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Meng YJ, Mankuzhy NP, Chawla M, Lee RP, Yorke ED, Zhang Z, Gelb E, Lim SB, Cuaron JJ, Wu AJ, Simone CB, Gelblum DY, Lovelock DM, Harris W, Rimner A. A Prospective Study on Deep Inspiration Breath Hold Thoracic Radiation Therapy Guided by Bronchoscopically Implanted Electromagnetic Transponders. Cancers (Basel) 2024; 16:1534. [PMID: 38672616 PMCID: PMC11048337 DOI: 10.3390/cancers16081534] [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: 02/27/2024] [Revised: 04/03/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Electromagnetic transponders bronchoscopically implanted near the tumor can be used to monitor deep inspiration breath hold (DIBH) for thoracic radiation therapy (RT). The feasibility and safety of this approach require further study. METHODS We enrolled patients with primary lung cancer or lung metastases. Three transponders were implanted near the tumor, followed by simulation with DIBH, free breathing, and 4D-CT as backup. The initial gating window for treatment was ±5 mm; in a second cohort, the window was incrementally reduced to determine the smallest feasible gating window. The primary endpoint was feasibility, defined as completion of RT using transponder-guided DIBH. Patients were followed for assessment of transponder- and RT-related toxicity. RESULTS We enrolled 48 patients (35 with primary lung cancer and 13 with lung metastases). The median distance of transponders to tumor was 1.6 cm (IQR 0.6-2.8 cm). RT delivery ranged from 3 to 35 fractions. Transponder-guided DIBH was feasible in all but two patients (96% feasible), where it failed because the distance between the transponders and the antenna was >19 cm. Among the remaining 46 patients, 6 were treated prone to keep the transponders within 19 cm of the antenna, and 40 were treated supine. The smallest feasible gating window was identified as ±3 mm. Thirty-nine (85%) patients completed one year of follow-up. Toxicities at least possibly related to transponders or the implantation procedure were grade 2 in six patients (six incidences, cough and hemoptysis), grade 3 in three patients (five incidences, cough, dyspnea, pneumonia, and supraventricular tachycardia), and grade 4 pneumonia in one patient (occurring a few days after implantation but recovered fully and completed RT). Toxicities at least possibly related to RT were grade 2 in 18 patients (41 incidences, most commonly cough, fatigue, and pneumonitis) and grade 3 in four patients (seven incidences, most commonly pneumonia), and no patients had grade 4 or higher toxicity. CONCLUSIONS Bronchoscopically implanted electromagnetic transponder-guided DIBH lung RT is feasible and safe, allowing for precise tumor targeting and reduced normal tissue exposure. Transponder-antenna distance was the most common challenge due to a limited antenna range, which could sometimes be circumvented by prone positioning.
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Affiliation(s)
- Yuzhong Jeff Meng
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Nikhil P. Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Mohit Chawla
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (M.C.); (R.P.L.)
| | - Robert P. Lee
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (M.C.); (R.P.L.)
| | - Ellen D. Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.); (W.H.)
| | - Zhigang Zhang
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA;
| | - Emily Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Seng Boh Lim
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.); (W.H.)
| | - John J. Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
- New York Proton Center, New York, NY 10035, USA; (C.B.S.II)
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
| | - Dale Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.); (W.H.)
| | - Wendy Harris
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.); (W.H.)
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II); (D.Y.G.)
- Department of Radiation Oncology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK), Partner Site DKTK-Freiburg, Robert-Koch-Strasse 3, 79106 Freiburg, Germany
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Dai J, Dong G, Zhang C, He W, Liu L, Wang T, Jiang Y, Zhao W, Zhao X, Xie Y, Liang X. Volumetric tumor tracking from a single cone-beam X-ray projection image enabled by deep learning. Med Image Anal 2024; 91:102998. [PMID: 37857066 DOI: 10.1016/j.media.2023.102998] [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: 08/19/2022] [Revised: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023]
Abstract
Radiotherapy serves as a pivotal treatment modality for malignant tumors. However, the accuracy of radiotherapy is significantly compromised due to respiratory-induced fluctuations in the size, shape, and position of the tumor. To address this challenge, we introduce a deep learning-anchored, volumetric tumor tracking methodology that employs single-angle X-ray projection images. This process involves aligning the intraoperative two-dimensional (2D) X-ray images with the pre-treatment three-dimensional (3D) planning Computed Tomography (CT) scans, enabling the extraction of the 3D tumor position and segmentation. Prior to therapy, a bespoke patient-specific tumor tracking model is formulated, leveraging a hybrid data augmentation, style correction, and registration network to create a mapping from single-angle 2D X-ray images to the corresponding 3D tumors. During the treatment phase, real-time X-ray images are fed into the trained model, producing the respective 3D tumor positioning. Rigorous validation conducted on actual patient lung data and lung phantoms attests to the high localization precision of our method at lowered radiation doses, thus heralding promising strides towards enhancing the precision of radiotherapy.
