1
|
Grimbergen G, Eijkelenkamp H, Snoeren LM, Bahij R, Bernchou U, van der Bijl E, Heerkens HD, Binda S, Ng SS, Bouchart C, Paquier Z, Brown K, Khor R, Chuter R, Freear L, Dunlop A, Mitchell RA, Erickson BA, Hall WA, Godoy Scripes P, Tyagi N, de Leon J, Tran C, Oh S, Renz P, Shessel A, Taylor E, Intven MP, Meijer GJ. Treatment planning for MR-guided SBRT of pancreatic tumors on a 1.5 T MR-Linac: A global consensus protocol. Clin Transl Radiat Oncol 2024; 47:100797. [PMID: 38831754 PMCID: PMC11145226 DOI: 10.1016/j.ctro.2024.100797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Background and purpose Treatment planning for MR-guided stereotactic body radiotherapy (SBRT) for pancreatic tumors can be challenging, leading to a wide variation of protocols and practices. This study aimed to harmonize treatment planning by developing a consensus planning protocol for MR-guided pancreas SBRT on a 1.5 T MR-Linac. Materials and methods A consortium was founded of thirteen centers that treat pancreatic tumors on a 1.5 T MR-Linac. A phased planning exercise was conducted in which centers iteratively created treatment plans for two cases of pancreatic cancer. Each phase was followed by a meeting where the instructions for the next phase were determined. After three phases, a consensus protocol was reached. Results In the benchmarking phase (phase I), substantial variation between the SBRT protocols became apparent (for example, the gross tumor volume (GTV) D99% ranged between 36.8 - 53.7 Gy for case 1, 22.6 - 35.5 Gy for case 2). The next phase involved planning according to the same basic dosimetric objectives, constraints, and planning margins (phase II), which led to a large degree of harmonization (GTV D99% range: 47.9-53.6 Gy for case 1, 33.9-36.6 Gy for case 2). In phase III, the final consensus protocol was formulated in a treatment planning system template and again used for treatment planning. This not only resulted in further dosimetric harmonization (GTV D99% range: 48.2-50.9 Gy for case 1, 33.5-36.0 Gy for case 2) but also in less variation of estimated treatment delivery times. Conclusion A global consensus protocol has been developed for treatment planning for MR-guided pancreatic SBRT on a 1.5 T MR-Linac. Aside from harmonizing the large variation in the current clinical practice, this protocol can provide a starting point for centers that are planning to treat pancreatic tumors on MR-Linac systems.
Collapse
Affiliation(s)
- Guus Grimbergen
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Louk M.W. Snoeren
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, Denmark
| | - Uffe Bernchou
- Department of Oncology, Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Denmark
| | - Erik van der Bijl
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Hanne D. Heerkens
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Shawn Binda
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia S.W. Ng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Christelle Bouchart
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Zelda Paquier
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Kerryn Brown
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Richard Khor
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | | | | | - Alex Dunlop
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Robert Adam Mitchell
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Charles Tran
- GenesisCare, Darlinghurst, New South Wales, Australia
| | - Seungjong Oh
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul Renz
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Andrea Shessel
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Edward Taylor
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Martijn P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| |
Collapse
|
2
|
Ferreira Silvério N, van den Wollenberg W, Betgen A, Wiersema L, Marijnen C, Peters F, van der Heide UA, Simões R, Janssen T. Evaluation of Deep Learning Clinical Target Volumes Auto-Contouring for Magnetic Resonance Imaging-Guided Online Adaptive Treatment of Rectal Cancer. Adv Radiat Oncol 2024; 9:101483. [PMID: 38706833 PMCID: PMC11066509 DOI: 10.1016/j.adro.2024.101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/11/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose Segmentation of clinical target volumes (CTV) on medical images can be time-consuming and is prone to interobserver variation (IOV). This is a problem for online adaptive radiation therapy, where CTV segmentation must be performed every treatment fraction, leading to longer treatment times and logistic challenges. Deep learning (DL)-based auto-contouring has the potential to speed up CTV contouring, but its current clinical use is limited. One reason for this is that it can be time-consuming to verify the accuracy of CTV contours produced using auto-contouring, and there is a risk of bias being introduced. To be accepted by clinicians, auto-contouring must be trustworthy. Therefore, there is a need for a comprehensive commissioning framework when introducing DL-based auto-contouring in clinical practice. We present such a framework and apply it to an in-house developed DL model for auto-contouring of the CTV in rectal cancer patients treated with MRI-guided online adaptive radiation therapy. Methods and Materials The framework for evaluating DL-based auto-contouring consisted of 3 steps: (1) Quantitative evaluation of the model's performance and comparison with IOV; (2) Expert observations and corrections; and (3) Evaluation of the impact on expected volumetric target coverage. These steps were performed on independent data sets. The framework was applied to an in-house trained nnU-Net model, using the data of 44 rectal cancer patients treated at our institution. Results The framework established that the model's performance after expert corrections was comparable to IOV, and although the model introduced a bias, this had no relevant impact on clinical practice. Additionally, we found a substantial time gain without reducing quality as determined by volumetric target coverage. Conclusions Our framework provides a comprehensive evaluation of the performance and clinical usability of target auto-contouring models. Based on the results, we conclude that the model is eligible for clinical use.
Collapse
Affiliation(s)
| | | | - Anja Betgen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lisa Wiersema
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Corrie Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Peters
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A. van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rita Simões
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Westerhoff JM, Daamen LA, Christodouleas JP, Blezer ELA, Choudhury A, Westley RL, Erickson BA, Fuller CD, Hafeez S, van der Heide UA, Intven MPW, Kirby AM, Lalondrelle S, Minsky BD, Mook S, Nowee ME, Marijnen CAM, Orrling KM, Sahgal A, Schultz CJ, Faivre-Finn C, Tersteeg RJHA, Tree AC, Tseng CL, Schytte T, Silk DM, Eggert D, Luzzara M, van der Voort van Zyp JRN, Verkooijen HM, Hall WA. Safety and Tolerability of Online Adaptive High-Field Magnetic Resonance-Guided Radiotherapy. JAMA Netw Open 2024; 7:e2410819. [PMID: 38691356 PMCID: PMC11063805 DOI: 10.1001/jamanetworkopen.2024.10819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/06/2024] [Indexed: 05/03/2024] Open
Abstract
Importance In 2018, the first online adaptive magnetic resonance (MR)-guided radiotherapy (MRgRT) system using a 1.5-T MR-equipped linear accelerator (1.5-T MR-Linac) was clinically introduced. This system enables online adaptive radiotherapy, in which the radiation plan is adapted to size and shape changes of targets at each treatment session based on daily MR-visualized anatomy. Objective To evaluate safety, tolerability, and technical feasibility of treatment with a 1.5-T MR-Linac, specifically focusing on the subset of patients treated with an online adaptive strategy (ie, the adapt-to-shape [ATS] approach). Design, Setting, and Participants This cohort study included adults with solid tumors treated with a 1.5-T MR-Linac enrolled in Multi Outcome Evaluation for Radiation Therapy Using the MR-Linac (MOMENTUM), a large prospective international study of MRgRT between February 2019 and October 2021. Included were adults with solid tumors treated with a 1.5-T MR-Linac. Data were collected in Canada, Denmark, The Netherlands, United Kingdom, and the US. Data were analyzed in August 2023. Exposure All patients underwent MRgRT using a 1.5-T MR-Linac. Radiation prescriptions were consistent with institutional standards of care. Main Outcomes and Measures Patterns of care, tolerability, and technical feasibility (ie, treatment completed as planned). Acute high-grade radiotherapy-related toxic effects (ie, grade 3 or higher toxic effects according to Common Terminology Criteria for Adverse Events version 5.0) occurring within the first 3 months after treatment delivery. Results In total, 1793 treatment courses (1772 patients) were included (median patient age, 69 years [range, 22-91 years]; 1384 male [77.2%]). Among 41 different treatment sites, common sites were prostate (745 [41.6%]), metastatic lymph nodes (233 [13.0%]), and brain (189 [10.5%]). ATS was used in 1050 courses (58.6%). MRgRT was completed as planned in 1720 treatment courses (95.9%). Patient withdrawal caused 5 patients (0.3%) to discontinue treatment. The incidence of radiotherapy-related grade 3 toxic effects was 1.4% (95% CI, 0.9%-2.0%) in the entire cohort and 0.4% (95% CI, 0.1%-1.0%) in the subset of patients treated with ATS. There were no radiotherapy-related grade 4 or 5 toxic effects. Conclusions and Relevance In this cohort study of patients treated on a 1.5-T MR-Linac, radiotherapy was safe and well tolerated. Online adaptation of the radiation plan at each treatment session to account for anatomic variations was associated with a low risk of acute grade 3 toxic effects.
Collapse
Affiliation(s)
- Jasmijn M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - Lois A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - John P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Erwin L. A. Blezer
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - Ananya Choudhury
- Department of Clinical Oncology, The University of Manchester, Manchester, United Kingdom
| | - Rosalyne L. Westley
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Clifton D. Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Shaista Hafeez
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Uulke A. van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anna M. Kirby
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Bruce D. Minsky
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marlies E. Nowee
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Arjun Sahgal
- Sunnybrook Health Sciences Centre-Odette Cancer Centre, Department of Radiation Oncology, Toronto, Ontario, Canada
| | | | - Corinne Faivre-Finn
- Department of Clinical Oncology, The University of Manchester, Manchester, United Kingdom
- The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | | | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, Radiation Oncology, London, United Kingdom
- The Institute of Cancer Research, London, United Kingdom
| | - Chia-Lin Tseng
- Sunnybrook Health Sciences Centre-Odette Cancer Centre, Department of Radiation Oncology, Toronto, Ontario, Canada
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Dustin M. Silk
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | | | | | | | - Helena M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, the Netherlands
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| |
Collapse
|
4
|
Sritharan K, Daamen L, Pathmanathan A, Schytte T, Pos F, Choudhury A, van der Voort van Zyp JR, Kerkmeijer LG, Hall W, Hall E, Verkooijen HM, Herbert T, Hafeez S, Mitchell A, Tree AC. MRI-guided radiotherapy in twenty fractions for localised prostate cancer; results from the MOMENTUM study. Clin Transl Radiat Oncol 2024; 46:100742. [PMID: 38440792 PMCID: PMC10909700 DOI: 10.1016/j.ctro.2024.100742] [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: 08/29/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
Background and purpose MRI-guided radiotherapy (MRIgRT) offers multiple potential advantages over CT-guidance. This study examines the potential clinical benefits of MRIgRT for men with localised prostate cancer, in the setting of moderately hypofractionated radiotherapy. We evaluate two-year toxicity outcomes, early biochemical response and patient-reported outcomes (PRO), using data obtained from a multicentre international registry study, for the first group of patients with prostate cancer who underwent treatment on a 1.5 T MR-Linac. Materials and methods Patients who were enrolled within the MOMENTUM study and received radical treatment with 60 Gy in 20 fractions were identified. PSA levels and CTCAE version 5.0 toxicity data were measured at follow-up visits. Those patients who consented to PRO data collection also completed EQ-5D-5L, EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires. Results Between November 2018 and June 2022, 146 patients who had MRIgRT for localised prostate cancer on the 1.5 T MR-Linac were eligible for this study. Grade 2 and worse gastro-intestinal (GI) toxicity was reported in 3 % of patients at three months whilst grade 2 and worse genitourinary (GU) toxicity was 7 % at three months. There was a significant decrease in the median PSA at 12 months. The results from both the EQ-5D-5L data and EORTC global health status scale indicate a decline in the quality of life (QoL) during the first six months. The mean change in score for the EORTC scale showed a decrease of 11.4 points, which is considered clinically important. QoL improved back to baseline by 24 months. Worsening of hormonal symptoms in the first six months was reported with a return to baseline by 24 months and sexual activity in all men worsened in the first three months and returned to baseline at 12 months. Conclusion This study establishes the feasibility of online-MRIgRT for localised prostate on a 1.5 T MR-Linac with low rates of toxicity, similar to that published in the literature. However, the clinical benefits of MRIgRT over conventional radiotherapy in the setting of moderate hypofractionation is not evident. Further research will focus on the delivery of ultrahypofractionated regimens, where the potential advantages of MRIgRT for prostate cancer may become more discernible.
Collapse
Affiliation(s)
- Kobika Sritharan
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Lois Daamen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Floris Pos
- The Netherlands Cancer Institute, The Netherlands
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, UK
| | | | | | | | - Emma Hall
- The Institute of Cancer Research, UK
| | - Helena M. Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Adam Mitchell
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| |
Collapse
|
5
|
Kolenbrander ID, Maspero M, Hendriksen AA, Pollitt R, van der Voort van Zyp JRN, van den Berg CAT, Pluim JPW, van Eijnatten MAJM. Deep-learning-based joint rigid and deformable contour propagation for magnetic resonance imaging-guided prostate radiotherapy. Med Phys 2024; 51:2367-2377. [PMID: 38408022 DOI: 10.1002/mp.17000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/05/2023] [Accepted: 02/04/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Deep learning-based unsupervised image registration has recently been proposed, promising fast registration. However, it has yet to be adopted in the online adaptive magnetic resonance imaging-guided radiotherapy (MRgRT) workflow. PURPOSE In this paper, we design an unsupervised, joint rigid, and deformable registration framework for contour propagation in MRgRT of prostate cancer. METHODS Three-dimensional pelvic T2-weighted MRIs of 143 prostate cancer patients undergoing radiotherapy were collected and divided into 110, 13, and 20 patients for training, validation, and testing. We designed a framework using convolutional neural networks (CNNs) for rigid and deformable registration. We selected the deformable registration network architecture among U-Net, MS-D Net, and LapIRN and optimized the training strategy (end-to-end vs. sequential). The framework was compared against an iterative baseline registration. We evaluated registration accuracy (the Dice and Hausdorff distance of the prostate and bladder contours), structural similarity index, and folding percentage to compare the methods. We also evaluated the framework's robustness to rigid and elastic deformations and bias field perturbations. RESULTS The end-to-end trained framework comprising LapIRN for the deformable component achieved the best median (interquartile range) prostate and bladder Dice of 0.89 (0.85-0.91) and 0.86 (0.80-0.91), respectively. This accuracy was comparable to the iterative baseline registration: prostate and bladder Dice of 0.91 (0.88-0.93) and 0.86 (0.80-0.92). The best models complete rigid and deformable registration in 0.002 (0.0005) and 0.74 (0.43) s (Nvidia Tesla V100-PCIe 32 GB GPU), respectively. We found that the models are robust to translations up to 52 mm, rotations up to 15∘ $^\circ$ , elastic deformations up to 40 mm, and bias fields. CONCLUSIONS Our proposed unsupervised, deep learning-based registration framework can perform rigid and deformable registration in less than a second with contour propagation accuracy comparable with iterative registration.
