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Lambri N, Longari G, Loiacono D, Brioso RC, Crespi L, Galdieri C, Lobefalo F, Reggiori G, Rusconi R, Tomatis S, Bellu L, Bramanti S, Clerici E, De Philippis C, Dei D, Navarria P, Carlo-Stella C, Franzese C, Scorsetti M, Mancosu P. Deep learning-based optimization of field geometry for total marrow irradiation delivered with volumetric modulated arc therapy. Med Phys 2024; 51:4402-4412. [PMID: 38634859 DOI: 10.1002/mp.17089] [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: 11/29/2023] [Revised: 03/20/2024] [Accepted: 04/05/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Total marrow (lymphoid) irradiation (TMI/TMLI) is a radiotherapy treatment used to selectively target the bone marrow and lymph nodes in conditioning regimens for allogeneic hematopoietic stem cell transplantation. A complex field geometry is needed to cover the large planning target volume (PTV) of TMI/TMLI with volumetric modulated arc therapy (VMAT). Five isocenters and ten overlapping fields are needed for the upper body, while, for patients with large anatomical conformation, two specific isocenters are placed on the arms. The creation of a field geometry is clinically challenging and is performed by a medical physicist (MP) specialized in TMI/TMLI. PURPOSE To develop convolutional neural networks (CNNs) for automatically generating the field geometry of TMI/TMLI. METHODS The dataset comprised 117 patients treated with TMI/TMLI between 2011 and 2023 at our Institute. The CNN input image consisted of three channels, obtained by projecting along the sagittal plane: (1) average CT pixel intensity within the PTV; (2) PTV mask; (3) brain, lungs, liver, bowel, and bladder masks. This "averaged" frontal view combined the information analyzed by the MP when setting the field geometry in the treatment planning system (TPS). Two CNNs were trained to predict the isocenters coordinates and jaws apertures for patients with (CNN-1) and without (CNN-2) isocenters on the arms. Local optimization methods were used to refine the models output based on the anatomy of the patient. Model evaluation was performed on a test set of 15 patients in two ways: (1) by computing the root mean squared error (RMSE) between the CNN output and ground truth; (2) with a qualitative assessment of manual and generated field geometries-scale: 1 = not adequate, 4 = adequate-carried out in blind mode by three MPs with different expertise in TMI/TMLI. The Wilcoxon signed-rank test was used to evaluate the independence of the given scores between manual and generated configurations (p < 0.05 significant). RESULTS The average and standard deviation values of RMSE for CNN-1 and CNN-2 before/after local optimization were 15 ± 2/13 ± 3 mm and 16 ± 2/18 ± 4 mm, respectively. The CNNs were integrated into a planning automation software for TMI/TMLI such that the MPs could analyze in detail the proposed field geometries directly in the TPS. The selection of the CNN model to create the field geometry was based on the PTV width to approximate the decision process of an experienced MP and provide a single option of field configuration. We found no significant differences between the manual and generated field geometries for any MP, with median values of 4 versus 4 (p = 0.92), 3 versus 3 (p = 0.78), 4 versus 3 (p = 0.48), respectively. Starting from October 2023, the generated field geometry has been introduced in our clinical practice for prospective patients. CONCLUSIONS The generated field geometries were clinically acceptable and adequate, even for an MP with high level of expertise in TMI/TMLI. Incorporating the knowledge of the MPs into the development cycle was crucial for optimizing the models, especially in this scenario with limited data.
