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An online adaptive plan library approach for intensity modulated proton therapy for head and neck cancer. Radiother Oncol 2022; 176:68-75. [PMID: 36150418 DOI: 10.1016/j.radonc.2022.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE In intensity modulated proton therapy (IMPT), the impact of setup errors and anatomical changes is commonly mitigated by robust optimization with population-based setup robustness (SR) settings and offline replanning. In this study we propose and evaluate an alternative approach based on daily plan selection from patient-specific pre-treatment established plan libraries (PLs). Clinical implementation of the PL strategy would be rather straightforward compared to daily online re-planning. MATERIALS AND METHODS For 15 head-and-neck cancer patients, the planning CT was used to generate a PL with 5 plans, robustly optimized for increasing SR: 0, 1, 2, 3, 5 mm, and 3% range robustness. Repeat CTs (rCTs) and realistic setup and range uncertainty distributions were used for simulation of treatment courses for the PL approach, treatments with fixed SR (fSR3) and a trigger-based offline adaptive schedule for 3 mm SR (fSR3OfA). Daily plan selection in the PL approach was based only on recomputed dose to the CTV on the rCT. RESULTS Compared to using fSR3 and fSR3OfA, the risk of xerostomia grade ≥ II & III and dysphagia ≥ grade III were significantly reduced with the PL. For 6/15 patients the risk of xerostomia and/or dysphagia ≥ grade II could be reduced by > 2% by using PL. For the other patients, adherence to target coverage constraints was often improved. fSR3OfA resulted in significantly improved coverage compared to PL for selected patients. CONCLUSION The proposed PL approach resulted in overall reduced NTCPs compared to fSR3 and fSR3OfA at limited cost in target coverage.
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Khalifa J, Supiot S, Pignot G, Hennequin C, Blanchard P, Pasquier D, Magné N, de Crevoisier R, Graff-Cailleaud P, Riou O, Cabaillé M, Azria D, Latorzeff I, Créhange G, Chapet O, Rouprêt M, Belhomme S, Mejean A, Culine S, Sargos P. Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder. Radiother Oncol 2021; 161:95-114. [PMID: 34118357 DOI: 10.1016/j.radonc.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations. METHODS AND MATERIALS In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy. RESULTS A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence. CONCLUSION The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France
| | - Géraldine Pignot
- Department of Urology, Institut Paoli Calmettes, Marseille, France
| | | | - Pierre Blanchard
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, Lille, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | | | - Pierre Graff-Cailleaud
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Olivier Riou
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | | | - David Azria
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | | | - Olivier Chapet
- Department of Radiotherapy, Hospices Civils de Lyon, France
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpétrière, APHP Sorbonne Université, Paris, France
| | - Sarah Belhomme
- Department of Medical Physics, Institut Bergonié, Bordeaux, France
| | - Arnaud Mejean
- Department of Urology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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Varnava M, Sumida I, Oda M, Kurosu K, Isohashi F, Seo Y, Otani K, Ogawa K. Dosimetric comparison between volumetric modulated arc therapy planning techniques for prostate cancer in the presence of intrafractional organ deformation. JOURNAL OF RADIATION RESEARCH 2021; 62:309-318. [PMID: 33341880 PMCID: PMC7948894 DOI: 10.1093/jrr/rraa123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 06/12/2023]
Abstract
The purpose of this study was to compare single-arc (SA) and double-arc (DA) treatment plans, which are planning techniques often used in prostate cancer volumetric modulated arc therapy (VMAT), in the presence of intrafractional deformation (ID) to determine which technique is superior in terms of target dose coverage and sparing of the organs at risk (OARs). SA and DA plans were created for 27 patients with localized prostate cancer. ID was introduced to the clinical target volume (CTV), rectum and bladder to obtain blurred dose distributions using an in-house software. ID was based on the motion probability function of each structure voxel and the intrafractional motion of the respective organs. From the resultant blurred dose distributions of SA and DA plans, various parameters, including the tumor control probability, normal tissue complication probability, homogeneity index, conformity index, modulation complexity score for VMAT, dose-volume indices and monitor units (MUs), were evaluated to compare the two techniques. Statistical analysis showed that most CTV and rectum parameters were significantly larger for SA plans than for DA plans (P < 0.05). Furthermore, SA plans had fewer MUs and were less complex (P < 0.05). The significant differences observed had no clinical significance, indicating that both plans are comparable in terms of target and OAR dosimetry when ID is considered. The use of SA plans is recommended for prostate cancer VMAT because they can be delivered in shorter treatment times than DA plans, and therefore benefit the patients.