Collapse
Affiliation(s)
- Iris D Kolenbrander
- Medical Image Analysis Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven Artificial Intelligence Systems Institute, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Matteo Maspero
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Allard A Hendriksen
- Computational Imaging, Centrum Wiskunde & Informatica, Amsterdam, The Netherlands
| | - Ryan Pollitt
- Medical Image Analysis Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Cornelis A T van den Berg
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Josien P W Pluim
- Medical Image Analysis Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven Artificial Intelligence Systems Institute, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Maureen A J M van Eijnatten
- Medical Image Analysis Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven Artificial Intelligence Systems Institute, Eindhoven University of Technology, Eindhoven, The Netherlands
| |
Collapse
|
6
|
de Mol van Otterloo S, Westerhoff J, Leer T, Rutgers R, Meijers L, Daamen L, Intven M, Verkooijen H. Patient expectation and experience of MR-guided radiotherapy using a 1.5T MR-Linac. Tech Innov Patient Support Radiat Oncol 2024; 29:100224. [PMID: 38162695 PMCID: PMC10755768 DOI: 10.1016/j.tipsro.2023.100224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/19/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024] Open
Abstract
Background and Purpose Online adaptive MR-guided radiotherapy (MRgRT) is a relatively new form of radiotherapy treatment, delivered using a MR-Linac. It is unknown what patients expect from this treatment and whether these expectations are met. This study evaluates whether patients' pre-treatment expectations of MRgRT are met and reports patients' on-table experience on a 1.5 T MR-Linac. Materials and methods All patients treated on the MR-Linac from November 2020 until April 2021, were eligible for inclusion. Patient expectation and experience were captured through questionnaires before, during, and three months after treatment. The on-table experience questionnaire included patient' physical and psychological coping. Patient-expected side effects, participation in daily and social activity, disease outcome and, disease related symptoms were compared to post-treatment experience. Results We included 113 patients who were primarily male (n = 100, 89 %), with a median age of 69 years (range 52-90). For on-table experience, ninety percent of patients (strongly) agreed to feeling calm during their treatment. Six and eight percent of patients found the treatment position or bed uncomfortable respectively. Twenty-eight percent of patients felt tingling sensations during treatment. After treatment, 79 % of patients' expectations were met. Most patients experienced an (better than) expected level of side effects (75 %), participation in daily- (83 %) and social activity (86 %) and symptoms (78 %). However, 33 % expected more treatment efficacy than experienced. Conclusion Treatment on the 1.5 T MR-Linac is well tolerated and meets patient expectations. Despite the fact that some patients expected greater treatment efficacy and the frequent occurrence of tingling sensations during treatment, most patient experiences were comparable or better than previously expected.
Collapse
Affiliation(s)
- S.R. de Mol van Otterloo
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - J.M. Westerhoff
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - T. Leer
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - R.H.A. Rutgers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.T.C. Meijers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - L.A. Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - M.P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
| | - H.M. Verkooijen
- Division of Imaging, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
7
|
Persson E, Goodwin E, Eiben B, Wetscherek A, Nill S, Oelfke U. Real-time motion-including dose estimation of simulated multi-leaf collimator-tracked magnetic resonance-guided radiotherapy. Med Phys 2024; 51:2221-2229. [PMID: 37898109 DOI: 10.1002/mp.16798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Real-time dose estimation is a key-prerequisite to enable online intra-fraction treatment adaptation in magnetic resonance (MR)-guided radiotherapy (MRgRT). It is an essential component for the assessment of the dosimetric benefits and risks of online adaptive treatments, such as multi-leaf collimator (MLC)-tracking. PURPOSE We present a proof-of-concept for a software workflow for real-time dose estimation of MR-guided adaptive radiotherapy based on real-time data-streams of the linac delivery parameters and target positions. METHODS A software workflow, combining our in-house motion management software DynaTrack, a real-time dose calculation engine that connects to a research version of the treatment planning software (TPS) Monaco (v.6.09.00, Elekta AB, Stockholm, Sweden) was developed and evaluated. MR-guided treatment delivery on the Elekta Unity MR-linac was simulated with and without MLC-tracking for three prostate patients, previously treated on the Elekta Unity MR-linac (36.25 Gy/five fractions). Three motion scenarios were used: no motion, regular motion, and erratic prostate motion. Accumulated monitor units (MUs), centre of mass target position and MLC-leaf positions, were forwarded from DynaTrack at a rate of 25 Hz to a Monte Carlo (MC) based dose calculation engine which utilises the research GPUMCD-library (Elekta AB, Stockholm, Sweden). A rigid isocentre shift derived from the selected motion scenarios was applied to a bulk density-assigned session MR-image. The respective electron density used for treatment planning was accessed through the research Monaco TPS. The software workflow including the online dose reconstruction was validated against offline dose reconstructions. Our investigation showed that MC-based real-time dose calculations that account for all linac states (including MUs, MLC positions and target position) were infeasible, hence states were randomly sampled and used for calculation as follows; Once a new linac state was received, a dose calculation with 106 photons was started. Linac states that arrived during the time of the ongoing calculation were put into a queue. After completion of the ongoing calculation, one new linac state was randomly picked from the queue and assigned the MU accumulated from the previous state until the last sample in the queue. The queue was emptied, and the process repeated throughout treatment simulation. RESULTS On average 27% (23%-30%) of received samples were used in the real-time calculation, corresponding to a calculation time for one linac state of 148 ms. Median gamma pass rate (2%/3 mm local) was 100.0% (99.9%-100%) within the PTV volume and 99.1% (90.1%-99.4.0%) with a 15% dose cut off. Differences in PTVDmean , CTVDmean , RectumD2% , and BladderD2% (offline-online, % of prescribed dose) were below 0.64%. Beam-by-beam comparisons showed deviations below 0.07 Gy. Repeated simulations resulted in standard deviations below 0.31% and 0.12 Gy for the investigated volume and dose criteria respectively. CONCLUSIONS Real-time dose estimation was successfully performed using the developed software workflow for different prostate motion traces with and without MLC-tracking. Negligible dosimetric differences were seen when comparing online and offline reconstructed dose, enabling online intra-fraction treatment decisions based on estimates of the delivered dose.
Collapse
Affiliation(s)
- Emilia Persson
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| | - Edmund Goodwin
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| | - Björn Eiben
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| | - Andreas Wetscherek
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| | - Simeon Nill
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| | - Uwe Oelfke
- Joint Department of Physics, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, UK
| |
Collapse
|
8
|
Daamen L, Westerhoff J, Couwenberg A, Braam P, Rütten H, den Hartogh M, Christodouleas J, Hall W, Verkooijen H, Intven M. Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study. Clin Transl Radiat Oncol 2024; 45:100721. [PMID: 38274389 PMCID: PMC10808928 DOI: 10.1016/j.ctro.2023.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/10/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Background and purpose This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment. Materials and methods Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019-2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented. Results A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] -17.4 [95 % confidence interval [CI] -31.2 to -3.7]), blood and mucus in stool (MD -31.1 [95 % CI -46.4 to -15.8]), and anxiety (MD -22.4 [95 % CI -34.0 to -10.9]) were improved. Conclusion High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment.
Collapse
Affiliation(s)
- L.A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - J.M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - A.M. Couwenberg
- The Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - P.M. Braam
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | - H. Rütten
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | | | - J.P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Hospital of the University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA, United States
| | - W.A. Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - H.M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - M.P.W. Intven
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| |
Collapse
|
9
|
Westley RL, Biscombe K, Dunlop A, Mitchell A, Oelfke U, Nill S, Murray J, Pathmanathan A, Hafeez S, Parker C, Ratnakumaran R, Alexander S, Herbert T, Hall E, Tree AC. Interim Toxicity Analysis From the Randomized HERMES Trial of 2- and 5-Fraction Magnetic Resonance Imaging-Guided Adaptive Prostate Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:682-687. [PMID: 37776979 DOI: 10.1016/j.ijrobp.2023.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE Ultrahypofractionated radiation therapy (UHRT) is an effective treatment for localized prostate cancer with an acceptable toxicity profile; boosting the visible intraprostatic tumor has been shown to improve biochemical disease-free survival with no significant effect on genitourinary (GU) and gastrointestinal (GI) toxicity. METHODS AND MATERIALS HERMES is a single-center noncomparative randomized phase 2 trial in men with intermediate or lower high risk prostate cancer. Patients were allocated (1:1) to 36.25 Gy in 5 fractions over 2 weeks or 24 Gy in 2 fractions over 8 days with an integrated boost to the magnetic resonance imaging (MRI) visible tumor of 27 Gy in 2 fractions. A minimization algorithm with a random element with risk group as a balancing factor was used for participant randomization. Treatment was delivered on the Unity MR-Linac (Elekta AB) with daily online adaption. The primary endpoint was acute GU Common Terminology Criteria for Adverse Events version 5.0 toxicity with the aim of excluding a doubling of the rate of acute grade 2+ GU toxicity seen in PACE. Analysis was by treatment received and included all participants who received at least 1 fraction of study treatment. This interim analysis was prespecified (stage 1 of a 2-stage Simon design) for when 10 participants in each treatment group had completed the acute toxicity monitoring period (12 weeks after radiation therapy). RESULTS Acute grade 2 GU toxicity was reported in 1 (10%) patient in the 5-fraction group and 2 (20%) patients in the 2-fraction group. No grade 3+ GU toxicities were reported. CONCLUSIONS At this interim analysis, the rate of GU toxicity in the 2-fraction and 5-fraction treatment groups was found to be below the prespecified threshold (5/10 grade 2+) and continuation of the study to complete recruitment of 23 participants per group was recommended.
Collapse
Affiliation(s)
- Rosalyne Laura Westley
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom.
| | | | - Alex Dunlop
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Adam Mitchell
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Simeon Nill
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Julia Murray
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Angela Pathmanathan
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Shaista Hafeez
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Chris Parker
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Ragu Ratnakumaran
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Sophie Alexander
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| | - Trina Herbert
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Institute of Cancer Research, London, United Kingdom
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Institute of Cancer Research, London, United Kingdom
| |
Collapse
|
10
|
Vinod SK, Merie R, Harden S. Quality of Decision Making in Radiation Oncology. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00067-0. [PMID: 38342658 DOI: 10.1016/j.clon.2024.02.001] [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: 11/09/2023] [Revised: 01/04/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
High-quality decision making in radiation oncology requires the careful consideration of multiple factors. In addition to the evidence-based indications for curative or palliative radiotherapy, this article explores how, in routine clinical practice, we also need to account for many other factors when making high-quality decisions. Foremost are patient-related factors, including preference, and the complex interplay between age, frailty and comorbidities, especially with an ageing cancer population. Whilst clinical practice guidelines inform our decisions, we need to account for their applicability in different patient groups and different resource settings. With particular reference to curative-intent radiotherapy, we explore decisions regarding dose fractionation schedules, use of newer radiotherapy technologies and multimodality treatment considerations that contribute to personalised patient-centred care.
Collapse
Affiliation(s)
- S K Vinod
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia; South West Sydney Clinical Campuses, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
| | - R Merie
- Icon Cancer Centre, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - S Harden
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
11
|
Yang B, Liu Y, Zhu J, Lu N, Dai J, Men K. Pretreatment information-aided automatic segmentation for online magnetic resonance imaging-guided prostate radiotherapy. Med Phys 2024; 51:922-932. [PMID: 37449545 DOI: 10.1002/mp.16608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND It is necessary to contour regions of interest (ROIs) for online magnetic resonance imaging (MRI)-guided adaptive radiotherapy (MRIgART). These updated contours are used for online replanning to obtain maximum dosimetric benefits. Contouring can be accomplished using deformable image registration (DIR) and deep learning (DL)-based autosegmentation methods. However, these methods may require considerable manual editing and thus prolong treatment time. PURPOSE The present study aimed to improve autosegmentation performance by integrating patients' pretreatment information in a DL-based segmentation algorithm. It is expected to improve the efficiency of current MRIgART process. METHODS Forty patients with prostate cancer were enrolled retrospectively. The online adaptive MR images, patient-specific planning computed tomography (CT), and contours in CT were used for segmentation. The deformable registration of planning CT and MR images was performed first to obtain a deformable CT and corresponding contours. A novel DL network, which can integrate such patient-specific information (deformable CT and corresponding contours) into the segmentation task of MR images was designed. We performed a four-fold cross-validation for the DL models. The proposed method was compared with DIR and DL methods on segmentation of prostate cancer. The ROIs included the clinical target volume (CTV), bladder, rectum, left femur head, and right femur head. Dosimetric parameters of automatically generated ROIs were evaluated using a clinical treatment planning system. RESULTS The proposed method enhanced the segmentation accuracy of conventional procedures. Its mean value of the dice similarity coefficient (93.5%) over the five ROIs was higher than both DIR (87.5%) and DL (87.2%). The number of patients (n = 40) that required major editing using DIR, DL, and our method were 12, 18, and 7 (CTV); 17, 4, and 1 (bladder); 8, 11, and 5 (rectum); 2, 4, and 1 (left femur head); and 3, 7, and 1 (right femur head), respectively. The Spearman rank correlation coefficient of dosimetry parameters between the proposed method and ground truth was 0.972 ± 0.040, higher than that of DIR (0.897 ± 0.098) and DL (0.871 ± 0.134). CONCLUSION This study proposed a novel method that integrates patient-specific pretreatment information into DL-based segmentation algorithm. It outperformed baseline methods, thereby improving the efficiency and segmentation accuracy in adaptive radiotherapy.
