicine, Radiologic Sciences/Drexel University, Philadelphia, PA 19129, USA
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Gough J, Hall W, Good J, Nash A, Aitken K. Technical Radiotherapy Advances – The Role of Magnetic Resonance Imaging-Guided Radiation in the Delivery of Hypofractionation. Clin Oncol (R Coll Radiol) 2022; 34:301-312. [DOI: 10.1016/j.clon.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/07/2022] [Accepted: 02/23/2022] [Indexed: 12/30/2022]
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Abstract
The delineation of organs at risk is the basis of radiotherapy oncologists' work. Indeed, the knowledge of this delineation enables to better identify the target volumes and to optimize dose distribution, involving the prognosis of the patients but also their future. The learning of this delineation must continue throughout the clinician's career. Some contour changes have appeared with better imaging, some volumes are now required due to development of knowledge of side effects. In addition, the increasing survival time of patients requires to be more systematic and precise in the delineations, both to avoid complications until now exceptional but also because re-irradiations are becoming more and more frequent. We present the update of the recommendations of the French Society for Radiation Oncology (SFRO) on new findings or adaptations to volumes at risk.
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Affiliation(s)
- G Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France.
| | - C Le Fèvre
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
| | - D Antoni
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
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Hall WA, Small C, Paulson E, Koay EJ, Crane C, Intven M, Daamen LA, Meijer GJ, Heerkens HD, Bassetti M, Rosenberg SA, Aitken K, Myrehaug S, Dawson LA, Lee P, Gani C, Chuong MD, Parikh PJ, Erickson BA. Magnetic Resonance Guided Radiation Therapy for Pancreatic Adenocarcinoma, Advantages, Challenges, Current Approaches, and Future Directions. Front Oncol 2021; 11:628155. [PMID: 34046339 PMCID: PMC8144850 DOI: 10.3389/fonc.2021.628155] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Pancreatic adenocarcinoma (PAC) has some of the worst treatment outcomes for any solid tumor. PAC creates substantial difficulty for effective treatment with traditional RT delivery strategies primarily secondary to its location and limited visualization using CT. Several of these challenges are uniquely addressed with MR-guided RT. We sought to summarize and place into context the currently available literature on MR-guided RT specifically for PAC. Methods A literature search was conducted to identify manuscript publications since September 2014 that specifically used MR-guided RT for the treatment of PAC. Clinical outcomes of these series are summarized, discussed, and placed into the context of the existing pancreatic literature. Multiple international experts were involved to optimally contextualize these publications. Results Over 300 manuscripts were reviewed. A total of 6 clinical outcomes publications were identified that have treated patients with PAC using MR guidance. Successes, challenges, and future directions for this technology are evident in these publications. MR-guided RT holds theoretical promise for the treatment of patients with PAC. As with any new technology, immediate or dramatic clinical improvements associated with its use will take time and experience. There remain no prospective trials, currently publications are limited to small retrospective experiences. The current level of evidence for MR guidance in PAC is low and requires significant expansion. Future directions and ongoing studies that are currently open and accruing are identified and reviewed. Conclusions The potential promise of MR-guided RT for PAC is highlighted, the challenges associated with this novel therapeutic intervention are also reviewed. Outcomes are very early, and will require continued and long term follow up. MR-guided RT should not be viewed in the same fashion as a novel chemotherapeutic agent for which dosing, administration, and toxicity has been established in earlier phase studies. Instead, it should be viewed as a novel procedural intervention which must be robustly tested, refined and practiced before definitive conclusions on the potential benefits or detriments can be determined. The future of MR-guided RT for PAC is highly promising and the potential implications on PAC are substantial.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Christina Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eugene J Koay
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D Heerkens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michael Bassetti
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, WI, United States
| | - Stephen A Rosenberg
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Katharine Aitken
- Department of Radiation Oncology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Percy Lee
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cihan Gani
- Department of Radiation Oncology, Faculty of Medicine, University of Tübingen, Tübingen, Germany
| | | | - Parag J Parikh
- Henry Ford Medical Center, Henry Ford Health System, Detroit, MI, United States