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Affiliation(s)
- Nicola Lambri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giorgio Longari
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Daniele Loiacono
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Ricardo Coimbra Brioso
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Leonardo Crespi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
- Health Data Science Centre, Human Technopole, Milan, Italy
| | - Carmela Galdieri
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Roberto Rusconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luisa Bellu
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefania Bramanti
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Chiara De Philippis
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Damiano Dei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carmelo Carlo-Stella
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ciro Franzese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Seravalli E, Bosman ME, Han C, Losert C, Pazos M, Engström PE, Engellau J, Fulcheri CPL, Zucchetti C, Saldi S, Ferrer C, Ocanto A, Hiniker SM, Clark CH, Hussein M, Misson-Yates S, Kobyzeva DA, Loginova AA, Hoeben BAW. Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation. Radiother Oncol 2024; 197:110366. [PMID: 38830537 DOI: 10.1016/j.radonc.2024.110366] [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: 01/25/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mirjam E Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Per E Engström
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jacob Engellau
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Claudio Zucchetti
- Section of Medical Physics, Perugia General Hospital, Perugia, Italy
| | - Simonetta Saldi
- Section of Radiation Oncology, Perugia General Hospital, Perugia, Italy
| | - Carlos Ferrer
- Department of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Abrahams Ocanto
- Department of Radiation Oncology, San Francisco de Asís University Hospital, GenesisCare, Madrid, Spain
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Catharine H Clark
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK; Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Medical Physics and Bioengineering Department, University College London, London, UK
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Sarah Misson-Yates
- Medical Physics Department, Guy's and St Thomas' Hospital, London, UK; UK School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK; National Physical Laboratory, Metrology for Medical Physics Centre, London, UK
| | - Daria A Kobyzeva
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
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Simiele E, Romero IO, Wang JY, Chen Y, Lozko Y, Severyn Y, Skinner L, Yang Y, Xing L, Gibbs I, Hiniker SM, Kovalchuk N. Automated contouring, treatment planning, and quality assurance for VMAT craniospinal irradiation (VMAT-CSI). Front Oncol 2024; 14:1378449. [PMID: 38660134 PMCID: PMC11039907 DOI: 10.3389/fonc.2024.1378449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Purpose Create a comprehensive automated solution for pediatric and adult VMAT-CSI including contouring, planning, and plan check to reduce planning time and improve plan quality. Methods Seventy-seven previously treated CSI patients (age, 2-67 years) were used for creation of an auto-contouring model to segment 25 organs at risk (OARs). The auto-contoured OARs were evaluated using the Dice Similarity Coefficient (DSC), 95% Hausdorff Distance (HD95), and a qualitative ranking by one physician and one physicist (scale: 1-acceptable, 2-minor edits, 3-major edits). The auto-planning script was developed using the Varian Eclipse Scripting API and tested with 20 patients previously treated with either low-dose VMAT-CSI (12 Gy) or high-dose VMAT-CSI (36 Gy + 18 Gy boost). Clinically relevant metrics, planning time, and blinded physician review were used to evaluate significance of differences between the auto and manual plans. Finally, the plan preparation for treatment and plan check processes were automated to improve efficiency and safety of VMAT-CSI. Results The auto-contours achieved an average DSC of 0.71 ± 0.15, HD95 of 4.81 ± 4.68, and reviewers' ranking of 1.22 ± 0.39, indicating close to "acceptable-as-is" contours. Compared to the manual CSI plans, the auto-plans for both dose regimens achieved statistically significant reductions in body V50% and Dmean for parotids, submandibular, and thyroid glands. The variance in the dosimetric parameters decreased for the auto-plans as compared to the manual plans indicating better plan consistency. From the blinded review, the auto-plans were marked as equivalent or superior to the manual-plans 88.3% of the time. The required time for the auto-contouring and planning was consistently between 1-2 hours compared to an estimated 5-6 hours for manual contouring and planning. Conclusions Reductions in contouring and planning time without sacrificing plan quality were obtained using the developed auto-planning process. The auto-planning scripts and documentation will be made freely available to other institutions and clinics.
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Liang X, Li P, Wu Q. A novel AP/PA total body irradiation technique using abutting IMRT fields at extended SSD. J Appl Clin Med Phys 2024; 25:e14213. [PMID: 38425126 PMCID: PMC11005982 DOI: 10.1002/acm2.14213] [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: 06/22/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE To develop a Total Body Irradiation (TBI) technique using IMRT at extended SSD that can be performed in any size Linac room. METHODS Patients studied were placed on a platform close to the floor, directly under the gantry with cranial-caudal axis parallel to the gantry rotation plane and at SSD ∼200 cm. Two abutting fields with the same external isocenter at gantry angles of ±21˚, collimator angle of 90˚, and field size of 25 × 40 cm2 are employed for both supine and prone positions. An iterative optimization algorithm was developed to generate a uniform dose at the patient mid-plane with adequate shielding to critical organs such as lungs and kidneys. The technique was validated in both phantom and patient CT images for treatment planning, and dose measurement and QA were performed in phantom. RESULTS A uniform dose distribution in the mid-plane within ±5% of the prescription dose was reached after a few iterations. This was confirmed with ion-chamber measurements in phantom. The mean dose to lungs and kidneys can be adjusted according to clinical requirements and can be as low as ∼25% of the prescription dose. For a typical prescription dose of 200 cGy/fraction, the total MU was ∼2400/1200 for the superior/inferior field. The overall treatment time for both supine/prone positions was ∼54 min to meet the maximum absorbed dose rate criteria of 15 cGy/min. IMRT QA with portal dosimetry shows excellent agreement. CONCLUSIONS We have developed a promising TBI technique using abutting IMRT fields at extended SSD. The patient is in a comfortable recumbent position with good reproducibility and less motion during treatment. An additional benefit of this technique is that full 3D dose distribution is available from the TPS with a DVH summary for organs of interest. The technique allows precise sparing of lungs and kidneys and can be executed in any linac room.
