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McWilliam A, Abravan A, Banfill K, Faivre-Finn C, van Herk M. Demystifying the Results of RTOG 0617: Identification of Dose Sensitive Cardiac Subregions Associated With Overall Survival. J Thorac Oncol 2023; 18:599-607. [PMID: 36738929 DOI: 10.1016/j.jtho.2023.01.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The RTOG 0617 trial presented a worse survival for patients with lung cancer treated in the high-dose (74 Gy) arm. In multivariable models, radiation level and whole-heart volumetric dose parameters were associated with survival. In this work, we consider heart subregions to explain the observed survival difference between radiation levels. METHODS Voxel-based analysis identified anatomical regions where the dose was associated with survival. Bootstrapping clinical and dosimetric variables into an elastic net model selected variables associated with survival. Multivariable Cox regression survival models assessed the significance of dose to the heart subregion, compared with whole heart v5 and v30. Finally, the trial outcome was assessed after propensity score matching of patients on lung dose, heart subregion dose, and tumor volume. RESULTS A total of 458 patients were eligible for voxel-based analysis. A region of significance (p < 0.001) was identified in the base of the heart. Bootstrapping selected mean lung dose, radiation level, log tumor volume, and heart region dose. The multivariable Cox model exhibited dose to the heart region (p = 0.02), and tumor volume (p = 0.03) were significantly associated with survival, and radiation level was not significant (p = 0.07). The models exhibited that whole heart v5 and v30 were not associated with survival, with radiation level being significant (p < 0.05). In the matched cohort, no significant survival difference was seen between radiation levels. CONCLUSIONS Dose to the base of the heart is associated with overall survival, partly removing the radiation level effect, and explaining that worse survival in the high-dose arm is owing, in part, to the heart subregion dose. By defining a heart avoidance region, future dose escalation trials may be feasible.
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Affiliation(s)
- Alan McWilliam
- The Division of Cancer Science, The University of Manchester, Manchester, United Kingdom; The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.
| | - Azadeh Abravan
- The Division of Cancer Science, The University of Manchester, Manchester, United Kingdom; The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Kathryn Banfill
- The Division of Cancer Science, The University of Manchester, Manchester, United Kingdom; The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- The Division of Cancer Science, The University of Manchester, Manchester, United Kingdom; The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- The Division of Cancer Science, The University of Manchester, Manchester, United Kingdom; The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
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Abravan A, Price G, Banfill K, Marchant T, Craddock M, Wood J, Aznar MC, McWilliam A, van Herk M, Faivre-Finn C. Role of Real-World Data in Assessing Cardiac Toxicity After Lung Cancer Radiotherapy. Front Oncol 2022; 12:934369. [PMID: 35928875 PMCID: PMC9344971 DOI: 10.3389/fonc.2022.934369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Radiation-induced heart disease (RIHD) is a recent concern in patients with lung cancer after being treated with radiotherapy. Most of information we have in the field of cardiac toxicity comes from studies utilizing real-world data (RWD) as randomized controlled trials (RCTs) are generally not practical in this field. This article is a narrative review of the literature using RWD to study RIHD in patients with lung cancer following radiotherapy, summarizing heart dosimetric factors associated with outcome, strength, and limitations of the RWD studies, and how RWD can be used to assess a change to cardiac dose constraints.
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Affiliation(s)
- Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Gareth Price
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Kathryn Banfill
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Tom Marchant
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Matthew Craddock
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Joe Wood
- Christie Medical Physics and Engineering, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Marianne C. Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
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Ghandourh W, Dowling J, Chlap P, Oar A, Jacob S, Batumalai V, Holloway L. Assessing tumor centrality in lung stereotactic ablative body radiotherapy (SABR): the effects of variations in bronchial tree delineation and potential for automated methods. Med Dosim 2020; 46:94-101. [PMID: 33067108 DOI: 10.1016/j.meddos.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/19/2020] [Accepted: 09/11/2020] [Indexed: 12/25/2022]
Abstract
Accurate delineation of the proximal bronchial tree (PBT) is crucial for appropriate assessment of lung tumor centrality and choice of Stereotactic Ablative Body Radiotherapy (SABR) dose prescription. Here, we investigate variabilities in manual PBT delineation and their potential to influence assessing lesion centrality. A fully automatic, intensity-based tool for PBT contouring and measuring distance to the target is also described. This retrospective analysis included a total of 61 patients treated with lung SABR. A subset of 41 patients was used as a training dataset, containing clinical PBT contour and additional subsequently generated manual contours. The tool was optimized and compared against manual contours in terms of volume, distance to the target and various overlap/similarity metrics. The remaining 20 patients were used as a validation dataset to investigate the dosimetric effects of variations between manual and automatic PBT contours. Considerable interobserver variability was observed, particularly in identifying the superior and inferior borders of the PBT. Automatic PBT contours were comparable to manual contours with average Dice of 0.63 to 0.79 and mean distance to agreement of 1.78 to 3.34 mm. No significant differences in dosimetric parameters were found between automatically and manually generated contours. A moderate negative correlation was found between PBT maximum dose and distance to the lesion (p < 0.05). Variability in manual PBT delineation may result in inconsistent assessment of tumor centrality. Automatic contouring can help standardize clinical practice, support investigations into the link between SABR outcomes and lesion proximity to central airways and the development of predictive toxicity models that incorporate precise measurements of tumor location in relation to high-risk organs.