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Affiliation(s)
- Maria Varnava
- Corresponding author. Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan. Tel: +81-6-6879-3482; Fax: +81-6-6879-3489;
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Michio Oda
- Department of Medical Technology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keita Kurosu
- Department of Medical Technology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keisuke Otani
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
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Cabaillé M, Gaston R, Belhomme S, Giraud A, Rouffilange J, Roubaud G, Sargos P. [Plan of the day adaptive radiotherapy for bladder cancer: Dosimetric and clinical results]. Cancer Radiother 2021; 25:308-315. [PMID: 33422418 DOI: 10.1016/j.canrad.2020.10.002] [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] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To account of individual intra-pelvic anatomical variations in muscle invasive bladder cancer (MIBC) irradiation, adaptive radiotherapy (ART) using a personalized plan library may have dosimetric and clinical benefits. MATERIAL AND METHODS The data from ten patients treated for localized MIBC according to the "plan of the day" (P0oD) individualized ART technique were collected and retrospectively analysed. Target volumes and organs at risk (OAR) were delineated at different bladder fill rates, resulting in two or three treatment plans. Daily Cone-Beam CT (CBCT) was used for the selection of PoD at each fraction. Retrospectively, we delineated rectal, intestinal and target volumes on each CBCT, to assess target volume coverage and dose sparing to healthy tissues. A comparison with the conventional radiotherapy technique was performed. The secondary objectives were toxicity and efficacy. RESULTS The target coverage was respected with the adaptive treatment: 97.3% for the bladder Clinical Target Volume (CTV) (99.5; [60.1-100]) and 98% for the bladder+lymph nodes CTV (98.6; [85.4-100]). Concerning OAR, the volume of healthy tissue spared was 43.7% on average and the V45Gy for the small bowel was 43,4cc (35; [0-129]) (versus 57,6cc). The rectal D50 was on average 18,7Gy for the adaptive treatment (15.9; [2.4-44.1]) versus 17Gy with the conventional approach. With a median follow-up of 2.94 years (95% CI: [0.92-4.02]), we observed three grade 3 toxicities (30%). No grade 4 toxicity was observed. The 2-year overall survival and progression-free survival rates were 65.6% (95% CI: [26-87.6]) and 45.7% (95% CI: [14.3-73]), respectively. CONCLUSION The ART technique using a PoD strategy showed a reduction of the irradiated healthy tissue volume while maintaining a similar bladder coverage, with an acceptable rate of toxicity.
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Affiliation(s)
- M Cabaillé
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France
| | - R Gaston
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - S Belhomme
- Département de Physique Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - A Giraud
- Unité de Recherche Épidémiologique et Clinique, Institut Bergonié, 33076 Bordeaux cedex, France
| | - J Rouffilange
- Département de Chirurgie Urologique, Clinique Saint Augustin, 33000 Bordeaux, France
| | - G Roubaud
- Département d'Oncologie Médicale, Institut Bergonié, 33076 Bordeaux cedex, France
| | - P Sargos
- Département de Radiothérapie, Institut Bergonié, 33076 Bordeaux cedex, France.
