Animation and radiobiological analysis of 3D motion in conformal radiotherapy

A validated tumor control probability model based on a meta-analysis of low, intermediate, and high-risk prostate cancer patients treated by photon, proton, or carbon-ion radiotherapy

PURPOSE

A fully heterogeneous population averaged mechanistic tumor control probability (TCP) model is appropriate for the analysis of external beam radiotherapy (EBRT). This has been accomplished for EBRT photon treatment of intermediate-risk prostate cancer. Extending the TCP model for low and high-risk patients would be beneficial in terms of overall decision making. Furthermore, different radiation treatment modalities such as protons and carbon-ions are becoming increasingly available. Consequently, there is a need for a complete TCP model.

METHODS

A TCP model was fitted and validated to a primary endpoint of 5-year biological no evidence of disease clinical outcome data obtained from a review of the literature for low, intermediate, and high-risk prostate cancer patients (5218 patients fitted, 1088 patients validated), treated by photons, protons, or carbon-ions. The review followed the preferred reporting item for systematic reviews and meta-analyses statement. Treatment regimens include standard fractionation and hypofractionation treatments. Residual analysis and goodness of fit statistics were applied.

RESULTS

The TCP model achieves a good level of fit overall, linear regression results in a p-value of <0.000 01 with an adjusted-weighted-R(2) value of 0.77 and a weighted root mean squared error (wRMSE) of 1.2%, to the fitted clinical outcome data. Validation of the model utilizing three independent datasets obtained from the literature resulted in an adjusted-weighted-R(2) value of 0.78 and a wRMSE of less than 1.8%, to the validation clinical outcome data. The weighted mean absolute residual across the entire dataset is found to be 5.4%.

CONCLUSIONS

This TCP model fitted and validated to clinical outcome data, appears to be an appropriate model for the inclusion of all clinical prostate cancer risk categories, and allows evaluation of current EBRT modalities with regard to tumor control prediction.

Evaluation of intrafraction patient movement for CNS and head & neck IMRT

Intrafraction patient motion is much more likely in intensity-modulated radiation therapy (IMRT) than in conventional radiotherapy primarily due to longer beam delivery times in IMRT treatment. In this study, we evaluated the uncertainty of intrafraction patient displacement in CNS and head and neck IMRT patients. Immobilization is performed in three steps: (1) the patient is immobilized with thermoplastic facemask, (2) the patient displacement is monitored using a commercial stereotactic infrared IR camera (ExacTrac, BrainLab) during treatment, and (3) repositioning is carried out as needed. The displacement data were recorded during beam-on time for the entire treatment duration for 5 patients using the camera system. We used the concept of cumulative time versus patient position uncertainty, referred to as an uncertainty time histogram (UTH), to analyze the data. UTH is a plot of the accumulated time during which a patient stays within the corresponding movement uncertainty. The University of Florida immobilization procedure showed an effective immobilization capability for CNS and head and neck IMRT patients by keeping the patient displacement less than 1.5 mm for 95% of treatment time (1.43 mm for 1, and 1.02 mm for 1, and less than 1.0 mm for 3 patients). The maximum displacement was 2.0 mm.

[Probabilities of controlling tumors and complications (TCP/NTCP) after radiotherapy: methodologic, physical, and biological aspects]

Radiotherapy is aimed at getting the best possible therapeutic ratio (tumor local control versus morbidity). Physicists and radiation oncologists have to evaluate explicitly or implicitly the probability of induced complications to normal surrounding tissues. This is based on published data and clinician's experience. Quantitative methods have been introduced with different models in order to predict the impact of partial or global irradiation on a normal organ. These models correspond to the Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP). These biological models may be useful to evaluate the quality of a treatment planning or for the optimization process. The methodologies used and the clinical data are developed and discussed.

Inclusion of geometric uncertainties in treatment plan evaluation

PURPOSE

To correctly evaluate realistic treatment plans in terms of absorbed dose to the clinical target volume (CTV), equivalent uniform dose (EUD), and tumor control probability (TCP) in the presence of execution (random) and preparation (systematic) geometric errors.

