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Finnegan RN, Quinn A, Booth J, Belous G, Hardcastle N, Stewart M, Griffiths B, Carroll S, Thwaites DI. Cardiac substructure delineation in radiation therapy - A state-of-the-art review. J Med Imaging Radiat Oncol 2024. [PMID: 38757728 DOI: 10.1111/1754-9485.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Delineation of cardiac substructures is crucial for a better understanding of radiation-related cardiotoxicities and to facilitate accurate and precise cardiac dose calculation for developing and applying risk models. This review examines recent advancements in cardiac substructure delineation in the radiation therapy (RT) context, aiming to provide a comprehensive overview of the current level of knowledge, challenges and future directions in this evolving field. Imaging used for RT planning presents challenges in reliably visualising cardiac anatomy. Although cardiac atlases and contouring guidelines aid in standardisation and reduction of variability, significant uncertainties remain in defining cardiac anatomy. Coupled with the inherent complexity of the heart, this necessitates auto-contouring for consistent large-scale data analysis and improved efficiency in prospective applications. Auto-contouring models, developed primarily for breast and lung cancer RT, have demonstrated performance comparable to manual contouring, marking a significant milestone in the evolution of cardiac delineation practices. Nevertheless, several key concerns require further investigation. There is an unmet need for expanding cardiac auto-contouring models to encompass a broader range of cancer sites. A shift in focus is needed from ensuring accuracy to enhancing the robustness and accessibility of auto-contouring models. Addressing these challenges is paramount for the integration of cardiac substructure delineation and associated risk models into routine clinical practice, thereby improving the safety of RT for future cancer patients.
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Affiliation(s)
- Robert N Finnegan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Quinn
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Gregg Belous
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Queensland, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Maegan Stewart
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Griffiths
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David I Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Radiotherapy Research Group, Leeds Institute of Medical Research, St James's Hospital and University of Leeds, Leeds, UK
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Schottstaedt AM, Paulson ES, Rubenstein JC, Chen X, Omari EA, Li XA, Schultz CJ, Puckett LL, Robinson CG, Alongi F, Gore EM, Hall WA. Development of a comprehensive cardiac atlas on a 1.5 Tesla Magnetic Resonance Linear Accelerator. Phys Imaging Radiat Oncol 2023; 28:100504. [PMID: 38035207 PMCID: PMC10682663 DOI: 10.1016/j.phro.2023.100504] [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: 06/01/2023] [Revised: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Background and purpose The 1.5 Tesla (T) Magnetic Resonance Linear Accelerator (MRL) provides an innovative modality for improved cardiac imaging when planning radiation treatment. No MRL based cardiac atlases currently exist, thus, we sought to comprehensively characterize cardiac substructures, including the conduction system, from cardiac images acquired using a 1.5 T MRL and provide contouring guidelines. Materials and methods Five volunteers were enrolled in a prospective protocol (NCT03500081) and were imaged on the 1.5 T MRL with Half Fourier Single-Shot Turbo Spin-Echo (HASTE) and 3D Balanced Steady-State Free Precession (bSSFP) sequences in axial, short axis, and vertical long axis. Cardiac anatomy was contoured by (AS) and confirmed by a board certified cardiologist (JR) with expertise in cardiac MR imaging. Results A total of five volunteers had images acquired with the HASTE sequence, with 21 contours created on each image. One of these volunteers had additional images obtained with 3D bSSFP sequences in the axial plane and additional images obtained with HASTE sequences in the key cardiac planes. Contouring guidelines were created and outlined. 15-16 contours were made for the short axis and vertical long axis. The cardiac conduction system was demonstrated with eleven representative contours. There was reasonable variation of contour volume across volunteers, with structures more clearly delineated on the 3D bSSFP sequence. Conclusions We present a comprehensive cardiac atlas using novel images acquired prospectively on a 1.5 T MRL. This cardiac atlas provides a novel resource for radiation oncologists in delineating cardiac structures for treatment with radiotherapy, with special focus on the cardiac conduction system.