Collapse
Affiliation(s)
- Bining Yang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxiang Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji Zhu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ningning Lu
- 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
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Men
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
12
|
Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
Collapse
Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
| |
Collapse
|
13
|
Guckenberger M, Andratschke N, Chung C, Fuller D, Tanadini-Lang S, Jaffray DA. The Future of MR-Guided Radiation Therapy. Semin Radiat Oncol 2024; 34:135-144. [PMID: 38105088 DOI: 10.1016/j.semradonc.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Magnetic resonance image guided radiation therapy (MRIgRT) is a relatively new technology that has already shown outcomes benefits but that has not yet reached its clinical potential. The improved soft-tissue contrast provided with MR, coupled with the immediacy of image acquisition with respect to the treatment, enables expansion of on-table adaptive protocols, currently at a cost of increased treatment complexity, use of human resources, and longer treatment slot times, which translate to decreased throughput. Many approaches are being investigated to meet these challenges, including the development of artificial intelligence (AI) algorithms to accelerate and automate much of the workflow and improved technology that parallelizes workflow tasks, as well as improvements in image acquisition speed and quality. This article summarizes limitations of current available integrated MRIgRT systems and gives an outlook about scientific developments to further expand the use of MRIgRT.
Collapse
Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland..
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Caroline Chung
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dave Fuller
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - David A Jaffray
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
14
|
Wu TC, Smith LM, Woolf D, Faivre-Finn C, Lee P. Exploring the Advantages and Challenges of MR-Guided Radiotherapy in Non-Small-Cell Lung Cancer: Who are the Optimal Candidates? Semin Radiat Oncol 2024; 34:56-63. [PMID: 38105094 DOI: 10.1016/j.semradonc.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The landscape of lung radiotherapy (RT) has rapidly evolved over the past decade with modern RT and surgical techniques, systemic therapies, and expanding indications for RT. To date, 2 MRI-guided RT (MRgRT) units, 1 using a 0.35T magnet and 1 using a 1.5T magnet, are available for commercial use with more systems in the pipeline. MRgRT offers distinct advantages such as real-time target tracking, margin reduction, and on-table treatment adaptation, which may help overcome many of the common challenges associated with thoracic RT. Nonetheless, the use of MRI for image guidance and the current MRgRT units also have intrinsic limitations. In this review article, we will discuss clinical experiences to date, advantages, challenges, and future directions of MRgRT to the lung.
Collapse
Affiliation(s)
- Trudy C Wu
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Lauren M Smith
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - David Woolf
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.; Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.; Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA..
| |
Collapse
|
15
|
McDonald BA, Cardenas CE, O'Connell N, Ahmed S, Naser MA, Wahid KA, Xu J, Thill D, Zuhour RJ, Mesko S, Augustyn A, Buszek SM, Grant S, Chapman BV, Bagley AF, He R, Mohamed ASR, Christodouleas J, Brock KK, Fuller CD. Investigation of autosegmentation techniques on T2-weighted MRI for off-line dose reconstruction in MR-linac workflow for head and neck cancers. Med Phys 2024; 51:278-291. [PMID: 37475466 PMCID: PMC10799175 DOI: 10.1002/mp.16582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND In order to accurately accumulate delivered dose for head and neck cancer patients treated with the Adapt to Position workflow on the 1.5T magnetic resonance imaging (MRI)-linear accelerator (MR-linac), the low-resolution T2-weighted MRIs used for daily setup must be segmented to enable reconstruction of the delivered dose at each fraction. PURPOSE In this pilot study, we evaluate various autosegmentation methods for head and neck organs at risk (OARs) on on-board setup MRIs from the MR-linac for off-line reconstruction of delivered dose. METHODS Seven OARs (parotid glands, submandibular glands, mandible, spinal cord, and brainstem) were contoured on 43 images by seven observers each. Ground truth contours were generated using a simultaneous truth and performance level estimation (STAPLE) algorithm. Twenty total autosegmentation methods were evaluated in ADMIRE: 1-9) atlas-based autosegmentation using a population atlas library (PAL) of 5/10/15 patients with STAPLE, patch fusion (PF), random forest (RF) for label fusion; 10-19) autosegmentation using images from a patient's 1-4 prior fractions (individualized patient prior [IPP]) using STAPLE/PF/RF; 20) deep learning (DL) (3D ResUNet trained on 43 ground truth structure sets plus 45 contoured by one observer). Execution time was measured for each method. Autosegmented structures were compared to ground truth structures using the Dice similarity coefficient, mean surface distance (MSD), Hausdorff distance (HD), and Jaccard index (JI). For each metric and OAR, performance was compared to the inter-observer variability using Dunn's test with control. Methods were compared pairwise using the Steel-Dwass test for each metric pooled across all OARs. Further dosimetric analysis was performed on three high-performing autosegmentation methods (DL, IPP with RF and 4 fractions [IPP_RF_4], IPP with 1 fraction [IPP_1]), and one low-performing (PAL with STAPLE and 5 atlases [PAL_ST_5]). For five patients, delivered doses from clinical plans were recalculated on setup images with ground truth and autosegmented structure sets. Differences in maximum and mean dose to each structure between the ground truth and autosegmented structures were calculated and correlated with geometric metrics. RESULTS DL and IPP methods performed best overall, all significantly outperforming inter-observer variability and with no significant difference between methods in pairwise comparison. PAL methods performed worst overall; most were not significantly different from the inter-observer variability or from each other. DL was the fastest method (33 s per case) and PAL methods the slowest (3.7-13.8 min per case). Execution time increased with a number of prior fractions/atlases for IPP and PAL. For DL, IPP_1, and IPP_RF_4, the majority (95%) of dose differences were within ± 250 cGy from ground truth, but outlier differences up to 785 cGy occurred. Dose differences were much higher for PAL_ST_5, with outlier differences up to 1920 cGy. Dose differences showed weak but significant correlations with all geometric metrics (R2 between 0.030 and 0.314). CONCLUSIONS The autosegmentation methods offering the best combination of performance and execution time are DL and IPP_1. Dose reconstruction on on-board T2-weighted MRIs is feasible with autosegmented structures with minimal dosimetric variation from ground truth, but contours should be visually inspected prior to dose reconstruction in an end-to-end dose accumulation workflow.
Collapse
Affiliation(s)
- Brigid A McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos E Cardenas
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Sara Ahmed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mohamed A Naser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kareem A Wahid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Raed J Zuhour
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Shane Mesko
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander Augustyn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samantha M Buszek
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Grant
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander F Bagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Renjie He
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Kristy K Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
16
|
Low DA, Fallone BG, Raaymakers BW. MRI-Guided Radiation Therapy Systems. Semin Radiat Oncol 2024; 34:14-22. [PMID: 38105089 DOI: 10.1016/j.semradonc.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
MR-Guided Radiation Therapy (MRIgRT) has been made possible only due to the ingenuity and commitment of commercial radiation therapy system vendors. Unlike conventional linear accelerator systems, MRIgRT systems have had to overcome significant and previously untested techniques to integrate the MRI systems with the radiation therapy delivery systems. Each of these three commercial systems has developed different approaches to integrating their MR and Linac functions. Each has also decided on a different main magnetic field strength, from 0.35T to 1.5T, as well as different design philosophies for other systems, such as the patient support assembly and treatment planning workflow. This paper is intended to provide the reader with a detailed understanding of each system's configuration so that the reader can better interpret the scientific literature concerning these commercial MRIgRT systems.
Collapse
Affiliation(s)
| | - B Gino Fallone
- Medical Physics Division, Oncology and Medical Physics Training Programs, University of Alberta and Medical Physics Department Cross Cancer Institute, Edmonton, AB, Canada
| | - Bas W Raaymakers
- Department of Radiotherapy, UMC Utrecht, Utrecht, The Netherlands
| |
Collapse
|
17
|
van Houdt PJ, Li S, Yang Y, van der Heide UA. Quantitative MRI on MR-Linacs: Towards Biological Image-Guided Adaptive Radiotherapy. Semin Radiat Oncol 2024; 34:107-119. [PMID: 38105085 DOI: 10.1016/j.semradonc.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Recognizing the potential of quantitative imaging biomarkers (QIBs) in radiotherapy, many studies have investigated the prognostic value of quantitative MRI (qMRI). With the introduction of MRI-guided radiotherapy systems, the practical challenges of repeated imaging have been substantially reduced. Since patients are treated inside an MRI scanner, acquisition of qMRI can be done during each fraction with limited or no prolongation of the fraction duration. In this review paper, we identify the steps that need been taken to move from MR as an imaging technique to a useful biomarker for MRI-guided radiotherapy (MRgRT).
Collapse
Affiliation(s)
- Petra J van Houdt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Shaolei Li
- SJTU-Ruijing, UIH Institute for Medical Imaging Technology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.; Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yingli Yang
- SJTU-Ruijing, UIH Institute for Medical Imaging Technology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.; Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands..
| |
Collapse
|
18
|
Eijkelenkamp H, Grimbergen G, Daamen LA, Heerkens HD, van de Ven S, Mook S, Meijer GJ, Molenaar IQ, van Santvoort HC, Paulson E, Erickson BA, Verkooijen HM, Hall WA, Intven MPW. Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac. Front Oncol 2023; 13:1040673. [PMID: 37854684 PMCID: PMC10579578 DOI: 10.3389/fonc.2023.1040673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT. Methods We evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3-12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan-Meier analysis to calculate the cumulative overall survival. Results A total of 80 patients were assessed with a median FU of 8 months (range 1-39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3-4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3-4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%. Conclusion Online adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3-4 toxicity and a stable QoL at 3 months of FU.
Collapse
Affiliation(s)
- Hidde Eijkelenkamp
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Guus Grimbergen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A. Daamen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia van de Ven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Stella Mook
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J. Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Izaak Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, Netherlands
| | | | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Ann Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - William Adrian Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Martijn P. W. Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| |
Collapse
|
19
|
Krogh SL, Brink C, Lorenzen EL, Samsøe E, Vogelius IR, Zukauskaite R, Vrou Offersen B, Eriksen JG, Hansen O, Johansen J, Olloni A, Ruhlmann CH, Hoffmann L, Nissen HD, Skovmos Nielsen M, Andersen K, Grau C, Hansen CR. A national repository of complete radiotherapy plans: design, Results, and experiences. Acta Oncol 2023; 62:1161-1168. [PMID: 37850659 DOI: 10.1080/0284186x.2023.2270143] [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: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Previously, many radiotherapy (RT) trials were based on a few selected dose measures. Many research questions, however, rely on access to the complete dose information. To support such access, a national RT plan database was created. The system focuses on data security, ease of use, and re-use of data. This article reports on the development and structure, and the functionality and experience of this national database. METHODS AND MATERIALS A system based on the DICOM-RT standard, DcmCollab, was implemented with direct connections to all Danish RT centres. Data is segregated into any number of collaboration projects. User access to the system is provided through a web interface. The database has a finely defined access permission model to support legal requirements. RESULTS Currently, data for more than 14,000 patients have been submitted to the system, and more than 50 research projects are registered. The system is used for data collection, trial quality assurance, and audit data set generation.Users reported that the process of submitting data, waiting for it to be processed, and then manually attaching it to a project was resource intensive. This was accommodated with the introduction of triggering features, eliminating much of the need for users to manage data manually. Many other features, including structure name mapping, RT plan viewer, and the Audit Tool were developed based on user input. CONCLUSION The DcmCollab system has provided an efficient means to collect and access complete datasets for multi-centre RT research. This stands in contrast with previous methods of collecting RT data in multi-centre settings, where only singular data points were manually reported. To accommodate the evolving legal environment, DcmCollab has been defined as a 'data processor', meaning that it is a tool for other research projects to use rather than a research project in and of itself.
Collapse
Affiliation(s)
- Simon Long Krogh
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Eva Samsøe
- Department of Oncology, Radiotherapy, Zealand University Hospital, Naestved, Denmark
| | | | - Ruta Zukauskaite
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus, Denmark
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Olfred Hansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Agon Olloni
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Lone Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Dahl Nissen
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | | | - Karen Andersen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Center for Particle Therapy, Aarhus, Denmark
| |
Collapse
|
20
|
Bernchou U, Schytte T, Bertelsen A, Lorenzen EL, Brink C, Mahmood F. Impact of abdominal compression on intra-fractional motion and delivered dose in magnetic resonance image-guided adaptive radiation ablation of adrenal gland metastases. Phys Med 2023; 114:102682. [PMID: 37717398 DOI: 10.1016/j.ejmp.2023.102682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/08/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023] Open
Abstract
PURPOSE The current study investigated the impact of abdominal compression on motion and the delivered dose during non-gated, magnetic resonance image (MRI)-guided radiation ablation of adrenal gland metastases. METHODS Thirty-one patients with adrenal gland metastases treated to 45-60 Gy in 3-8 fractions on a 1.5 T MRI-linac were included in the study. The patients were breathing freely (n = 14) or with motion restricted by using an abdominal compression belt (n = 17). The time-resolved position of the target in online 2D cine MR images acquired during treatment was assessed and used to estimate the dose delivered to the GTV and abutting luminal organs at risk (OAR). RESULTS The median (range) 3D root-mean-square target position error was significantly higher in patients treated without a compression belt [2.9 (1.9-5.6) mm] compared to patients using the belt [2.1 (1.2-3.5) mm] (P < 0.01). The median (range) GTV V95% was significantly reduced from planned 98.6 (65.9-100) % to delivered 96.5 (64.5-99.9) % due to motion (P < 0.01). Most prominent dose reductions were found in patients showing either large target drift or respiration motion and were mainly treated without abdominal compression. Motion did not lead to an increased number of constraint violations for luminal OAR. CONCLUSIONS Acceptable target coverage and dose to OAR was observed in the vast majority of patients despite intra-fractional motion during adaptive MRI-guided radiation ablation. The use of abdominal compression significantly reduced the target position error and prevented the most prominent target coverage degradations and is, therefore, recommended as motion management at MRI-linacs.