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
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Wei D, Zaid MM, Katz MH, Prakash LR, Kim M, Tzeng CWD, Lee JE, Agrawal A, Rashid A, Wang H, Varadhachary G, Wolff RA, Tamm EP, Bhosale PR, Maitra A, Koay EJ, Wang H. Clinicopathological correlation of radiologic measurement of post-therapy tumor size and tumor volume for pancreatic ductal adenocarcinoma. Pancreatology 2021; 21:200-207. [PMID: 33221151 PMCID: PMC7855532 DOI: 10.1016/j.pan.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Tumor size measurement is critical for accurate tumor staging in patients with pancreatic ductal adenocarcinoma (PDAC). However, accurate tumor size measurement is challenging in patients who received neoadjuvant therapy before resection, due to treatment-induced fibrosis and tumor invasion beyond the grossly identified tumor area. In this study, we evaluated the correlation between the tumor size and tumor volume measured on post-therapy computed tomography (CT) scans and the pathological measurement. Also, we investigated the correlation between these measurements and clinicopathological parameters and survival. MATERIALS AND METHODS Retrospectively, we evaluated 343 patients with PDAC who received neoadjuvant therapy, followed by pancreaticoduodenectomy and had pre-operative pancreatic protocol CT imaging. We measured the longest tumor diameter (RadL) and the radiological tumor volume (RadV) on the post-therapy CT scan, then we categorized RadL into four radiologic tumor stages (RTS) based on the current AJCC staging (8th edition) protocol and RadV based on the median. Pearson correlation or Spearman's coefficient (δ), T-test and ANOVA was used to test the correlation between the radiological and pathological measurement. Chi-square analysis was used to test the correlation with the tumor pathological response, lymph-node metastasis and margin status and Kaplan-Meier and Cox-proportional hazard for survival analysis. P-value < 0.05 was considered significant. RESULTS As a continuous variable, RadL showed a positive linear correlation with the post-therapy pathologic tumor size in the overall patient population (Pearson correlation coefficient: 0.72, P < 0.001) and RadV (δ: 0.63, p < 0.0001). However, there was no correlation between RadL and pathologic tumor size in patients with ypT0 and those with pathologic tumor size of ≤1.0 cm. Post-therapy RTS and RadV group correlated with ypT stage, tumor response grades using either CAP or MDA grading system, distance of superior mesenteric artery margin and tumor recurrence/metastasis. CONCLUSION Although RadL tends to understage ypT in PDAC patients who had no radiologically detectable tumor or small tumors (RTS0 or RTS1), radiologic measurement of post-therapy tumor size may be used as a marker for the pathologic tumor staging and tumor response to neoadjuvant therapy.
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Affiliation(s)
- Dongguang Wei
- Department of Anatomical Pathology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Mohamed M Zaid
- Department of Radiation Oncology, University of Texas, Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Matthew H Katz
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Michael Kim
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Anshuman Agrawal
- Department of Radiation Oncology, University of Texas, Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Asif Rashid
- Department of Anatomical Pathology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Hua Wang
- Department of Gastrointestinal Medical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Gauri Varadhachary
- Department of Gastrointestinal Medical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Eric P Tamm
- Department of Diagnostic Radiology, University of Texas MD Anderson, Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Priya R Bhosale
- Department of Diagnostic Radiology, University of Texas MD Anderson, Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Anirban Maitra
- Department of Anatomical Pathology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA; Department of Translational Molecular Pathology, University of Texas MD, Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas, Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Huamin Wang
- Department of Anatomical Pathology, University of Texas, MD Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA; Department of Translational Molecular Pathology, University of Texas MD, Anderson Cancer Center, 515 Holcombe Blvd, Houston, TX, 77030, USA.
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9
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Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines. Cancers (Basel) 2020; 12:cancers12071729. [PMID: 32610592 PMCID: PMC7407382 DOI: 10.3390/cancers12071729] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on (i) the current indications by the available national and international guidelines; (ii) the current standard indications for target volume delineation in radiotherapy (RT); (iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); (iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; (v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and (vi) a multimodal integration opportunity: the combination of RT with immunotherapy.