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Affiliation(s)
- Aronne M. Schottstaedt
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - Eric S. Paulson
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
- Medical College of Wisconsin, Department of Radiology, Milwaukee, WI, United States
| | - Jason C. Rubenstein
- Medical College of Wisconsin, Department of Radiology, Milwaukee, WI, United States
- Medical College of Wisconsin, Department of Cardiology, Milwaukee, WI, United States
| | - Xinfeng Chen
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - Eenas A. Omari
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - X Allen Li
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - Chris J. Schultz
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - Lindsay L. Puckett
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - Clifford G. Robinson
- Washington University, Department of Radiation Oncology, St. Louis, MO, United States
| | - Filippo Alongi
- IRCCS Sacro Cuore Don Calabria Hospital, Department of Radiation Oncology, Negrar-Verona, Italy & University of Brescia, Faculty of Medicine, Brescia, Italy
| | - Elizabeth M. Gore
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - William A. Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
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Stefan MF, Herghelegiu CG, Magda SL. Accelerated Atherosclerosis and Cardiovascular Toxicity Induced by Radiotherapy in Breast Cancer. Life (Basel) 2023; 13:1631. [PMID: 37629488 PMCID: PMC10455250 DOI: 10.3390/life13081631] [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: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
The number of patients diagnosed with breast cancer and cardiovascular disease is continuously rising. Treatment options for breast cancer have greatly evolved, but radiotherapy (RT) still has a key role in it. Despite many advances in RT techniques, cardiotoxicity is one of the most important side effects. The new cardio-oncology guidelines recommend a baseline evaluation, risk stratification and follow-up of these patients. Cardiotoxicity induced by RT can be represented by almost all forms of cardiovascular disease, with atherosclerosis being the most frequent. An interdisciplinary team should manage these patients, in order to have maximum therapeutic effect and minimum cardiovascular toxicity. This review will summarize the current incidence, risk factors, mechanisms and follow-up of RT-induced cardiovascular toxicity.
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Affiliation(s)
- Miruna Florina Stefan
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
| | - Catalin Gabriel Herghelegiu
- Institutul National Pentru Sanatatea Mamei si a Copilului “Alessandrescu Rusescu”, 020395 Bucharest, Romania;
| | - Stefania Lucia Magda
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania
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Shen J, Gu P, Wang Y, Wang Z. Advances in automatic delineation of target volume and cardiac substructure in breast cancer radiotherapy (Review). Oncol Lett 2023; 25:110. [PMID: 36817059 PMCID: PMC9932716 DOI: 10.3892/ol.2023.13697] [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: 09/14/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
Postoperative adjuvant radiotherapy plays an important role in the treatment of patients with breast cancer. With the continuous development of radiotherapeutic technologies, the requirements for radiotherapeutic accuracy are increasingly high. The accuracy of target volume and organ at risk delineation significantly affects the effect of radiotherapy. Automatic delineation software has been continuously developed for the automatic delineation of target areas and organs at risk. Automatic segmentation based on an atlas and deep learning is a hot topic in current clinical research. Automatic delineation can not only reduce the workload and delineation times, but also establish a uniform delineation standard and reduce inter-observer and intra-observer differences. In patients with breast cancer, especially in patients who undergo left breast radiotherapy, the protection of the heart is particularly important. Treating the whole heart as an organ at risk cannot meet the clinical needs, and it is necessary to limit the dose to specific cardiac substructures. The present review discusses the importance of automatic delineation of target volume and cardiac substructure in radiotherapy for patients with breast cancer.
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Affiliation(s)
- Jingjing Shen
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200438, P.R. China
| | - Peihua Gu
- Department of Oncology and Radiotherapy, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai 200438, P.R. China
| | - Yun Wang
- Department of Oncology and Radiotherapy, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai 200438, P.R. China
| | - Zhongming Wang
- Department of Oncology and Radiotherapy, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai 200438, P.R. China,Correspondence to: Dr Zhongming Wang, Department of Oncology and Radiotherapy, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, 999 Shiguang Road, Shanghai 200438, P.R. China, E-mail:
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Baaken D, Merzenich H, Schmidt M, Bekes I, Schwentner L, Janni W, Wöckel A, Mayr M, Mose S, Merz T, Ghilescu V, Renner J, Bartkowiak D, Wiegel T, Blettner M, Schmidberger H, Wollschläger D. A nested case-control study on radiation dose-response for cardiac events in breast cancer patients in Germany. Breast 2022; 65:1-7. [PMID: 35716531 PMCID: PMC9207715 DOI: 10.1016/j.breast.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Previous studies with the majority of breast cancer (BC) patients treated up to 2000 provided evidence that radiation dose to the heart from radiotherapy (RT) was linearly associated with increasing risk for long-term cardiac disease. RT techniques changed substantially over time. This study aimed to investigate the dose-dependent cardiac risk in German BC patients treated with more contemporary RT. METHODS In a cohort of 11,982 BC patients diagnosed in 1998-2008, we identified 494 women treated with 3D-conformal RT who subsequently developed a cardiac event. Within a nested case-control approach, these cases were matched to 988 controls. Controls were patients without a cardiac event after RT until the index date of the corresponding case. Separate multivariable conditional logistic regression models were used to assess the association of radiation to the complete heart and to the left anterior heart wall (LAHW) with cardiac events. RESULTS Mean dose to the heart for cases with left-sided BC was 4.27 Gy and 1.64 Gy for cases with right-sided BC. For controls, corresponding values were 4.31 Gy and 1.66 Gy, respectively. The odds ratio (OR) per 1 Gy increase in dose to the complete heart was 0.99 (95% confidence interval (CI): 0.94-1.05, P = .72). The OR per 1 Gy increase in LAHW dose was 1.00 (95% CI: 0.98-1.01, P = .68). CONCLUSIONS Contrary to previous studies, our study provided no evidence that radiation dose to the heart from 3D-conformal RT for BC patients treated between 1998 and 2008 was associated with risk of cardiac events.
