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Winter JD, Reddy V, Li W, Craig T, Raman S. Impact of technological advances in treatment planning, image guidance, and treatment delivery on target margin design for prostate cancer radiotherapy: an updated review. Br J Radiol 2024; 97:31-40. [PMID: 38263844 PMCID: PMC11027310 DOI: 10.1093/bjr/tqad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/22/2023] [Accepted: 11/21/2023] [Indexed: 01/25/2024] Open
Abstract
Recent innovations in image guidance, treatment delivery, and adaptive radiotherapy (RT) have created a new paradigm for planning target volume (PTV) margin design for patients with prostate cancer. We performed a review of the recent literature on PTV margin selection and design for intact prostate RT, excluding post-operative RT, brachytherapy, and proton therapy. Our review describes the increased focus on prostate and seminal vesicles as heterogenous deforming structures with further emergence of intra-prostatic GTV boost and concurrent pelvic lymph node treatment. To capture recent innovations, we highlight the evolution in cone beam CT guidance, and increasing use of MRI for improved target delineation and image registration and supporting online adaptive RT. Moreover, we summarize new and evolving image-guidance treatment platforms as well as recent reports of novel immobilization strategies and motion tracking. Our report also captures recent implementations of artificial intelligence to support image guidance and adaptive RT. To characterize the clinical impact of PTV margin changes via model-based risk estimates and clinical trials, we highlight recent high impact reports. Our report focusses on topics in the context of PTV margins but also showcase studies attempting to move beyond the PTV margin recipes with robust optimization and probabilistic planning approaches. Although guidelines exist for target margins conventional using CT-based image guidance, further validation is required to understand the optimal margins for online adaptation either alone or combined with real-time motion compensation to minimize systematic and random uncertainties in the treatment of patients with prostate cancer.
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Affiliation(s)
- Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Varun Reddy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
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Sun X, Dai Z, Xu M, Guo X, Su H, Li Y. Quantifying 6D tumor motion and calculating PTV margins during liver stereotactic radiotherapy with fiducial tracking. Front Oncol 2022; 12:1021119. [DOI: 10.3389/fonc.2022.1021119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
ObjectiveOur study aims to estimate intra-fraction six-dimensional (6D) tumor motion with rotational correction and the related correlations between motions of different degrees of freedom (DoF), as well as quantify sufficient anisotropic clinical target volume (CTV) to planning target volume (PTV) margins during stereotactic body radiotherapy (SBRT) of liver cancer with fiducial tracking technique.MethodsA cohort of 12 patients who were implanted with 3 or 4 golden markers were included in this study, and 495 orthogonal kilovoltage (kV) pairs of images acquired during the first fraction were used to extract the spacial position of each golden marker. Translational and rotational motions of tumor were calculated based on the marker coordinates by using an iterative closest point (ICP) algorithm. Moreover, the Pearson product-moment correlation coefficients (r) were applied to quantify the correlations between motions with different degrees of freedom (DoFs). The population mean displacement (MP¯), systematic error (Σ) and random error (σ) were obtained to calculate PTV margins based on published recipes.ResultsThe mean translational variability of tumors were 0.56, 1.24 and 3.38 mm in the left-right (LR, X), anterior-posterior (AP, Y), and superior-inferior (SI, Z) directions, respectively. The average rotational angles θX , θY and θZ around the three coordinate axes were 0.88, 1.24 and 1.12, respectively. (|r|>0.4) was obtainted between Y -Z , Y - θZ , Z -θZ and θX - θY . The PTV margins calculated based on 13 published recipes in X, Y, and Z directions were 1.08, 2.26 and 5.42 mm, and the 95% confidence interval (CI) of them were (0.88,1.28), (1.99,2.53) and (4.78,6.05), respectively.ConclusionsThe maximum translational motion was in SI direction, and the largest correlation coefficient of Y-Z was obtained. We recommend margins of 2, 3 and 7 mm in LR, AP and SI directions, respectively.