Collapse
Affiliation(s)
- Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark; Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Anders Bertelsen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| | - Faisal Mahmood
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19 3., 5000 Odense C, Denmark.
| |
Collapse
|
21
|
Longitudinal diffusion and volumetric kinetics of head and neck cancer magnetic resonance on a 1.5 T MR-linear accelerator hybrid system: A prospective R-IDEAL stage 2a imaging biomarker characterization/pre-qualification study. Clin Transl Radiat Oncol 2023; 42:100666. [PMID: 37583808 PMCID: PMC10424120 DOI: 10.1016/j.ctro.2023.100666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/17/2023] Open
Abstract
Objectives We aim to characterize the serial quantitative apparent diffusion coefficient (ADC) changes of the target disease volume using diffusion-weighted imaging (DWI) acquired weekly during radiation therapy (RT) on a 1.5 T MR-Linac and correlate these changes with tumor response and oncologic outcomes for head and neck squamous cell carcinoma (HNSCC) patients as part of a programmatic R-IDEAL biomarker characterization effort. Methods Thirty patients with HNSCC who received curative-intent RT at MD Anderson Cancer Center, were included. Baseline and weekly MRI were obtained, and various ADC parameters were extracted from the regions of interest (ROIs). Baseline and weekly ADC parameters were correlated with response during and after RT, and the recurrence using the Mann-Whitney U test. The Wilcoxon signed-rank test was used to compare the weekly ADC versus baseline values. Weekly volumetric changes (Δvolume) for each ROI were correlated with ΔADC using Spearman's Rho test. Recursive partitioning analysis (RPA) identified the optimal ΔADC threshold associated with different oncologic outcomes. Results There was a significant rise in all ADC parameters at different time points of RT compared to baseline for both gross primary disease (GTV-P) and gross nodal disease volumes (GTV-N). The increased ADC values for GTV-P were statistically significant only for primary tumors achieving complete remission (CR) during RT. RPA identified GTV-P ΔADC 5th percentile > 13% at the mid-RT as the most significant parameter associated with primary tumors' CR during RT (p < 0.001). There was a significant decrease in residual volume of both GTV-P & GTV-N throughout the course of RT. A significant negative correlation between mean ΔADC and Δvolume for GTV-P at the 3rd and 4th week of RT was detected (r = -0.39, p = 0.044 & r = -0.45, p = 0.019, respectively). Conclusion Assessment of ADC kinetics at regular intervals throughout RT seems to be correlated with RT response. Further studies with larger cohorts and multi-institutional data are needed for validation of ΔADC as a model for prediction of response to RT.
Collapse
|
22
|
Verweij ME, Tanaka MD, Kensen CM, van der Heide UA, Marijnen CAM, Janssen T, Vijlbrief T, van Grevenstein WMU, Moons LMG, Koopman M, Lacle MM, Braat MNGJA, Chalabi M, Maas M, Huibregtse IL, Snaebjornsson P, Grotenhuis BA, Fijneman R, Consten E, Pronk A, Smits AB, Heikens JT, Eijkelenkamp H, Elias SG, Verkooijen HM, Schoenmakers MMC, Meijer GJ, Intven M, Peters FP. Towards Response ADAptive Radiotherapy for organ preservation for intermediate-risk rectal cancer (preRADAR): protocol of a phase I dose-escalation trial. BMJ Open 2023; 13:e065010. [PMID: 37321815 PMCID: PMC10277084 DOI: 10.1136/bmjopen-2022-065010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/07/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Organ preservation is associated with superior functional outcome and quality of life (QoL) compared with total mesorectal excision (TME) for rectal cancer. Only 10% of patients are eligible for organ preservation following short-course radiotherapy (SCRT, 25 Gy in five fractions) and a prolonged interval (4-8 weeks) to response evaluation. The organ preservation rate could potentially be increased by dose-escalated radiotherapy. Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is anticipated to reduce radiation-induced toxicity and enable radiotherapy dose escalation. This trial aims to establish the maximum tolerated dose (MTD) of dose-escalated SCRT using online adaptive MRgRT. METHODS AND ANALYSIS The preRADAR is a multicentre phase I trial with a 6+3 dose-escalation design. Patients with intermediate-risk rectal cancer (cT3c-d(MRF-)N1M0 or cT1-3(MRF-)N1M0) interested in organ preservation are eligible. Patients are treated with a radiotherapy boost of 2×5 Gy (level 0), 3×5 Gy (level 1), 4×5 Gy (level 2) or 5×5 Gy (level 3) on the gross tumour volume in the week following standard SCRT using online adaptive MRgRT. The trial starts on dose level 1. The primary endpoint is the MTD based on the incidence of dose-limiting toxicity (DLT) per dose level. DLT is a composite of maximum one in nine severe radiation-induced toxicities and maximum one in three severe postoperative complications, in patients treated with TME or local excision within 26 weeks following start of treatment. Secondary endpoints include the organ preservation rate, non-DLT, oncological outcomes, patient-reported QoL and functional outcomes up to 2 years following start of treatment. Imaging and laboratory biomarkers are explored for early response prediction. ETHICS AND DISSEMINATION The trial protocol has been approved by the Medical Ethics Committee of the University Medical Centre Utrecht. The primary and secondary trial results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER WHO International Clinical Trials Registry (NL8997; https://trialsearch.who.int).
Collapse
Affiliation(s)
- Maaike E Verweij
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Max D Tanaka
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Chavelli M Kensen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas Janssen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tineke Vijlbrief
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Leon M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon N G J A Braat
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Myriam Chalabi
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Inge L Huibregtse
- Department of Gastroenterology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Remond Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, The Netherlands
| | - Anke B Smits
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Joost T Heikens
- Department of Surgery, Hospital Rivierenland, Tiel, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Gert J Meijer
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Femke P Peters
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| |
Collapse
|
23
|
El-Habashy DM, Wahid KA, He R, McDonald B, Rigert J, Mulder SJ, Lim TY, Wang X, Yang J, Ding Y, Naser MA, Ng SP, Bahig H, Salzillo TC, Preston KE, Abobakr M, Shehata MA, Elkhouly EA, Alagizy HA, Hegazy AH, Mohammadseid M, Terhaard C, Philippens M, Rosenthal DI, Wang J, Lai SY, Dresner A, Christodouleas JC, Mohamed ASR, Fuller CD. Longitudinal diffusion and volumetric kinetics of head and neck cancer magnetic resonance on a 1.5T MR-Linear accelerator hybrid system: A prospective R-IDEAL Stage 2a imaging biomarker characterization/ pre-qualification study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.04.23289527. [PMID: 37205359 PMCID: PMC10187456 DOI: 10.1101/2023.05.04.23289527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Objectives We aim to characterize the serial quantitative apparent diffusion coefficient (ADC) changes of the target disease volume using diffusion-weighted imaging (DWI) acquired weekly during radiation therapy (RT) on a 1.5T MR-Linac and correlate these changes with tumor response and oncologic outcomes for head and neck squamous cell carcinoma (HNSCC) patients as part of a programmatic R-IDEAL biomarker characterization effort. Methods Thirty patients with pathologically confirmed HNSCC who received curative-intent RT at the University of Texas MD Anderson Cancer Center, were included in this prospective study. Baseline and weekly Magnetic resonance imaging (MRI) (weeks 1-6) were obtained, and various ADC parameters (mean, 5 th , 10 th , 20 th , 30 th , 40 th , 50 th , 60 th , 70 th , 80 th , 90 th and 95 th percentile) were extracted from the target regions of interest (ROIs). Baseline and weekly ADC parameters were correlated with response during RT, loco-regional control, and the development of recurrence using the Mann-Whitney U test. The Wilcoxon signed-rank test was used to compare the weekly ADC versus baseline values. Weekly volumetric changes (Δvolume) for each ROI were correlated with ΔADC using Spearman's Rho test. Recursive partitioning analysis (RPA) was performed to identify the optimal ΔADC threshold associated with different oncologic outcomes. Results There was an overall significant rise in all ADC parameters during different time points of RT compared to baseline values for both gross primary disease volume (GTV-P) and gross nodal disease volumes (GTV-N). The increased ADC values for GTV-P were statistically significant only for primary tumors achieving complete remission (CR) during RT. RPA identified GTV-P ΔADC 5 th percentile >13% at the 3 rd week of RT as the most significant parameter associated with CR for primary tumor during RT (p <0.001). Baseline ADC parameters for GTV-P and GTV-N didn't significantly correlate with response to RT or other oncologic outcomes. There was a significant decrease in residual volume of both GTV-P & GTV-N throughout the course of RT. Additionally, a significant negative correlation between mean ΔADC and Δvolume for GTV-P at the 3 rd and 4 th week of RT was detected (r = -0.39, p = 0.044 & r = -0.45, p = 0.019, respectively). Conclusion Assessment of ADC kinetics at regular intervals throughout RT seems to be correlated with RT response. Further studies with larger cohorts and multi-institutional data are needed for validation of ΔADC as a model for prediction of response to RT.
Collapse
Affiliation(s)
- Dina M El-Habashy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Clinical Oncology and Nuclear Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Kareem A Wahid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Renjie He
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brigid McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jillian Rigert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel J. Mulder
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tze Yee Lim
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yao Ding
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mohamed A Naser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health Melbourne, Australia
| | - Houda Bahig
- Department of radiology, radiation oncology and nuclear medicine, Université de Montréal, Canada
| | - Travis C Salzillo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn E Preston
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Moamen Abobakr
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mohamed A Shehata
- Department of Clinical Oncology and Nuclear Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Enas A Elkhouly
- Department of Clinical Oncology and Nuclear Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Hagar A Alagizy
- Department of Clinical Oncology and Nuclear Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Amira H Hegazy
- Department of Clinical Oncology and Nuclear Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Mustefa Mohammadseid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chris Terhaard
- Department of Radiation Therapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle Philippens
- Department of Radiation Therapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David I. Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y. Lai
- Department of Head and Neck Surgery, Division of Surgery,The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alex Dresner
- Philips Healthcare MR Oncology, Cleveland, Ohio, USA
| | | | | | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
24
|
Outcomes of Patients Referred for Cardiac Rehabilitation After Left Ventricular Assist Device Implantation. ASAIO J 2023; 69:304-308. [PMID: 35920751 DOI: 10.1097/mat.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A single-center continuous-flow left ventricular assist device (LVAD) cohort (n = 503) was reviewed for patients with information on cardiac rehabilitation (CR) participation (n = 273) over a 13-year period. The analysis was then limited LVAD recipients who fit into three main CR categories: those who graduated CR (n = 138), those who were able to but declined participation (n = 61), and those who were too sick to complete or start CR (n = 28). To assess the association between CR categories and mortality and hospitalizations on LVAD support, multivariate cox regression and negative binomial regression analyses were performed, respectively. Among those who started CR and had the opportunity to finish (enough follow-up time, insurance coverage), 79% graduated. Those who graduated CR had a 96% survival at 1 year (95% confidence interval [CI], 91-98). Compared with the graduated group, those in the too sick group had an increased hazards rate of mortality (hazard ratio, 2.85; 95% CI, 1.49-5.44; p < 0.01) and an increase in the incidence rate of hospitalizations (incidence rate ratio, 1.74; 95% CI, 1.14-2.66, p = 0.01). This study is the largest to date to report outcomes of LVAD recipients referred for CR. The lower readmission rates and high survival in the group that graduated CR provides further evidence for the safety of CR in LVAD recipients.
Collapse
|
25
|
Boldrini L, Alongi F, Romano A, Charles Davies D, Bassetti M, Chiloiro G, Corradini S, Gambacorta MA, Placidi L, Tree AC, Westley R, Nicosia L. Current practices and perspectives on the integration of contrast agents in MRI-guided radiation therapy clinical practice: a worldwide survey. Clin Transl Radiat Oncol 2023; 40:100615. [PMID: 36968577 PMCID: PMC10034422 DOI: 10.1016/j.ctro.2023.100615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
Aims The introduction of on-line magnetic resonance image-guided radiotherapy (MRIgRT) has led to an improvement in the therapeutic workflow of radiotherapy treatments thanks to the better visualization of therapy volumes assured by the higher soft tissue contrast. Magnetic Resonance contrast agents (MRCA) could improve the target delineation in on-line MRIgRT planning as well as reduce inter-observer variability and enable innovative treatment optimization protocols. The aim of this survey is to investigate the utilization of MRCA among centres that clinically implemented on-line MRIgRT technology. Methods In September 2021, we conducted an online survey consisting of a sixteen-question questionnaire that was distributed to the all the hospitals around the world equipped with MR Linacs. The questionnaire was developed by two Italian 0.35 T and 1.5 T MR-Linac centres and was validated by four other collaborating centres, using a Delphi consensus methodology. Results The survey was distributed to 52 centres and 43 centres completed it (82.7%). Among these centres, 23 institutions (53.5%) used the 0.35T MR-Linac system, while the remaining 20 (46.5%) used the 1.5T MR-Linac system.According to results obtained, 25 (58%) of the centres implemented the use of MRCA for on-line MRIgRT. Gadoxetate (Eovist®; Primovist®) was reported to be the most used MRCA (80%) and liver the most common site of application (58%). Over 70% of responders agreed/strongly agreed to the need for international guidelines. Conclusions The use of MRCA in clinical practice presents several pitfalls and future research will be necessary to understand the actual advantage derived from the use of MRCA in clinical practice, their toxicity profiles and better define the need of formulating guidelines for standardising the use of MRCA in MRIgRT workflow.
