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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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Lalya I, Benchakroun N, Sifat H, El Kacemi H, B Amaoui, El Hfid M, Sahraoui S, El Mazghi SA, Tahri A, Benider A, Acharki A. [Stereotactic radiotherapy in Morocco : Inventory and technological compatibility with the minimum requirements of international recommendations of good practice]. Cancer Radiother 2023; 27:676-681. [PMID: 37482465 DOI: 10.1016/j.canrad.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023]
Affiliation(s)
- I Lalya
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Hôpital Militaire d'Instruction Mohammed-V, Rabat, Maroc; Université Mohammed-V, Rabat, Maroc.
| | - N Benchakroun
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Centre d'oncologie Mohammed VI- CHU de Casablanca, Casablanca, Maroc; Université Hassan II, Casablanca, Maroc
| | - H Sifat
- Hôpital Militaire d'Instruction Mohammed-V, Rabat, Maroc; Université Mohammed-V, Rabat, Maroc
| | - H El Kacemi
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Université Mohammed-V, Rabat, Maroc; Institut National d'Oncologie (INO), Rabat, Maroc
| | - B Amaoui
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Centre universitaire d'oncologie, Agadir, Maroc
| | - M El Hfid
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Centre universitaire d'oncologie, Tanger, Maroc
| | - S Sahraoui
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Centre d'oncologie Mohammed VI- CHU de Casablanca, Casablanca, Maroc; Université Hassan II, Casablanca, Maroc
| | - S A El Mazghi
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Centre international d'oncologie, Fès, Maroc
| | - A Tahri
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Clinique spécialisée d'oncologie Menara, Marrakech, Maroc
| | - A Benider
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Clinique d'oncologie Ryad, Casablanca, Maroc
| | - A Acharki
- Association d'Oncologie Radiothérapie du Maroc (AORAM), Casablanca, Maroc; Clinique d'oncologie Ryad, Casablanca, Maroc
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Abulimiti M, Yang X, Li M, Huan F, Zhang Y, Jun L. Application of four-dimensional cone beam computed tomography in lung cancer radiotherapy. Radiat Oncol 2023; 18:69. [PMID: 37069641 PMCID: PMC10108471 DOI: 10.1186/s13014-023-02259-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 04/05/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVE This study explored the application of four-dimensional cone beam computed tomography (4D CBCT) in lung cancer patients, seeking to improve the accuracy of radiotherapy and to establish a uniform protocol for the application of 4D CBCT in radiotherapy for lung cancer. METHODS 4D CBCT was applied to evaluate tumor volume response (TVR), motion, and center coordinates during radiotherapy in 67 eligible individuals with lung cancer diagnoses. The differences between 4D CBCT and 3D CBCT in different registration methods were compared. RESULTS TVR was observed during treatment in 41% of patients (28/67), with a mean volume reduction of 41.7% and a median time to TVR of 19 days. Tumor motion was obvious in 16 patients, with a mean value of 0.52 cm (0.22 to 1.34 cm), and in 3 of 6 tumors close to the diaphragm (0.28 to 0.66 cm). Gray value registration based on mean density projection could still achieve close results to the 4D gray value registration. However, when the registration was based on bone alone, partial off-targeting occurred in the treatment in 41.8% of cases. The off-target rate was 19.0% when the tumor motion was ≤ 0.5 cm and 52.2% when the motion was > 0.5 cm. CONCLUSION Tumor volume and motion of intrapulmonary lesions in individuals diagnosed with lung cancer varied significantly in the third week of radiotherapy. 4D CBCT may be more advantageous for isolated lesions without reference to relative anatomical structures or those near the diaphragm. Grayscale registration based on mean density projection is feasible.
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Affiliation(s)
- Muyasha Abulimiti
- National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Xu Yang
- Department of Radiation Oncology, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Minghui Li
- Department of Radiation Oncology, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Fukui Huan
- Department of Radiation Oncology, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yanxin Zhang
- Department of Radiation Oncology, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Liang Jun
- Department of Radiation Oncology, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Paoletti L, Ceccarelli C, Menichelli C, Aristei C, Borghesi S, Tucci E, Bastiani P, Cozzi S. Special stereotactic radiotherapy techniques: procedures and equipment for treatment simulation and dose delivery. Rep Pract Oncol Radiother 2022; 27:1-9. [PMID: 35402024 PMCID: PMC8989452 DOI: 10.5603/rpor.a2021.0129] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/14/2021] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiotherapy (SRT ) is a multi-step procedure with each step requiring extreme accuracy. Physician-dependent accuracy includes appropriate disease staging, multi-disciplinary discussion with shared decision-making, choice of morphological and functional imaging methods to identify and delineate the tumor target and organs at risk, an image-guided patient set-up, active or passive management of intra-fraction movement, clinical and instrumental follow-up. Medical physicist-dependent accuracy includes use of advanced software for treatment planning and more advanced Quality Assurance procedures than required for conventional radiotherapy. Consequently, all the professionals require appropriate training in skills for high-quality SRT. Thanks to the technological advances, SRT has moved from a “frame-based” technique, i.e. the use of stereotactic coordinates which are identified by means of rigid localization frames, to the modern “frame-less” SRT which localizes the target volume directly, or by means of anatomical surrogates or fiducial markers that have previously been placed within or near the target. This review describes all the SRT steps in depth, from target simulation and delineation procedures to treatment delivery and image-guided radiation therapy. Target movement assessment and management are also described.
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Affiliation(s)
- Lisa Paoletti
- Radiotherapy Unit, AUSL Toscana Centro, Florence, Italy
| | | | | | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - Enrico Tucci
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | | | - Salvatore Cozzi
- Radiation Oncology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
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Falcinelli L, Menichelli C, Casamassima F, Aristei C, Borghesi S, Ingrosso G, Draghini L, Tagliagambe A, Badellino S, di Monale E Bastia MB. Stereotactic radiotherapy for lung oligometastases. Rep Pract Oncol Radiother 2022; 27:23-31. [PMID: 35402023 PMCID: PMC8989443 DOI: 10.5603/rpor.a2022.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
Abstract
30–60% of cancer patients develop lung metastases, mostly from primary tumors in the colon-rectum, lung, head and neck area, breast and kidney. Nowadays, stereotactic radiotherapy (SRT ) is considered the ideal modality for treating pulmonary metastases. When lung metastases are suspected, complete disease staging includes a total body computed tomography (CT ) and/or positron emission tomography-computed tomography (PET -CT ) scan. PET -CT has higher specificity and sensitivity than a CT scan when investigating mediastinal lymph nodes, diagnosing a solitary lung lesion and detecting distant metastases. For treatment planning, a multi-detector planning CT scan of the entire chest is usually performed, with or without intravenous contrast media or esophageal lumen opacification, especially when central lesions have to be irradiated. Respiratory management is recommended in lung SRT, taking the breath cycle into account in planning and delivery. For contouring, co-registration and/or matching planning CT and diagnostic images (as provided by contrast enhanced CT or PET-CT ) are useful, particularly for central tumors. Doses and fractionation schedules are heterogeneous, ranging from 33 to 60 Gy in 3–6 fractions. Independently of fractionation schedule, a BED10 > 100 Gy is recommended for high local control rates. Single fraction SRT (ranges 15–30 Gy) is occasionally administered, particularly for small lesions. SRT provides tumor control rates of up to 91% at 3 years, with limited toxicities. The present overview focuses on technical and clinical aspects related to treatment planning, dose constraints, outcome and toxicity of SRT for lung metastases.
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Affiliation(s)
- Lorenzo Falcinelli
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | | | | | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | | | | | - Serena Badellino
- Radiation Oncology Department, A.O.U. Città della Salute e della Scienza, Turin, Italy
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Holla R, Khanna D, Narayanan VKS, Dutta DN. Analysis of normal lung irradiation in radiosurgery treatments: a comparison of lung optimized treatment (LOT) on cyberknife, 4D target volume on helical tomotherapy, and DIBH on linear accelerator. Phys Eng Sci Med 2021; 44:1321-1329. [PMID: 34724161 DOI: 10.1007/s13246-021-01064-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
Quantitative retrospective analysis of the normal lung irradiation due to the variations of the ITV volume based on the techniques used for upper lobe (UL), mid lobe (ML), and lower lobe (LL) lung tumours when used with 2-view, 1-view, 0-view based LOT technique on Cyberknife, AveIP on Helical Tomotherapy, and DIBH on VMAT systems. In the treatment of lung tumours, patients medically inoperable or those who are unwilling to undergo surgery have the option to be treated using radiation therapy. There are many motion control techniques available for the treatment of the moving target, such as movement encompassment, respiratory gating, breath-hold, motion reduction, and tumour monitoring. ITV generation is dependent on technique and hence the volume of the PTVs will differ based on the technique used. This study aimed to determine the influence of these ITVs on the irradiated normal lung volume for UL, ML, and LL lung tumours for 23 patients. The mean difference in the PTV volumes generated with the 0-view technique was significant with that of 2-view and DIBH techniques (p-value < 0.04). The mean difference in the PTV volumes generated by 2-view and DIBH was small for UL, ML, and LL tumours. V5 of the combined lung with the 0-view method was 5% compared to the 2-view method for UL tumours (p-value = 0.04) and the same was 9.5%, and 16.8% for ML and LL tumours (p-value < 0.04). In contrast to all other techniques, lung volume parameters V5, V10, V20, and V30 for the 0-view technology were consistently higher irrespective of the tumour location in the lung. The observed maximum mean lung dose (MLD) was 6.2 Gy ± 2.7 Gy with the 0-view technique and the minimum was 3.85 Gy ± 1.75 Gy with the DIBH technique. The difference in MLD between DIBH and 2-view was negligible (p-value = 0.67). The MLD increased for LL tumours from 4 Gy to 6.5 Gy from the 2-view to 0-view technique (p-value = 0.009). There was a significant increase in MLD for LL tumours with the 0-view technique compared to AveIP (1.9 Gy, p-value = 0.04) and DIBH (2.0 Gy, p-value = 0.003) technique. For ML and UL tumours, except for 0-view and 1-view, the difference in the MLD between the rest of the methods was not significant (p-value > 0.11). In the treatment of lung tumour patients with SBRT, this study has demonstrated 2-view with Cyberknife and DIBH with VMAT treatment techniques have optimal normal lung tissue sparing. There was a significant increase in the average lung volume receiving 5%,10%, 20%, and 30% dose when comparing the 1-view, 0-view, AveIP, and DIBH techniques to the 2-view technique. However, DIBH with VMAT was dosimetrically advantageous for ML and LL tumours, while providing significantly shorter treatment times than any other technique studied.