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Affiliation(s)
- Xiaomin Liang
- Medical Physics Graduate ProgramDuke Kunshan UniversityKunshanJiangsuChina
| | - Peixiong Li
- Medical Physics Graduate ProgramDuke Kunshan UniversityKunshanJiangsuChina
| | - Qiuwen Wu
- Department of Radiation OncologyDuke University Medical CenterDurhamNorth CarolinaUSA
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Melton MK, Stanley DN, Iqbal Z, Keene KS, Simiele E, McDonald A. Acute Toxicity of Total Body Irradiation Using Volumetric Arc Therapy With a Focus on the Effect of Lung Dose Rate. Adv Radiat Oncol 2024; 9:101430. [PMID: 38406392 PMCID: PMC10882112 DOI: 10.1016/j.adro.2023.101430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/27/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose To report adverse effects of high dose total body irradiation (TBI) delivered using a volumetric arc therapy (VMAT) technique and to assess pulmonary toxicity at dose rates of 40 and 100 monitor units per minute (MU/min). Methods and Materials This retrospective study included patients >18 years old who received ≥8 Gy TBI using a VMAT technique. The TBI dose was prescribed to a planning target volume consisting of a 0.5 cm retraction of the body with the lungs subtracted. The objective function specified planning target volume coverage goals of D100% ≥ 90% and Dmax <130%. A lung dose control structure consisting of a 1 cm retraction of the lung volume was limited to Dmean <75%. Treatments were initially delivered with a dose rate of 40 MU/min for the thoracic isocenters and 100 MU/min for the other isocenters. Beginning in January 2021, a dose rate of 100 MU/min was used for all isocenters. All treatments were administered in 2 Gy fractions delivered twice daily. Acute toxicity was assessed for 30 days after TBI. Results A total of 29 patients were included in this analysis who received TBI between January 2019 and October 2021. Prescription dose ranged from 8 to 12 Gy. Mean lung dose was 7.9 Gy (SD, 1.4 Gy) for patients treated at 40 MU/min and for patients treated at 100 MU/min 7.1 Gy (SD, 1.3 Gy). Mucositis was the most common grade 3 toxicity and occurred in 10 (34%) patients. Only 1 instance of pneumonitis was observed and occurred in a patient who received a mean lung dose of 10.1 Gy delivered at 40 MU/min. Conclusions In this cohort of patients who received high dose TBI using a VMAT technique, the composite rate of acute toxicity was not unexpectedly high. We did not observe an increase in lung toxicity after increasing the dose rate of the thoracic isocenters from 40 MU/min to 100 MU/min.