Collapse
Affiliation(s)
- Luca Boldrini
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
- University of Brescia, Brescia, Italy
| | - Angela Romano
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Corresponding author.
| | - Diepriye Charles Davies
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, USA
| | - Giuditta Chiloiro
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maria Antonietta Gambacorta
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, Sutton, UK
- The Institute of Cancer Research, London, UK
| | - Rosalyne Westley
- The Royal Marsden NHS Foundation Trust, Sutton, UK
- The Institute of Cancer Research, London, UK
| | - Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| |
Collapse
|
26
|
Kensen CM, Betgen A, Wiersema L, Peters FP, Kayembe MT, Marijnen CAM, van der Heide UA, Janssen TM. Online Adaptive MRI-Guided Radiotherapy for Primary Tumor and Lymph Node Boosting in Rectal Cancer. Cancers (Basel) 2023; 15:cancers15041009. [PMID: 36831354 PMCID: PMC9953931 DOI: 10.3390/cancers15041009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
The purpose of this study was to characterize the motion and define the required treatment margins of the pathological mesorectal lymph nodes (GTVln) for two online adaptive MRI-guided strategies for sequential boosting. Secondly, we determine the margins required for the primary gross tumor volume (GTVprim). Twenty-eight patients treated on a 1.5T MR-Linac were included in the study. On T2-weighted images for adaptation (MRIadapt) before and verification after irradiation (MRIpost) of five treatment fractions per patient, the GTVln and GTVprim were delineated. With online adaptive MRI-guided radiotherapy, daily plan adaptation can be performed through the use of two different strategies. In an adapt-to-shape (ATS) workflow the interfraction motion is effectively corrected by redelineation and the only relevant motion is intrafraction motion, while in an adapt-to-position (ATP) workflow the margin (for GTVln) is dominated by interfraction motion. The margin required for GTVprim will be identical to the ATS workflow, assuming each fraction would be perfectly matched on GTVprim. The intrafraction motion was calculated between MRIadapt and MRIpost for the GTVln and GTVprim separately. The interfraction motion of the GTVln was calculated with respect to the position of GTVprim, assuming each fraction would be perfectly matched on GTVprim. PTV margins were calculated for each strategy using the Van Herk recipe. For GTVln we randomly sampled the original dataset 20 times, with each subset containing a single randomly selected lymph node for each patient. The resulting margins for ATS ranged between 3 and 4 mm (LR), 3 and 5 mm (CC) and 5 and 6 mm (AP) based on the 20 randomly sampled datasets for GTVln. For ATP, the margins for GTVln were 10-12 mm in LR and AP and 16-19 mm in CC. The margins for ATS for GTVprim were 1.7 mm (LR), 4.7 mm (CC) and 3.2 mm anterior and 5.6 mm posterior. Daily delineation using ATS of both target volumes results in the smallest margins and is therefore recommended for safe dose escalation to the primary tumor and lymph nodes.
Collapse
Affiliation(s)
- Chavelli M. Kensen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Anja Betgen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Lisa Wiersema
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Femke P. Peters
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Mutamba T. Kayembe
- Department of Scientific Administration, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Uulke A. van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Tomas M. Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)-20-5122164
| |
Collapse
|
27
|
Smith L, Kuncic Z, Byrne HL, Waddington D. Nanoparticles for MRI-guided radiation therapy: a review. Cancer Nanotechnol 2022. [DOI: 10.1186/s12645-022-00145-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AbstractThe development of nanoparticle agents for MRI-guided radiotherapy is growing at an increasing pace, with clinical trials now underway and many pre-clinical evaluation studies ongoing. Gadolinium and iron-oxide-based nanoparticles remain the most clinically advanced nanoparticles to date, although several promising candidates are currently under varying stages of development. Goals of current and future generation nanoparticle-based contrast agents for MRI-guided radiotherapy include achieving positive signal contrast on T1-weighted MRI scans, local radiation enhancement at clinically relevant concentrations and, where applicable, avoidance of uptake by the reticuloendothelial system. Exploiting the enhanced permeability and retention effect or the use of active targeting ligands on nanoparticle surfaces is utilised to promote tumour uptake. This review outlines the current status of promising nanoparticle agents for MRI-guided radiation therapy, including several platforms currently undergoing clinical evaluation or at various stages of the pre-clinical development process. Challenges facing nanoparticle agents and possible avenues for current and future development are discussed.
Collapse
|
28
|
Teunissen FR, Willigenburg T, Tree AC, Hall WA, Choi SL, Choudhury A, Christodouleas JP, de Boer JCJ, de Groot-van Breugel EN, Kerkmeijer LGW, Pos FJ, Schytte T, Vesprini D, Verkooijen HM, van der Voort van Zyp JRN. Magnetic Resonance-Guided Adaptive Radiation therapy for Prostate Cancer: The First Results from the MOMENTUM study-An International Registry for the Evidence-Based Introduction of Magnetic Resonance-Guided Adaptive Radiation Therapy. Pract Radiat Oncol 2022; 13:e261-e269. [PMID: 36462619 DOI: 10.1016/j.prro.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Magnetic resonance (MR)-guided radiation therapy (MRgRT) is a new technique for treatment of localized prostate cancer (PCa). We report the 12-month outcomes for the first PCa patients treated within an international consortium (the MOMENTUM study) on a 1.5T MR-Linac system with ultrahypofractionated radiation therapy. METHODS AND MATERIALS Patients treated with 5 × 7.25 Gy were identified. Prostate specific antigen-level, physician-reported toxicity (Common Terminology Criteria for Adverse Events [CTCAE]), and patient-reported outcomes (Quality of Life Questionnaire PR25 and Quality of Life Questionnaire C30 questionnaires) were recorded at baseline and at 3, 6, and 12 months of follow-up (FU). Pairwise comparative statistics were conducted to compare outcomes between baseline and FU. RESULTS The study included 425 patients with localized PCa (11.4% low, 82.0% intermediate, and 6.6% high-risk), and 365, 313, and 186 patients reached 3-, 6-, and 12-months FU, respectively. Median prostate specific antigen level declined significantly to 1.2 ng/mL and 0.1 ng/mL at 12 months FU for the nonandrogen deprivation therapy (ADT) and ADT group, respectively. The peak of genitourinary and gastrointestinal CTCAE toxicity was reported at 3 months FU, with 18.7% and 1.7% grade ≥2, respectively. The QLQ-PR25 questionnaire outcomes showed significant deterioration in urinary domain score at all FU moments, from 8.3 (interquartile range [IQR], 4.1-16.6) at baseline to 12.4 (IQR, 8.3-24.8; P = .005) at 3 months, 12.4 (IQR, 8.3-20.8; P = .018;) at 6 months, and 12.4 (IQR, 8.3-20.8; P = .001) at 12 months. For the non-ADT group, physician- and patient-reported erectile function worsened significantly between baseline and 12 months FU. CONCLUSIONS Ultrahypofractionated MR-guided radiation therapy for localized PCa using a 1.5T MR-Linac is effective and safe. The peak of CTCAE genitourinary and gastrointestinal toxicity was reported at 3 months FU. Furthermore, for patients without ADT, a significant increase in CTCAE erectile dysfunction was reported at 12 months FU. These data are useful for educating patients on expected outcomes and informing study design of future comparative-effectiveness studies.
Collapse
Affiliation(s)
- Frederik R Teunissen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas Willigenburg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison C Tree
- Department of Urological Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seungtaek L Choi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - John P Christodouleas
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Elekta AB, Stockholm, Sweden
| | - Johannes C J de Boer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Helena M Verkooijen
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht University, Utrecht, The Netherlands
| | | |
Collapse
|
29
|
Teunissen FR, Hehakaya C, Meijer RP, van Melick HHE, Verkooijen HM, van der Voort van Zyp JRN. Patient preferences for treatment modalities for localised prostate cancer. BJUI COMPASS 2022; 4:214-222. [PMID: 36816141 PMCID: PMC9931535 DOI: 10.1002/bco2.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 10/09/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives To assess the patient preferences and utility scores for the different conventional and innovative treatment modalities for localised prostate cancer (PCa). Subjects and Methods Patients treated for localised PCa and healthy volunteers were invited to fill out a treatment-outcome scenario questionnaire. Participants ranked six different treatments for localised PCa from most to least favourable, prior to information. In a next step, treatment procedures, toxicity, risk of biochemical recurrence and follow-up regimen were comprehensibly described for each of the six treatments (i.e. treatment-outcome scenarios), after which patients re-ranked the six treatments. Additionally, participants gave a visual analogue scale (VAS) and time trade-off (TTO) score for each scenario. Differences between utility scores were tested by Friedman tests with post hoc Wilcoxon signed-rank tests. Results Eighty patients and twenty-nine healthy volunteers were included in the study. Before receiving treatment-outcome scenario information, participants ranked magnetic resonance-guided adaptive radiotherapy most often as their first choice (35%). After treatment information was received, active surveillance was most often ranked as the first choice (41%). Utility scores were significantly different between the six treatment-outcome scenarios, and active surveillance, non- and minimal-invasive treatments received higher scores. Conclusions Active surveillance and non-invasive treatment for localised PCa were the most preferred options by PCa patients and healthy volunteers and received among the highest utility scores. Treatment preferences change after treatment information is received.
Collapse
Affiliation(s)
- Frederik R. Teunissen
- Department of Radiation OncologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Charisma Hehakaya
- Department of Radiation OncologyUniversity Medical Center UtrechtUtrechtThe Netherlands,Imaging and Oncology DivisionUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Richard P. Meijer
- Department of Oncological UrologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | - Helena M. Verkooijen
- Imaging and Oncology DivisionUniversity Medical Center UtrechtUtrechtThe Netherlands,Utrecht UniversityUtrechtThe Netherlands
| | | |
Collapse
|
30
|
Lagendijk JJW, Raaymakers BW, Intven MPW, van der Voort van Zyp JRN. ESTRO Breur lecture 2022: Real-time MRI-guided radiotherapy: The next generation standard? Radiother Oncol 2022; 176:244-248. [PMID: 36446518 DOI: 10.1016/j.radonc.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jan J W Lagendijk
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands
| | - Bas W Raaymakers
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands
| | - Martijn P W Intven
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, The Netherlands.
| | | |
Collapse
|
31
|
Okamoto H, Igaki H, Chiba T, Shibuya K, Sakasai T, Jingu K, Inaba K, Kuroda K, Aoki S, Tatsumi D, Nakamura M, Kadoya N, Furuyama Y, Kumazaki Y, Tohyama N, Tsuneda M, Nishioka S, Itami J, Onishi H, Shigematsu N, Uno T. Practical guidelines of online MR-guided adaptive radiotherapy. JOURNAL OF RADIATION RESEARCH 2022; 63:730-740. [PMID: 35946325 PMCID: PMC9494538 DOI: 10.1093/jrr/rrac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/02/2022] [Indexed: 06/15/2023]
Abstract
The first magnetic resonance (MR)-guided radiotherapy system in Japan was installed in May 2017. Implementation of online MR-guided adaptive radiotherapy (MRgART) began in February 2018. Online MRgART offers greater treatment accuracy owing to the high soft-tissue contrast in MR-images (MRI), compared to that in X-ray imaging. The Japanese Society for Magnetic Resonance in Medicine (JSMRM), Japan Society of Medical Physics (JSMP), Japan Radiological Society (JRS), Japanese Society of Radiological Technology (JSRT), and Japanese Society for Radiation Oncology (JASTRO) jointly established the comprehensive practical guidelines for online MRgART. These guidelines propose the essential requirements for clinical implementation of online MRgART with respect to equipment, personnel, institutional environment, practice guidance, and quality assurance/quality control (QA/QC). The minimum requirements for related equipment and QA/QC tools, recommendations for safe operation of MRI system, and the implementation system are described. The accuracy of monitor chamber and detector in dose measurements should be confirmed because of the presence of magnetic field. The ionization chamber should be MR-compatible. Non-MR-compatible devices should be used in an area that is not affected by the static magnetic field (outside the five Gauss line), and their operation should be checked to ensure that they do not affect the MR image quality. Dose verification should be performed using an independent dose verification system that has been confirmed to be reliable through commissioning. This guideline proposes the checklists to ensure the safety of online MRgART. Successful clinical implementation of online MRgART requires close collaboration between physician, radiological technologist, nurse, and medical physicist.
Collapse
Affiliation(s)
- Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Hiroshi Igaki
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Tel: +81(3)3542-2511; E-mail/Fax: , +81(3) 3547-5291
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Keiko Shibuya
- Department of Radiation Oncology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, 545-8586, Japan
| | - Tatsuya Sakasai
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Miyagi, 980-8574, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Science, School of Information Science and Technology, Tokai University, Hiratsuka, 259-1292, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | | | - Mitsuhiro Nakamura
- Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, 606-8507, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Miyagi, 980-8574, Japan
| | - Yoshinobu Furuyama
- Department of Radiology, Chiba University Hospital, Chiba, 260-8677, Japan
| | - Yu Kumazaki
- Department of Radiation Oncology, International Medical Center, Saitama Medical University, Saitama, 350-1298, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Advanced Imaging & Radiation Oncology Makuhari Clinic, Chiba, 261-0024, Japan
| | - Masato Tsuneda
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, Chiba, 260-8677, Japan
| | - Shie Nishioka
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, 602-8026, Japan
| | - Jun Itami
- Shin-Matsudo Accuracy Radiation Therapy Center, Shin-Matsudo Central General Hospital, Chiba, 270-0034, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, 409-3898, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, 260-8677, Japan
| |
Collapse
|
32
|
Hall WA, Kishan AU, Hall E, Nagar H, Vesprini D, Paulson E, Van der Heide UA, Lawton CAF, Kerkmeijer LGW, Tree AC. Adaptive magnetic resonance image guided radiation for intact localized prostate cancer how to optimally test a rapidly emerging technology. Front Oncol 2022; 12:962897. [PMID: 36132128 PMCID: PMC9484536 DOI: 10.3389/fonc.2022.962897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Prostate cancer is a common malignancy for which radiation therapy (RT) provides an excellent management option with high rates of control and low toxicity. Historically RT has been given with CT based image guidance. Recently, magnetic resonance (MR) imaging capabilities have been successfully integrated with RT delivery platforms, presenting an appealing, yet complex, expensive, and time-consuming method of adapting and guiding RT. The precise benefits of MR guidance for localized prostate cancer are unclear. We sought to summarize optimal strategies to test the benefits of MR guidance specifically in localized prostate cancer. Methods A group of radiation oncologists, physicists, and statisticians were identified to collectively address this topic. Participants had a history of treating prostate cancer patients with the two commercially available MRI-guided RT devices. Participants also had a clinical focus on randomized trials in localized prostate cancer. The goal was to review both ongoing trials and present a conceptual focus on MRI-guided RT specifically in the definitive treatment of prostate cancer, along with developing and proposing novel trials for future consideration. Trial hypotheses, endpoints, and areas for improvement in localized prostate cancer that specifically leverage MR guided technology are presented. Results Multiple prospective trials were found that explored the potential of adaptive MRI-guided radiotherapy in the definitive treatment of prostate cancer. Different primary areas of improvement that MR guidance may offer in prostate cancer were summarized. Eight clinical trial design strategies are presented that summarize options for clinical trials testing the potential benefits of MRI-guided RT. Conclusions The number and scope of trials evaluating MRI-guided RT for localized prostate cancer is limited. Yet multiple promising opportunities to test this technology and potentially improve outcomes for men with prostate cancer undergoing definitive RT exist. Attention, in the form of multi-institutional randomized trials, is needed.