MATERIALS AND METHODS

The dose matrix is blurred with all execution errors to estimate the total dose distribution of all fractions. To include preparation errors, the CTV is randomly displaced (and optionally rotated) many times with respect to its planned position while computing the dose, EUD, and TCP for the CTV using the blurred dose matrix. Probability distributions of these parameters are computed by combining the results with the probability of each particular preparation error. We verified the method by comparing it with an analytic solution. Next, idealized and realistic prostate plans were tested with varying margins and varying execution and preparation error levels.

RESULTS

Probability levels for the minimum dose, computed with the new method, are within 1% of the analytic solution. The impact of rotations depends strongly on the CTV shape. A margin of 10 mm between the CTV and planning target volume is adequate for three-field prostate treatments given the accuracy level in our department; i.e., the TCP in a population of patients, TCP(pop), is reduced by less than 1% due to geometric errors. When reducing the margin to 6 mm, the dose must be increased from 80 to 87 Gy to maintain the same TCP(pop). Only in regions with a high-dose gradient does such a margin reduction lead to a decrease in normal tissue dose for the same TCP(pop). Based on a rough correspondence of 84% minimum dose with 98% EUD, a margin recipe was defined. To give 90% of patients at least 98% EUD, the planning target volume margin must be approximately 2.5 Sigma + 0.7 sigma - 3 mm, where Sigma and sigma are the combined standard deviations of the preparation and execution errors. This recipe corresponds accurately with 1% TCP(pop) loss for prostate plans with clinically reasonable values of Sigma and sigma.

CONCLUSION

The new method computes in a few minutes the influence of geometric errors on the statistics of target dose and TCP(pop) in clinical treatment plans. Too small margins lead to a significant loss of TCP(pop) that is difficult to compensate for by dose escalation.

The required number of treatment imaging days for an effective off-line correction of systematic errors in conformal radiotherapy of prostate cancer--a radiobiological analysis

BACKGROUND AND PURPOSE

To use radiobiological modelling to estimate the number of initial days of treatment imaging required to gain most of the benefit from off-line correction of systematic errors in the conformal radiation therapy of prostate cancer.

MATERIALS AND METHODS

Treatment plans based on the anatomical information of a representative patient were generated assuming that the patient is treated with a multi leaf collimator (MLC) four-field technique and a total isocentre dose of 72 Gy delivered in 36 daily fractions. Target position variations between fractions were simulated from standard deviations of measured data found in the literature. Off-line correction of systematic errors was assumed to be performed only once based on the measured errors during the initial days of treatment. The tumour control probability (TCP) was calculated using the Webb and Nahum model.

RESULTS

Simulation of daily variations in the target position predicted a marked reduction in TCP if the planning target volume (PTV) margin was smaller than 4 mm (TCP decreased by 3.4% for 2 mm margin). The systematic components of target position variations had greater effect on the TCP than the random components. Off-line correction of estimated systematic errors reduced the decrease in TCP due to target daily displacements, nevertheless, the resulting TCP levels for small margins were still less than the TCP level obtained with the use of an adequate PTV margin of approximately 10 mm. The magnitude of gain in TCP expected from the correction depended on the number of treatment imaging days used for the correction and the PTV margin applied. Gains of 2.5% in TCP were estimated from correction of systematic errors performed after 6 initial days of treatment imaging for a 2 mm PTV margin. The effect of various possible magnitudes of systematic and random components on the gain in TCP expected from correction and on the number of imaging days required was also investigated.

CONCLUSIONS

Daily variations of target position markedly reduced the TCP if small margins were used. Off-line correction of systematic errors can only partly compensate for these TCP reductions. The adequate number of treatment imaging days required for systematic error correction depends on the magnitude of the random component compared with the systematic component, and on the size of PTV margin used. For random components equal to or smaller than the systematic component, 3 consecutive treatment imaging days are estimated to be sufficient to gain most of the benefit from correction for current clinically used margins (6-10 mm); otherwise more days are required.