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10
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Lukovic J, Henke L, Gani C, Kim TK, Stanescu T, Hosni A, Lindsay P, Erickson B, Khor R, Eccles C, Boon C, Donker M, Jagavkar R, Nowee ME, Hall WA, Parikh P, Dawson LA. MRI-Based Upper Abdominal Organs-at-Risk Atlas for Radiation Oncology. Int J Radiat Oncol Biol Phys 2020; 106:743-753. [PMID: 31953061 DOI: 10.1016/j.ijrobp.2019.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/02/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of our study was to provide a guide for identification and contouring of upper abdominal organs-at-risk (OARs) in the setting of online magnetic resonance imaging (MRI)-guided radiation treatment planning and delivery. METHODS AND MATERIALS After a needs assessment survey, it was determined that an upper abdominal MRI-based atlas of normal OARs would be of benefit to radiation oncologists and radiation therapists. An anonymized diagnostic 1.5T MRI from a patient with typical upper abdominal anatomy was used for atlas development. Two MRI sequences were selected for contouring, a T1-weighted gadoxetic acid contrast-enhanced MRI acquired in the hepatobiliary phase and axial fast imaging with balanced steady-state precession. Two additional clinical MRI sequences from commercial online MRI-guided radiation therapy systems were selected for contouring and were included in the final atlas. Contours from each data set were completed and reviewed by radiation oncologists, along with a radiologist who specializes in upper abdominal imaging, to generate a consensus upper abdominal MRI-based OAR atlas. RESULTS A normal OAR atlas was developed, including recommendations for contouring. The atlas and contouring guidance are described, and high-resolution MRI images and contours are displayed. OARs, such as the bile duct and biliary tree, which may be better seen on MRI than on computed tomography, are highlighted. The full DICOM/DICOM-RT MRI images from both the diagnostic and clinical online MRI-guided radiation therapy systems data sets have been made freely available, for educational purposes, at econtour.org. CONCLUSIONS This MRI contouring atlas for upper abdominal OARs should provide a useful reference for contouring and education. Its routine use may help to improve uniformity in contouring in radiation oncology planning and OAR dose calculation. Full DICOM/DICOM-RT images are available online and provide a valuable educational resource for upper abdominal MRI-based radiation therapy planning and delivery.
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Affiliation(s)
- Jelena Lukovic
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lauren Henke
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Tae K Kim
- Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Stanescu
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Patricia Lindsay
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Richard Khor
- Department of Radiation Oncology, Austin Health, Melbourne, Australia
| | - Cynthia Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Cheng Boon
- Department of Clinical Oncology, Rutherford Cancer Centre North West, Liverpool, United Kingdom
| | - Mila Donker
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Raj Jagavkar
- Department of Radiation Oncology, St. Vincent's Hospital Sydney, Sydney, Australia
| | - Marlies E Nowee
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag Parikh
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Laura A Dawson
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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11
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Oar A, Lee M, Le H, Hruby G, Dalfsen R, Pryor D, Lee D, Chu J, Holloway L, Briggs A, Barbour A, Chander S, Ng SP, Samra J, Shakeshaft J, Goldstein D, Nguyen N, Goodman KA, Chang DT, Kneebone A. Australasian Gastrointestinal Trials Group (AGITG) and Trans-Tasman Radiation Oncology Group (TROG) Guidelines for Pancreatic Stereotactic Body Radiation Therapy (SBRT). Pract Radiat Oncol 2019; 10:e136-e146. [PMID: 31761541 DOI: 10.1016/j.prro.2019.07.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Nonrandomized data exploring pancreas stereotactic body radiation therapy (SBRT) has demonstrated excellent local control rates and low toxicity. Before commencing a randomized trial investigating pancreas SBRT, standardization of prescription dose, dose constraints, simulation technique, and clinical target volume delineation are required. METHODS AND MATERIALS Specialists in radiation oncology, medical oncology, hepatobiliary surgery, and gastroenterology attended 2 consecutive Australasian Gastrointestinal Trials Group workshops in 2017 and 2018. Sample cases were discussed during workshop contact with specifically invited international speakers highly experienced in pancreas SBRT. Furthermore, sample cases were contoured and planned between workshop contact to finalize dose constraints and clinical target volume delineation. RESULTS Over 2 separate workshops, consensus was reached on dose and simulation technique. The working group recommended a dose prescription of 40 Gy in 5 fractions. Treatment delivery during end-expiratory breath hold with triple-phase contrast enhanced computed tomography was recommended. In addition, dose constraints, stepwise contouring guidelines, and an anatomic atlas for pancreatic SBRT were developed. CONCLUSIONS Pancreas SBRT is emerging as a promising treatment modality requiring prospective evaluation in randomized studies. This work attempts to standardize dose, simulation technique, and volume delineation to support the delivery of high quality SBRT in a multicenter study.