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Affiliation(s)
- Jingjing Dai
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Guoya Dong
- School of Health Sciences and Biomedical Engineering, Hebei University of Technology, Hebei Key Laboratory of Bioelectromagnetics and Neural Engineering, Tianjin Key Laboratory of Bioelectricity and Intelligent Health, 300130, Tianjin, China
| | - Chulong Zhang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Wenfeng He
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Lin Liu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Tangsheng Wang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Yuming Jiang
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem,North Carolina, 27157, USA
| | - Wei Zhao
- School of Physics, Beihang University, Beijing, 100191, China
| | - Xiang Zhao
- Department of Radiology, Tianjin Medical University General Hospital, 300050, China
| | - Yaoqin Xie
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Xiaokun Liang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
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3
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Cheng JC, Buduhan G, Venkataraman S, Tan L, Sasaki D, Bashir B, Ahmed N, Kidane B, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Wong R, Kim JO. Endobronchially Implanted Real-Time Electromagnetic Transponder Beacon-Guided, Respiratory-Gated SABR for Moving Lung Tumors: A Prospective Phase 1/2 Cohort Study. Adv Radiat Oncol 2023; 8:101243. [PMID: 37408673 PMCID: PMC10318214 DOI: 10.1016/j.adro.2023.101243] [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: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Endobronchial electromagnetic transponder beacons (EMT) provide real-time, precise positional data of moving lung tumors. We report results of a phase 1/2, prospective, single-arm cohort study evaluating the treatment planning effects of EMT-guided SABR for moving lung tumors. Methods and Materials Eligible patients were adults, Eastern Cooperative Oncology Group 0 to 2, with T1-T2N0 non-small cell lung cancer or pulmonary metastasis ≤4 cm with motion amplitude ≥5 mm. Three EMTs were endobronchially implanted using navigational bronchoscopy. Four-dimensional free-breathing computed tomography simulation scans were obtained, and end-exhalation phases were used to define the gating window internal target volume. A 3-mm expansion of gating window internal target volume defined the planning target volume (PTV). EMT-guided, respiratory-gated (RG) SABR was delivered (54 Gy/3 fractions or 48 Gy/4 fractions) using volumetric modulated arc therapy. For each RG-SABR plan, a 10-phase image-guided SABR plan was generated for dosimetric comparison. PTV/organ-at-risk (OAR) metrics were tabulated and analyzed using the Wilcoxon signed-rank pair test. Treatment outcomes were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours; version 1.1). Results Of 41 patients screened, 17 were enrolled and 2 withdrew from the study. Median age was 73 years, with 7 women. Sixty percent had T1/T2 non-small cell lung cancer and 40% had M1 disease. Median tumor diameter was 1.9 cm with 73% of targets located peripherally. Mean respiratory tumor motion was 1.25 cm (range, 0.53-4.04 cm). Thirteen tumors were treated with EMT-guided SABR and 47% of patients received 48 Gy in 4 fractions while 53% received 54 Gy in 3 fractions. RG-SABR yielded an average PTV reduction of 46.9% (P < .005). Lung V5, V10, V20, and mean lung dose had mean relative reductions of 11.3%, 20.3%, 31.1%, and 20.3%, respectively (P < .005). Dose to OARs was significantly reduced (P < .05) except for spinal cord. At 6 months, mean radiographic tumor volume reduction was 53.5% (P < .005). Conclusions EMT-guided RG-SABR significantly reduced PTVs of moving lung tumors compared with image-guided SABR. EMT-guided RG-SABR should be considered for tumors with large respiratory motion amplitudes or those located in close proximity to OARs.