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Affiliation(s)
- Michael Kole Melton
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Dennis N. Stanley
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Zohaib Iqbal
- Department of Radiation Oncology, The University of Texas Southwestern, Dallas, Texas
| | - Kimberly S. Keene
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Eric Simiele
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew McDonald
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
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Romero IO, Simiele EA, Lozko Y, Severyn Y, Skinner LB, Yang Y, Wang JY, Xing L, Gibbs I, Hiniker SM, Kovalchuk N. Automating the Treatment Planning Process for Volumetric Modulated Arc Therapy Craniospinal Irradiation. Pract Radiat Oncol 2024; 14:e165-e172. [PMID: 38048988 DOI: 10.1016/j.prro.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
PURPOSE The purpose of this work is to develop a method to automate the treatment planning process of craniospinal irradiation (CSI) using volumetric modulated arc therapy. METHODS AND MATERIALS Two scripts were developed using the Eclipse Scripting Application Programming Interface to perform auto-plan preparation and optimization. Ten patients (age, 5-44 years) previously treated at our institution with low dose volumetric modulated arc therapy CSI (prescription of 12 Gy) before total body irradiation were selected to evaluate the efficacy of the proposed auto-planning process. Paired t tests compared the dosimetric indices of the auto-plans to the manually generated clinical plans. All plans were normalized to 95% of planning target volume (PTV) coverage with the prescription dose. Two physicians and one physicist were asked to evaluate the manual plans and auto-plans of each patient in a blinded retrospective review and to indicate clinical acceptability and which plans were preferred for treatment. RESULTS Compared with the manual CSI plans, the auto plans obtained significant reductions in Dmean to the parotids, submandibular glands, larynx, thyroid, and significant reduction in the plan PTV Dmax and D0.03 cc. The standard deviation range of the dosimetric parameters was greatly reduced for auto plans (range, 0.1-1.3 Gy) relative to manual plans (range, 0.4-5.9 Gy) indicating better plan consistency. Among the 10 patients, the auto-plans were preferred over the manual plans 90% of the time by the reviewing experts. The required time for auto-planning was approximately 1 hour compared with estimated 4 or more hours for manual planning. CONCLUSIONS Reductions in planning time without sacrifices in plan quality were obtained using the auto-planning process compared with manual planning. Variation in plan quality was also reduced. The auto-planning scripts will be made freely available to other institutions and clinics.
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Affiliation(s)
- Ignacio O Romero
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Eric A Simiele
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Yuliia Lozko
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Yuliia Severyn
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lawrie B Skinner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Yong Yang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jen-Yeu Wang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lei Xing
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Iris Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California.
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Ngo N, Blomain ES, Simiele E, Romero I, Hoppe RT, Hiniker SM, Kovalchuk N. Improved organ sparing using auto-planned Stanford volumetric modulated arc therapy for total body irradiation technique. Pediatr Blood Cancer 2023; 70:e30589. [PMID: 37486149 DOI: 10.1002/pbc.30589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE/OBJECTIVES To evaluate dosimetric differences between auto-planned volumetric modulated arc therapy (VMAT) total body irradiation (TBI) technique and two-dimensional radiotherapy using anterior-posterial/posterio-anterial beams (2D AP/PA) TBI technique. METHODS Ten pediatric patients treated with VMAT-TBI on Varian c-arm linac were included in this study. VMAT-TBI plans were generated using our in-house developed and publicly shared auto-planning scripts. For each VMAT-TBI plan, a 2D AP/PA plan was created replicating the institution's clinical setup with the patient positioned at extended source to skin distance (SSD) with a compensator to account for differences in patient thickness, 50% transmission daily lung blocks, and electron chest wall boosts prescribed to 50% of the photon prescription. Clinically relevant metrics were analyzed and compared between the VMAT and 2D plans. RESULTS All VMAT-TBI plans achieved planned target volume (PTV) D90% ≥ 100% of prescription. VMAT-TBI PTV D90% significantly increased (7.1% ± 2.9%, p < .001) compared to the 2D technique, whereas no differences were observed in global Dmax (p < .2) and PTV V110% (p < .4). Compared to the 2D plans, significant decreases in the Dmean to the lungs (-25.6% ± 11.5%, p < .001) and lungs-1 cm (-34.1% ± 10.1%, p < .001) were observed with the VMAT plans. The VMAT technique also enabled decrease of dose to other organs: kidneys Dmean (-32.5% ± 5.0%, p < .001) and lenses Dmax (-5.3% ± 8.1%, p = .03); and in addition, for 2 Gy prescription: testes/ovaries Dmean (-41.5% ± 11.5%, p < .001), brain Dmean (-22.6% ± 5.4%, p = .002), and thyroid Dmean (-18.2% ± 16.0%, p = .03). CONCLUSIONS Superior lung sparing with improved target coverage and similar global Dmax were observed with the VMAT plans as compared to 2D plans. In addition, VMAT-TBI plans provided greater dose reductions in gonads, kidneys, brain, thyroid, and lenses.