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Copeland A, Barron A, Fontenot J. Analytical setup margin for spinal stereotactic body radiotherapy based on measured errors. Radiat Oncol 2021; 16:234. [PMID: 34876160 PMCID: PMC8650541 DOI: 10.1186/s13014-021-01956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/22/2021] [Indexed: 12/25/2022] Open
Abstract
Background No consensus currently exists about the correct margin size to use for spinal SBRT. Margins have been proposed to account for various errors individually, but not with all errors combined to result in a single margin value. The purpose of this work was to determine a setup margin for five-fraction spinal SBRT based on known errors during radiotherapy to achieve at least 90% coverage of the clinical target volume with the prescription dose for at least 90% of patients and not exceed a 30 Gy point dose or 23 Gy to 10% of the spinal cord subvolume. Methods The random and systematic error components of intrafraction motion, residual setup error, and end-to-end system accuracy were measured. The patient’s surface displacement was measured to quantify intrafraction motion, the residual setup error was quantified by re-registering accepted daily cone beam computed tomography setup images, and the displacement between measured and planned dose profiles in a phantom quantified the end-to-end system accuracy. These errors and parameters were used to identify the minimum acceptable margin size. The margin recommendation was validated by assessing dose delivery across 140 simulated patient plans suffering from various random shifts representative of the measured errors. Results The errors were quantified in three dimensions and the analytical margin generated was 2.4 mm. With this margin applied in the superior/inferior direction only, at least 90% of the CTV was covered with the prescription dose for 96% of the 140 patients simulated with minimal negative effect on the spinal cord dose levels. Conclusions The findings of this work support that a 2.4 mm margin applied in the superior/inferior direction can achieve at least 90% coverage of the CTV for at least 90% of dual-arc volumetric modulated arc therapy spinal SBRT patients in the presence of errors when immobilized with vacuum bags.
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Affiliation(s)
- Audrey Copeland
- Department of Physics and Astronomy, Louisiana State University and Agricultural and Mechanical College, Baton Rouge, LA, USA.
| | - Addie Barron
- Department of Physics and Astronomy, Louisiana State University and Agricultural and Mechanical College, Baton Rouge, LA, USA
| | - Jonas Fontenot
- Department of Physics and Astronomy, Louisiana State University and Agricultural and Mechanical College, Baton Rouge, LA, USA.,Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, LA, USA
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Sharma M, Nano TF, Akkati M, Milano MT, Morin O, Feng M. A systematic review and meta-analysis of liver tumor position variability during SBRT using various motion management and IGRT strategies. Radiother Oncol 2021; 166:195-202. [PMID: 34843841 DOI: 10.1016/j.radonc.2021.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To suggest PTV margins for liver SBRT with different motion management strategies based on a systematic review and meta-analysis. METHODS In accordance with Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analyses (PRISMA), a systematic review in PubMed, Embase and Medline databases was performed for liver tumor position variability. From an initial 533 studies published before October 2020, 36 studies were categorized as 18 free-breathing (FB; npatients = 401), 9 abdominal compression (AC; npatients = 145) and 9 breath-hold (BH; npatients = 126). A meta-analysis was performed on inter- and intra-fraction position variability to report weighted-mean with 95% confidence interval (CI95) in superior-inferior (SI), left-right (LR) and anterior-posterior (AP) directions. Furthermore, weighted-mean ITV margins were computed for FB (nstudies = 15, npatients = 373) and AC (nstudies = 6, npatients = 97) and PTV margins were computed for FB (nstudies = 6, npatients = 95), AC (nstudies = 7, npatients = 106) and BH (nstudies = 8, npatients = 133). RESULTS The FB weighted-mean intra-fraction variability, ITV margins and weighted-standard-deviation in mm were SI-9.7, CI95 = 9.3-10.1, 13.5 ± 4.9; LR-5.4, CI95 = 5.3-5.6, 7.3 ± 7.9; and AP-4.2, CI95 = 4.0-4.4, 6.3 ± 7.6. The inter-fraction-based results were SI-4.7, CI95 = 4.3-5.1, 5.7 ± 1.7; LR-1.4, CI95 = 1.1-1.6, 3.6 ± 2.7; and AP-2.8, CI95 = 2.5-3.1, 4.8 ± 2.1. For AC intra-fraction results in mm were SI-1.8, CI95 = 1.6-2.0, 2.6 ± 1.2; LR-0.7, CI95 = 0.6-0.8, 1.7 ± 1.5; and AP-0.9, CI95 = 0.8-1.0, 1.9 ± 1.7. The inter-fraction results were SI-2.6, CI95 = 2.3-3.0, 5.2 ± 2.9; LR-1.9, CI95 = 1.7-2.1, 4.0 ± 2.2; and AP-2.9, CI95 = 2.5-3.2, 5.8 ± 2.7. For BH the inter-fraction variability, and the weighted-mean PTV margins and weighted-standard-deviation in mm were SI-2.4, CI95 = 2.1-2.7, 5.6 ± 2.9; LR-1.8, CI95 = 1.3-2.2, 5.5 ± 1.7; and AP-1.4; CI95 = 1.2-1.7, 6.1 ± 2.1. CONCLUSION Our meta-analysis suggests a symmetric weighted-mean PTV margin of 6 mm might be appropriate for BH. For AC and FB, asymmetric PTV margins (weighted-mean margin of 4 mm (AP), 6 mm (SI/LR)) might be appropriate. For FB, if larger (>ITV margin) intra-fraction variability observed, the additional intra- and inter-fraction variability should be accounted in the PTV margin.