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Cabaillé M, Khalifa J, Tessier AM, Belhomme S, Créhange G, Sargos P. [A review of adaptive radiotherapy for bladder cancer]. Cancer Radiother 2021; 25:271-278. [PMID: 33402293 DOI: 10.1016/j.canrad.2020.08.046] [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: 07/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Radiation therapy (RT) for muscle invasive bladder cancer (MIBC) is challenging, with observed variations in bladder shape and size resulting in inappropriate coverage of the target volumes (CTV). Large margins were historically applied around the CTV, increasing the dose delivered to organs at risk (OAR). With repositioning imaging and visualization of soft tissues during image guided RT, an opportunity to consider these movements and deformations appeared possible with an adaptive RT approach (ART). MATERIALS AND METHODS A bibliographic search on the PubMed database has been done in January 2019. Studies focusing on patients with MIBC, treating on ART, with the objectives of feasibility, clinical and/or dosimetric evaluation and comparison with a standard irradiation technique were eligible. The purpose of this review was to define the different ART techniques used in clinical practice, to discuss their advantages compared to conventional RT in terms of target volume's coverage and OAR dose and to describe their feasibility in clinical practice. RESULTS A total of 30 studies were selected. The strategies known as "composite offline", "plan of the day" not individualized or individualized, and "re-optimization" have been identified. All the studies have shown a significant benefit of ART in target coverage and dose of OAR, especially the rectum and small bowel. All ART plans produced are not used during RT sessions. Inter-observer variability for the selection of these plans can be observed. The practical implementation within a department required staff education and training, and increases the duration of treatment preparation. The "A-POLO" approach seems to be the most suitable for practice. CONCLUSION ART is the technique of choice for bladder cancer RT. The "plan of the day" approach, individualized according to the A-POLO methodology, seems to be the most effective. The emergence of daily re-optimization, especially using MRI-Linac, is promising. The correlation between dosimetric benefits and clinical efficacy and safety results should be demonstrated into future trials.
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Affiliation(s)
- M Cabaillé
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - J Khalifa
- Département de radiothérapie, Institut universitaire du Cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - A M Tessier
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - G Créhange
- Département de radiothérapie, Institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - P Sargos
- Département de radiothérapie, Institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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Collins SD, Leech MM. A review of plan library approaches in adaptive radiotherapy of bladder cancer. Acta Oncol 2018; 57:566-573. [PMID: 29299945 DOI: 10.1080/0284186x.2017.1420908] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Large variations in the shape and size of the bladder volume are commonly observed in bladder cancer radiotherapy (RT). The clinical target volume (CTV) is therefore frequently inadequately treated and large isotropic margins are inappropriate in terms of dose to organs at risk (OAR); thereby making adaptive radiotherapy (ART) attractive for this tumour site. There are various methods of ART delivery, however, for bladder cancer, plan libraries are frequently used. MATERIAL AND METHODS A review of published studies on plan libraries for bladder cancer using four databases (Pubmed, Science Direct, Embase and Cochrane Library) was conducted. The endpoints selected were accuracy and feasibility of initiation of a plan library strategy into a RT department. RESULTS Twenty-four articles were included in this review. The majority of studies reported improvement in accuracy with 10 studies showing an improvement in planning target volume (PTV) and CTV coverage with plan libraries, some by up to 24%. Seventeen studies showed a dose reduction to OARs, particularly the small bowel V45Gy, V40Gy, V30Gy and V10Gy, and the rectal V30Gy. However, the occurrence of no suitable plan was reported in six studies, with three studies showing no significant difference between adaptive and non-adaptive strategies in terms of target coverage. In addition, inter-observer variability in plan selection appears to remain problematic. The additional resources, education and technology required for the initiation of plan library selection for bladder cancer may hinder its routine clinical implementation, with eight studies illustrating increased treatment time required. CONCLUSIONS While there is a growing body of evidence in support of plan libraries for bladder RT, many studies differed in their delivery approach. The advent of the clinical use of the MRI-linear accelerator will provide RT departments with the opportunity to consider daily online adaption for bladder cancer as an alternate to plan library approaches.