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Affiliation(s)
- Wsam Ghandourh
- South Western Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia.
| | - Jason Dowling
- Commonwealth Scientific and Industrial Research Organisation (CSIRO), Australia; Australian E-Health Research Centre, Herston, QLD 4029, Australia
| | - Phillip Chlap
- South Western Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Andrew Oar
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Sydney, Australia; Western Sydney University, Campbelltown, New South Wales, Australia; Radiation Oncology Centres, Gold Coast University Hospital, Gold Coast, Australia
| | - Susannah Jacob
- South Western Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Sydney, Australia
| | - Vikneswary Batumalai
- South Western Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Sydney, Australia
| | - Lois Holloway
- South Western Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia; Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia; Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, USA
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Nardone V, Giugliano FM, Reginelli A, Sangiovanni A, Mormile M, Iadanza L, Cappabianca S, Guida C. 4D CT analysis of organs at risk (OARs) in stereotactic radiotherapy. Radiother Oncol 2020; 151:10-14. [PMID: 32622777 DOI: 10.1016/j.radonc.2020.06.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 12/25/2022]
Abstract
Internal organs at risk volumes (IRV) represent the propagation of organs at risk (OARs) in 4DCT. Sixty consecutive patients that underwent 4DCT for thoracic stereotactic radiotherapy were analyzed and IRVs for heart, trachea, esophagus, bronchial tree, great vessels, and spinal cord were calculated. IRVs were then tested for the respect of dose constraints. IRVs were significantly bigger than standard OARs (p-value <0.001 for all the IRVs). IRVs that did not respect the dose constraints were, respectively, 7/60 (11.7%) for Heart IRV, 6/60 (10%) for Esophagus IRV, 11/60 (18.3%) for Trachea IRV, 16/60 (26.6%) for Bronchial Tree and 0/60 (0%) for great vessel and spinal cord IRV. In the subset of central targets, the percentage of plans that can be unacceptable taking into consideration OARs motion reaches 42%. The correlation of IRVs with clinical parameters and toxicity deserves future investigations in prospective trials.
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Affiliation(s)
- Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, Naples, Italy.
| | | | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Mormile
- Unit of Radiation Oncology, Ospedale del Mare, Naples, Italy
| | - Luciano Iadanza
- Unit of Radiation Oncology, Rummo General Hospital, Benevento, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Cesare Guida
- Unit of Radiation Oncology, Ospedale del Mare, Naples, Italy
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Quantitative evaluation of 4D Cone beam CT scans with reduced scan time in lung cancer patients. Radiother Oncol 2019; 136:64-70. [PMID: 31015131 PMCID: PMC6598855 DOI: 10.1016/j.radonc.2019.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 11/21/2022]
Abstract
Fast (2 min) 4D CBCT can be simulated accurately from long (4 min) scans. Registration was accurate for 96.6% of simulated 2 min scans. Acquired 2 min scan registration was accurate in 6/8 patients. 2 min 4D CBCT produces sufficient image quality for IGRT in lung cancer patients.
Purpose Image guided radiotherapy (IGRT) based on respiration correlated cone-beam CT (4D-CBCT) provides accurate tumour localisation in lung cancer patients by taking into account respiratory motion when deriving setup correction. However, 4D-CBCT scan times are typically longer than for acquisition of 3D-CBCT scans, e.g. 4 min. This work aims to quantitatively evaluate the effect of reduced scan times on 4D-CBCT image quality and registration accuracy in lung cancer patients. Methods and materials Scan times down to 1 min were simulated by retaining only projection images corresponding to every second, third or fourth respiratory cycle in forty-four 4D-CBCTs from 15 lung cancer patients. In addition twenty 2-minute scans were acquired for 12 lung cancer patients. Image quality was quantified by assessing registration accuracy in the shorter scan times, comparing to the 4-minute scan registration result where available as reference. Results Use of 2-minute scans had little impact on registration accuracy or ability to detect tumour motion: automatic registration accuracy was within 2 mm in 6/8 scans analysed with 2-minute acquisitions, and 96.6% of registration discrepancies were within 2 mm for the simulated scans. When the scan time simulated was below 2 min, automatic registration results still agreed within 2 mm for 84.7% of scans, however visual image quality was considerably degraded. Conclusion A 4D-CBCT acquisition time of 2 min produces scans of sufficient image quality for IGRT in most lung cancer patients, as demonstrated quantitatively by assessing the impact on automatic registration accuracy in simulated and real acquisitions.
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