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Affiliation(s)
| | - D Khanna
- Department of Physics, Karunya Institute of Technology and Sciences, Coimbatore, 641114, India
| | | | - Deb Narayan Dutta
- Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
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Kord M, Kluge A, Kufeld M, Kalinauskaite G, Loebel F, Stromberger C, Budach V, Gebauer B, Acker G, Senger C. Risks and Benefits of Fiducial Marker Placement in Tumor Lesions for Robotic Radiosurgery: Technical Outcomes of 357 Implantations. Cancers (Basel) 2021; 13:cancers13194838. [PMID: 34638321 PMCID: PMC8508340 DOI: 10.3390/cancers13194838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Robotic radiosurgery (RRS) allows for the accurate treatment of primary tumors or metastases with high single doses. However, organ motion during or between fractions can lead to imprecise irradiation. We sought to evaluate the risks and advantages of fiducial marker (FM) implantation regarding clinical complications, marker migration, and motion amplitude. Complications were most common in Synchrony®-tracked lesions affected by respiratory motion, particularly lung lesions. Pneumothoraces and pulmonary bleeding were the most common complications. An increased complication rate was associated with concomitant biopsy sampling and FM implantation. Most FM migration observed in this study occurred after CT-guided placements and clinical FM insertions. The largest motion amplitudes were observed in hepatic and lower lung lobe lesions. This study highlights the benefits of marker implantation, especially in lesions with a large motion amplitude, including hepatic lesions and lesions of the lower lobe of the lung located >100.0 mm from the spine. Abstract Fiducial markers (FM) inserted into tumors increase the precision of irradiation during robotic radiosurgery (RRS). This retrospective study evaluated the clinical complications, marker migration, and motion amplitude of FM implantations by analyzing 288 cancer patients (58% men; 63.1 ± 13.0 years) who underwent 357 FM implantations prior to RRS with CyberKnife, between 2011 and 2019. Complications were classified according to the Society of Interventional Radiology (SIR) guidelines. The radial motion amplitude was calculated for tumors that moved with respiration. A total of 725 gold FM was inserted. SIR-rated complications occurred in 17.9% of all procedures. Most complications (32.0%, 62/194 implantations) were observed in Synchrony®-tracked lesions affected by respiratory motion, particularly in pulmonary lesions (46.9% 52/111 implantations). Concurrent biopsy sampling was associated with a higher complication rate (p = 0.001). FM migration occurred in 3.6% after CT-guided and clinical FM implantations. The largest motion amplitudes were observed in hepatic (20.5 ± 11.0 mm) and lower lung lobe (15.4 ± 10.5 mm) lesions. This study increases the awareness of the risks of FM placement, especially in thoracic lesions affected by respiratory motion. Considering the maximum motion amplitude, FM placement remains essential in hepatic and lower lung lobe lesions located >100.0 mm from the spine.
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Affiliation(s)
- Melina Kord
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Anne Kluge
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Markus Kufeld
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Goda Kalinauskaite
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Franziska Loebel
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Carmen Stromberger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Bernhard Gebauer
- Department of Radiology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany;
| | - Gueliz Acker
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Acadamy, Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Correspondence: ; Tel.: +49-30-450-557221
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Holla R, Khanna D, Narayanan VKS. Dose delivery accuracy on helical tomotherapy for 4-dimensional tumor motion - a phantom study. Rep Pract Oncol Radiother 2021; 26:380-388. [PMID: 34277091 PMCID: PMC8281919 DOI: 10.5603/rpor.a2021.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/25/2021] [Indexed: 11/25/2022] Open
Abstract
Background The advances in image guidance and capability of highly conformal dose deliveries made possible the use of helical tomotherapy (HT) for lung cancer treatment. To determine the effect of respiratory motion on the delivered dose in HT, film dosimetry using a dynamic phantom was performed. This was a phantom study to determine the effect of motion on the delivered dose in HT. Materials and methods 4D computed tomography (4DCT) was acquired for various target motions of CIRS dynamic phantom (CIRS Inc., Norfolk, USA) with 2.5cm diameter spherical target of volume 8.2 cc moving in the COS4 motion pattern. AveIP images and treatment plans were generated in the HT planning system. Target excursions during treatment delivery were changed in the superior-inferior, anteroposterior and lateral directions. The breathing cycle time was varied from 4 to 5 sec. and also the delivery interruptions were introduced. A film was exposed for each delivery and gamma analysis was performed. Results The gamma pass rate (GPR) with 3%, 2 mm criteria for the target motion in the S-I direction showed a significant reduction from 97.5% to 54.4% as the motion increased from 3 mm to 8 mm (p = 0.03). For the target motion in S-I = 8 mm, L-R = A-P = 3 mm, the percentage decrease in the GPR was 74% (p = 0.001) for three interruptions. Conclusion The ITV based approach in HT is ideal for a shallow breathing situation when the tumor excursions were confined to 5 mm in the S-I and 3 mm in L-R and A-P directions.
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Affiliation(s)
| | - David Khanna
- Department of Physics, Karunya Institute of Technology and Sciences, Coimbatore, India
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Eiben B, Bertholet J, Menten MJ, Nill S, Oelfke U, McClelland JR. Consistent and invertible deformation vector fields for a breathing anthropomorphic phantom: a post-processing framework for the XCAT phantom. Phys Med Biol 2020; 65:165005. [PMID: 32235043 DOI: 10.1088/1361-6560/ab8533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Breathing motion is challenging for radiotherapy planning and delivery. This requires advanced four-dimensional (4D) imaging and motion mitigation strategies and associated validation tools with known deformations. Numerical phantoms such as the XCAT provide reproducible and realistic data for simulation-based validation. However, the XCAT generates partially inconsistent and non-invertible deformations where tumours remain rigid and structures can move through each other. We address these limitations by post-processing the XCAT deformation vector fields (DVF) to generate a breathing phantom with realistic motion and quantifiable deformation. An open-source post-processing framework was developed that corrects and inverts the XCAT-DVFs while preserving sliding motion between organs. Those post-processed DVFs are used to warp the first XCAT-generated image to consecutive time points providing a 4D phantom with a tumour that moves consistently with the anatomy, the ability to scale lung density as well as consistent and invertible DVFs. For a regularly breathing case, the inverse consistency of the DVFs was verified and the tumour motion was compared to the original XCAT. The generated phantom and DVFs were used to validate a motion-including dose reconstruction (MIDR) method using isocenter shifts to emulate rigid motion. Differences between the reconstructed doses with and without lung density scaling were evaluated. The post-processing framework produced DVFs with a maximum [Formula: see text]-percentile inverse-consistency error of 0.02 mm. The generated phantom preserved the dominant sliding motion between the chest wall and inner organs. The tumour of the original XCAT phantom preserved its trajectory while deforming consistently with the underlying tissue. The MIDR was compared to the ground truth dose reconstruction illustrating its limitations. MIDR with and without lung density scaling resulted in small dose differences up to 1 Gy (prescription 54 Gy). The proposed open-source post-processing framework overcomes important limitations of the original XCAT phantom and makes it applicable to a wider range of validation applications within radiotherapy.
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Affiliation(s)
- Björn Eiben
- Centre for Medical Image Computing, Radiotherapy Image Computing Group, Department of Medical Physics and Biomedical Engineering University College London, London, United Kingdom of Great Britain and Northern Ireland
- Authors contributed equally
| | - Jenny Bertholet
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Authors contributed equally
| | - Martin J Menten
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Simeon Nill
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Uwe Oelfke
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Jamie R McClelland
- Centre for Medical Image Computing, Radiotherapy Image Computing Group, Department of Medical Physics and Biomedical Engineering University College London, London, United Kingdom of Great Britain and Northern Ireland
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Zhao W, Han B, Yang Y, Buyyounouski M, Hancock SL, Bagshaw H, Xing L. Incorporating imaging information from deep neural network layers into image guided radiation therapy (IGRT). Radiother Oncol 2019; 140:167-174. [PMID: 31302347 DOI: 10.1016/j.radonc.2019.06.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/06/2019] [Accepted: 06/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE To investigate a novel markerless prostate localization strategy using a pre-trained deep learning model to interpret routine projection kilovoltage (kV) X-ray images in image-guided radiation therapy (IGRT). MATERIALS AND METHODS We developed a personalized region-based convolutional neural network to localize the prostate treatment target without implanted fiducials. To train the deep neural network (DNN), we used the patient's planning computed tomography (pCT) images with pre-delineated prostate target to generate a large amount of synthetic kV projection X-ray images in the geometry of onboard imager (OBI) system. The DNN model was evaluated by retrospectively studying 10 patients who underwent prostate IGRT. Three out of the ten patients who had implanted fiducials and the fiducials' positions in the OBI images acquired for treatment setup were examined to show the potential of the proposed method for prostate IGRT. Statistical analysis using Lin's concordance correlation coefficient was calculated to assess the results along with the difference between the digitally reconstructed radiographs (DRR) derived and DNN predicted locations of the prostate. RESULTS Differences between the predicted target positions using DNN and their actual positions are (mean ± standard deviation) 1.58 ± 0.43 mm, 1.64 ± 0.43 mm, and 1.67 ± 0.36 mm in anterior-posterior, lateral, and oblique directions, respectively. Prostate position identified on the OBI kV images is also found to be consistent with that derived from the implanted fiducials. CONCLUSIONS Highly accurate, markerless prostate localization based on deep learning is achievable. The proposed method is useful for daily patient positioning and real-time target tracking during prostate radiotherapy.
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Affiliation(s)
- Wei Zhao
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Bin Han
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Yong Yang
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Mark Buyyounouski
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Steven L Hancock
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Hilary Bagshaw
- Stanford University, Department of Radiation Oncology, Stanford, USA.
| | - Lei Xing
- Stanford University, Department of Radiation Oncology, Stanford, USA.
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11
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Tian S, Switchenko JM, Cassidy RJ, Escott CE, Castillo R, Patel PR, Curran WJ, Higgins KA. Predictors of pneumonitis-free survival following lung stereotactic body radiation therapy. Transl Lung Cancer Res 2019; 8:15-23. [PMID: 30788231 DOI: 10.21037/tlcr.2018.10.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Radiation pneumonitis is a common toxicity following lung stereotactic body radiation therapy (SBRT). We explored whether motion management technique, in conjunction with patient and treatment characteristics, is a predictor of radiation pneumonitis-free survival (PNFS). Methods A single institution multi-center lung SBRT database was retrospectively reviewed. PNFS was defined as time to earliest onset of radiation pneumonitis or last clinical follow-up. Patients were simulated using a 4-dimensional approach, and those with 1 cm or greater tumor motion were selected for respiratory-gated treatment. Real-time Position Management and phase-based gating were employed. Univariate and multivariable Cox proportional hazard models were fit for relevant covariates to determine the impact of free-breathing versus respiratory-gated treatment on PNFS. Results The initial treatment courses of 208 patients were included, with a median follow-up length of 23 months. The median age at treatment was 71 years. About 91.8% of patient had early stage (T1-2) non-small cell lung cancer and were treated with common regimens including 10 Gy ×5, 12 Gy ×4 and 18 Gy ×3; 26.4% underwent respiratory-gated SBRT. The overall rate of grade 3 or higher radiation pneumonitis was 10.1%. PNFS was not significantly different between patients treated with respiratory-gated versus free-breathing SBRT (HR =0.88; P=0.707); tumor location and fractionation were predictors of PNFS in the multivariate setting. Conclusions The method of motion management does not appear to impact PNFS when the tolerance for tumor displacement is 1 cm or less for free-breathing treatment planning and delivery. This approach may be appropriate when selecting patients for respiratory gating.
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Affiliation(s)
- Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Chase E Escott
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Richard Castillo
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
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12
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Automated ultrafast kilovoltage-megavoltage cone-beam CT for image guided radiotherapy of lung cancer: System description and real-time results. Z Med Phys 2018; 28:110-120. [PMID: 29429610 DOI: 10.1016/j.zemedi.2018.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 11/21/2017] [Accepted: 01/15/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To establish a fully automated kV-MV CBCT imaging method on a clinical linear accelerator that allows image acquisition of thoracic targets for patient positioning within one breath-hold (∼15s) under realistic clinical conditions. METHODS AND MATERIALS Our previously developed FPGA-based hardware unit which allows synchronized kV-MV CBCT projection acquisition is connected to a clinical linear accelerator system via a multi-pin switch; i.e. either kV-MV imaging or conventional clinical mode can be selected. An application program was developed to control the relevant linac parameters automatically and to manage the MV detector readout as well as the gantry angle capture for each MV projection. The kV projections are acquired with the conventional CBCT system. GPU-accelerated filtered backprojection is performed separately for both data sets. After appropriate grayscale normalization both modalities are combined and the final kV-MV volume is re-imported in the CBCT system to enable image matching. To demonstrate adequate geometrical accuracy of the novel imaging system the Penta-Guide phantom QA procedure is performed. Furthermore, a human plastinate and different tumor shapes in a thorax phantom are scanned. Diameters of the known tumor shapes are measured in the kV-MV reconstruction. RESULTS An automated kV-MV CBCT workflow was successfully established in a clinical environment. The overall procedure, from starting the data acquisition until the reconstructed volume is available for registration, requires ∼90s including 17s acquisition time for 100° rotation. It is very simple and allows target positioning in the same way as for conventional CBCT. Registration accuracy of the QA phantom is within ±1mm. The average deviation from the known tumor dimensions measured in the thorax phantom was 0.7mm which corresponds to an improvement of 36% compared to our previous kV-MV imaging system. CONCLUSIONS Due to automation the kV-MV CBCT workflow is speeded up by a factor of >10 compared to the manual approach. Thus, the system allows a simple, fast and reliable imaging procedure and fulfills all requirements to be successfully introduced into the clinical workflow now, enabling single-breath-hold volume imaging.