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Affiliation(s)
- Andrew Oar
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast; Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.
| | - Mark Lee
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - George Hruby
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Raymond Dalfsen
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Australia
| | | | - Julie Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lois Holloway
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia; South Western Clinical School, University of New South Wales, Sydney, Australia; Institute of Medical Physics, University of Sydney, Sydney, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Adam Briggs
- Royal North Shore Hospital, Sydney, Australia
| | - Andrew Barbour
- Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Diamantina Institute, Translational Research Institute, Woolloongabba, Australia
| | - Sarat Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jas Samra
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - John Shakeshaft
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - David Goldstein
- Department of Medical Oncology, Nelune Cancer Centre, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Nam Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Andrew Kneebone
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
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12
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Caravatta L, Cellini F, Simoni N, Rosa C, Niespolo RM, Lupattelli M, Picardi V, Macchia G, Sainato A, Mantello G, Dionisi F, Rosetto ME, Fusco V, Navarria F, De Paoli A, Guido A, Vecchi C, Basilico R, Cianci R, Delli Pizzi A, Di Nicola M, Mattiucci GC, Valentini V, Morganti AG, Genovesi D. Magnetic resonance imaging (MRI) compared with computed tomography (CT) for interobserver agreement of gross tumor volume delineation in pancreatic cancer: a multi-institutional contouring study on behalf of the AIRO group for gastrointestinal cancers. Acta Oncol 2019; 58:439-447. [PMID: 30632876 DOI: 10.1080/0284186x.2018.1546899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Due to the high soft tissue resolution, magnetic resonance imaging (MRI) could improve the accuracy of pancreatic tumor delineation in radiation treatment planning. A multi-institutional study was proposed to evaluate the impact of MRI on inter-observer agreement in gross tumor volume (GTV) and duodenum delineation for pancreatic cancer compared with computer tomography (CT). MATERIAL AND METHODS Two clinical cases of borderline resectable (Case 1) and unresectable (Case 2) pancreatic cancer were selected. In two sequential steps, diagnostic contrast-enhanced CT scan and MRI sequences were sent to the participating centers. CT-GTVs were contoured while blinded to MRI data sets. DICE index was used to evaluate the spatial overlap accuracy. RESULTS Thirty-one radiation oncologists from different Institutions submitted the delineated volumes. CT- and MRI-GTV mean volumes were 21.6 ± 9.0 cm3 and 17.2 ± 6.0 cm3, respectively for Case 1, and 31.3 ± 15.6 cm3 and 33.2 ± 20.2 cm3, respectively for Case 2. Resulting MRI-GTV mean volume was significantly smaller than CT-GTV in the borderline resectable case (p < .05). A substantial agreement was shown by the median DICE index for CT- and MRI-GTV resulting as 0.74 (IQR: 0.67-0.75) and 0.61 (IQR: 0.57-0.67) for Case 1; a moderate agreement was instead reported for Case 2: 0.59 (IQR:0.52-0.66) and 0.53 (IQR:0.42-0.62) for CT- and MRI-GTV, respectively. CONCLUSION Diagnostic MRI resulted in smaller GTV in borderline resectable case with a substantial agreement between observers, and was comparable to CT scan in interobserver variability, in both cases. The greater variability in the unresectable case underlines the critical issues related to the outlining when vascular structures are more involved. The integration of MRI with contrast-enhancement CT, thanks to its high definition of tumor relationship with neighboring vessels, could offer a greater accuracy of target delineation.