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Affiliation(s)
- Nicholas Ngo
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Erik S Blomain
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Eric Simiele
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Ignacio Romero
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Richard T Hoppe
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Susan M Hiniker
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
| | - Nataliya Kovalchuk
- Radiation Oncology Department, Stanford University Cancer Center, Palo Alto, California, USA
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Godson HF, Raj JS, Sebastian P, Ponmalar RY, Babu ES, Paul I, Krishna R, Backianathan S, George B, Ravindran PB, Balakrishnan R. Feasibility study of total marrow lymphoid irradiation with volumetric modulated arc therapy: clinical implementation in a tertiary care center. Strahlenther Onkol 2023; 199:922-935. [PMID: 37278833 DOI: 10.1007/s00066-023-02100-x] [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: 11/24/2022] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Total marrow lymphoid irradiation (TMLI) with volumetric modulated arc therapy (VMAT) is challenging due to large treatment fields with multiple isocenters, field matching at junctions, and targets being surrounded by many organs at risk. This study aimed to describe our methodology for safe dose escalation and accurate dose delivery of TMLI treatment with the VMAT technique based on early experience at our center. MATERIALS AND METHODS Computed tomography (CT) scans were acquired in head-first supine and feet-first supine orientations for each patient with an overlap at mid-thigh. VMAT plans were generated for 20 patients on the head-first CT images with either three or four isocenters in the Eclipse treatment planning system (Varian Medical Systems Inc., Palo Alto, CA) and the treatment was delivered in a Clinac 2100 C/D linear accelerator (Varian Medical Systems Inc., Palo Alto, CA). RESULTS Five patients were treated with a prescription dose of 13.5 Gy in 9 fractions and 15 patients were treated with an escalated dose of 15 Gy in 10 fractions. The mean doses to 95% of the clinical target volume (CTV) and planning target volume (PTV) were 14.3 ± 0.3 Gy and 13.6 ± 0.7 Gy for the prescription doses of 15 Gy, and 13 ± 0.2 Gy and 12.3 ± 0.3 Gy for the prescription doses of 13.5 Gy, respectively. Mean dose to the lung in both schedules was 8.7 ± 0.6 Gy. The overall time taken to execute the treatment plans was approximately 2 h for the first fraction and 1.5 h for subsequent fractions. The average in-room time of 15.5 h per patient over 5 days leads to potential changes in the regular treatment schedules for other patients. CONCLUSION This feasibility study highlights the methodology adopted for safe implementation of TMLI with the VMAT technique at our institution. Escalation of dose to the target with adequate coverage and sparing of critical structures was achieved with the adopted treatment technique. Clinical implementation of this methodology at our center could serve as a practical guide to start the VMAT-based TMLI program safely by others who are keen to start this service.
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Affiliation(s)
- Henry Finlay Godson
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Jose Solomon Raj
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Patricia Sebastian
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Retna Y Ponmalar
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Ebenezer Suman Babu
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Ivin Paul
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Raj Krishna
- Department of Radiation Oncology, Amala Institute of Medical Sciences, Trissur, Kerala, India
| | - Selvamani Backianathan
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Paul B Ravindran
- Department of Radiation Oncology, Christian Institute of Health Sciences and Research, Dimapur, Nagaland, India
| | - Rajesh Balakrishnan
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India.
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9
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Frederick R, Van Dyke L, Hudson A, Pierce G. Advanced automated treatment planning for total body irradiation: Implementation and effects on standardization. Phys Med 2023; 112:102623. [PMID: 37356420 DOI: 10.1016/j.ejmp.2023.102623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/29/2023] [Accepted: 06/11/2023] [Indexed: 06/27/2023] Open
Abstract
PURPOSE This work describes the automation of our volumetric modulated arc therapy (VMAT) total body irradiation (TBI) treatment planning. It also aims to determine if plan standardization is impacted by automation. METHODS We introduced automated beam placement for TBI in March 2021. For manual beam placement pre-2021, Python-modified DICOM files were imported to pre-set cumulative meterset weights, with other parameters selected by dosimetrists. Our automated planning script automates these processes and sets gantry stop angles and isocentre placement. To determine the impact of automation on plan standardization, we performed a retrospective review of a matched cohort of 168 patients. Plan parameters were compared with an external standard, and passing rates compared between patient cohorts. The dosimetric impact was investigated by comparing a Body-5 mm homogeneity index (HI = D2%/D98%) and mean lung dose (MLD) between cohorts. RESULTS Results are listed for manual and automated groups respectively. Median (range) passing rates were 97.7% (96.1-100) and 99.2% (98.3-100). Automated plans had a significantly higher passing rate (p ≪ 0.05) and smaller variance (p = 0.001). Most failures were attributed to human error. Automated plans also had more consistent parameter identifiers. After considering dimensional outliers, median (range) Body-5 mm HI were 1.18 (1.14-1.23) and 1.18 (1.15-1.26), and mean ± standard deviation MLD were 103.8 ± 1.3% and 104.1 ± 0.9%. Variances were not significantly different between Body-5 mm HI (p = 0.092) but were for MLD (p = 0.013). CONCLUSIONS Implementation of automated planning in TBI resulted in significantly improved plan standardization. The decrease in variance of the MLD for the automated planning group points towards a potential dosimetric benefit of automation.