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13
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Bainbridge H, Salem A, Tijssen RHN, Dubec M, Wetscherek A, Van Es C, Belderbos J, Faivre-Finn C, McDonald F. Magnetic resonance imaging in precision radiation therapy for lung cancer. Transl Lung Cancer Res 2017; 6:689-707. [PMID: 29218271 PMCID: PMC5709138 DOI: 10.21037/tlcr.2017.09.02] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022]
Abstract
Radiotherapy remains the cornerstone of curative treatment for inoperable locally advanced lung cancer, given concomitantly with platinum-based chemotherapy. With poor overall survival, research efforts continue to explore whether integration of advanced radiation techniques will assist safe treatment intensification with the potential for improving outcomes. One advance is the integration of magnetic resonance imaging (MRI) in the treatment pathway, providing anatomical and functional information with excellent soft tissue contrast without exposure of the patient to radiation. MRI may complement or improve the diagnostic staging accuracy of F-18 fluorodeoxyglucose position emission tomography and computerized tomography imaging, particularly in assessing local tumour invasion and is also effective for identification of nodal and distant metastatic disease. Incorporating anatomical MRI sequences into lung radiotherapy treatment planning is a novel application and may improve target volume and organs at risk delineation reproducibility. Furthermore, functional MRI may facilitate dose painting for heterogeneous target volumes and prediction of normal tissue toxicity to guide adaptive strategies. MRI sequences are rapidly developing and although the issue of intra-thoracic motion has historically hindered the quality of MRI due to the effect of motion, progress is being made in this field. Four-dimensional MRI has the potential to complement or supersede 4D CT and 4D F-18-FDG PET, by providing superior spatial resolution. A number of MR-guided radiotherapy delivery units are now available, combining a radiotherapy delivery machine (linear accelerator or cobalt-60 unit) with MRI at varying magnetic field strengths. This novel hybrid technology is evolving with many technical challenges to overcome. It is anticipated that the clinical benefits of MR-guided radiotherapy will be derived from the ability to adapt treatment on the fly for each fraction and in real-time, using 'beam-on' imaging. The lung tumour site group of the Atlantic MR-Linac consortium is working to generate a challenging MR-guided adaptive workflow for multi-institution treatment intensification trials in this patient group.
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Affiliation(s)
- Hannah Bainbridge
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Ahmed Salem
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | - Michael Dubec
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Andreas Wetscherek
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Corinne Van Es
- The University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jose Belderbos
- The Netherlands Cancer Institute and The Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Corinne Faivre-Finn
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Fiona McDonald
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Arns A, Blessing M, Fleckenstein J, Stsepankou D, Boda-Heggemann J, Hesser J, Lohr F, Wenz F, Wertz H. Phantom-based evaluation of dose exposure of ultrafast combined kV-MV-CBCT towards clinical implementation for IGRT of lung cancer. PLoS One 2017; 12:e0187710. [PMID: 29125857 PMCID: PMC5681289 DOI: 10.1371/journal.pone.0187710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/24/2017] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Combined ultrafast 90°+90° kV-MV-CBCT within single breath-hold of 15s has high clinical potential for accelerating imaging for lung cancer patients treated with deep inspiration breath-hold (DIBH). For clinical feasibility of kV-MV-CBCT, dose exposure has to be small compared to prescribed dose. In this study, kV-MV dose output is evaluated and compared to clinically-established kV-CBCT. METHODS Accurate dose calibration was performed for kV and MV energy; beam quality was determined. For direct comparison of MV and kV dose output, relative biological effectiveness (RBE) was considered. CT dose index (CTDI) was determined and measurements in various representative locations of an inhomogeneous thorax phantom were performed to simulate the patient situation. RESULTS A measured dose of 20.5mGE (Gray-equivalent) in the target region was comparable to kV-CBCT (31.2mGy for widely-used, and 9.1mGy for latest available preset), whereas kV-MV spared healthy tissue and reduced dose to 6.6mGE (30%) due to asymmetric dose distribution. The measured weighted CTDI of 12mGE for kV-MV lay in between both clinical presets. CONCLUSIONS Dosimetric properties were in agreement with established imaging techniques, whereas exposure to healthy tissue was reduced. By reducing the imaging time to a single breath-hold of 15s, ultrafast combined kV-MV CBCT shortens patient time at the treatment couch and thus improves patient comfort. It is therefore usable for imaging of hypofractionated lung DIBH patients.
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Affiliation(s)
- Anna Arns
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Manuel Blessing
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Dzmitry Stsepankou
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Juergen Hesser
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Lohr
- Struttura Complessa di Radioterapia, Dipartimento di Oncologia, Az. Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Frederik Wenz
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Hansjoerg Wertz
- Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Tan Z, Liu C, Zhou Y, Shen W. Preliminary comparison of the registration effect of 4D-CBCT and 3D-CBCT in image-guided radiotherapy of Stage IA non-small-cell lung cancer. JOURNAL OF RADIATION RESEARCH 2017; 58:854-861. [PMID: 28992047 PMCID: PMC5710603 DOI: 10.1093/jrr/rrx040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/04/2017] [Indexed: 06/07/2023]
Abstract
In this study, we compared the registration effectiveness of 4D cone-beam computed tomography (CBCT) and 3D-CBCT for image-guided radiotherapy in 20 Stage IA non-small-cell lung cancer (NSCLC) patients. Patients underwent 4D-CBCT and 3D-CBCT immediately before radiotherapy, and the X-ray Volume Imaging software system was used for image registration. We performed automatic bone registration and soft tissue registration between 4D-CBCT or 3D-CBCT and 4D-CT images; the regions of interest (ROIs) were the vertebral body on the layer corresponding to the tumor and the internal target volume region. The relative displacement of the gross tumor volume between the 4D-CBCT end-expiratory phase sequence and 4D-CT was used to evaluate the registration error. Among the 20 patients (12 males, 8 females; 35-67 years old; median age, 52 years), 3 had central NSCLC and 17 had peripheral NSCLC, 8 in the upper or middle lobe and 12 in the lower lobe (maximum tumor diameter range, 18-27 mm). The internal motion range in three-dimensional space was 12.52 ± 2.65 mm, accounting for 47.8 ± 15.3% of the maximum diameter of each tumor. The errors of image-guided registration using 4D-CBCT and 3D-CBCT on the x (left-right), y (superior-inferior), z (anterior-posterior) axes, and 3D space were 0.80 ± 0.21 mm and 1.08 ± 0.25 mm, 2.02 ± 0.46 mm and 3.30 ± 0.53 mm, 0.52 ± 0.16 mm and 0.85 ± 0.24 mm, and 2.25 ± 0.44 mm and 3.59 ± 0.48 mm (all P < 0.001), respectively. Thus, 4D-CBCT is preferable to 3D-CBCT for image guidance in small pulmonary tumors because 4D-CBCT can reduce the uncertainty in the tumor location resulting from internal motion caused by respiratory movements, thereby increasing the image-guidance accuracy.
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Affiliation(s)
- Zhibo Tan
- Department of Oncology, Shenzhen Hospital of Southern Medical University, #1333 Xinhu Road, Bao'an District, Shenzhen 518110, Guangdong Province, PR China
- Department of Radiation Oncology, Sichuan Cancer Hospital, #55 Renmin Road South, Wuhou District, Chengdu 610041, Sichuan Province, PR China
| | - Chuanyao Liu
- Department of Rehabilitation, Shenzhen Hospital of Southern Medical University, #1333 Xinhu Road, Bao'an District, Shenzhen 518110, Guangdong Province, PR China
| | - Ying Zhou
- Department of Oncology and Hematology, Shenzhen Hospital of Southern Medical University, #1333 Xinhu Road, Bao'an District, Shenzhen 518110, Guangdong Province, PR China
| | - Weixi Shen
- Department of Oncology, Shenzhen Hospital of Southern Medical University, #1333 Xinhu Road, Bao'an District, Shenzhen 518110, Guangdong Province, PR China
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16
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Bainbridge HE, Menten MJ, Fast MF, Nill S, Oelfke U, McDonald F. Treating locally advanced lung cancer with a 1.5T MR-Linac - Effects of the magnetic field and irradiation geometry on conventionally fractionated and isotoxic dose-escalated radiotherapy. Radiother Oncol 2017; 125:280-285. [PMID: 28987747 PMCID: PMC5710994 DOI: 10.1016/j.radonc.2017.09.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/21/2017] [Accepted: 09/09/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE This study investigates the feasibility and potential benefits of radiotherapy with a 1.5T MR-Linac for locally advanced non-small cell lung cancer (LA NSCLC) patients. MATERIAL AND METHODS Ten patients with LA NSCLC were retrospectively re-planned six times: three treatment plans were created according to a protocol for conventionally fractionated radiotherapy and three treatment plans following guidelines for isotoxic target dose escalation. In each case, two plans were designed for the MR-Linac, either with standard (∼7mm) or reduced (∼3mm) planning target volume (PTV) margins, while one conventional linac plan was created with standard margins. Treatment plan quality was evaluated using dose-volume metrics or by quantifying dose escalation potential. RESULTS All generated treatment plans fulfilled their respective planning constraints. For conventionally fractionated treatments, MR-Linac plans with standard margins had slightly increased skin dose when compared to conventional linac plans. Using reduced margins alleviated this issue and decreased exposure of several other organs-at-risk (OAR). Reduced margins also enabled increased isotoxic target dose escalation. CONCLUSION It is feasible to generate treatment plans for LA NSCLC patients on a 1.5T MR-Linac. Margin reduction, facilitated by an envisioned MRI-guided workflow, enables increased OAR sparing and isotoxic target dose escalation for the respective treatment approaches.
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Affiliation(s)
- Hannah E Bainbridge
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom.
| | - Martin J Menten
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Martin F Fast
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Simeon Nill
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom
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Abstract
Patient motion can cause misalignment of the tumour and toxicities to the healthy lung tissue during lung stereotactic body radiation therapy (SBRT). Any deviations from the reference setup can miss the target and have acute toxic effects on the patient with consequences onto its quality of life and survival outcomes. Correction for motion, either immediately prior to treatment or intra-treatment, can be realized with image-guided radiation therapy (IGRT) and motion management devices. The use of these techniques has demonstrated the feasibility of integrating complex technology with clinical linear accelerator to provide a higher standard of care for the patients and increase their quality of life.