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Affiliation(s)
- Jui Chih Cheng
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Lawrence Tan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Sasaki
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Bashir Bashir
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naseer Ahmed
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Biniam Kidane
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmet Leylek
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Butler
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Boyd McCurdy
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Ralph Wong
- Medical Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julian O. Kim
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada
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Eppenga R, Heerink W, Smit J, Kuhlmann K, Ruers T, Nijkamp J. Real-Time Wireless Tumor Tracking in Navigated Liver Resections: An Ex Vivo Feasibility Study. Ann Surg Oncol 2022; 29:3951-3960. [PMID: 35195825 PMCID: PMC9072277 DOI: 10.1245/s10434-022-11364-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical navigation systems generally require intraoperative steps, such as intraoperative imaging and registration, to link the system to the patient anatomy. Because this hampers surgical workflow, we developed a plug-and-play wireless navigation system that does not require any intraoperative steps. In this ex vivo study on human hepatectomy specimens, the feasibility was assessed of using this navigation system to accurately resect a planned volume with small margins to the lesion. METHODS For ten hepatectomy specimens, a planning CT was acquired in which a virtual spherical lesion with 5 mm margin was delineated, inside the healthy parenchyma. Using two implanted trackers, the real-time position of this planned resection volume was visualized on a screen, relative to the used tracked pointer. Experienced liver surgeons were asked to accurately resect the nonpalpable planned volume, fully relying on the navigation screen. Resected and planned volumes were compared using CT. RESULTS The surgeons resected the planned volume while cutting along its border with a mean accuracy of - 0.1 ± 2.4 mm and resected 98 ± 12% of the planned volume. Nine out of ten resections were radical and one case showed a cut of 0.8 mm into the lesion. The sessions took approximately 10 min each, and no considerable technical issues were encountered. CONCLUSIONS This ex vivo liver study showed that it is feasible to accurately resect virtual hepatic lesions with small planned margins using our novel navigation system, which is promising for clinical applications where nonpalpable hepatic metastases have to be resected with small resection margins.
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Affiliation(s)
- Roeland Eppenga
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Wout Heerink
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jasper Smit
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Koert Kuhlmann
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Theo Ruers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Nanobiophysics Group, Faculty TNW, University of Twente, Enschede, The Netherlands
| | - Jasper Nijkamp
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Casutt A, Kinj R, Ozsahin EM, von Garnier C, Lovis A. Fiducial markers for stereotactic lung radiation therapy: review of the transthoracic, endovascular and endobronchial approaches. Eur Respir Rev 2022; 31:31/163/210149. [PMID: 35022258 DOI: 10.1183/16000617.0149-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/09/2021] [Indexed: 11/05/2022] Open
Abstract
Stereotactic body radiation therapy is an alternative to surgery for early-stage, inoperable peripheral non-small cell lung cancer. As opposed to linear accelerator (linac)-based (e.g. gating) and free-breathing techniques, CyberKnife® with Synchrony® technology allows accurate radiation delivery by means of a real-time respiratory motion tracking system using, in most cases, metal fiducial markers (FMs) placed in the vicinity of the target. The aims of this review are as follows. First, to describe the safety and efficacy of the transthoracic, endovascular and endobronchial FM insertion techniques for peripheral pulmonary lesions (PPLs). Second, to analyse performance in terms of the migration and tracking rates of different FM types. Recent developments in FM tracking for central lesions will also be reviewed. In conclusion, for PPLs, the endobronchial approach provides a low rate of pneumothorax, offers the possibility of concurrent diagnostic sampling for both the PPL and the lymph nodes, and, finally, reduces the intervention time compared to other techniques. In this context, coil-tailed and coil-spring FMs have shown the lowest migration rate with a consequently high tracking rate.