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Affiliation(s)
- Rebecca Frederick
- Department of Medical Physics, Tom Baker Cancer Centre, 1331 29 Street NW, Calgary, Alberta T2N 4N2, Canada; Department of Physics and Astronomy, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada.
| | - Lukas Van Dyke
- Department of Medical Physics, Tom Baker Cancer Centre, 1331 29 Street NW, Calgary, Alberta T2N 4N2, Canada
| | - Alana Hudson
- Department of Medical Physics, Tom Baker Cancer Centre, 1331 29 Street NW, Calgary, Alberta T2N 4N2, Canada; Department of Oncology, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - Greg Pierce
- Department of Physics and Astronomy, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada; Department of Oncology, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada; Varian Medical Systems, Inc., 3100 Hansen Way, Palo Alto, CA 94304, United States
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10
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Court L, Aggarwal A, Burger H, Cardenas C, Chung C, Douglas R, du Toit M, Jaffray D, Jhingran A, Mejia M, Mumme R, Muya S, Naidoo K, Ndumbalo J, Nealon K, Netherton T, Nguyen C, Olanrewaju N, Parkes J, Shaw W, Trauernicht C, Xu M, Yang J, Zhang L, Simonds H, Beadle BM. Addressing the Global Expertise Gap in Radiation Oncology: The Radiation Planning Assistant. JCO Glob Oncol 2023; 9:e2200431. [PMID: 37471671 PMCID: PMC10581646 DOI: 10.1200/go.22.00431] [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: 12/18/2022] [Revised: 02/08/2023] [Accepted: 04/24/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Automation, including the use of artificial intelligence, has been identified as a possible opportunity to help reduce the gap in access and quality for radiotherapy and other aspects of cancer care. The Radiation Planning Assistant (RPA) project was conceived in 2015 (and funded in 2016) to use automated contouring and treatment planning algorithms to support the efforts of oncologists in low- and middle-income countries, allowing them to scale their efforts and treat more patients safely and efficiently (to increase access). DESIGN In this review, we discuss the development of the RPA, with a particular focus on clinical acceptability and safety/risk across jurisdictions as these are important indicators for the successful future deployment of the RPA to increase radiotherapy availability and ameliorate global disparities in access to radiation oncology. RESULTS RPA tools will be offered through a webpage, where users can upload computed tomography data sets and download automatically generated contours and treatment plans. All interfaces have been designed to maximize ease of use and minimize risk. The current version of the RPA includes automated contouring and planning for head and neck cancer, cervical cancer, breast cancer, and metastases to the brain. CONCLUSION The RPA has been designed to bring high-quality treatment planning to more patients across the world, and it may encourage greater investment in treatment devices and other aspects of cancer treatment.
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Affiliation(s)
- Laurence Court
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ajay Aggarwal
- Guy's and St Thomas' Hospital, London, United Kingdom
| | - Hester Burger
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Christine Chung
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Raphael Douglas
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monique du Toit
- Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - David Jaffray
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anuja Jhingran
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Mejia
- Benavides Cancer Institute, University of Santo Tomas, Manila, Philippines
| | - Raymond Mumme
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Komeela Naidoo
- Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | | | - Kelly Nealon
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Niki Olanrewaju
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeannette Parkes
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Willie Shaw
- University of the Free State, Bloemfontein, South Africa
| | | | - Melody Xu
- University of California San Francisco, San Francisco, CA
| | - Jinzhong Yang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lifei Zhang
- The University of Texas MD Anderson Cancer Center, Houston, TX
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11
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Hao C, Ladbury C, Wong J, Dandapani S. Modern Radiation for Hematologic Stem Cell Transplantation: Total Marrow and Lymphoid Irradiation or Intensity-Modulated Radiation Therapy Total Body Irradiation. Surg Oncol Clin N Am 2023; 32:475-495. [PMID: 37182988 DOI: 10.1016/j.soc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The development of large-field intensity-modulated radiation therapy (IMRT) has enabled the implementation of total marrow irradiation (TMI), total marrow and lymphoid irradiation (TMLI), and IMRT total body irradiation (TBI). IMRT TBI limits doses to organs at risk, primarily the lungs and in some cases the kidneys and lenses, which may mitigate complications. TMI/TMLI allows for dose escalation above TBI radiation therapy doses to malignant sites while still sparing organs at risk. Although still sparingly used, these techniques have established feasibility and demonstrated promise in reducing the adverse effects of TBI while maintaining and potentially improving survival outcomes.