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Affiliation(s)
- Vincent Caillet
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; School of Physics, University of Sydney, Sydney, Australia.
| | - Jeremy T Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; School of Physics, University of Sydney, Sydney, Australia
| | - Paul Keall
- School of Medicine, University of Sydney, Sydney, Australia
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18
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Mao B, Verma V, Zheng D, Zhu X, Bennion NR, Bhirud AR, Poole MA, Zhen W. Target migration from re-inflation of adjacent atelectasis during lung stereotactic body radiotherapy. World J Clin Oncol 2017; 8:300-304. [PMID: 28638802 PMCID: PMC5465022 DOI: 10.5306/wjco.v8.i3.300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 02/06/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is a widely accepted option for the treatment of medically inoperable early-stage non-small cell lung cancer (NSCLC). Herein, we highlight the importance of interfraction image guidance during SBRT. We describe a case of early-stage NSCLC associated with segmental atelectasis that translocated 15 mm anteroinferiorly due to re-expansion of the adjacent segmental atelectasis following the first fraction. The case exemplifies the importance of cross-sectional image-guided radiotherapy that shows the intended target, as opposed to aligning based on rigid anatomy alone, especially in cases associated with potentially “volatile” anatomic areas.
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Binkley MS, King MT, Shrager JB, Bush K, Chaudhuri AA, Popat R, Gensheimer MF, Maxim PG, Henry Guo H, Diehn M, Nair VS, Loo BW. Pulmonary function after lung tumor stereotactic ablative radiotherapy depends on regional ventilation within irradiated lung. Radiother Oncol 2017; 123:270-275. [PMID: 28460826 DOI: 10.1016/j.radonc.2017.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/07/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine if regional ventilation within irradiated lung volume predicts change in pulmonary function test (PFT) measurements after stereotactic ablative radiotherapy (SABR) of lung tumors. METHODS We retrospectively identified 27 patients treated from 2007 to 2014 at our institution who received: (1) SABR without prior thoracic radiation; (2) pre-treatment 4-dimensional computed tomography (4-D CT) imaging; (3) pre- and post-SABR PFTs <15months from treatment. We defined the ventilation ratio (VR20BED3) as the quotient of mean ventilation (mean Jacobian-based per-voxel volume change on deformably registered inhale/exhale 4-D CT phases) within the 20Gy biologically effective dose (α/β=3Gy) isodose volume and that of the total lung volume (TLV). RESULTS Most patients had moderate to very severe COPD by GOLD criteria (n=19, 70.1%). Higher VR20BED3 significantly predicted worse change in Forced Expiratory Volume/s normalized by baseline value (ΔFEV1/FEV1pre, p=0.04); n=7 had VR20BED3>1 (high regional ventilation) and worse ΔFEV1/FEV1pre (median=-0.16, range=-0.230 to -0.20). Five had VR20BED3<1 (low regional ventilation) and improved ΔFEV1/FEV1pre (median=0.13, range=0.07 to 0.20). In a multivariable linear model, increasing VR20BED3 and time to post-SABR PFT predicted decreasing ΔFEV1/FEV1pre (R2=0.25, p=0.03). CONCLUSIONS After SABR to high versus low functioning lung regions, we found worsened or improved global pulmonary function, respectively. If pre-SABR VR20BED3 is validated as a predictor of eventual post-SABR PFT in larger studies, it may be used for individualized treatment planning to preserve or even improve pulmonary function after SABR.
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Affiliation(s)
- Michael S Binkley
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States
| | - Martin T King
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University School of Medicine, United States; Stanford Cancer Institute and Department of Medicine, United States
| | - Karl Bush
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States
| | - Aadel A Chaudhuri
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States
| | - Rita Popat
- Department of Health Research & Policy, Stanford University School of Medicine, United States
| | - Michael F Gensheimer
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States
| | - Peter G Maxim
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States; Stanford Cancer Institute and Department of Medicine, United States
| | - H Henry Guo
- Department of Radiology, Stanford University School of Medicine, United States
| | - Maximilian Diehn
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States; Institute for Stem Cell Biology & Regenerative Medicine, Stanford University School of Medicine, United States; Stanford Cancer Institute and Department of Medicine, United States
| | - Viswam S Nair
- Department of Radiology, Stanford University School of Medicine, United States; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford Cancer Institute and Department of Medicine, United States; Stanford Cancer Institute and Department of Medicine, United States.
| | - Billy W Loo
- Department of Radiation Oncology and Cancer Institute, Stanford University School of Medicine, United States; Stanford Cancer Institute and Department of Medicine, United States.
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Schwarz M, Cattaneo GM, Marrazzo L. Geometrical and dosimetrical uncertainties in hypofractionated radiotherapy of the lung: A review. Phys Med 2017; 36:126-139. [DOI: 10.1016/j.ejmp.2017.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/23/2016] [Accepted: 02/14/2017] [Indexed: 12/25/2022] Open
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Katoh N, Soda I, Tamamura H, Takahashi S, Uchinami Y, Ishiyama H, Ota K, Inoue T, Onimaru R, Shibuya K, Hayakawa K, Shirato H. Clinical outcomes of stage I and IIA non-small cell lung cancer patients treated with stereotactic body radiotherapy using a real-time tumor-tracking radiotherapy system. Radiat Oncol 2017; 12:3. [PMID: 28057036 PMCID: PMC5217432 DOI: 10.1186/s13014-016-0742-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate the clinical outcomes of stage I and IIA non-small cell lung cancer (NSCLC) patients treated with stereotactic body radiotherapy (SBRT) using a real-time tumor-tracking radiotherapy (RTRT) system. Materials and methods Patterns-of-care in SBRT using RTRT for histologically proven, peripherally located, stage I and IIA NSCLC was retrospectively investigated in four institutions by an identical clinical report format. Patterns-of-outcomes was also investigated in the same manner. Results From September 2000 to April 2012, 283 patients with 286 tumors were identified. The median age was 78 years (52–90) and the maximum tumor diameters were 9 to 65 mm with a median of 24 mm. The calculated biologically effective dose (10) at the isocenter using the linear-quadratic model was from 66 Gy to 126 Gy with a median of 106 Gy. With a median follow-up period of 28 months (range 0–127), the overall survival rate for the entire group, for stage IA, and for stage IB + IIA was 75%, 79%, and 65% at 2 years, and 64%, 70%, and 50% at 3 years, respectively. In the multivariate analysis, the favorable predictive factor was female for overall survival. There were no differences between the clinical outcomes at the four institutions. Grade 2, 3, 4, and 5 radiation pneumonitis was experienced by 29 (10.2%), 9 (3.2%), 0, and 0 patients. The subgroup analyses revealed that compared to margins from gross tumor volume (GTV) to planning target volume (PTV) ≥ 10 mm, margins < 10 mm did not worsen the overall survival and local control rates, while reducing the risk of radiation pneumonitis. Conclusions This multi-institutional retrospective study showed that the results were consistent with the recent patterns-of-care and patterns-of-outcome analysis of SBRT. A prospective study will be required to evaluate SBRT using a RTRT system with margins from GTV to PTV < 10mm. Electronic supplementary material The online version of this article (doi:10.1186/s13014-016-0742-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Norio Katoh
- Department of Radiation Oncology, Hokkaido University Hospital, North-14 West-5, Kita-ku, Sapporo, Japan. .,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan.
| | - Itaru Soda
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroyasu Tamamura
- Department of Nuclear Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Shotaro Takahashi
- Department of Therapeutic Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yusuke Uchinami
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiromichi Ishiyama
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kiyotaka Ota
- Department of Nuclear Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Tetsuya Inoue
- Department of Radiation Oncology, Hokkaido University Hospital, North-14 West-5, Kita-ku, Sapporo, Japan
| | - Rikiya Onimaru
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Keiko Shibuya
- Department of Therapeutic Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kazushige Hayakawa
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroki Shirato
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan.,Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Apnea-like suppression of respiratory motion: First evaluation in radiotherapy. Radiother Oncol 2016; 118:220-6. [PMID: 26979264 DOI: 10.1016/j.radonc.2015.10.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/11/2015] [Accepted: 10/11/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Compensation for respiratory motion is needed while administering radiotherapy (RT) to tumors that are moving with respiration to reduce the amount of irradiated normal tissues and potentially decrease radiation-induced collateral damages. The purpose of this study was to test a new ventilation system designed to induce apnea-like suppression of respiratory motion and allow long enough breath hold durations to deliver complex RT. MATERIAL AND METHODS The High Frequency Percussive Ventilation system was initially tested in a series of 10 volunteers and found to be well tolerated, allowing a median breath hold duration of 11.6 min (range 3.9-16.5 min). An evaluation of this system was subsequently performed in 4 patients eligible for adjuvant breast 3D conformal RT, for lung stereotactic body RT (SBRT), lung volumetric modulated arc therapy (VMAT), and VMAT for palliative pleural metastases. RESULTS When compared to free breathing (FB) and maximal inspiration (MI) gating, this Percussion Assisted RT (PART) offered favorable dose distribution profiles in 3 out of the 4 patients tested. PART was applied in these 3 patients with good tolerance, without breaks during the "beam on time period" throughout the overall courses of RT. The mean duration of the apnea-like breath hold that was necessary for delivering all the RT fractions was 7.61 min (SD=2.3). CONCLUSIONS This first clinical implementation of PART was found to be feasible, tolerable and offers new opportunities in the field of RT for suppressing respiratory motion.
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Registration uncertainties between 3D cone beam computed tomography and different reference CT datasets in lung stereotactic body radiation therapy. Radiat Oncol 2016; 11:142. [PMID: 27782858 PMCID: PMC5080749 DOI: 10.1186/s13014-016-0720-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/22/2016] [Indexed: 12/25/2022] Open
Abstract
Background The aim of this study was to analyze differences in couch shifts (setup errors) resulting from image registration of different CT datasets with free breathing cone beam CTs (FB-CBCT). As well automatic as manual image registrations were performed and registration results were correlated to tumor characteristics. Methods FB-CBCT image registration was performed for 49 patients with lung lesions using slow planning CT (PCT), average intensity projection (AIP), maximum intensity projection (MIP) and mid-ventilation CTs (MidV) as reference images. Both, automatic and manual image registrations were applied. Shift differences were evaluated between the registered CT datasets for automatic and manual registration, respectively. Furthermore, differences between automatic and manual registration were analyzed for the same CT datasets. The registration results were statistically analyzed and correlated to tumor characteristics (3D tumor motion, tumor volume, superior-inferior (SI) distance, tumor environment). Results Median 3D shift differences over all patients were between 0.5 mm (AIPvsMIP) and 1.9 mm (MIPvsPCT and MidVvsPCT) for the automatic registration and between 1.8 mm (AIPvsPCT) and 2.8 mm (MIPvsPCT and MidVvsPCT) for the manual registration. For some patients, large shift differences (>5.0 mm) were found (maximum 10.5 mm, automatic registration). Comparing automatic vs manual registrations for the same reference CTs, ∆AIP achieved the smallest (1.1 mm) and ∆MIP the largest (1.9 mm) median 3D shift differences. The standard deviation (variability) for the 3D shift differences was also the smallest for ∆AIP (1.1 mm). Significant correlations (p < 0.01) between 3D shift difference and 3D tumor motion (AIPvsMIP, MIPvsMidV) and SI distance (AIPvsMIP) (automatic) and also for 3D tumor motion (∆PCT, ∆MidV; automatic vs manual) were found. Conclusions Using different CT datasets for image registration with FB-CBCTs can result in different 3D couch shifts. Manual registrations achieved partly different 3D shifts than automatic registrations. AIP CTs yielded the smallest shift differences and might be the most appropriate CT dataset for registration with 3D FB-CBCTs.