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Affiliation(s)
- Alessio Casutt
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland .,University of Lausanne, UNIL, Lausanne, Switzerland
| | - Rémy Kinj
- University of Lausanne, UNIL, Lausanne, Switzerland.,Dept of Radiation Oncology, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Esat-Mahmut Ozsahin
- University of Lausanne, UNIL, Lausanne, Switzerland.,Dept of Radiation Oncology, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Christophe von Garnier
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland.,University of Lausanne, UNIL, Lausanne, Switzerland
| | - Alban Lovis
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland.,University of Lausanne, UNIL, Lausanne, Switzerland
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Harris W, Yorke E, Li H, Czmielewski C, Chawla M, Lee RP, Hotca-Cho A, McKnight D, Rimner A, Lovelock DM. Can bronchoscopically implanted anchored electromagnetic transponders be used to monitor tumor position and lung inflation during deep inspiration breath-hold lung radiotherapy? Med Phys 2022; 49:2621-2630. [PMID: 35192211 PMCID: PMC9007909 DOI: 10.1002/mp.15565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/22/2022] [Accepted: 02/05/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the efficacy of using bronchoscopically implanted anchored electromagnetic transponders (EMTs) as surrogates for 1) tumor position and 2) repeatability of lung inflation during deep-inspiration breath-hold (DIBH) lung radiotherapy. METHODS 41 patients treated with either hypofractionated (HF) or conventional (CF) lung radiotherapy on an IRB approved prospective protocol using coached DIBH were evaluated for this study. Three anchored EMTs were bronchoscopically implanted into small airways near or within the tumor. DIBH treatment was gated by tracking the EMT positions. Breath-hold cone-beam-CTs (CBCTs) were acquired prior to every HF treatment or weekly for CF patients. Retrospectively, rigid registrations between each CBCT and the breath-hold planning CT were performed to match to 1) spine 2) EMTs and 3) tumor. Absolute differences in registration between EMTs and spine were analyzed to determine surrogacy of EMTs for lung inflation. Differences in registration between EMTs and tumor were analyzed to determine surrogacy of EMTs for tumor position. The stability of the EMTs was evaluated by analyzing the difference between inter-EMT displacements recorded at treatment from that of the plan for the CF patients, as well as the geometric residual (GR) recorded at the time of treatment. RESULTS 219 CBCTs were analyzed. The average differences between EMT centroid and spine registration among all CBCTs were 0.45±0.42cm, 0.29±0.28cm, and 0.18±0.15cm in superior-inferior (SI), anterior-posterior (AP) and lateral directions, respectively. Only 59% of CBCTs had differences in registration <0.5cm for EMT centroid compared to spine, indicating that lung inflation is not reproducible from simulation to treatment. The average differences between EMT centroid and tumor registration among all CBCTs were 0.13±0.13cm, 0.14±0.13cm and 0.12±0.12cm in SI, AP and lateral directions, respectively. 95% of CBCTs resulted in <0.5cm change between EMT centroid and tumor registration, indicating that EMT positions correspond well with tumor position during treatments. Six out of the 7 recorded CF patients had average differences in inter-EMT displacements to be ≤0.26cm and average GR ≤0.22cm, indicating that the EMTs are stable throughout treatment. CONCLUSIONS Bronchoscopically implanted anchored EMTs are good surrogates for tumor position and are reliable for maintaining tumor position when tracked during DIBH treatment, as long as the tumor size and shape are stable. Large differences in registration between EMTs and spine for many treatments suggest that lung inflation achieved at simulation is often not reproduced. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Wendy Harris
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Henry Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Christian Czmielewski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Mohit Chawla
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Robert P Lee
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Alexandra Hotca-Cho
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Dominique McKnight
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065
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Mah D, Yorke E, Zemanaj E, Han Z, Liu H, George J, Lambiase J, Czmielewski C, Lovelock DM, Rimner A, Shepherd AF. A Planning Comparison of IMRT vs. Pencil Beam Scanning for Deep Inspiration Breath Hold Lung Cancers. Med Dosim 2021; 47:26-31. [PMID: 34426041 DOI: 10.1016/j.meddos.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
Deep inspiration breath hold (DIBH) has dosimetric advantages for lung cancer patients treated with external beam therapy, but is difficult for many patients to perform. Proton therapy permits sparing of the downstream organs at risk (OAR). We compared conventionally fractionated proton (p) and photon(x) plans on both free breathing (FB) and DIBH planning CTs to determine the effect of DIBH with proton therapy. We evaluated 24 plans from 6 lung cancer patients treated with photon DIBH on a prospective protocol. All patients were re-planned using pencil beam scanning (PBS) proton therapy. New plans were generated for FB datasets with both modalities. All plans were renormalized to 60 Gy. We evaluated dosimetric parameters for heart, lung and esophagus. We also compared FBp to DIBHx parameters to quantify how FBp plans compare to DIBHx plans. Significant differences were found for lung metrics V20 and mean lung dose between FB and DIBH plans regardless of treatment modality. Furthermore, lung metrics for FBp were comparable or superior to DIBHx, suggesting that FB protons may be a viable alternative for those patients that cannot perform DIBH with IMRT. The heart dose metrics were significantly different for the 5 out of 6 patients where the PTV overlapped the heart as DIBH moved heart out of the high dose volume. Heart dose metrics were further reduced by proton therapy. DIBH offers similar relative advantages for lung sparing for PBS as it does for IMRT but the magnitude of the DIBH related gains in OAR sparing were smaller for PBS than IMRT. FBp plans offer similar or better lung and heart sparing compared to DIBHx plans. For IMRT patients who have difficulty performing DIBH, FB protons may offer an alternative.