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Affiliation(s)
- Manju Sharma
- University of California, San Francisco, United States.
| | - Tomi F Nano
- University of California, San Francisco, United States
| | | | | | - Olivier Morin
- University of California, San Francisco, United States
| | - Mary Feng
- University of California, San Francisco, United States
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Imaging prior to radiotherapy impacts in-vitro survival. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 16:138-143. [PMID: 33458357 PMCID: PMC7807556 DOI: 10.1016/j.phro.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/20/2022]
Abstract
Background and purpose Cone Beam Computed Tomography (CBCT) is routinely used in radiotherapy to identify the position of the target volume. The aim of this study was to determine whether the CBCT dose, when followed by the treatment, influences the therapeutic outcomes as determined by in-vitro clonogenic cell survival in a radiobiological experiment. Materials and methods Human cell lines, four cancer and one normal, were exposed to a 6 MV photon beam, produced by a linear accelerator. For half of each sample, a prior imaging dose was delivered using the on-board CBCT. A sample size of n = 103 was used to achieve statistical power. Results The experimental group of cell lines exposed to CBCT imaging prior to treatment exhibited a reduction in mean cancer cell survival of ~17 times (p = 0.02) greater than predicted from the average dose response and equivalent to more than 5% of the therapeutic dose, compared to 11 times greater than predicted for normal cells (n.s.). Conclusion The greater than predicted reduction in survival resulting from the additional CBCT dose is consistent with radiation-induced bystander effects.
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Miao J, Xu Y, Tian Y, Liu Z, Dai J. A study of nonuniform CTV to PTV margin expansion incorporating both rotational and translational uncertainties. J Appl Clin Med Phys 2019; 20:78-86. [PMID: 31793203 PMCID: PMC6909174 DOI: 10.1002/acm2.12763] [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: 08/09/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE In this work, we implemented a method to obtain a nonuniform clinical target volume (CTV) to planning target volume (PTV) margin caused by both rotational and translational uncertainties and evaluated it in the treatment planning system (TPS). MATERIALS AND METHOD Based on a previously published statistical model, the relationship between a target margin and the distance d (from isocenter to target point), setup uncertainties, and significance level was established. For a single CTV, it can be thought as a combination of many small volume elements or target points. The margin of each point could be obtained using the suggested statistical model. The whole nonuniform CTV-PTV margin was determined by the union of all possible margins of the CTV boundary points. This method was implemented in the Pinnacle3 treatment planning system and compared with uniform margin algorithm. Ten vertebral metastases targets and multiple brain metastases targets were chosen for evaluation. RESULTS The combined CTV-PTV margin as a function of d for various initial translational margin and rotational uncertainties was calculated. The combined margin increases as d, rotational uncertainties and translational margin increase. For the same rotational uncertainty, a smaller initial translational margin requires a larger rotational margin to compensate for the rotational error. Compared with the uniform margin algorithm, the advantage of this method is that it could minimize the PTVs volume for given CTVs to obtain same significance level. Using vertebral metastases targets and multiple brain metastases targets, a series of volume difference was obtained for various translational margins and rotational uncertainties. The volume difference of PTV could be more than 17% when translational margin is 2 mm and rotational uncertainty is 1.4°. CONCLUSION Nonuniform margin algorithm could avoid excessive compensation for the CTV boundary points near isocenter. This method could be used for clinical margin determination and might be useful for the protection of risk organs.