Collapse
Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Emma Hall
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Himanshu Nagar
- Depart of Radiation Oncology, Weill Cornell Medicine, Department of Radiation Oncology, New York, NY, United States
| | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uulke A. Van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Colleen A. F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Linda G. W. Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, and the Institute of Cancer Research, Sutton, United Kingdom
| |
Collapse
|
33
|
Hehakaya C, Sharma AM, van der Voort Van Zijp JR, Grobbee DE, Verkooijen HM, Izaguirre EW, Moors EH. Implementation of Magnetic Resonance Imaging-Guided Radiation Therapy in Routine Care: Opportunities and Challenges in the United States. Adv Radiat Oncol 2022; 7:100953. [PMID: 35651662 PMCID: PMC9149022 DOI: 10.1016/j.adro.2022.100953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Magnetic resonance image (MRI)-guided radiation therapy with the 1.5 Tesla magnetic resonance linear accelerator (MR-Linac) is a rapidly evolving and emerging treatment. The MR-Linac literature mainly focused on clinical and technological factors in technology implementation, but it is relatively silent on health care system-related factors. Consequently, there is a lack of understanding of opportunities and barriers in implementing the MR-Linac from a health care system perspective. This study addresses this gap with a case study of the US health care system. Methods and Materials An exploratory, qualitative research design was used. Data collection consisted of 23 semistructured interviews ranging from clinical experts at the radiation therapy and radiology department to insurance commissioners in 7 US hospitals. Analysis of opportunities and barriers was guided by the Nonadoption, Abandonment, Scale-up, Spread and Sustainability framework for new medical technologies in health care organizations. Results Opportunities included high-precision MR-guidance during radiation therapy with potential continued technical advances and better patient outcomes. MR-Linac also offers opportunities for research, professional, and economic development. Barriers included the lack of empirical evidence of clinical effectiveness, technological complexity, and large staffing and structural investments. Furthermore, the presence of patients with disadvantaged socioeconomic background, and the lack of appropriate reimbursement as well as regulatory conditions can hinder technology implementation. Conclusions Our study confirms the current literature on implementing the MR-Linac, but also reveals additional challenges for the US health care system. Alongside the well-known clinical and technical factors, also professional, socioeconomic, market, and governing influences affect technology implementation. These findings highlight new connections to facilitate technology uptake and provide a richer start to understanding its long-term effect.
Collapse
Affiliation(s)
- Charisma Hehakaya
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands
- Corresponding author
| | - Ankur M. Sharma
- University of Tennessee Health Science Center, Memphis, Tennessee
- Centre for Evidence-Based Medicine and Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England
| | | | - Diederick E. Grobbee
- Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Helena M. Verkooijen
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
| | | | - Ellen H.M. Moors
- Innovation Studies, Copernicus Institute of Sustainable Development, Utrecht University, The Netherlands
| |
Collapse
|
34
|
Boterberg T, Dunlea C, Harrabi S, Janssens G, Laprie A, Whitfield G, Gaze M. Contemporary paediatric radiation oncology. Arch Dis Child 2022; 108:archdischild-2021-323059. [PMID: 35851293 DOI: 10.1136/archdischild-2021-323059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/03/2022] [Indexed: 11/03/2022]
Abstract
Treatment with ionising radiation is a valuable component of treatment schedules for a many children and young people with cancer. While some form of radiotherapy has been in use for over 100 years, a series of innovations has revolutionised paediatric radiation oncology. Mostly, high-energy X-ray photons are used, but proton beam radiotherapy is increasingly offered, especially in children and young people. This is to reduce the radiation exposure of healthy normal tissues and so the likelihood of adverse effects. Other methods of radiotherapy delivery include brachytherapy and molecular radiotherapy. The most appropriate treatment technique should be selected for every child. Advances in computers and imaging, developments in the technology of radiation delivery and a better understanding of pathology and molecular biology of cancer, coupled with parallel improvements in surgery and systemic therapy, have led to a transformation of practice in recent decades. Initially an empirical art form, radiotherapy for children has become a technically advanced, evidence-based cornerstone of increasingly personalised cancer medicine with solid scientific foundations. Late sequelae of treatment-the adverse effects once accepted as the cost of cure-have been significantly reduced in parallel with increased survival rates. The delivery of radiotherapy to children and young people requires a specialised multiprofessional team including radiation oncologists, therapeutic radiographers, play specialists and physicists among others. This article reviews the types of radiotherapy now available and outlines the pathway of the child through treatment. It aims to demonstrate to paediatricians how contemporary paediatric radiation oncology differs from past practice.
Collapse
Affiliation(s)
- Tom Boterberg
- Department of Radiotherapy, University of Ghent, Ghent, Belgium
| | - Cathy Dunlea
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Semi Harrabi
- Department of Radiotherapy, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Geert Janssens
- Department of Paediatric Oncology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands
| | - Anne Laprie
- Department of Radiotherapy, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Gillian Whitfield
- Department of Radiotherapy, Christie Hospital, Manchester, Manchester, UK
| | - Mark Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
35
|
Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
Collapse
Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
36
|
Allam N, Jeffrey Zabel W, Demidov V, Jones B, Flueraru C, Taylor E, Alex Vitkin I. Longitudinal in-vivo quantification of tumour microvascular heterogeneity by optical coherence angiography in pre-clinical radiation therapy. Sci Rep 2022; 12:6140. [PMID: 35414078 PMCID: PMC9005734 DOI: 10.1038/s41598-022-09625-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging cancer treatment due to its logistical and potential therapeutic benefits as compared to conventional radiotherapy. However, its mechanism of action is yet to be fully understood, likely involving the ablation of tumour microvasculature by higher doses per fraction used in SBRT. In this study, we hypothesized that longitudinal imaging and quantification of the vascular architecture may elucidate the relationship between the microvasculature and tumour response kinetics. Pancreatic human tumour xenografts were thus irradiated with single doses of \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$10$$\end{document}10, \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$20$$\end{document}20 and \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$30$$\end{document}30 Gy to simulate the first fraction of a SBRT protocol. Tumour microvascular changes were monitored with optical coherence angiography for up to \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$8$$\end{document}8 weeks following irradiation. The temporal kinetics of two microvascular architectural metrics were studied as a function of time and dose: the diffusion-limited fraction, representing poorly vascularized tissue \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$>150$$\end{document}>150 μm from the nearest detected vessel, and the vascular distribution convexity index, a measure of vessel aggregation at short distances. These biological metrics allowed for dose dependent temporal evaluation of tissue (re)vascularization and vessel aggregation after radiotherapy, showing promise for determining the SBRT dose–response relationship.
Collapse
Affiliation(s)
- Nader Allam
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada.
| | - W Jeffrey Zabel
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Valentin Demidov
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada.,Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Blake Jones
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Costel Flueraru
- National Research Council Canada, Information Communication Technology, 1200 Montreal Rd, Ottawa, ON, K1A 0R6, Canada
| | - Edward Taylor
- Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.,Department of Radiation Oncology, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada
| | - I Alex Vitkin
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada. .,Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada. .,Department of Radiation Oncology, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.
| |
Collapse
|
37
|
Lakomy DS, Yang J, Vedam S, Wang J, Lee B, Sobremonte A, Castillo P, Hughes N, Mohammadsaid M, Jhingran A, Klopp AH, Choi S, Fuller CD, Lin LL. Clinical implementation and initial experience with a 1.5 Tesla MR-linac for MR-guided radiotherapy for gynecologic cancer: An R-IDEAL stage 1/2a first in humans/feasibility study of new technology implementation. Pract Radiat Oncol 2022; 12:e296-e305. [PMID: 35278717 DOI: 10.1016/j.prro.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Magnetic resonance imaging-guided linear accelerator systems (MR-linacs) can facilitate the daily adaptation of radiotherapy plans. Here, we report our early clinical experience using an MR-linac for adaptive radiotherapy of gynecologic malignancies. METHODS AND MATERIALS Treatments were planned with an Elekta Monaco v5.4.01 and delivered by a 1.5 Tesla Elekta Unity MR-linac. The system offers a choice of daily adaptation based on either position (ATP) or shape (ATS) of the tumor and surrounding normal structures. The ATS approach has the option of manually editing the contours of tumors and surrounding normal structures before the plan is adapted. Here we documented the duration of each treatment fraction; set-up variability (assessed by isocenter shifts in each plan) between fractions; and, for quality assurance, calculated the percentage of plans meeting the γ-criterion of 3%/3-mm distance to agreement. Deformable accumulated dose calculations were used to compare accumulated versus planned dose for patient treated with exclusively ATP fractions. RESULTS Of the 10 patients treated with 90 fractions on the MR-linac, most received boost doses to recurrence in nodes or isolated tumors. Each treatment fraction lasted a median 32 minutes; fractions were shorter with ATP than with ATS (30 min vs 42 min, P<0.0001). The γ criterion for all fraction plans exceeded >90% (median 99.9%, range 92.4%-100%), i.e., all plans passed quality assurance testing. The average extent of isocenter shift was <0.5 cm in each axis. The accumulated dose to the gross tumor volume was within 5% of the reference plan for all ATP cases. Accumulated doses for lesions in the pelvic periphery were within <1% of the reference plan as opposed to -1.6% to -4.4% for central pelvic tumors. CONCLUSIONS The MR-linac is a reliable and clinically feasible tool for treating patients with gynecologic cancer.
Collapse
Affiliation(s)
- David S Lakomy
- Departments of Radiation Oncology; Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Jinzhong Yang
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sastry Vedam
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jihong Wang
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Belinda Lee
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Angela Sobremonte
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela Castillo
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil Hughes
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mustefa Mohammadsaid
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | |
Collapse
|
38
|
Hansen CR, Hussein M, Bernchou U, Zukauskaite R, Thwaites D. Plan quality in radiotherapy treatment planning - Review of the factors and challenges. J Med Imaging Radiat Oncol 2022; 66:267-278. [PMID: 35243775 DOI: 10.1111/1754-9485.13374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022]
Abstract
A high-quality treatment plan aims to best achieve the clinical prescription, balancing high target dose to maximise tumour control against sufficiently low organ-at-risk dose for acceptably low toxicity. Treatment planning (TP) includes multiple steps from simulation/imaging and segmentation to technical plan production and reporting. Consistent quality across this process requires close collaboration and communication between clinical and technical experts, to clearly understand clinical requirements and priorities and also practical uncertainties, limitations and compromises. TP quality depends on many aspects, starting from commissioning and quality management of the treatment planning system (TPS), including its measured input data and detailed understanding of TPS models and limitations. It requires rigorous quality assurance of the whole planning process and it links to plan deliverability, assessable by measurement-based verification. This review highlights some factors influencing plan quality, for consideration for optimal plan construction and hence optimal outcomes for each patient. It also indicates some challenges, sources of difference and current developments. The topics considered include: the evolution of TP techniques; dose prescription issues; tools and methods to evaluate plan quality; and some aspects of practical TP. The understanding of what constitutes a high-quality treatment plan continues to evolve with new techniques, delivery methods and related evidence-based science. This review summarises the current position, noting developments in the concept and the need for further robust tools to help achieve it.
Collapse
Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia.,Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - David Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
39
|
Sritharan K, Tree A. MR-guided radiotherapy for prostate cancer: state of the art and future perspectives. Br J Radiol 2022; 95:20210800. [PMID: 35073158 PMCID: PMC8978250 DOI: 10.1259/bjr.20210800] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/16/2021] [Accepted: 12/22/2021] [Indexed: 12/25/2022] Open
Abstract
Advances in radiotherapy technology have increased precision of treatment delivery and in some tumour types, improved cure rates and decreased side effects. A new generation of radiotherapy machines, hybrids of an MRI scanner and a linear accelerator, has the potential to further transform the practice of radiation therapy in some cancers. Facilitating superior image quality and the ability to change the dose distribution online on a daily basis (termed "daily adaptive replanning"), MRI-guided radiotherapy machines allow for new possibilities including increasing dose, for hard to treat cancers, and more selective sparing of healthy tissues, where toxicity reduction is the key priority.These machines have already been used to treat most types of cancer, although experience is still in its infancy. This review summarises the potential and current evidence for MRI-guided radiotherapy, with a predominant focus on prostate cancer. Current advantages and disadvantages are discussed including a realistic appraisal of the likely potential to improve patient outcomes. In addition, horizon scanning for near-term possibilities for research and development will hopefully delineate the potential role for this technology over the next decade.
Collapse
|
40
|
Boekhoff M, Bouwmans R, Doornaert P, Intven M, Lagendijk J, van Lier A, Rasing M, van de Ven S, Meijer G, Mook S. Clinical implementation and feasibility of long-course fractionated MR-guided chemoradiotherapy for patients with esophageal cancer: an R-IDEAL stage 1b/2a evaluation of technical innovation. Clin Transl Radiat Oncol 2022; 34:82-89. [PMID: 35372703 PMCID: PMC8971577 DOI: 10.1016/j.ctro.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
Online MR-guided long-course fractionated chemoradiotherapy for patients with esophageal cancer was feasible in 7 out of 9 patients. Median treatment time was 53 min per fraction. MRgRT resulted in a reduction in mean heart dose (12%) and mean lung dose (26%) compared to CBCT-guided radiotherapy. Limited intrafraction motion was observed during dose delivery.