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Affiliation(s)
- Claire Hao
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA.
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12
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Lambri N, Dei D, Hernandez V, Castiglioni I, Clerici E, Crespi L, De Philippis C, Loiacono D, Navarria P, Reggiori G, Rusconi R, Tomatis S, Bramanti S, Scorsetti M, Mancosu P. Automatic planning of the lower extremities for total marrow irradiation using volumetric modulated arc therapy. Strahlenther Onkol 2023; 199:412-419. [PMID: 36326856 PMCID: PMC10033624 DOI: 10.1007/s00066-022-02014-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/25/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Total marrow (and lymphoid) irradiation (TMI-TMLI) is limited by the couch travel range of modern linacs, which forces the treatment delivery to be split into two plans with opposite orientations: a head-first supine upper-body plan, and a feet-first supine lower extremities plan. A specific field junction is thus needed to obtain adequate target coverage in the overlap region of the two plans. In this study, an automatic procedure was developed for field junction creation and lower extremities plan optimization. METHODS Ten patients treated with TMI-TMLI at our institution were selected retrospectively. The planning of the lower extremities was performed automatically. Target volume parameters (CTV_J‑V98% > 98%) at the junction region and several dose statistics (D98%, Dmean, and D2%) were compared between automatic and manual plans. The modulation complexity score (MCS) was used to assess plan complexity. RESULTS The automatic procedure required 60-90 min, depending on the case. All automatic plans achieved clinically acceptable dosimetric results (CTV_J‑V98% > 98%), with significant differences found at the junction region, where Dmean and D2% increased on average by 2.4% (p < 0.03) and 3.0% (p < 0.02), respectively. Similar plan complexity was observed (median MCS = 0.12). Since March 2022, the automatic procedure has been introduced in our clinic, reducing the TMI-TMLI simulation-to-delivery schedule by 2 days. CONCLUSION The developed procedure allowed treatment planning of TMI-TMLI to be streamlined, increasing efficiency and standardization, preventing human errors, while maintaining the dosimetric plan quality and complexity of manual plans. Automated strategies can simplify the future adoption and clinical implementation of TMI-TMLI treatments in new centers.
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Affiliation(s)
- Nicola Lambri
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Damiano Dei
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Victor Hernandez
- Department of Medical Physics, Hospital Universitari Sant Joan de Reus, IISPV, Tarragona, Spain
| | - Isabella Castiglioni
- Department of Physics "G. Occhialini", University of Milan-Bicocca, piazza della Scienza 2, 20126, Milano, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Leonardo Crespi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
- Human Techopole, Centre for Health Data Science, Milan, Italy
| | - Chiara De Philippis
- Bone Marrow Transplantation Unit, IRCCS Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Daniele Loiacono
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Giacomo Reggiori
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Roberto Rusconi
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Stefania Bramanti
- Bone Marrow Transplantation Unit, IRCCS Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy.