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Affiliation(s)
- Luciana Caravatta
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Francesco Cellini
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Nicola Simoni
- Radiotherapy Unit Azienda Ospedaliera Universitaria, Verona, Italy
| | - Consuelo Rosa
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | | | - Marco Lupattelli
- Radiation Oncology Section University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Vincenzo Picardi
- Radiotherapy Unit Department of Oncology, ‘Giovanni Paolo II’ Foundation Catholic University of Sacred Heart, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit Department of Oncology, ‘Giovanni Paolo II’ Foundation Catholic University of Sacred Heart, Campobasso, Italy
| | - Aldo Sainato
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Francesco Dionisi
- Proton Therapy Unit, Department of Oncology, Azienda Provinciale per i Servizi Sanitari, APSS, Trento, Italy
| | | | - Vincenzo Fusco
- Department of Radiation Oncology, Centro di Riferimento Oncologico Regionale, Rionero in Vulture, Potenza, Italy
| | - Federico Navarria
- Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Antonino De Paoli
- Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Raffaella Basilico
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Roberta Cianci
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Andrea Delli Pizzi
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics Department of Medical, Oral and Biotechnological Sciences ‘G. D'Annunzio’ University, Chieti, Italy
| | - Gian Carlo Mattiucci
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Vincenzo Valentini
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology Center, Department of Experimental Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Domenico Genovesi
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
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Sarkar V, Lloyd S, Paxton A, Huang L, Su FC, Tao R, Tward J, Zhao H, Salter B. Daily breathing inconsistency in pancreas SBRT: a 4DCT study. J Gastrointest Oncol 2019; 9:989-995. [PMID: 30603117 DOI: 10.21037/jgo.2018.09.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Stereotactic body radiation therapy (SBRT) treatments of pancreatic cancer typically employ relatively small margins. This study characterizes the motion of high visibility structures in close proximity to the pancreas to determine how much the motion envelope of such a structure changes due to respiratory variation between fractions. Methods Fanbeam, four-dimensional computed tomography (4DCT) studies acquired initially for planning and again prior to each treatment for 6 patients were used to fully characterize the change in motion of high-contrast structures in close proximity to the pancreas. Results Three of the six patients investigated had structures that showed a change in motion over the course of treatment that would not have been covered when using the typical 3 mm planning target volume (PTV) margins. For most of these large changes in motion envelope, a 4 mm uniform PTV margin would have allowed for coverage of the tumor. Conclusions Half of the patients showed a change in motion envelope greater than would be covered by the commonly used PTV margins in pancreas SBRT. This shows that the impact of small margins must be very carefully considered during the planning process.
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Affiliation(s)
- Vikren Sarkar
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Adam Paxton
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Long Huang
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Fan-Chi Su
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Randa Tao
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Jonathan Tward
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Hui Zhao
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
| | - Bill Salter
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA
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14
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Heerkens HD, van Vulpen M, Erickson B, Reerink O, Intven MP, van den Berg CA, Molenaar IQ, Vleggaar FP, Meijer GJ. MRI guided stereotactic radiotherapy for locally advanced pancreatic cancer. Br J Radiol 2018; 91:20170563. [PMID: 30063383 DOI: 10.1259/bjr.20170563] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE: We want to explore the safety and technical feasibility of MRI-guided stereotactic radiotherapy for locally advanced pancreatic cancer. METHODS: A custom-made abdominal corset was manufactured to reduce breathing induced tumour motion. Delineation of the tumour and organs at risk (OARs) was performed on CT and multiparametric MRI. Tumour motion was quantified with cine MRI. After treatment planning, the static dose distribution was convolved with the cine MRI-based motion trajectory to simulate the delivered dose to the tumour and OARs. Stereotactic body radiation therapy (SBRT) was carried out up to a dose of 24 G in three fractions in 1 week. RESULTS: From July 2013 to January 2016, 20 patients were included. Tumours and OARs were clearly visible with contrast-enhanced CT and MRI. After simulation of the delivered dose taking the motion into account, an adequate target coverage was achieved with acceptable dose in the OARs. No Grade3 or higher treatment related toxicity was observed. CONCLUSION: MRI-guided SBRT for pancreatic cancer is technical feasible and safe, with no treatment related grade ≥3 toxicity. New strategies are applied, including an individual corset to reduce breathing motion, MRI-based delineation and simulation of motion-integrated dose distributions. ADVANCES IN KNOWLEDGE: This article is the first to describe an MRI-integrated workflow in SBRT for locally advanced pancreatic cancer. In addition, it demonstrated that SBRT with an abdominal corset to reduce tumour motion is feasible and safe. TRIAL REGISTRATION: This trial was registered at www.clinicaltrials.gov (NCT01898741) on July 9, 2013.
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Affiliation(s)
- Hanne D Heerkens
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Marco van Vulpen
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht , The Netherlands.,2 Department of Radiation Oncology, Holland Particle Therapy Centre , Delft , The Netherlands
| | - Beth Erickson
- 3 Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA
| | - Onne Reerink
- 4 Department of Radiation Oncology, Isala Clinic , Zwolle , The Netherlands
| | - Martijn Pw Intven
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Cornelis At van den Berg
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - I Quintus Molenaar
- 5 Department of Surgery, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Frank P Vleggaar
- 6 Department of Gastroenterology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Gert J Meijer
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht , The Netherlands
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