Purpose This R-Ideal stage 1b/2a study describes the workflow and feasibility of long-course fractionated online adaptive MR-guided chemoradiotherapy with reduced CTV-to-PTV margins on the 1.5T MR-Linac for patients with esophageal cancer. Methods Patients with esophageal cancer scheduled to undergo chemoradiation were treated on a 1.5T MR-Linac. Daily MR-images were acquired for online contour adaptation and replanning. Contours were manually adapted to match the daily anatomy and an isotropic CTV-to-PTV margin of 6 mm was applied. Time was recorded for all individual steps in the workflow. Feasibility and patient tolerability were defined as on-table time of ≤60 min and completion of >95% of the fractions on the MR-Linac, respectively. Positioning verification and post-treatment MRIs were retrospectively analyzed and dosimetric parameters were compared to standard non-adaptive conventional treatment plans. Results Nine patients with esophageal cancer were treated with chemoradiation; eight patients received 41.4 Gy in 23 fractions and one received 50.4 Gy in 28 fractions. Four patients received all planned fractions on the MR-Linac, whereas for two patients >5% of fractions were rescheduled to a conventional linac for reasons of discomfort. A total of 183 (86%) of 212 scheduled fractions were successfully delivered on the MR-Linac. Three fractions ended prematurely due to technical issues and 26 fractions were rescheduled on a conventional linac due to MR-Linac downtime (n = 10), logistical reasons (n = 3) or discomfort (n = 13). The median time per fraction was 53 min (IQR = 3 min). Daily adapted MR-Linac plans had similar target coverage, whereas dose to the organs-at-risk was significantly reduced compared to conventional treatment (26% and 12% reduction in mean lung and heart dose, respectively). Conclusion Daily online adaptive fractionated chemoradiotherapy with reduced PTV margins is moderately feasible for esophageal cancer and results in better sparing of heart and lungs. Future studies should focus on further optimization and acceleration of the current workflow.
Collapse
|
41
|
Price AT, Knutson NC, Kim T, Green OL. Commissioning a secondary dose calculation software for a 0.35 T MR-linac. J Appl Clin Med Phys 2022; 23:e13452. [PMID: 35166011 PMCID: PMC8906210 DOI: 10.1002/acm2.13452] [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: 12/21/2020] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022] Open
Abstract
Secondary external dose calculations for a 0.35 T magnetic resonance image-guided radiation therapy (MRgRT) are needed within the radiation oncology community to follow safety standards set forth within the field. We evaluate the commercially available software, RadCalc, in its ability to accurately perform monitor unit dose calculations within a magnetic field. We also evaluate the potential effects of a 0.35 T magnetic field upon point dose calculations. Monitor unit calculations were evaluated with (wMag) and without (noMag) a magnetic field considerations in RadCalc for the ViewRay MRIdian. The magnetic field is indirectly accounted for by using asymmetric profiles for calculation. The introduction of double-stacked multi-leaf collimator leaves was also included in the monitor unit calculations and a single transmission value was determined. A suite of simple and complex geometries with a variety field arrangements were calculated for each method to demonstrate the effect of the 0.35 T magnetic field on monitor unit calculations. Finally, 25 patient-specific treatment plans were calculated using each method for comparison. All simple geometries calculated in RadCalc were within 2% of treatment planning system (TPS) values for both methods, except for a single noMag off-axis comparison. All complex muilt-leaf collimator (MLC) pattern calculations were within 5%. All complex phantom geometry calculations were within 5% except for a single field within a lung phantom at a distal point. For the patient calculations, the noMag method average percentage difference was 0.09 ± 2.5% and the wMag average percentage difference was 0.08 ± 2.5%. All results were within 5% for the wMag method. We performed monitor unit calculations for a 0.35 T MRgRT system using a commercially available secondary monitor unit dose calculation software and demonstrated minimal impact of the 0.35 T magnetic field on monitor unit dose calculations. This is the first investigation demonstrating successful calculations of dose using RadCalc in the low-field 0.35 T ViewRay MRIdian system.
Collapse
Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nels C Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Taeho Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
42
|
Cardenas CE, Blinde SE, Mohamed ASR, Ng SP, Raaijmakers C, Philippens M, Kotte A, Al-Mamgani AA, Karam I, Thomson DJ, Robbins J, Newbold K, Fuller CD, Terhaard C, On Behalf Of The, Bahig H, Blanchard P, Dehnad H, Doornaert P, Elhalawani H, Frank SJ, Garden A, Gunn GB, Hamming-Vrieze O, Kamal M, Kasperts N, Lee LW, McDonald BA, McPartlin A, Meheissen MA, Morrison WH, Navran A, Nutting CM, Pameijer F, Phan J, Poon I, Rosenthal DI, Smid EJ, Sykes AJ. Comprehensive Quantitative Evaluation of Variability in MR-guided Delineation of Oropharyngeal Gross Tumor Volumes and High-risk Clinical Target Volumes: An R-IDEAL Stage 0 Prospective Study. Int J Radiat Oncol Biol Phys 2022; 113:426-436. [PMID: 35124134 DOI: 10.1016/j.ijrobp.2022.01.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Tumor and target volume manual delineation remains a challenging task in head-and-neck cancer radiotherapy. The purpose of this study was to conduct a multi-institutional evaluation of manual delineations of gross tumor volume (GTV), high-risk clinical target volume (CTV), parotids, and submandibular glands on treatment simulation MR scans of oropharyngeal cancer (OPC) patients. METHODS Pre-treatment T1-weighted (T1w), T1-weighted with gadolinium contrast (T1w+C) and T2-weighted (T2w) MRI scans were retrospectively collected for 4 OPC patients under an IRB-approved protocol. The scans were provided to twenty-six radiation oncologists from seven international cancer centers who participated in this delineation study. In addition, patients' clinical history and physical examination findings, along with a medical photographic image and radiological results, were provided. The contours were compared using overlap/distance metrics using both STAPLE and pair-wise comparisons. Lastly, participants completed a brief questionnaire to assess participants' experience and CTV delineation institutional practices. RESULTS Large variability was measured between observers' delineations for GTVs and CTVs. The mean Dice Similarity Coefficient values across all physicians' delineations for GTVp, GTVn, CTVp, and CTVn were 0.77, 0.67, 0.77, and 0.69, respectively, for STAPLE comparison and 0.67, 0.60, 0.67, and 0.58, respectively, for pair-wise analysis. Normal tissue contours were defined more consistently when considering overlap/distance metrics. The median radiation oncology clinical experience was 7 years. The median experience delineating on MRI was 3.5 years. The GTV-to-CTV margin used was 10 mm for six of seven participant institutions. One institution used 8 mm and three participants (from three different institutions) used a margin of 5 mm. CONCLUSION The data from this study suggests that appropriate guidelines, contouring quality assurance sessions, and training are still needed for the adoption of MR-based treatment planning for head-and-neck cancers. Such efforts should play a critical role in reducing delineation variation and ensure standardization of target design across clinical practices.
Collapse
Affiliation(s)
- Carlos E Cardenas
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Sanne E Blinde
- Department of Radiation Oncology, Klinikum Kassel, Kassel, Germany
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Cornelis Raaijmakers
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle Philippens
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexis Kotte
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Abrahim A Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - David J Thomson
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jared Robbins
- Department of Radiation Oncology, University of Arizona, Tucson, Arizona, USA
| | - Kate Newbold
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Chris Terhaard
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - On Behalf Of The
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Blanchard
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Homan Dehnad
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patricia Doornaert
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hesham Elhalawani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adam Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mona Kamal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicolien Kasperts
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lip Wai Lee
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Brigid A McDonald
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew McPartlin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mohamed Am Meheissen
- Alexandria Clinical Oncology Department, Alexandria University, Alexandria, Egypt
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arash Navran
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Frank Pameijer
- Department of Radiology, Division of Imaging & Oncology, University Medical Center, Utrecht, The Netherlands
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ernst J Smid
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew J Sykes
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
43
|
Møller PK, Pappot H, Bernchou U, Schytte T, Mortensen ZV, Brúnni MFÁ, Dieperink KB. Feasibility, usability and acceptance of weekly electronic patient-reported outcomes among patients receiving pelvic CT- or online MR-guided radiotherapy - A prospective pilot study. Tech Innov Patient Support Radiat Oncol 2022; 21:8-15. [PMID: 34977367 PMCID: PMC8686059 DOI: 10.1016/j.tipsro.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Abstract
Recruitment for weekly self-reporting of symptoms in radiotherapy is feasible. The frequency and time spent on responding to 18 symptomatic AEs weekly is feasible. Adherence to weekly self-reporting is high in a population with a sizable proportion of patients age 70 or above. Real-time feedback from clinicians is requested by the patients.
Introduction The potential of patient symptoms being monitored longitudinally in radiotherapy (RT) is still unexploited. When novel technologies like online adaptive MR-guided radiotherapy (MRgRT) are evaluated, weekly electronic patient-reported outcomes (ePROs) may add knowledge about the symptom trajectory. This study aimed at evaluating feasibility, usability and acceptance of weekly ePRO among patients receiving pelvic radiotherapy. Materials and Methods In a mixed-methods convergent design, a prospective pilot study enrolled patients referred to pelvic radiotherapy with curative intent. Patients used their own device at home to self-report PRO weekly during and four weeks following radiotherapy and week 8, 12, and 24 (paper-questionnaire as an alternative). Feasibility was extracted from the ePRO software. The Patient Feedback Form and patient interviews were used to explore usability and patient acceptance. Patients were informed that clinicians had no access to PRO responses. Results In total, 40 patients were included; 32 patients with prostate cancer and 8 with cervical cancer (consent rate 87%), median age 68 (36–76). The majority did digital reporting (93%). 85% of patients responded to ≥80% of the weekly questionnaires with 91% average adherence to weekly completion (60% for follow-up), although lower for patients ≥age 70. Time spent on ePRO (97%) and frequency of reporting (92%) was considered appropriate. Interviews (n = 14) revealed the application was usable and the patients requested real-time feedback from the clinicians. Conclusion Recruitment for ePRO during radiotherapy was feasible and adherence to weekly self-reporting high. The digital application was usable and weekly frequency and time spent acceptable. Real-time feedback from the clinicians is requested by the patients.
Collapse
Key Words
- AE, Adverse event
- Acceptance
- CTCAE, Common Terminology Criteria of Adverse Events
- ECOG, Eastern Cooperative Oncology Group
- EORTC, European Organization for Research and Treatment of Cancer
- Feasibility
- Gy, Gray
- MR, Magnetic resonance
- MRgRT, Magnetic resonance guided radiotherapy
- NCI, National Cancer Institute
- Online MRgRT
- PRO, Patient-Reported Outcome
- PRO-CTCAE, Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events
- Patient-reported outcome (PRO)
- QLQ-C30, EORTC general core module
- QoL, Quality of life
- RT, Radiotherapy
- Radiotherapy
- Usability
- WHO, World Health Organization Performance Status
- ePRO, Electronic Patient-Reported Outcome
Collapse
Affiliation(s)
- P K Møller
- Department of Oncology, AgeCare, Academy of Geriatric Cancer Research, Odense University Hospital, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
| | - H Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen and Department of Clinical Medicine, University of Copenhagen, Denmark
| | - U Bernchou
- Department of Clinical Research, University of Southern Denmark, Denmark.,Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | - T Schytte
- Department of Oncology, Odense University Hospital, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
| | - Z V Mortensen
- Department of Oncology, Odense University Hospital, Denmark
| | - M F Á Brúnni
- Department of Oncology, Odense University Hospital, Denmark
| | - K B Dieperink
- Department of Oncology, AgeCare, Academy of Geriatric Cancer Research, Odense University Hospital, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
| |
Collapse
|
44
|
Wang MH, Kim A, Ruschin M, Tan H, Soliman H, Myrehaug S, Detsky J, Husain Z, Atenafu EG, Keller B, Sahgal A, Tseng CL. Comparison of Prospectively Generated Glioma Treatment Plans Clinically Delivered on Magnetic Resonance Imaging (MRI)-Linear Accelerator (MR-Linac) Versus Conventional Linac: Predicted and Measured Skin Dose. Technol Cancer Res Treat 2022; 21:15330338221124695. [PMID: 36071647 PMCID: PMC9459463 DOI: 10.1177/15330338221124695] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Magnetic resonance imaging-linear accelerator
radiotherapy is an innovative technology that requires special consideration for
secondary electron interactions within the magnetic field, which can alter dose
deposition at air–tissue interfaces. As part of ongoing quality assurance and
quality improvement of new radiotherapy technologies, the purpose of this study
was to evaluate skin dose modelled from the treatment planning systems of a
magnetic resonance imaging-linear accelerator and a conventional linear
accelerator, and then correlate with in vivo measurements of delivered skin dose
from each linear accelerator. Methods: In this prospective cohort
study, 37 consecutive glioma patients had treatment planning completed and
approved prior to radiotherapy initiation using commercial treatment planning
systems: a Monte Carlo-based algorithm for magnetic resonance imaging-linear
accelerator or a convolution-based algorithm for conventional linear
accelerator. In vivo skin dose was measured using an optically stimulated
luminescent dosimeter. Results: Monte Carlo-based magnetic
resonance imaging-linear accelerator plans and convolution-based conventional
linear accelerator plans had similar dosimetric parameters for target volumes
and organs-at-risk. However, magnetic resonance imaging-linear accelerator plans
had 1.52 Gy higher mean dose to air cavities (P < .0001) and
1.10 Gy higher mean dose to skin (P < .0001). In vivo skin
dose was 14.5% greater for magnetic resonance imaging-linear accelerator
treatments (P = .0027), and was more accurately predicted by
Monte Carlo-based calculation (ρ = 0.95,
P < .0001) versus convolution-based
(ρ = 0.80, P = .0096).
Conclusion: This is the first prospective dosimetric comparison
of glioma patients clinically treated on both magnetic resonance imaging-linear
accelerator and conventional linear accelerator. Our findings suggest that skin
doses were significantly greater with magnetic resonance imaging-linear
accelerator plans but correlated better with in vivo measurements of actual skin
dose from delivered treatments. Future magnetic resonance imaging-linear
accelerator planning processes are being designed to account for skin dosimetry
and treatment delivery.