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13
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Marquez C, Hui C, Simiele E, Blomain E, Oh J, Bertaina A, Klein O, Shyr D, Jiang A, Hoppe RT, Kovalchuk N, Hiniker SM. Volumetric modulated arc therapy total body irradiation in pediatric and adolescent/young adult patients undergoing stem cell transplantation: Early outcomes and toxicities. Pediatr Blood Cancer 2022; 69:e29689. [PMID: 35373904 DOI: 10.1002/pbc.29689] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/16/2022] [Accepted: 03/10/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Total body irradiation (TBI) is an important component of many conditioning regimens for hematopoietic stem cell transplantation (HSCT), most commonly used in pediatric and adolescent/young adult (AYA) patients. We aimed to evaluate outcomes and toxicities among pediatric and AYA patients treated with TBI utilizing volumetric modulated arc therapy total body irradiation (VMAT-TBI). METHODS We reviewed pediatric and AYA patients treated with VMAT-TBI at our institution from 2019 to 2021. Data on patient and disease characteristics, treatment details, outcomes and toxicities were collected. Overall survival (OS) and relapse-free survival (RFS) were analyzed using the Kaplan-Meier method. RESULTS Among 38 patients, 16 (42.1%) were treated with myeloablative regimens and 22 (57.9%) with nonmyeloablative regimens. Median age was 7.2 years (range: 1-27) and median follow-up was 8.7 months (range: 1-21). Lungs Dmean was 7.3 ± 0.3 Gy for myeloablative regimens (range: 6.8-7.8). Kidneys were spared to average mean dose of 71.4 ± 4.8% of prescription dose. Gonadal sparing was achieved for patients treated for nonmalignant diseases to Dmean of 0.7 ± 0.1 Gy. No patient experienced primary graft failure; one (2.6%) experienced secondary graft failure. The most common grade 1-2 acute toxicities were nausea (68.4%) and fatigue (55.3%). Mucositis was the most common grade 3-4 acute toxicity, affecting 39.5% of patients. There were no cases of pneumonitis or nephrotoxicity attributable to TBI. CONCLUSION VMAT-TBI offers increased ability to spare organs at risk in pediatric and AYA patients undergoing HSCT, with a favorable acute/subacute toxicity profile and excellent disease control.
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Affiliation(s)
- Cesar Marquez
- Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | - Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Eric Simiele
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Erik Blomain
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Justin Oh
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Orly Klein
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford, California, USA
| | - David Shyr
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Alice Jiang
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
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14
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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15
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Kovalchuk N, Simiele E, Skinner L, Yang Y, Howell N, Lewis J, Hui C, Blomain ES, Hoppe RT, Hiniker SM. The Stanford VMAT TBI Technique. Pract Radiat Oncol 2022; 12:245-258. [PMID: 35182803 DOI: 10.1016/j.prro.2021.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE In this work, we describe the technical aspects of the XXX VMAT TBI technique, compare it to other VMAT TBI techniques, and share our initial experience. METHODS From September 2019 to August 2021, 35 patients were treated with VMAT TBI at our institution. Treatment planning was performed using in-house developed automated planning scripts. Organ sparing depended on the regimen: myeloablative (lungs, kidneys, and lenses); non-myeloablative with benign disease (lungs, kidneys, lenses, gonads, brain, and thyroid). Quality assurance was performed using EPID portal dosimetry and Mobius3D. Robustness was evaluated for the first ten patients by performing local and global isocenter shifts of 5 mm. Treatment was delivered using IGRT for every isocenter and every fraction. In-vivo measurements were performed on the matchline between the VMAT and AP/PA fields and on the testes for the first fraction. RESULTS The lungs, lungs-1cm, and kidneys Dmean were consistently spared to 57.6±4.4%, 40.7±5.5%, and 70.0±9.9% of the prescription dose, respectively. Gonadal sparing (Dmean=0.69±0.13 Gy) was performed for all patients with benign disease. The average PTV D1cc was 120.7±6.4% for all patients. The average Gamma passing rate for the VMAT plans was 98.1±1.6% (criteria of 3%/2mm). Minimal differences were observed between Mobius3D- and EclipseAAA-calculated PTV Dmean (0.0±0.3%) and lungs Dmean (-2.5±1.2%). Robustness evaluation showed that the PTV Dmax and lungs Dmean are insensitive to small positioning deviations between the VMAT isocenters (1.1±2.4% and 1.2±1.0%, respectively). The average matchline dose measurement indicated patient setup was reproducible (96.1±4.5% relative to prescription dose). Treatment time, including patient setup and beam-on, was 47.5±9.5 min. CONCLUSIONS The XXX VMAT TBI technique, from simulation to treatment delivery, was presented and compared to other VMAT TBI techniques. Together with publicly shared autoplanning scripts, our technique may provide the gateway for wider adaptation of this technology and the possibility of multi-institutional studies in the cooperative group setting.
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Affiliation(s)
- Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Eric Simiele
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Lawrie Skinner
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Yong Yang
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Nicole Howell
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Jonathan Lewis
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Erik S Blomain
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States.
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