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Affiliation(s)
- Shane D. Collins
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
| | - Michelle M. Leech
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College, Dublin, Ireland
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Sumida I, Yamaguchi H, Das IJ, Anetai Y, Kizaki H, Aboshi K, Tsujii M, Yamada Y, Tamari K, Seo Y, Isohashi F, Yoshioka Y, Ogawa K. Robust plan optimization using edge-enhanced intensity for intrafraction organ deformation in prostate intensity-modulated radiation therapy. PLoS One 2017; 12:e0173643. [PMID: 28282417 PMCID: PMC5345858 DOI: 10.1371/journal.pone.0173643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 02/23/2017] [Indexed: 11/18/2022] Open
Abstract
This study evaluated a method for prostate intensity-modulated radiation therapy (IMRT) based on edge-enhanced (EE) intensity in the presence of intrafraction organ deformation using the data of 37 patients treated with step-and-shoot IMRT. On the assumption that the patient setup error was already accounted for by image guidance, only organ deformation over the treatment course was considered. Once the clinical target volume (CTV), rectum, and bladder were delineated and assigned dose constraints for dose optimization, each voxel in the CTV derived from the DICOM RT-dose grid could have a stochastic dose from the different voxel location according to the probability density function as an organ deformation. The stochastic dose for the CTV was calculated as the mean dose at the location through changing the voxel location randomly 1000 times. In the EE approach, the underdose region in the CTV was delineated and optimized with higher dose constraints that resulted in an edge-enhanced intensity beam to the CTV. This was compared to a planning target volume (PTV) margin (PM) approach in which a CTV to PTV margin equivalent to the magnitude of organ deformation was added to obtain an optimized dose distribution. The total monitor units, number of segments, and conformity index were compared between the two approaches, and the dose based on the organ deformation of the CTV, rectum, and bladder was evaluated. The total monitor units, number of segments, and conformity index were significantly lower with the EE approach than with the PM approach, while maintaining the dose coverage to the CTV with organ deformation. The dose to the rectum and bladder were significantly reduced in the EE approach compared with the PM approach. We conclude that the EE approach is superior to the PM with regard to intrafraction organ deformation.
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Affiliation(s)
- Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
| | - Hajime Yamaguchi
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Indra J. Das
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, United States of America
| | - Yusuke Anetai
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hisao Kizaki
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Keiko Aboshi
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Mari Tsujii
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Yuji Yamada
- Department of Radiation Oncology, NTT West Osaka hospital, Tennoji-ku, Osaka, Japan
| | - Keisuke Tamari
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
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Thörnqvist S, Hysing LB, Tuomikoski L, Vestergaard A, Tanderup K, Muren LP, Heijmen BJM. Adaptive radiotherapy strategies for pelvic tumors - a systematic review of clinical implementations. Acta Oncol 2016; 55:943-58. [PMID: 27055486 DOI: 10.3109/0284186x.2016.1156738] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Introdution: Variation in shape, position and treatment response of both tumor and organs at risk are major challenges for accurate dose delivery in radiotherapy. Adaptive radiotherapy (ART) has been proposed to customize the treatment to these motion/response patterns of the individual patients, but increases workload and thereby challenges clinical implementation. This paper reviews strategies and workflows for clinical and in silico implemented ART for prostate, bladder, gynecological (gyne) and ano-rectal cancers. MATERIAL AND METHODS Initial identification of papers was based on searches in PubMed. For each tumor site, the identified papers were screened independently by two researches for selection of studies describing all processes of an ART workflow: treatment monitoring and evaluation, decision and execution of adaptations. Both brachytherapy and external beam studies were eligible for review. RESULTS The review consisted of 43 clinical studies and 51 in silico studies. For prostate, 1219 patients were treated with offline re-planning, mainly to adapt prostate motion relative to bony anatomy. For gyne 1155 patients were treated with online brachytherapy re-planning while 25 ano-rectal cancer patients were treated with offline re-planning, all to account for tumor regression detected by magnetic resonance imaging (MRI)/computed tomography (CT). For bladder and gyne, 161 and 64 patients, respectively, were treated with library-based online plan selection to account for target volume and shape variations. The studies reported sparing of rectum (prostate and bladder cancer), bladder (ano-rectal cancer) and bowel cavity (gyne and bladder cancer) as compared to non-ART. CONCLUSION Implementations of ART were dominated by offline re-planning and online brachytherapy re-planning strategies, although recently online plan selection workflows have increased with the availability of cone-beam CT. Advantageous dosimetric and outcome patterns using ART was documented by the studies of this review. Despite this, clinical implementations were scarce due to challenges in target/organ re-contouring and suboptimal patient selection in the ART workflows.