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Rieber J, Abbassi-Senger N, Adebahr S, Andratschke N, Blanck O, Duma M, Eble MJ, Ernst I, Flentje M, Gerum S, Hass P, Henkenberens C, Hildebrandt G, Imhoff D, Kahl H, Klass ND, Krempien R, Lohaus F, Lohr F, Petersen C, Schrade E, Streblow J, Uhlmann L, Wittig A, Sterzing F, Guckenberger M. Influence of Institutional Experience and Technological Advances on Outcome of Stereotactic Body Radiation Therapy for Oligometastatic Lung Disease. Int J Radiat Oncol Biol Phys 2016; 98:511-520. [PMID: 27843031 DOI: 10.1016/j.ijrobp.2016.09.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/12/2016] [Accepted: 09/16/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Many technological and methodical advances have made stereotactic body radiotherapy (SBRT) more accurate and more efficient during the last years. This study aims to investigate whether experience in SBRT and technological innovations also translated into improved local control (LC) and overall survival (OS). METHODS AND MATERIALS A database of 700 patients treated with SBRT for lung metastases in 20 German centers between 1997 and 2014 was used for analysis. It was the aim of this study to investigate the impact of fluorodeoxyglucose positron-emission tomography (FDG-PET) staging, biopsy confirmation, image guidance, immobilization, and dose calculation algorithm, as well as the influence of SBRT experience, on LC and OS. RESULTS Median follow-up time was 14.3 months (range, 0-131.9 months), with 2-year LC and OS of 81.2% (95% confidence interval [CI] 75.8%-85.7%) and 54.4% (95% CI 50.2%-59.0%), respectively. In multivariate analysis, all treatment technologies except FDG-PET staging did not significantly influence outcome. Patients who received pre-SBRT FDG-PET staging showed superior 1- and 2-year OS of 82.7% (95% CI 77.4%-88.6%) and 64.8% (95% CI 57.5%-73.3%), compared with patients without FDG-PET staging resulting in 1- and 2-year OS rates of 72.8% (95% CI 67.4%-78.8%) and 52.6% (95% CI 46.0%-60.4%), respectively (P=.012). Experience with SBRT was identified as the main prognostic factor for LC: institutions with higher SBRT experience (patients treated with SBRT within the last 2 years of the inclusion period) showed superior LC compared with less-experienced centers (P≤.001). Experience with SBRT within the last 2 years was independent from known prognostic factors for LC. CONCLUSION Investigated technological and methodical advancements other than FDG-PET staging before SBRT did not significantly improve outcome in SBRT for pulmonary metastases. In contrast, LC was superior with increasing SBRT experience of the individual center.
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Affiliation(s)
- Juliane Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany.
| | | | - Sonja Adebahr
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany; German Cancer Consortium, Heidelberg, Partner Site Freiburg, Freiburg, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Radiation Oncology, University of Rostock, Rostock, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Marciana Duma
- Department of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Michael J Eble
- Department of Radiation Oncology, University Hospital Aachen, Aachen, Germany
| | - Iris Ernst
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Sabine Gerum
- Department of Radiation Oncology, Ludwig Maximilians University Munich, Munich, Germany
| | - Peter Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Christoph Henkenberens
- Department of Radiotherapy and Special Oncology, Medical School Hannover, Hannover, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University of Rostock, Rostock, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Henning Kahl
- Department of Radiation Oncology, Hospital Augsburg, Augsburg, Germany
| | | | - Robert Krempien
- Department of Radiation Oncology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Fabian Lohaus
- Department of Radiation Oncology, Medical Faculty and University Hospital C.G. Carus, Technical University Dresden, Dresden, Germany; German Cancer Research Center, Heidelberg and German Cancer Consortium partner site Dresden, Dresden, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany
| | - Cordula Petersen
- Department of Radiation Oncology, University Hospital Hamburg, Hamburg, Germany
| | - Elsge Schrade
- Department of Radiation Oncology, Hospital Heidenheim, Heidenheim, Germany
| | - Jan Streblow
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Andrea Wittig
- Department of Radiotherapy and Radiation Oncology, Philipps-University Marburg, University Hospital Giessen and Marburg, Marburg, Germany
| | - Florian Sterzing
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Heidelberg, Germany; German Cancer Research Center, Clinical Cooperation Unit Radiation Oncology, Heidelberg, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
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Sterpin E, Barragan A, Souris K, Lee JA. [Robust treatment planning in proton therapy]. Cancer Radiother 2016; 20:523-9. [PMID: 27614528 DOI: 10.1016/j.canrad.2016.07.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 11/28/2022]
Abstract
The concentration of the dose delivered by protons at the end of their path, the Bragg peak, has the potential to improve external radiotherapy treatments. Unfortunately, the main strength of the protons, their finite range, is also their greatest weakness. Any uncertainty on the range may lead to inadequate target coverage or excessive toxicity. The uncertainties have multiple origins and include, among others, ballistic errors, morphological modifications or inaccurate estimations of the physical quantities necessary to predict the proton range. Uncertainties have been part of daily practice in conventional radiotherapy with X-rays for a long time. However, dose distributions delivered with X-rays are much less sensitive to uncertainties than the ones delivered with protons. This relative insensitivity enabled the management of uncertainties through safety margins using a simple formalism. The conditions of validity of this formalism are much more restrictive for proton therapy, leading to the need of developing new tools and adapted strategies to manage accurately these uncertainties. The objective of this paper is to present a vision for the management of uncertainties in proton therapy in the continuity of formalisms established for X-rays. The latter are first summarized before discussing the necessary developments in order to consistently apply them to protons.
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Affiliation(s)
- E Sterpin
- Katholieke Universiteit Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, O&N I Herestraat 49, 3000 Leuven, Belgique; Université catholique de Louvain, Center of Molecular Imaging, Radiotherapy and Oncology, institut de recherche expérimentale et clinique, avenue Hippocrate 54, 1200 Brussels, Belgique.
| | - A Barragan
- Université catholique de Louvain, Center of Molecular Imaging, Radiotherapy and Oncology, institut de recherche expérimentale et clinique, avenue Hippocrate 54, 1200 Brussels, Belgique
| | - K Souris
- Université catholique de Louvain, Center of Molecular Imaging, Radiotherapy and Oncology, institut de recherche expérimentale et clinique, avenue Hippocrate 54, 1200 Brussels, Belgique
| | - J A Lee
- Université catholique de Louvain, Center of Molecular Imaging, Radiotherapy and Oncology, institut de recherche expérimentale et clinique, avenue Hippocrate 54, 1200 Brussels, Belgique
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Peulen H, Mantel F, Guckenberger M, Belderbos J, Werner-Wasik M, Hope A, Giuliani M, Grills I, Sonke JJ. Validation of High-Risk Computed Tomography Features for Detection of Local Recurrence After Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 96:134-41. [DOI: 10.1016/j.ijrobp.2016.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/16/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
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Garibaldi C, Piperno G, Ferrari A, Surgo A, Muto M, Ronchi S, Bazani A, Pansini F, Cremonesi M, Jereczek-Fossa BA, Orecchia R. Translational and rotational localization errors in cone-beam CT based image-guided lung stereotactic radiotherapy. Phys Med 2016; 32:859-65. [PMID: 27289354 DOI: 10.1016/j.ejmp.2016.05.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Accurate localization is crucial in delivering safe and effective stereotactic body radiation therapy (SBRT). The aim of this study was to analyse the accuracy of image-guidance using the cone-beam computed tomography (CBCT) of the VERO system in 57 patients treated for lung SBRT and to calculate the treatment margins. MATERIALS AND METHODS The internal target volume (ITV) was obtained by contouring the tumor on maximum and mean intensity projection CT images reconstructed from a respiration correlated 4D-CT. Translational and rotational tumor localization errors were identified by comparing the manual registration of the ITV to the motion-blurred tumor on the CBCT and they were corrected by means of the robotic couch and the ring rotation. A verification CBCT was acquired after correction in order to evaluate residual errors. RESULTS The mean 3D vector at initial set-up was 6.6±2.3mm, which was significantly reduced to 1.6±0.8mm after 6D automatic correction. 94% of the rotational errors were within 3°. The PTV margins used to compensate for residual tumor localization errors were 3.1, 3.5 and 3.3mm in the LR, SI and AP directions, respectively. CONCLUSIONS On-line image guidance with the ITV-CBCT matching technique and automatic 6D correction of the VERO system allowed a very accurate tumor localization in lung SBRT.
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Affiliation(s)
- Cristina Garibaldi
- Unit of Radiation Research, European Institute of Oncology, Milano, Italy.
| | - Gaia Piperno
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Annamaria Ferrari
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Matteo Muto
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Sara Ronchi
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Alessia Bazani
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Floriana Pansini
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Marta Cremonesi
- Unit of Radiation Research, European Institute of Oncology, Milano, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, Milano, Italy; Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Roberto Orecchia
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy; Scientific Director, European Institute of Oncology, Milano, Italy
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Sun Y, Ge H, Cheng S, Yang C, Zhu Q, Li D, Tian Y. Evaluation of interfractional variation of the centroid position and volume of internal target volume during stereotactic body radiotherapy of lung cancer using cone-beam computed tomography. J Appl Clin Med Phys 2016; 17:461-472. [PMID: 27074466 PMCID: PMC5874940 DOI: 10.1120/jacmp.v17i2.5835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 02/14/2016] [Accepted: 11/04/2015] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to determine interfractional variation of the centroid position and volume of internal target volume (ITV) during stereotactic body radiation therapy (SBRT) of lung cancer. From January 2014 to August 2014, a total of 32 patients with 37 primary or metastatic lung tumors were enrolled in our study. All patients received SBRT treatment in 4-5 fractions to a median dose of 48 Gy. Both 3D CT and 4D CT scans were used for radiotherapy treatment planning. 3D CBCT was acquired prior to treatment delivery to verify patient positioning. A total of 163 3D CBCT images were available for evaluation. 3D CBCT scans acquired for verification were registered with simulation CT scans. The ITVs were contoured on all verification 3D CBCT scans and compared to the initial gross target volume (GTV) or ITV in treatment planning system. GTV was based on 3D CT while ITV was based on both 3D CT and 4D CT. To assess the interfractional variation of ITV centroid position, we used vertebrae body adja-cent to the tumor as reference point when performing the registration procedure. To eliminate the effect of time on tumor volume between simulation CT scan and the first fraction, the interfractional variation of ITV was evaluated from the first fraction to the last fraction. The overall 3D vector shift was 4.4 ± 2.5 mm (range: 0.4-13.8 mm). The interfractional variation of ITV centroid position in superior-inferior, anterior-posterior, and left-right directions were -0.7 ± 2.7 mm, -1.4 ± 3.4 mm, and -0.5 ± 2.2 mm, respectively. No significant difference was observed between three directions (p = 0.147). Large interfractional variations (≥ 5 mm) were observed in 12 fractions (9.3%) in superior-inferior direction, 24 fractions (18.6%) in anterior-posterior direction, and 5 fractions (3.9%) in left-right direction. No time trend of tumor volume change measured in 3D CBCT was detected during four fractions (p = 0.074). A significant (p = 0.010) time trend was detected when evaluating the time trend of ITV change during 5 fractions and diameter was found to be significantly correlated with the ITV change (p = 0.000). ITV did not show significant regression during SBRT treatment, but interfractional variation in the ITV centroid position was observed, especially in anterior-posterior direc-tion. An isotropic margin of 7 mm around ITV might be necessary for adequate coverage of interfractional variation of ITV centroid position, but only in case no soft tissue-based setup is performed during SBRT treatment.
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Affiliation(s)
- Yanan Sun
- The Affiliated Cancer Hospital of Zhengzhou University.