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Affiliation(s)
- Dan Baaken
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany.
| | - Hiltrud Merzenich
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
| | - Marcus Schmidt
- University Medical Center of the Johannes Gutenberg-University Mainz, Department of Obstetrics and Gynecology, 55101, Mainz, Germany
| | - Inga Bekes
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Lukas Schwentner
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Wolfgang Janni
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Achim Wöckel
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany; University Hospital Würzburg, 97080, Würzburg, Germany
| | - Manfred Mayr
- Strahlentherapie Süd am Klinikum Kaufbeuren, 87600, Kaufbeuren, Germany
| | - Stephan Mose
- Schwarzwald-Baar Klinikum, Klinik für Strahlentherapie und Radioonkologie, 78052, Villingen-Schwenningen, Germany
| | - Thomas Merz
- Kliniken Landkreis Heidenheim gGmbH, Department of Radiation Oncology and Radiotherapy, 89522, Heidenheim, Germany
| | - Voica Ghilescu
- Kliniken Landkreis Heidenheim gGmbH, Department of Radiation Oncology and Radiotherapy, 89522, Heidenheim, Germany
| | - Jona Renner
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Detlef Bartkowiak
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Thomas Wiegel
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Maria Blettner
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
| | - Heinz Schmidberger
- University Medical Center of the Johannes Gutenberg-University Mainz, Department of Radiation Oncology and Radiation Therapy, 55101, Mainz, Germany
| | - Daniel Wollschläger
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
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Kundrát P, Rennau H, Remmele J, Sebb S, Simonetto C, Kaiser JC, Hildebrandt G, Wolf U, Eidemüller M. Anatomy-dependent lung doses from 3D-conformal breast-cancer radiotherapy. Sci Rep 2022; 12:10909. [PMID: 35764679 PMCID: PMC9240052 DOI: 10.1038/s41598-022-14149-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/02/2022] [Indexed: 12/14/2022] Open
Abstract
This study aims to identify key anatomic features that govern the individual variability of lung doses from breast-cancer radiotherapy. 3D conformal, intensity-modulated and hybrid techniques with 50.4 Gy whole-breast dose were planned for 128 patients. From their CT images, 17 anatomic measures were assessed and tested as predictors for lung dose-volume characteristics. Tangential techniques yielded mean ipsilateral lung doses in the range of 3–11 Gy. This inter-patient variability was explained to almost 40% by central lung distance, and to almost 60% if this measure was complemented by midplane lung width and maximum heart distance. Also the variability in further dose-volume metrics such as volume fractions receiving 5, 20 or 40 Gy could be largely explained by the anatomy. Multi-field intensity-modulated radiotherapy reduced high-exposed lung volumes, but resulted in higher mean ipsilateral lung doses and larger low-dose burden. Contralateral lung doses ranged from 0.3 to 1 Gy. The results highlight that there are large differences in lung doses among breast-cancer patients. Most of this inter-individual variability can be explained by a few anatomic features. The results will be implemented in a dedicated software tool to provide personalized estimates of long-term health risks related to breast-cancer radiotherapy. The results may also be used to identify favourable as well as problematic anatomies, and serve as a quick quantitative benchmark for individual treatment plans.
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Affiliation(s)
- Pavel Kundrát
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. .,Department of Radiation Dosimetry, Nuclear Physics Institute of the CAS, Na Truhlářce 39/64, 180 00, Prague 8, Libeň, Czech Republic.
| | - Hannes Rennau
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Julia Remmele
- Department of Radiation Oncology, Universität Leipzig Klinik für Strahlentherapie, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Sabine Sebb
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Cristoforo Simonetto
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Jan Christian Kaiser
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Ulrich Wolf
- Department of Radiation Oncology, Universität Leipzig Klinik für Strahlentherapie, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Markus Eidemüller
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
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