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Affiliation(s)
- Junjie Miao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingjie Xu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tian
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiqiang Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kishan AU, Tyran M, Weng J, Upadhyaya S, Lamb J, Steinberg M, King C, Cao M. Stereotactic body radiotherapy to the prostate and pelvic lymph nodes: A detailed dosimetric analysis of a phase II prospective trial. Br J Radiol 2019; 92:20181001. [PMID: 30912957 DOI: 10.1259/bjr.20181001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To evaluate the dosimetric ramifications of simultaneously irradiating the prostate and pelvic lymph nodes (PLNs) with a stereotactic body radiotherapy approach based on rigid registration to intraprostatic markers (IPMs). METHODS AND MATERIALS Nineteen patients received concurrent SBRT to the prostate and PLNs on a phase II clinical trial. The translational and rotation shifts required for rigid registration to bony anatomy and changes in bladder and rectal anatomy were compared between patients with > 90% and < 90% coverage of the nodal clinical target volume (CTVN ) as drawn on fractional kilovoltage cone-beam CTs. Stepwise multivariable regression models evaluated relationships between these anatomical parameters and the change in V100%CTVN. RESULTS The average V100%CTVN per patient was 92.4 % (IQR, 90.2 - 96.4 %). For five patients (26.3%), the average was 85.0 % (IQR, 82.4-88.3 %). The left-right and superior-inferior translational shifts, sagittal rotational shift, and change in bladder volume were significantly different ( p < 0.05 for all via Student's t-test). Changes in bladder height, left/right shift, superior/inferior shift, 3-D shift, and axial rotation as significant predictors of change in dosing of V100%CTVN. CONCLUSION While simultaneous SBRT to the prostate and PLNs based on rigid registration to IPMs provides adequate PLN coverage in most instances, overall coverage may be lower than anticipated if anatomy is unstable. Careful evaluation of bladder filling on kV-CBCT before treatment may be the most practical method for estimating accuracy prior to treatment. ADVANCES IN KNOWLEDGE Simultaneous SBRT to the prostate and PLNs based on rigid registration to IPMs provides adequate PLN coverage in most instances.
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Affiliation(s)
- Amar U Kishan
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA.,2 Department of Urology, University of California , Los Angeles , USA
| | - Marguerite Tyran
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA.,3 Institut Paoli Calmettes , Marseille , France
| | - Julius Weng
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA
| | - Shrinivasa Upadhyaya
- 4 Department of Biological and Agricultural Engineering, University of California , Davis , USA
| | - James Lamb
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA
| | - Michael Steinberg
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA
| | - Christopher King
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA
| | - Minsong Cao
- 1 Department of Radiation Oncology, University of California , Los Angeles , USA
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Björeland U, Jonsson J, Alm M, Beckman L, Nyholm T, Thellenberg-Karlsson C. Inter-fraction movements of the prostate and pelvic lymph nodes during IGRT. ACTA ACUST UNITED AC 2018; 7:357-366. [PMID: 30595810 PMCID: PMC6290663 DOI: 10.1007/s13566-018-0366-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 11/15/2018] [Indexed: 12/25/2022]
Abstract
Objectivities The aim of this study was to evaluate inter-fraction movements of lymph node regions that are commonly included in the pelvic clinical target volume (CTV) for high-risk prostate cancer patients. We also aimed to evaluate if the movements affect the planning target volumes. Methods Ten prostate cancer patients were included. The patients underwent six MRI scans, from treatment planning to near end of treatment. The CTV movements were analyzed with deformable registration technique with the CTV divided into sections. The validity of the deformable registration was assessed by comparing the results for individual lymph nodes that were possible to identify in all scans. Results Using repetitive MRI, measurements showed that areas inside the CTV (lymph nodes) in some extreme cases were as mobile as the prostate and not fixed to the bones. The lymph node volumes closest to the prostate did not tend to follow the prostate motion. The more cranial lymph node volumes moved less, but still independently, and they were not necessarily fixed to the pelvic bones. In 95% of the cases, the lymph node motion in the R-L direction was 2–4 mm, in the A-P direction 2–7 mm, and in the C-C direction 2–5 mm depending on the CTV section. Conclusion Lymph nodes and prostate were most mobile in the A-P direction, followed by the C-C and R-L directions. This movement should be taken into account when deciding the margins for the planning target volumes (PTV). Electronic supplementary material The online version of this article (10.1007/s13566-018-0366-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulrika Björeland
- Department of Radiation Sciences, Umeå University, Sjukhusfysik, Sundsvallssjukhus, 85186 Sundsvall, Sweden
| | - Joakim Jonsson
- Department of Radiation Sciences, Umeå University, Sjukhusfysik, Sundsvallssjukhus, 85186 Sundsvall, Sweden
| | - Magnus Alm
- Department of Radiation Sciences, Umeå University, Sjukhusfysik, Sundsvallssjukhus, 85186 Sundsvall, Sweden
| | - Lars Beckman
- Department of Radiation Sciences, Umeå University, Sjukhusfysik, Sundsvallssjukhus, 85186 Sundsvall, Sweden
| | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Sjukhusfysik, Sundsvallssjukhus, 85186 Sundsvall, Sweden
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