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Affiliation(s)
- Sara Thörnqvist
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Potential dosimetric benefit of an adaptive plan selection strategy for short-course radiotherapy in rectal cancer patients. Radiother Oncol 2016; 119:525-30. [DOI: 10.1016/j.radonc.2016.04.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 11/20/2022]
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12
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Vestergaard A, Hafeez S, Muren LP, Nill S, Høyer M, Hansen VN, Grønborg C, Pedersen EM, Petersen JB, Huddart R, Oelfke U. The potential of MRI-guided online adaptive re-optimisation in radiotherapy of urinary bladder cancer. Radiother Oncol 2016; 118:154-9. [PMID: 26631646 DOI: 10.1016/j.radonc.2015.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Adaptive radiotherapy (ART) using plan selection is being introduced clinically for bladder cancer, but the challenge of how to compensate for intra-fractional motion remains. The purpose of this study was to assess target coverage with respect to intra-fractional motion and the potential for normal tissue sparing in MRI-guided ART (MRIGART) using isotropic (MRIGARTiso), an-isotropic (MRIGARTanIso) and population-based margins (MRIGARTpop). MATERIALS AND METHODS Nine bladder cancer patients treated in a phase II trial of plan selection underwent 6-7 weekly repeat MRI series, each with volumetric scans acquired over a 10 min period. Adaptive re-planning on the 0 min MRI scans was performed using density override, simulating a hypo-fractionated schedule. Target coverage was evaluated on the 10 min scan to quantify the impact of intra-fractional motion. RESULTS MRIGARTanIso reduced the course-averaged PTV by median 304 cc compared to plan selection. Bladder shifts affected target coverage in individual fractions for all strategies. Two patients had a v95% of the bladder below 98% for MRIGARTiso. MRIGARTiso decreased the bowel V25 with 15-46 cc compared to MRIGARTpop. CONCLUSION Online re-optimised ART has a considerable normal tissue sparing potential. MRIGART with online corrections for target shift during a treatment fraction should be considered in ART for bladder cancer.
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Affiliation(s)
- Anne Vestergaard
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark; Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Shaista Hafeez
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Ludvig P Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Simeon Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Morten Høyer
- Department of Oncology, AarhusUniversity/Aarhus University Hospital, Denmark
| | - Vibeke N Hansen
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Caroline Grønborg
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Erik M Pedersen
- Department of Radiology, Aarhus University/Aarhus University Hospital, Denmark
| | - Jørgen B Petersen
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Robert Huddart
- Academic Urology Unit, The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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A comparison between two clinically applied plan library strategies in adaptive radiotherapy of bladder cancer. Radiother Oncol 2015; 117:448-52. [DOI: 10.1016/j.radonc.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/28/2015] [Accepted: 10/09/2015] [Indexed: 11/18/2022]
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Grau C, Overgaard J, Høyer M, Tanderup K, Lindegaard JC, Muren LP. Biology-guided adaptive radiotherapy (BiGART) is progressing towards clinical reality. Acta Oncol 2015; 54:1245-50. [PMID: 26390238 DOI: 10.3109/0284186x.2015.1076992] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Cai Grau
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Jens Overgaard
- b Department of Experimental Clinical Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Morten Høyer
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Kari Tanderup
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
| | | | - Ludvig Paul Muren
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
- c Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
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Grønborg C, Vestergaard A, Høyer M, Söhn M, Pedersen EM, Petersen JB, Agerbæk M, Muren LP. Intra-fractional bladder motion and margins in adaptive radiotherapy for urinary bladder cancer. Acta Oncol 2015; 54:1461-6. [PMID: 26313410 DOI: 10.3109/0284186x.2015.1062138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The bladder is a tumour site well suited for adaptive radiotherapy (ART) due to large inter-fractional changes, but it also displays considerable intra-fractional motion. The aim of this study was to assess target coverage with a clinically applied method for plan selection ART and to estimate population-based and patient-specific intra-fractional margins, also relevant for a future re-optimisation strategy. MATERIAL AND METHODS Nine patients treated in a clinical phase II ART trial of daily plan selection for bladder cancer were included. In the library plans, 5 mm isotropic margins were added to account for intra-fractional changes. Pre-treatment and weekly repeat magnetic resonance imaging (MRI) series were acquired in which a full three-dimensional (3D) volume was scanned every second min for 10 min (a total of 366 scans in 61 series). Initially, the bladder clinical target volume (CTV) was delineated in all scans. The t = 0 min scan was then rigidly registered to the planning computed tomography (CT) and plan selections were simulated using the CTV_0 (at t = 0 min). To assess intra-fractional motion, coverage of the CTV_10 (at t = 10 min) was quantified using the applied PTV. Population-based margins were calculated using the van Herk margin recipe while patient-specific margins were calculated using a linear model. RESULTS For 49% of the cases, the CTV_10 extended more than 5 mm outside the CTV_0. However, in 58 of the 61 cases (97%) CTV_10 was covered by the selected PTV. Population-based margins of 14 mm Sup/Ant, 9 mm Post and 5 mm Inf/Lat were sufficient to cover the bladder. Using patient-specific margins, the overlap between PTV and bowel-cavity was reduced from 137 cm(3) with the plan selection strategy to 24 cm(3). CONCLUSION In this phase II ART trial, 5 mm isotropic margin for intra-fractional motion was sufficient even though considerable intra-fractional motion was observed. In online re-optimised ART, population-based margin can be applied although patient-specific margins are preferable.