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Affiliation(s)
- Dennis Mah
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Entela Zemanaj
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Zhiqiang Han
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Haoyang Liu
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jobin George
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jason Lambiase
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Christian Czmielewski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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8
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Hardcastle N, Briggs A, Caillet V, Angelis G, Chrystall D, Jayamanne D, Shepherd M, Harris B, Haddad C, Eade T, Keall P, Booth J. Quantification of the geometric uncertainty when using implanted markers as a surrogate for lung tumor motion. Med Phys 2021; 48:2724-2732. [PMID: 33626183 DOI: 10.1002/mp.14788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/26/2020] [Accepted: 01/19/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Fiducial markers are used as surrogates for tumor location during radiation therapy treatment. Developments in lung fiducial marker and implantation technology have provided a means to insert markers endobronchially for tracking of lung tumors. This study quantifies the surrogacy uncertainty (SU) when using endobronchially implanted markers as a surrogate for lung tumor position. METHODS We evaluated SU for 17 patients treated in a prospective electromagnetic-guided MLC tracking trial. Tumor and markers were segmented on all phases of treatment planning 4DCTs and all frames of pretreatment kilovoltage fluoroscopy acquired from lateral and frontal views. The difference in tumor and marker position relative to end-exhale position was calculated as the SU for both imaging methods and the distributions of uncertainties analyzed. RESULTS The mean (range) tumor motion amplitude in the 4DCT scan was 5.9 mm (1.7-11.7 mm) in the superior-inferior (SI) direction, 2.2 mm (0.9-5.5 mm) in the left-right (LR) direction, and 3.9 mm (1.2-12.9 mm) in the anterior-posterior (AP) direction. Population-based analysis indicated symmetric SU centered close to 0 mm, with maximum 5th/95th percentile values over all axes of -2.0 mm/2.1 mm with 4DCT, and -2.3/1.3 mm for fluoroscopy. There was poor correlation between the SU measured with 4DCT and that measured with fluoroscopy on a per-patient basis. We observed increasing SU with increasing surrogate motion. Based on fluoroscopy analysis, the mean (95% CI) SU was 5% (2%-8%) of the motion magnitude in the SI direction, 16% (6%-26%) of the motion magnitude in the LR direction, and 33% (23%-42%) of the motion magnitude in the AP direction. There was no dependence of SU on marker distance from the tumor. CONCLUSION We have quantified SU due to use of implanted markers as surrogates for lung tumor motion. Population 95th percentile range are up to 2.3 mm, indicating the approximate contribution of SU to total geometric uncertainty. SU was relatively small compared with the SI motion, but substantial compared with LR and AP motion. Due to uncertainty in estimations of patient-specific SU, it is recommended that population-based margins are used to account for this component of the total geometric uncertainty.
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Affiliation(s)
- Nicholas Hardcastle
- Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Adam Briggs
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia
| | - Vincent Caillet
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia.,ACRF Image X Institute, School of Medicine, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Giorgios Angelis
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia.,School of Physics, University of Sydney, Camperdown, NSW, 2042, Australia
| | - Danielle Chrystall
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia
| | - Dasantha Jayamanne
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia.,School of Medicine, University of Sydney, Camperdown, NSW, 2042, Australia
| | - Meegan Shepherd
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia
| | - Ben Harris
- School of Medicine, University of Sydney, Camperdown, NSW, 2042, Australia.,Dept Respiratory and Sleep Medicine, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Carol Haddad
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia
| | - Thomas Eade
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia.,School of Medicine, University of Sydney, Camperdown, NSW, 2042, Australia
| | - Paul Keall
- ACRF Image X Institute, School of Medicine, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Rd St Leonards, NSW, 2065, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Camperdown, NSW, 2042, Australia
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