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Arns A, Blessing M, Fleckenstein J, Stsepankou D, Boda-Heggemann J, Simeonova-Chergou A, Hesser J, Lohr F, Wenz F, Wertz H. Towards clinical implementation of ultrafast combined kV-MV CBCT for IGRT of lung cancer : Evaluation of registration accuracy based on phantom study. Strahlenther Onkol 2016; 192:312-21. [PMID: 26864049 DOI: 10.1007/s00066-016-0947-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Combined kV-MV cone-beam CT (CBCT) is a promising approach to accelerate imaging for patients with lung tumors treated with deep inspiration breath-hold. During a single breath-hold (15 s), a 3D kV-MV CBCT can be acquired, thus minimizing motion artifacts and increasing patient comfort. Prior to clinical implementation, positioning accuracy was evaluated and compared to clinically established imaging techniques. METHODS AND MATERIALS An inhomogeneous thorax phantom with four tumor-mimicking inlays was imaged in 10 predefined positions and registered to a planning CT. Novel kV-MV CBCT imaging (90° arc) was compared to clinically established kV-chest CBCT (360°) as well as nonclinical kV-CBCT and low-dose MV-CBCT (each 180°). Manual registration, automatic registration provided by the manufacturer and an additional in-house developed manufacturer-independent framework based on the MATLAB registration toolkit were applied. RESULTS Systematic setup error was reduced to 0.05 mm by high-precision phantom positioning with optical tracking. Stochastic mean displacement errors were 0.5 ± 0.3 mm in right-left, 0.4 ± 0.4 mm in anteroposterior and 0.0 ± 0.4 mm in craniocaudal directions for kV-MV CBCT with manual registration (maximum errors of no more than 1.4 mm). Clinical kV-chest CBCT resulted in mean errors of 0.2 mm (other modalities: 0.4-0.8 mm). Similar results were achieved with both automatic registration methods. CONCLUSION The comparison study of repositioning accuracy between novel kV-MV CBCT and clinically established volume imaging demonstrated that registration accuracy is maintained below 1 mm. Since imaging time is reduced to one breath-hold, kV-MV CBCT is ideal for image guidance, e.g., in lung stereotactic ablative radiotherapy.
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Affiliation(s)
- Anna Arns
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Manuel Blessing
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Dzmitry Stsepankou
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Anna Simeonova-Chergou
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jürgen Hesser
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Hansjörg Wertz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Haus 4, Ebene 0, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Mege JP, Wenzhao S, Veres A, Auzac G, Diallo I, Lefkopoulos D. Evaluation of MVCT imaging dose levels during helical IGRT: comparison between ion chamber, TLD, and EBT3 films. J Appl Clin Med Phys 2016; 17:143-157. [PMID: 26894346 PMCID: PMC5690206 DOI: 10.1120/jacmp.v17i1.5774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/19/2015] [Accepted: 07/02/2015] [Indexed: 11/23/2022] Open
Abstract
The purpose of this investigation was to evaluate the dose on megavoltage CT (MVCT) images required for tomotherapy. As imaging possibilities are often used before each treatment and usually used several times before the session, we tried to evaluate the dose delivered during the procedure. For each scanning mode (fine, normal, and coarse), we first established the relative variation of these doses according to different technical parameters (explored length, patient setup). These dose variations measured with the TomoPhant, also known as Cheese phantom, showed the expected variations (due to the variation of scattered radiation) of 15% according to the explored length and ± 5% according to the phantom setup (due to the variation of the point of measurement in the bore). In order to estimate patient doses, an anthropomorphic phantom was used for thermoluminescent and film dosimetry. The degree of agreement between the two methods was very satisfactory (the differences correspond to 5 mGy per imaging session) for the three sites studied (head & neck, thorax, and abdomen). These measurements allowed us to estimate the delivered dose of between 1 cGy and 4 cGy according to the site and imaging mode. Finally, we attempted to investigate a way to calculate this delivered dose in our patients from the study conducted on a cylindrical phantom and by taking into account data from the initial kV-CT scan. The results we obtained were close to our measurements, with discrepancies below 5 mGy per MVCT.
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Intensity-modulated radiotherapy for lung cancer: current status and future developments. J Thorac Oncol 2015; 9:1598-608. [PMID: 25436795 DOI: 10.1097/jto.0000000000000346] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Radiotherapy plays an important role in the management of lung cancer, with over 50% of patients receiving this modality at some point during their treatment. Intensity-modulated radiotherapy (IMRT) is a technique that adds fluence modulation to beam shaping, which improves radiotherapy dose conformity around the tumor and spares surrounding normal structures. Treatment with IMRT is becoming more widely available for the treatment of lung cancer, despite the paucity of high level evidence supporting the routine use of this more resource intense and complex technique. In this review article, we have summarized data from planning and clinical studies, discussed challenges in implementing IMRT, and made recommendations on the minimum requirements for safe delivery of IMRT.
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Goossens S, Descampe A, Orban de Xivry J, Lee JA, Delor A, Janssens G, Geets X. Impact of motion induced artifacts on automatic registration of lung tumors in Tomotherapy. Phys Med 2015; 31:963-968. [DOI: 10.1016/j.ejmp.2015.07.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 06/11/2015] [Accepted: 07/06/2015] [Indexed: 12/25/2022] Open
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Wang W, Yuan F, Wang G, Lin Z, Pan Y, Chen L. Three-dimensional conformal radiotherapy by delineations on CT-based simulation in different respiratory phases for the treatment of senile patients with non-small cell lung cancer. Onco Targets Ther 2015; 8:2461-7. [PMID: 26392773 PMCID: PMC4573072 DOI: 10.2147/ott.s86642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIM This study aimed to evaluate the application of three-dimensional conformal radiotherapy (3D-CRT) for elderly patients with non-small cell lung cancer (NSCLC) based on computed tomography (CT) simulations in different respiratory phases. METHODS A total of 64 patients aged >70 years old with NSCLC were treated by 3D-CRT using CT images in different respiratory phases. The gross tumor volumes (GTVs) at the end of inspiration and end of expiration were combined to obtain the total GTV, which was close to the motional range of tumors during respiration, and no additional expansion of the clinical target volume (CTAV) to planning target volume (PTV) (CTAV:PTV) was included during the recording of respiratory movements. Patients were also planned according to the classic 3D-CRT approach. Efficacy, prognostic factors, and side effects were evaluated. RESULTS Compared with the classic approach, the average PTV was 18.9% lower (median: 17.3%), and the average lung volume receiving a prescribed dose for a tumor was 22.4% lower (median: 20.9%). The 1-, 2-, and 3-year survival rates were 70.6%, 54.9%, and 29.4%, respectively, with an overall tumor response rate of 79.7%. The Karnofsky performance status and N stage were independent prognostic factors, whereas age was not. CONCLUSION Without affecting therapeutic effects, CT simulations in different respiratory phases were well-tolerated in elderly patients with NSCLC, could effectively reduce PTV, and could improve the quality of life.
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Affiliation(s)
- Weifeng Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China ; Department of Radiation Oncology, Haikou municipal hospital, Haikou, Hainan Province, People's Republic of China
| | - Feng Yuan
- Department of Radiation Oncology, Haikou municipal hospital, Haikou, Hainan Province, People's Republic of China
| | - Guoping Wang
- Department of Radiation Oncology, Haikou municipal hospital, Haikou, Hainan Province, People's Republic of China
| | - Zhiren Lin
- Department of Radiation Oncology, Haikou municipal hospital, Haikou, Hainan Province, People's Republic of China
| | - Yanling Pan
- Department of Radiation Oncology, Haikou municipal hospital, Haikou, Hainan Province, People's Republic of China
| | - Longhua Chen
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
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Kang KM, Jeong BK, Choi HS, Yoo SH, Hwang UJ, Lim YK, Jeong H. Combination effects of tissue heterogeneity and geometric targeting error in stereotactic body radiotherapy for lung cancer using CyberKnife. J Appl Clin Med Phys 2015; 16:193-204. [PMID: 26699300 PMCID: PMC5690167 DOI: 10.1120/jacmp.v16i5.5397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 07/13/2015] [Accepted: 05/13/2015] [Indexed: 12/31/2022] Open
Abstract
We have investigated the combined effect of tissue heterogeneity and its variation associated with geometric error in stereotactic body radiotherapy (SBRT) for lung cancer. The treatment plans for eight lung cancer patients were calculated using effective path length (EPL) correction and Monte Carlo (MC) algorithms, with both having the same beam configuration for each patient. These two kinds of plans for individual patients were then subsequently recalculated with adding systematic and random geometric errors. In the ordinary treatment plans calculated with no geometric offset, the EPL calculations, compared with the MC calculations, largely overestimated the doses to PTV by ∼21%, whereas the overestimation were markedly lower in GTV by ∼12% due to relatively higher density of GTV than of PTV. When recalculating the plans for individual patients with assigning the systematic and random geometric errors, no significant changes in the relative dose distribution, except for overall shift, were observed in the EPL calculations, whereas largely altered in the MC calculations with a consistent increase in dose to GTV. Considering the better accuracy of MC than EPL algorithms, the present results demonstrated the strong coupling of tissue heterogeneity and geometric error, thereby emphasizing the essential need for simultaneous correction for tissue heterogeneity and geometric targeting error in SBRT of lung cancer. PACS numbers: 87.55.D, 87.55.kh, 87.53.Ly, 87.55.‐x
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Affiliation(s)
- Ki Mun Kang
- GyeongSang National University; Gyeongsang National University Hospital.
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Hass P, Mohnike K. Extending the Frontiers Beyond Thermal Ablation by Radiofrequency Ablation: SBRT, Brachytherapy, SIRT (Radioembolization). VISZERALMEDIZIN 2015; 30:245-52. [PMID: 26288597 PMCID: PMC4513802 DOI: 10.1159/000366088] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Metastatic spread of the primary is still defined as the systemic stage of disease in treatment guidelines for various solid tumors. This definition is the rationale for systemic therapy. Interestingly and despite the concept of systemic involvement, surgical resection as a local treatment has proven to yield long-term outcomes in a subset of patients with limited metastatic disease, supporting the concept of oligometastatic disease. Radiofrequency ablation has yielded favorable outcomes in patients with hepatocellular carcinoma and colorectal metastases, and some studies indicate its prognostic potential in combined treatments with systemic therapies. However, some significant technical limitations apply, such as size limitation, heat sink effects, and unpredictable heat distribution to adjacent risk structures. Interventional and non-invasive radiotherapeutic techniques may overcome these limitations, expanding the options for oligometastatic patients and cytoreductive concepts. Current data suggest very high local control rates even in large tumors at any given location in the human body. The article focusses on the characteristics and possibilities of stereotactic body radiation therapy, interstitial high-dose-rate brachytherapy, and Yttrium-90 radioembolization. In this article, we discuss the differences of the technical preferences as well as their impact on indications. Current data is presented and discussed with a focus on application in oligometastatic or cytoreductive concepts in different tumor biologies.
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Affiliation(s)
- Peter Hass
- Department of Radiotherapy, Universitätsklinik Magdeburg AÖR, Magdeburg, Germany ; International School of Image-Guided Interventions/Deutsche Akademie für Mikrotherapie, Magdeburg, Germany
| | - Konrad Mohnike
- International School of Image-Guided Interventions/Deutsche Akademie für Mikrotherapie, Magdeburg, Germany ; Department of Radiology and Nuclear Medicine, Universitätsklinik Magdeburg AÖR, Magdeburg, Germany
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Böhler A, Weichenberger H, Gaisberger C, Sedlmayer F, Deutschmann H. Collimator based tracking with an add-on multileaf collimator: Moduleaf. Phys Med Biol 2015; 60:3257-69. [PMID: 25826405 DOI: 10.1088/0031-9155/60/8/3257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Radiotherapy is one of the most important methods used for the treatment of cancer. Irradiating a moving target is also one of the most challenging tasks to accomplish in modern radiotherapy. We have developed a tracking system by modifying an add-on collimator, the Siemens Moduleaf, for realtime applications in radiotherapy. As the add-on collimator works nearly completely independently of the linear accelerator (LinAc), no modifications to the latter were necessary. The adaptations to the Moduleaf were mainly software-based. In order to reduce the complexity of the system, outdated electronic parts were replaced with newer components where practical.Verification was performed by measuring the latency of the system as well as the impact on applied dose to a predefined target volume, moving in the leaf's travel direction. Latency measurements in the software were accomplished by comparing the target and current positions of the leaves. For dose measurements, a Gafchromic EBT2 film was placed beneath the target 4D phantom, in between solid water plates and moved alongside with it. Comparing the dose distribution on the film with a moving target between 'tracking disabled' towards 'tracking enabled' functions resulted in penumbra widths of 23 mm to 4 mm for 0.1 Hz sinusoidal movements with an amplitude of 32 mm, respectively. The maximum speed was therefore 20 mm s(-1). Latency was measured to be less than 50 ms for the signal runtimes. Based on the results, a tracking-capable add-on collimator seems to be a useful tool for reducing the margins for the treatment of small, slow-moving targets.