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Affiliation(s)
- Caroline Grønborg
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Anne Vestergaard
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Morten Høyer
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Matthias Söhn
- c Department of Radiation Oncology , University Hospital Grosshadern , LMU Munich, Munich , Germany
| | - Erik M Pedersen
- d Department of Radiology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Jørgen B Petersen
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Mads Agerbæk
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
| | - Ludvig P Muren
- a Department of Medical Physics , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
- b Department of Oncology , Aarhus University/Aarhus University Hospital , Aarhus , Denmark
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Korhonen J, Kapanen M, Sonke JJ, Wee L, Salli E, Keyriläinen J, Seppälä T, Tenhunen M. Feasibility of MRI-based reference images for image-guided radiotherapy of the pelvis with either cone-beam computed tomography or planar localization images. Acta Oncol 2015; 54:889-95. [PMID: 25233439 DOI: 10.3109/0284186x.2014.958197] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE This study introduces methods to conduct image-guided radiotherapy (IGRT) of the pelvis with either cone-beam computed tomography (CBCT) or planar localization images by relying solely on magnetic resonance imaging (MRI)-based reference images. MATERIAL AND METHODS Feasibility of MRI-based reference images for IGRT was evaluated against kV CBCT (50 scans, 5 prostate cancer patients) and kV & MV planar (5 & 5 image pairs and patients) localization images by comparing the achieved patient position corrections to those obtained by standard CT-based reference images. T1/T2*-weighted in-phase MRI, Hounsfield unit conversion-based heterogeneous pseudo-CT, and bulk pseudo-CT images were applied for reference against localization CBCTs, and patient position corrections were obtained by automatic image registration. IGRT with planar localization images was performed manually by 10 observers using reference digitally reconstructed radiographs (DRRs) reconstructed from the pseudo-CTs and standard CTs. Quality of pseudo-DRRs against CT-DRRs was evaluated with image similarity metrics. RESULTS The SDs of differences between CBCT-to-MRI and CBCT-to-CT automatic gray-value registrations were ≤1.0 mm & ≤0.8° and ≤2.5 mm & ≤3.6° with 10 cm diameter cubic VOI and prostate-shaped VOI, respectively. The corresponding values for reference heterogeneous pseudo-CT were ≤1.0 mm & ≤0.7° and ≤2.2 mm & ≤3.3°, respectively. Heterogeneous pseudo-CT was the only type of MRI-based reference image working reliably with automatic bone registration (SDs were ≤0.9 mm & ≤0.7°). The differences include possible residual errors from planning CT to MRI registration. The image similarity metrics were significantly (p≤0.01) better in agreement between heterogeneous pseudo-DRRs and CT-DRRs than between bulk pseudo-DRRs and CT-DRRs. The SDs of differences in manual registrations (3D) with planar kV and MV localization images were ≤1.0 mm and ≤1.7 mm, respectively, between heterogeneous pseudo-DRRs and CT-DRRs, and ≤1.4 mm and ≤2.1 mm between bulk pseudo-DRRs and CT-DRRs. CONCLUSION This study demonstrated that it is feasible to conduct IGRT of the pelvis with MRI-based reference images.