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Affiliation(s)
- A Böhler
- Institute for Research and Development on Advanced Radiation Technologies, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
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Miura H, Inoue T, Shiomi H, Oh RJ. Differences in rates of radiation-induced true and false rib fractures after stereotactic body radiation therapy for Stage I primary lung cancer. JOURNAL OF RADIATION RESEARCH 2015; 56:332-7. [PMID: 25504640 PMCID: PMC4380054 DOI: 10.1093/jrr/rru107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 10/10/2014] [Accepted: 10/14/2014] [Indexed: 05/30/2023]
Abstract
The purpose of this study was to analyze the dosimetry and investigate the clinical outcomes of radiation-induced rib fractures (RIRFs) after stereotactic body radiotherapy (SBRT). A total of 126 patients with Stage I primary lung cancer treated with SBRT, who had undergone follow-up computed tomography (CT) at least 12 months after SBRT and who had no previous overlapping radiation exposure were included in the study. We used the Mantel-Haenszel method and multiple logistic regression analysis to compare risk factors. We analyzed D(0.5 cm(3)) (minimum absolute dose received by a 0.5-cm(3) volume) and identified each rib that received a biologically effective dose (BED) (BED3, using the linear-quadratic (LQ) formulation assuming an α/β = 3) of at least 50 Gy. Of the 126 patients, 46 (37%) suffered a total of 77 RIRFs. The median interval from SBRT to RIRF detection was 15 months (range, 3-56 months). The 3-year cumulative probabilities were 45% (95% CI, 34-56%) and 3% (95% CI, 0-6%), for Grades 1 and 2 RIRFs, respectively. Multivariate analysis showed that tumor location was a statistically significant risk factor for the development of Grade 1 RIRFs. Of the 77 RIRFs, 71 (92%) developed in the true ribs (ribs 1-7), and the remaining six developed in the false ribs (ribs 8-12). The BED3 associated with 10% and 50% probabilities of RIRF were 55 and 210 Gy to the true ribs and 240 and 260 Gy to the false ribs. We conclude that RIRFs develop more frequently in true ribs than in false ribs.
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Affiliation(s)
- Hideharu Miura
- Miyakojima IGRT Clinic, 1-16-22 Miyakojima Hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Toshihiko Inoue
- Miyakojima IGRT Clinic, 1-16-22 Miyakojima Hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hiroya Shiomi
- Miyakojima IGRT Clinic, 1-16-22 Miyakojima Hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Ryoong-Jin Oh
- Miyakojima IGRT Clinic, 1-16-22 Miyakojima Hondori, Miyakojima-ku, Osaka, 534-0021, Japan
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Are therapeutic radiographers able to achieve clinically acceptable verification for stereotactic lung radiotherapy treatment (SBRT)? JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s1460396914000478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractPurposeThe aim of this study was to assess the feasibility of radiographer led verification of cone-beam computed tomography (CBCT) images for patients with solitary lung tumours treated with stereotactic body radiotherapy treatment (SBRT).Material and methodsCBCT setup images of 20 patients from the first fraction of each patient were retrospectively registered by therapeutic radiographers. The displacements recorded were compared with the clinical oncologist’s original online match. The time taken by radiographers to verify the CBCT images was also recorded.ResultsOverall agreement for all radiographers when compared with the clinical oncologist match was 91%. Interobserver variations between radiographers were X plane 0·87 (0·76–0·94); Y plane 0·74 (0·51–0·88); and Z plane 0·88 (0·78–0·95) intraclass correlation coefficient and 95% confidence interval. The average time taken for verification was 128 seconds.ConclusionTherapeutic radiographers are able to verify CBCT images for thorax SBRT with results comparable to the ‘gold standard’ clinical oncologists’ match, however additional training will be provided for online verification. The time taken was within acceptable limits.
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Feasibility study of automated framework for estimating lung tumor locations for target-based patient positioning in stereotactic body radiotherapy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:653974. [PMID: 25629051 PMCID: PMC4299540 DOI: 10.1155/2015/653974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/31/2014] [Accepted: 10/31/2014] [Indexed: 12/25/2022]
Abstract
Objective. To investigate the feasibility of an automated framework for estimating the lung tumor locations for tumor-based patient positioning with megavolt-cone-beam computed tomography (MV-CBCT) during stereotactic body radiotherapy (SBRT). Methods. A lung screening phantom and ten lung cancer cases with solid lung tumors, who were treated with SBRT, were employed to this study. The locations of tumors in MV-CBCT images were estimated using a tumor-template matching technique between a tumor template and the MV-CBCT. Tumor templates were produced by cropping the gross tumor volume (GTV) regions, which were enhanced by a Sobel filter or a blob structure enhancement (BSE) filter. Reference tumor locations (grand truth) were determined based on a consensus between a radiation oncologist and a medical physicist. Results. According to the results of the phantom study, the average Euclidean distances of the location errors in the original, Sobel-filtered, and BSE-filtered images were 2.0 ± 4.1 mm, 12.8 ± 9.4 mm, and 0.4 ± 0.5 mm, respectively. For clinical cases, these were 3.4 ± 7.1 mm, 7.2 ± 11.6 mm, and 1.6 ± 1.2 mm, respectively. Conclusion. The feasibility study suggests that our proposed framework based on the BSE filter may be a useful tool for tumor-based patient positioning in SBRT.
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Uzel EK, Abacıoğlu U. Treatment of early stage non-small cell lung cancer: surgery or stereotactic ablative radiotherapy? Balkan Med J 2015; 32:8-16. [PMID: 25759766 PMCID: PMC4342143 DOI: 10.5152/balkanmedj.2015.15553] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/27/2014] [Indexed: 12/20/2022] Open
Abstract
The management of early-stage Non-small Cell Lung Cancer (NSCLC) has improved recently due to advances in surgical and radiation modalities. Minimally-invasive procedures like Video-assisted thoracoscopic surgery (VATS) lobectomy decreases the morbidity of surgery, while the numerous methods of staging the mediastinum such as endobronchial and endoscopic ultrasound-guided biopsies are helping to achieve the objectives much more effectively. Stereotactic Ablative Radiotherapy (SABR) has become the frontrunner as the standard of care in medically inoperable early stage NSCLC patients, and has also been branded as tolerable and highly effective. Ongoing researches using SABR are continuously validating the optimal dosing and fractionation schemes, while at the same time instituting its role for both inoperable and operable patients.
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Affiliation(s)
- Esengül Koçak Uzel
- Department of Radiation Oncology, Neolife Medical Center, İstanbul, Turkey
| | - Ufuk Abacıoğlu
- Department of Radiation Oncology, Neolife Medical Center, İstanbul, Turkey
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Interfractional variations of tumor centroid position and tumor regression during stereotactic body radiotherapy for lung tumor. BIOMED RESEARCH INTERNATIONAL 2014; 2014:372738. [PMID: 25548770 PMCID: PMC4274869 DOI: 10.1155/2014/372738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/11/2014] [Accepted: 10/02/2014] [Indexed: 12/25/2022]
Abstract
Purpose. To determine interfractional changes of lung tumor centroid position and tumor regression during stereotactic body radiation therapy (SBRT). Methods and Materials. 34 patients were treated by SBRT in 4-5 fractions to a median dose of 50 Gy. The CT scans acquired for verification were registered with simulation CT scans. The gross target volume (GTV) was contoured on all verification CT scans and compared to the initial GTV in treatment plan system. Results. The mean (±standard deviation, SD) three-dimension vector shift was 5.2 ± 3.1 mm. The mean (±SD) interfractional variations of tumor centroid position were −0.7 ± 4.5 mm in anterior-posterior (AP) direction, 0.2 ± 3.1 mm in superior-inferior (SI) direction, and 0.4 ± 2.4 mm in right-left (RL) direction. Large interfractional variations (≥5 mm) were observed in 5 fractions (3.3%) in RL direction, 16 fractions (10.5%) in SI direction, and 36 fractions (23.5%) in AP direction. Tumor volume did not decrease significantly during lung SBRT. Conclusions. Small but insignificant tumor volume regression was observed during lung SBRT. While the mean interfractional variations of tumor centroid position were minimal in three directions, variations more than 5 mm account for approximately a third of all, indicating additional margin for PTV, especially in AP direction.
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Trakul N, Koong AC, Chang DT. Stereotactic body radiotherapy in the treatment of pancreatic cancer. Semin Radiat Oncol 2014; 24:140-7. [PMID: 24635871 DOI: 10.1016/j.semradonc.2013.11.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Most patients diagnosed with pancreatic cancer are unable to have a curative surgical resection. Chemoradiation is a standard of care treatment for patients with locally advanced unresectable disease, but local failure rates are high with conventionally fractionated radiotherapy. However, stereotactic body radiotherapy (SBRT) or stereotactic ablative radiotherapy offers an alternative type of radiation therapy, which allows for the delivery of high-dose, conformal radiation. The high doses and shorter overall treatment time with SBRT may provide advantages in local control, disease outcomes, quality of life, and cost-effectiveness, and further investigation is currently underway. Here, we review the technology behind SBRT for pancreatic malignancy and its future direction in the overall management of pancreatic cancer.
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Affiliation(s)
- Nicholas Trakul
- Department of Radiation Oncology, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Albert C Koong
- Department of Radiation Oncology, Stanford University School of Medicine and Cancer Center, Stanford, CA
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine and Cancer Center, Stanford, CA.
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Serpa M, Baier K, Cremers F, Guckenberger M, Meyer J. Suitability of markerless EPID tracking for tumor position verification in gated radiotherapy. Med Phys 2014; 41:031702. [PMID: 24593706 DOI: 10.1118/1.4863597] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To maximize the benefits of respiratory gated radiotherapy (RGRT) of lung tumors real-time verification of the tumor position is required. This work investigates the feasibility of markerless tracking of lung tumors during beam-on time in electronic portal imaging device (EPID) images of the MV therapeutic beam. METHODS EPID movies were acquired at ∼2 fps for seven lung cancer patients with tumor peak-to-peak motion ranges between 7.8 and 17.9 mm (mean: 13.7 mm) undergoing stereotactic body radiotherapy. The external breathing motion of the abdomen was synchronously measured. Both datasets were retrospectively analyzed in PortalTrack, an in-house developed tracking software. The authors define a three-step procedure to run the simulations: (1) gating window definition, (2) gated-beam delivery simulation, and (3) tumor tracking. First, an amplitude threshold level was set on the external signal, defining the onset of beam-on/-off signals. This information was then mapped onto a sequence of EPID images to generate stamps of beam-on/-hold periods throughout the EPID movies in PortalTrack, by obscuring the frames corresponding to beam-off times. Last, tumor motion in the superior-inferior direction was determined on portal images by the tracking algorithm during beam-on time. The residual motion inside the gating window as well as target coverage (TC) and the marginal target displacement (MTD) were used as measures to quantify tumor position variability. RESULTS Tumor position monitoring and estimation from beam's-eye-view images during RGRT was possible in 67% of the analyzed beams. For a reference gating window of 5 mm, deviations ranging from 2% to 86% (35% on average) were recorded between the reference and measured residual motion. TC (range: 62%-93%; mean: 77%) losses were correlated with false positives incidence rates resulting mostly from intra-/inter-beam baseline drifts, as well as sudden cycle-to-cycle fluctuations in exhale positions. Both phenomena can lead to considerable deviations (with MTD values up to a maximum of 7.8 mm) from the intended tumor position, and in turn may result in a marginal miss. The difference between tumor traces determined within the gating window against ground truth trajectory maps was 1.1 ± 0.7 mm on average (range: 0.4-2.3 mm). CONCLUSIONS In this retrospective analysis of motion data, it is demonstrated that the system is capable of determining tumor positions in the plane perpendicular to the beam direction without the aid of fiducial markers, and may hence be suitable as an online verification tool in RGRT. It may be possible to use the tracking information to enable on-the-fly corrections to intra-/inter-beam variations by adapting the gating window by means of a robotic couch.
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Affiliation(s)
- Marco Serpa
- Institute for Research and Development on Advanced Radiation Technologies (radART), Paracelsus Medical University, 5020 Salzburg, Austria; University Clinic for Radiotherapy and Radio-Oncology, Landeskrankenhaus Salzburg, Paracelsus Medical University Clinics, 5020 Salzburg, Austria; and Department of Physics and Astronomy, University of Canterbury, Christchurch 8140, New Zealand
| | - Kurt Baier
- Department of Radiation Oncology, University of Wuerzburg, D-97080 Wuerzburg, Germany
| | - Florian Cremers
- Department of Radiation Oncology, University Medical Center Hamburg Eppendorf, D-20246 Hamburg, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University of Wuerzburg, D-97080 Wuerzburg, Germany
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington, Seattle, Washington 98195, USA
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Chi A, Nguyen NP, Komaki R. The potential role of respiratory motion management and image guidance in the reduction of severe toxicities following stereotactic ablative radiation therapy for patients with centrally located early stage non-small cell lung cancer or lung metastases. Front Oncol 2014; 4:151. [PMID: 25009800 PMCID: PMC4070060 DOI: 10.3389/fonc.2014.00151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 05/30/2014] [Indexed: 12/25/2022] Open
Abstract
Image guidance allows delivery of very high doses of radiation over a few fractions, known as stereotactic ablative radiotherapy (SABR). This treatment is associated with excellent outcome for early stage non-small cell lung cancer and metastases to the lungs. In the delivery of SABR, central location constantly poses a challenge due to the difficulty of adequately sparing critical thoracic structures that are immediately adjacent to the tumor if an ablative dose of radiation is to be delivered to the tumor target. As of current, various respiratory motion management and image guidance strategies can be used to ensure accurate tumor target localization prior and/or during daily treatment, which allows for maximal and safe reduction of set up margins. The incorporation of both may lead to the most optimal normal tissue sparing and the most accurate SABR delivery. Here, the clinical outcome, treatment related toxicities, and the pertinent respiratory motion management/image guidance strategies reported in the current literature on SABR for central lung tumors are reviewed.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | | | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center , Houston, TX , USA
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Cole A, Hanna G, Jain S, O'Sullivan J. Motion Management for Radical Radiotherapy in Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2014; 26:67-80. [DOI: 10.1016/j.clon.2013.11.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 11/28/2022]
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Boda-Heggemann J, Frauenfeld A, Weiss C, Simeonova A, Neumaier C, Siebenlist K, Attenberger U, Heußel CP, Schneider F, Wenz F, Lohr F. Clinical outcome of hypofractionated breath-hold image-guided SABR of primary lung tumors and lung metastases. Radiat Oncol 2014; 9:10. [PMID: 24401323 PMCID: PMC3909294 DOI: 10.1186/1748-717x-9-10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 12/23/2013] [Indexed: 01/04/2023] Open
Abstract
Background Stereotactic Ablative RadioTherapy (SABR) of lung tumors/metastases has been shown to be an effective treatment modality with low toxicity. Outcome and toxicity were retrospectively evaluated in a unique single-institution cohort treated with intensity-modulated image-guided breath-hold SABR (igSABR) without external immobilization. The dose–response relationship is analyzed based on Biologically Equivalent Dose (BED). Patients and methods 50 lesions in 43 patients with primary NSCLC (n = 27) or lung-metastases of various primaries (n = 16) were consecutively treated with igSABR with Active-Breathing-Coordinator (ABC®) and repeat-breath-hold cone-beam-CT. After an initial dose-finding/-escalation period, 5x12 Gy for peripheral lesions and single doses of 5 Gy to varying dose levels for central lesions were applied. Overall-survival (OS), progression-free-survival (PFS), progression pattern, local control (LC) and toxicity were analyzed. Results The median BED2 was 83 Gy. 12 lesions were treated with a BED2 of <80 Gy, and 38 lesions with a BED2 of >80 Gy. Median follow-up was 15 months. Actuarial 1- and 2-year OS were 67% and 43%; respectively. Cause of death was non-disease-related in 27%. Actuarial 1- and 2-year PFS was 42% and 28%. Progression site was predominantly distant. Actuarial 1- and 2 year LC was 90% and 85%. LC showed a trend for a correlation to BED2 (p = 0.1167). Pneumonitis requiring conservative treatment occurred in 23%. Conclusion Intensity-modulated breath-hold igSABR results in high LC-rates and low toxicity in this unfavorable patient cohort with inoperable lung tumors or metastases. A BED2 of <80 Gy was associated with reduced local control.
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Affiliation(s)
- Judit Boda-Heggemann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Padda SK, Burt BM, Trakul N, Wakelee HA. Early-stage non-small cell lung cancer: surgery, stereotactic radiosurgery, and individualized adjuvant therapy. Semin Oncol 2013; 41:40-56. [PMID: 24565580 DOI: 10.1053/j.seminoncol.2013.12.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite cures in early stage (IA-IIB) non-small cell lung cancer (NSCLC), the 5-year survival rate is only 36%-73%. Surgical resection via lobectomy is the treatment of choice in early-stage NSCLC, with the goal being complete anatomic resection of the tumor and mediastinal lymph node evaluation. Newer technologies, including the minimally invasive thoracoscopic approach and the many techniques available to stage the mediastinum, have introduced advantages over traditional approaches in achieving this goal. The advent of stereotactic ablative radiotherapy (SABR) has changed how we treat those patients who cannot undergo surgery secondary to comorbidities or patient preference. SABR allows for precise radiation delivery in a short course and at high doses. Adjuvant cisplatin-based chemotherapy is the standard of care for completely resected high-risk stage IB and stage II NSCLC based on a ~5% improvement in 5-year overall survival. The concept of customized adjuvant chemotherapy is emerging, and we will explore the potential value of targeting tumor mutations with available drugs (ie, epidermal growth factor receptor [EGFR] mutations with erlotinib), a strategy that for the moment should be restricted to clinical trials.
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Affiliation(s)
- Sukhmani K Padda
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | - Bryan M Burt
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nicholas Trakul
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, CA.
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Guckenberger M, Andratschke N, Alheit H, Holy R, Moustakis C, Nestle U, Sauer O. Definition of stereotactic body radiotherapy: principles and practice for the treatment of stage I non-small cell lung cancer. Strahlenther Onkol 2013; 190:26-33. [PMID: 24052011 PMCID: PMC3889283 DOI: 10.1007/s00066-013-0450-y] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 08/05/2013] [Indexed: 02/08/2023]
Abstract
This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of other international societies. SBRT is defined as a method of external beam radiotherapy (EBRT) that accurately delivers a high irradiation dose to an extracranial target in one or few treatment fractions. Detailed recommendations concerning the principles and practice of SBRT for early stage non-small cell lung cancer (NSCLC) are given. These cover the entire treatment process; from patient selection, staging, treatment planning and delivery to follow-up. SBRT was identified as the method of choice when compared to best supportive care (BSC), conventionally fractionated radiotherapy and radiofrequency ablation. Based on current evidence, SBRT appears to be on a par with sublobar resection and is an effective treatment option in operable patients who refuse lobectomy.
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Affiliation(s)
- M Guckenberger
- Department of Radiation Oncology, University of Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany,
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Chan MKH, Kwong DLW, Law GML, Tam E, Tong A, Lee V, Ng SCY. Dosimetric evaluation of four-dimensional dose distributions of CyberKnife and volumetric-modulated arc radiotherapy in stereotactic body lung radiotherapy. J Appl Clin Med Phys 2013; 14:4229. [PMID: 23835388 PMCID: PMC5714543 DOI: 10.1120/jacmp.v14i4.4229] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 03/09/2013] [Accepted: 02/27/2013] [Indexed: 12/02/2022] Open
Abstract
Advanced image‐guided stereotatic body lung radiotherapy techniques using volumetric‐modulated arc radiotherapy (VMAT) with four‐dimensional cone‐beam computed tomography (4D CBCT) and CyberKnife with real‐time target tracking have been clinically implemented by different authors. However, dosimetric comparisons between these techniques are lacking. In this study, 4D CT scans of 14 patients were used to create VMAT and CyberKnife treatment plans using 4D dose calculations. The GTV and the organs at risk (OARs) were defined on the end‐exhale images for CyberKnife planning and were then deformed to the midventilation images (MidV) for VMAT optimization. Direct 4D Monte Carlo dose optimizations were performed for CyberKnife (4DCK). Four‐dimensional dose calculations were also applied to VMAT plans to generate the 4D dose distributions (4DVMAT) on the exhale images for direct comparisons with the 4DCK plans. 4DCK and 4DVMAT showed comparable target conformity (1.31±0.13 vs. 1.39±0.24,p=0.05). GTV mean doses were significantly higher with 4DCK. Statistical differences of dose volume metrics were not observed in the majority of OARs studied, except for esophagus, with 4DVMAT yielding marginally higher D1% than 4DCK. The normal tissue volumes receiving 80%, 50%, and 30% of the prescription dose (V80%,V50%, and V30%) were higher with 4DVMAT, whereas 4DCK yielded slightly higher V10% in posterior lesions than 4DVMAT. VMAT resulted in much less monitor units and therefore greater delivery efficiency than CyberKnife. In general, it was possible to produce dosimetrically acceptable plans with both techniques. The selection of treatment modality should consider the dosimetric results as well as the patient's tolerance of the treatment process specific to the SBRT technique. PACS numbers: 87.53.Ly, 87.55.km
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Affiliation(s)
- Mark K H Chan
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China.
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Verstegen NE, Lagerwaard FJ, Senan S. Developments in early-stage NSCLC: advances in radiotherapy. Ann Oncol 2013; 23 Suppl 10:x46-51. [PMID: 22987992 DOI: 10.1093/annonc/mds301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
An increase in the number of predominantly elderly patients with early-stage non-small-cell lung cancer is anticipated in many Western populations. Patients often have major co-morbidities and are at increased risk for surgical morbidity and mortality. In the past decade, the use of stereotactic ablative radiotherapy (SABR) has achieved excellent results, with only mild toxicity in such vulnerable patient groups, leading to SABR becoming accepted as a standard of care for unfit patients in several countries. The planning and delivery of SABR has rapidly improved in recent years, particularly with the use of 'on-board' imaging at treatment units, and shortened treatment delivery times. Increasingly, more central tumors are being treated using lower doses per fraction (so-called risk-adapted schemes). It is also becoming clear that long-term follow-up should take place at specialist centers in order to distinguish the evolving fibrosis that is frequently observed from the relatively infrequent local recurrences. Given the high local control rates and limited toxicity, increasing attention is being paid to the use of SABR in the subgroup of so-called borderline operable patients, and clinical trials comparing surgery and SABR in these patients are ongoing.
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Affiliation(s)
- N E Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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