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Affiliation(s)
- Juha Korhonen
- Clinical Research Institute Helsinki University Central Hospital Ltd , Helsinki , Finland
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Elstrøm UV, Olsen SRK, Muren LP, Petersen JBB, Grau C. The impact of CBCT reconstruction and calibration for radiotherapy planning in the head and neck region - a phantom study. Acta Oncol 2014; 53:1114-24. [PMID: 24975372 DOI: 10.3109/0284186x.2014.927073] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The applicability of cone-beam computed tomography (CBCT) image sets for dose calculation purposes relies on high image quality and CT number accuracy. In this study we have investigated the use of stoichiometric calibration for transforming CT numbers into physical parameters, in combination with a new CBCT scatter correction algorithm, focusing on head and neck geometries. METHODS CBCT projections were acquired using an On-Board-Imager (OBI v1.4; Varian Medical Systems) using both low- and high-dose clinical image acquisition protocols. The CBCT projections were reconstructed twice, using both the standard method (OBI) as well as an experimental pre-clinical reconstruction algorithm (Full Fan Experimental - FFE). Stoichiometric calibration was performed using both a phantom from CIRS with nine tissue equivalent inserts (ranging from lung to dense bone) as well as with a custom made cylindrical PMMA head and neck phantom with variable 'head' diameter and with cavities designed to fit the inserts from a Gammex RMI phantom. To benchmark the CBCT performance, the same calibration procedures were performed using two conventional CT scanners. For assessment of influence on dose-volume parameters, the head part of the anthropomorphic Alderson phantom was scanned, reconstructed with both CT and CBCT using the stoichiometric calibration curves, and finally used to compare IMRT dose calculations. RESULTS The stoichiometric CBCT calibrations with the CIRS phantom resulted in an excellent fit between calculated and measured CT numbers (R = 1.000 for all combinations tested), equivalent to the results for the conventional scanners. Using the PMMA phantom, the stoichiometric calibration curves again showed excellent agreement, although the OBI reconstruction showed marginally increasing deviation from the unity line as the phantom size decreased. For the dose-volume parameters, deviations well within 1% were seen between the different reconstruction methods and acquisition modes. CONCLUSION This study showed that the combination of an improved reconstruction method and stoichiometric calibration improved the CT number accuracy of CBCT scans acquired for head and neck phantoms. In particular, a radial size dependence of the scanned object similar to that in conventional CT could be achieved. Although high density inhomogeneities still are challenging for the reconstruction process, clinically acceptable agreement in key dose-volume parameters between CT-based and CBCT-based IMRT planning calculations on a humanoid phantom was found.
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Affiliation(s)
- Ulrik V Elstrøm
- Department of Oncology, Aarhus University Hospital , Aarhus , Denmark
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Vestergaard A, Muren LP, Lindberg H, Jakobsen KL, Petersen JBB, Elstrøm UV, Agerbæk M, Høyer M. Normal tissue sparing in a phase II trial on daily adaptive plan selection in radiotherapy for urinary bladder cancer. Acta Oncol 2014; 53:997-1004. [PMID: 24957559 DOI: 10.3109/0284186x.2014.928419] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Background: Patients with urinary bladder cancer often display large changes in the shape and size of their bladder target during a course of radiotherapy (RT), making adaptive RT (ART) appealing for this tumour site. We are conducting a clinical phase II trial of daily plan selection-based ART for bladder cancer and here report dose-volume data from the first 20 patients treated in the trial. MATERIAL AND METHODS All patients received 60 Gy in 30 fractions to the bladder; in 13 of the patients the pelvic lymph nodes were simultaneously treated to 48 Gy. Daily patient set-up was by use of cone beam computed tomography (CBCT) guidance. The first 5 fractions were delivered with large, population-based (non-adaptive) margins. The bladder contours from the CBCTs acquired in the first 4 fractions were used to create a patient-specific library of three plans, corresponding to a small, medium and large size bladder. From fraction 6, daily online plan selection was performed, where the smallest plan covering the bladder was selected prior to each treatment delivery. A total of 600 treatment fractions in the 20 patients were evaluated. RESULTS Small, medium and large size plans were used almost equally often, with an average of 10, 9 and 11 fractions, respectively. The median volume ratio of the course-averaged PTV (PTV-ART) relative to the non-adaptive PTV was 0.70 (range: 0.46-0.89). A linear regression analysis showed a 183 cm(3) (CI 143-223 cm(3)) reduction in PTV-ART compared to the non-adaptive PTV (R(2) = 0.94). CONCLUSION Daily adaptive plan selection in RT of bladder cancer results in a considerable normal tissue sparing, of a magnitude that we expect will translate into a clinically significant reduction of the treatment-related morbidity.
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Affiliation(s)
- Anne Vestergaard
- Department of Medical Physics, Aarhus University Hospital/Aarhus University , Aarhus , Denmark
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