Collapse
Affiliation(s)
- Michael H Wang
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Anthony Kim
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Hendrick Tan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, 7989University Health Network, 7938University of Toronto, Toronto, Ontario, Canada
| | - Brian Keller
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
45
|
Daamen LA, de Mol van Otterloo SR, van Goor IWJM, Eijkelenkamp H, Erickson BA, Hall WA, Heerkens HD, Meijer GJ, Molenaar IQ, van Santvoort HC, Verkooijen HM, Intven MPW. Online adaptive MR-guided stereotactic radiotherapy for unresectable malignancies in the upper abdomen using a 1.5T MR-linac. Acta Oncol 2022; 61:111-115. [PMID: 34879792 DOI: 10.1080/0284186x.2021.2012593] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Introduction of online adaptive MR-guided radiotherapy enables stereotactic body radiation therapy (SBRT) of upper abdominal tumors. This study aimed to evaluate the feasibility of MR-guided SBRT on a 1.5 T MR-linac in patients with unresectable upper abdominal malignancies. MATERIAL AND METHODS Patients treated at the UMC Utrecht (April 2019 to December 2020) were identified in the prospective 'Multi-OutcoMe EvaluatioN of radiation Therapy Using the MR-linac' (MOMENTUM) study. Feasibility of treatment was arbitrarily defined as an on-table time interval of ≤60 min for >75% of delivered fractions and completion of >95% of fractions as scheduled, reflecting patient tolerability. Acute treatment-related toxicity was assessed at 3 months of follow-up and graded according to the National Cancer Institute Common Terminology Criteria of Adverse Events version 5.0. RESULTS Twenty-five consecutive patients with a median follow-up time of 8 (range 4-23) months were treated with 35 Gray (n = 4) and 40 Gray (n = 21) in five fractions over 2 weeks. For all fractions, contours were adapted based on the daily anatomy and delivered within 47 min/fraction (range 30-74). In 98/117 fractions (84%), adapted treatment was completed within 1 h. All patients received the scheduled irradiation dose as planned. No acute grade 3 toxicity or higher was reported. Treatment resulted in pain alleviation in 11/13 patients. DISCUSSION Online adaptive MR-guided SBRT on a 1.5 T MR-linac is feasible and well-tolerated in patients with unresectable upper abdominal malignancies. Dose escalation studies, followed by comparative studies, are needed to determine the optimal radiation dose for irradiation of upper abdominal malignancies.
Collapse
Affiliation(s)
- Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | | | - Iris W. J. M. van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hanne D. Heerkens
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Helena M. Verkooijen
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
46
|
Lübeck Christiansen R, Dysager L, Rønn Hansen C, Robenhagen Jensen H, Schytte T, Junker Nyborg C, Smedegaard Bertelsen A, Nielsen Agergaard S, Mahmood F, Hansen S, Hansen O, Brink C, Bernchou U. Online adaptive radiotherapy potentially reduces toxicity for high-risk prostate cancer treatment. Radiother Oncol 2021; 167:165-171. [PMID: 34923034 DOI: 10.1016/j.radonc.2021.12.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE With daily, MR-guided online adapted radiotherapy (MRgART) it may be possible to reduce the PTV in pelvic RT. This study investigated the potential reduction in normal tissue complication probability (NTCP) of MRgART compared to standard radiotherapy for high-risk prostate cancer. MATERIALS AND METHODS Twenty patients treated with 78 Gy to the prostate and 56 Gy to elective pelvic lymph nodes were included. VMAT plans were generated with standard clinical PTV margins. Additionally to the planning MR, patients had three MRI scans during treatment to simulate an MRgART. A reference plan with PTV margins determined for MRgART was created per patient and adapted to each of the following MRs. Adapted plans were warped to the planning MR for dose accumulation. The standard plan was rigidly registered to each adaptation MR before it was warped to the planning MR for dose accumulation. Dosimetric impact was compared by DVH analysis and potential clinical effects were assessed by NTCP modeling. RESULTS MRgART yielded statistically significant lower doses for the bladder wall, rectum and peritoneal cavity, compared to the standard RT, which translated into reduced median risks of urine incontinence (ΔNTCP 2.8%), urine voiding pain (ΔNTCP 2.8%) and acute gastrointestinal toxicity (ΔNTCP 17.4%). Mean population accumulated doses were as good or better for all investigated OAR when planned for MRgART as standard RT. CONCLUSION Online adapted radiotherapy may reduce the dose to organs at risk in high-risk prostate cancer patients, due to reduced PTV margins. This potentially translates to significant reductions in the risks of acute and late adverse effects.
Collapse
Affiliation(s)
- Rasmus Lübeck Christiansen
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital.
| | - Lars Dysager
- Department of Oncology, Odense University Hospital
| | - Christian Rønn Hansen
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | | | - Tine Schytte
- Department of Clinical Research, University of Southern Denmark; Department of Oncology, Odense University Hospital
| | | | | | | | - Faisal Mahmood
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | | | - Olfred Hansen
- Department of Clinical Research, University of Southern Denmark; Department of Oncology, Odense University Hospital
| | - Carsten Brink
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| | - Uffe Bernchou
- Department of Clinical Research, University of Southern Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital
| |
Collapse
|
47
|
Rütten H, Verhoef C, van Weelden WJ, Smits A, Dhanis J, Ottevanger N, Pijnenborg JMA. Recurrent Endometrial Cancer: Local and Systemic Treatment Options. Cancers (Basel) 2021; 13:cancers13246275. [PMID: 34944893 PMCID: PMC8699325 DOI: 10.3390/cancers13246275] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/18/2021] [Accepted: 12/08/2021] [Indexed: 12/25/2022] Open
Abstract
The treatment of recurrent endometrial cancer is a challenge. Because of earlier treatments and the site of locoregional recurrence, in the vaginal vault or pelvis, morbidity can be high. A total of about 4 to 20% of the patients with endometrial cancer develop a locoregional recurrence, mostly among patients with locally advanced disease. The treatment options are dependent on previous treatments and the site of recurrence. Local and locoregional recurrences can be treated curatively with surgery or (chemo)radiotherapy with acceptable toxicity and control rates. Distant recurrences can be treated with palliative systemic therapy, i.e., first-line chemotherapy or hormonal therapy. Based on the tumor characteristics and molecular profile, there can be a role for immunotherapy. The evidence on targeted therapy is limited, with no approved treatment in the current guidelines. In selected cases, there might be an indication for local treatment in oligometastatic disease. Because of the novel techniques in radiotherapy, disease control can often be achieved at limited toxicity. Further studies are warranted to analyze the survival outcome and toxicity of newer treatment strategies. Patient selection is very important in deciding which treatment is of most benefit, and better prediction models based on the patient- and tumor characteristics are necessary.
Collapse
Affiliation(s)
- Heidi Rütten
- Department of Radiation Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands;
- Correspondence:
| | - Cornelia Verhoef
- Department of Radiation Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Willem Jan van Weelden
- Department of Obstetrics & Gynaecology, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.v.W.); (A.S.); (J.M.A.P.)
| | - Anke Smits
- Department of Obstetrics & Gynaecology, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.v.W.); (A.S.); (J.M.A.P.)
| | - Joëlle Dhanis
- Faculty of Medical Sciences, Radboud University, Houtlaan 4, 6525 XZ Nijmegen, The Netherlands;
| | - Nelleke Ottevanger
- Department of Medical Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Johanna M. A. Pijnenborg
- Department of Obstetrics & Gynaecology, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.v.W.); (A.S.); (J.M.A.P.)
| |
Collapse
|
48
|
Jacobs M, Kerkmeijer L, de Ruysscher D, Brunenberg E, Boersma L, Verheij M. Implementation of MR-linac and proton therapy in two radiotherapy departments in The Netherlands: Recommendations based on lessons learned. Radiother Oncol 2021; 167:14-24. [PMID: 34915064 DOI: 10.1016/j.radonc.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/06/2021] [Indexed: 12/26/2022]
Abstract
Recently, two new treatment techniques, i.e. proton therapy and MR-linac based radiotherapy (RT), have been introduced in Dutch RT centres with major impact on daily practice. The content and context of these techniques are frequently described in scientific literature while little is reported about the implementation phase. This process is complex due to a variety of aspects, such as the involvement of multiple stakeholders, significant unpredictability in the start-up phase, the impact of the learning curve, standard operating procedures under development, new catchment areas, and extensive training programs. Insight about implementation in daily care is utterly important for clinics that are about to introduce these new technologies in order to prevent that every centre needs to reinvent the wheel. This position paper gives an overview of the implementation of proton therapy and MR-linac based RT in two large academic RT centres in the Netherlands, i.e. Maastro and Radboudumc respectively. With this paper we aim to report our lessons learned, in order to facilitate other RT centres that consider introducing these and other new techniques in their departments.
Collapse
Affiliation(s)
- Maria Jacobs
- Tilburg School of Economics and Management, Tilburg University, The Netherlands.
| | - Linda Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Ellen Brunenberg
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
49
|
Interrater agreement of contouring of the neurovascular bundles and internal pudendal arteries in neurovascular-sparing magnetic resonance-guided radiotherapy for localized prostate cancer. Clin Transl Radiat Oncol 2021; 32:29-34. [PMID: 34825071 PMCID: PMC8605225 DOI: 10.1016/j.ctro.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 11/20/2022] Open
Abstract
Interrater DSC of the NVB was 0.60 and 0.61 for the left and right side respectively. Interrater DSC of the IPA was 0.59 for the left and right side. Agreement was best for the inferior half (i.e. prostate apex to midgland) of the NVB. Agreement improved with MRI optimization and rater training.
Background and purpose Radiation damage to neural and vascular tissue, such as the neurovascular bundles (NVBs) and internal pudendal arteries (IPAs), during radiotherapy for prostate cancer (PCa) may cause erectile dysfunction. Neurovascular-sparing magnetic resonance-guided adaptive radiotherapy (MRgRT) aims to preserve erectile function after treatment. However, the NVBs and IPAs are not routinely contoured in current radiotherapy practice. Before neurovascular-sparing MRgRT for PCa can be implemented, the interrater agreement of the contouring of the NVBs and IPAs on pre-treatment MRI needs to be assessed. Materials and methods Four radiation oncologists independently contoured the prostate, NVB, and IPA in an unselected consecutive series of 15 PCa patients, on pre-treatment MRI. Dice similarity coefficients (DSCs) for pairwise interrater agreement of contours were calculated. Additionally, the DCS of a subset of the inferior half of the NVB contours (i.e. approximately prostate midgland to apex level) was calculated. Results Median overall interrater DSC for the left and right NVB was 0.60 (IQR: 0.54 – 0.68) and 0.61 (IQR: 0.53 – 0.69) respectively and for the left and right IPA 0.59 (IQR: 0.53 – 0.64) and 0.59 (IQR: 0.52 – 0.64) respectively. Median overall interrater DSC for the inferior half of the left NVB was 0.67 (IQR: 0.58 – 0.74) and 0.67 (IQR: 0.61 – 0.71) for the right NVB. Conclusion We found that the interrater agreement for the contouring of the NVB and IPA improved with enhancement of the MRI sequence as well as further training of the raters. The agreement was best in the subset of the inferior half of the NVB, where a good agreement is clinically most relevant for neurovascular-sparing MRgRT for PCa.
Collapse
Key Words
- CC, corpus cavernosum
- CT, computed tomography
- DSC, Dice similarity coefficient
- EBRT, external beam radiation therapy
- Erectile function sparing
- GRRAS, Guidelines for Reporting Reliability and Agreement Studies
- Gy, gray
- IPA, internal pudendal artery
- IQR, interquartile range
- Internal pudendal artery (IPA)
- Interrater agreement
- Localized prostate cancer (PCa)
- MRI, magnetic resonance imaging
- MRgRT, magnetic resonance-guided adaptive radiotherapy
- Magnetic resonance-guided radiotherapy (MRgRT)
- NCCN, National Comprehensive Cancer Network
- NVB, neurovascular bundle
- Neurovascular bundle (NVB)
- Neurovascular-sparing
- OAR, organs at risk
- PB, penile bulb
- PCa, prostate cancer
- PTV, planning target volume
Collapse
|
50
|
de Mol van Otterloo SR, Christodouleas JP, Blezer ELA, Akhiat H, Brown K, Choudhury A, Eggert D, Erickson BA, Daamen LA, Faivre-Finn C, Fuller CD, Goldwein J, Hafeez S, Hall E, Harrington KJ, van der Heide UA, Huddart RA, Intven MPW, Kirby AM, Lalondrelle S, McCann C, Minsky BD, Mook S, Nowee ME, Oelfke U, Orrling K, Philippens MEP, Sahgal A, Schultz CJ, Tersteeg RJHA, Tijssen RHN, Tree AC, van Triest B, Tseng CL, Hall WA, Verkooijen HM. Patterns of Care, Tolerability, and Safety of the First Cohort of Patients Treated on a Novel High-Field MR-Linac Within the MOMENTUM Study: Initial Results From a Prospective Multi-Institutional Registry. Int J Radiat Oncol Biol Phys 2021; 111:867-875. [PMID: 34265394 PMCID: PMC9764331 DOI: 10.1016/j.ijrobp.2021.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/09/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE High-field magnetic resonance-linear accelerators (MR-Linacs), linear accelerators combined with a diagnostic magnetic resonance imaging (MRI) scanner and online adaptive workflow, potentially give rise to novel online anatomic and response adaptive radiation therapy paradigms. The first high-field (1.5T) MR-Linac received regulatory approval in late 2018, and little is known about clinical use, patient tolerability of daily high-field MRI, and toxicity of treatments. Herein we report the initial experience within the MOMENTUM Study (NCT04075305), a prospective international registry of the MR-Linac Consortium. METHODS AND MATERIALS Patients were included between February 2019 and October 2020 at 7 institutions in 4 countries. We used descriptive statistics to describe the patterns of care, tolerability (the percentage of patients discontinuing their course early), and safety (grade 3-5 Common Terminology Criteria for Adverse Events v.5 acute toxicity within 3 months after the end of treatment). RESULTS A total 943 patients participated in the MOMENTUM Study, 702 of whom had complete baseline data at the time of this analysis. Patients were primarily male (79%) with a median age of 68 years (range, 22-93) and were treated for 39 different indications. The most frequent indications were prostate (40%), oligometastatic lymph node (17%), brain (12%), and rectal (10%) cancers. The median number of fractions was 5 (range, 1-35). Six patients discontinued MR-Linac treatments, but none due to an inability to tolerate repeated high-field MRI. Of the 415 patients with complete data on acute toxicity at 3-month follow-up, 18 (4%) patients experienced grade 3 acute toxicity related to radiation. No grade 4 or 5 acute toxicity related to radiation was observed. CONCLUSIONS In the first 21 months of our study, patterns of care were diverse with respect to clinical utilization, body sites, and radiation prescriptions. No patient discontinued treatment due to inability to tolerate daily high-field MRI scans, and the acute radiation toxicity experience was encouraging.
Collapse
Affiliation(s)
| | | | - Erwin L A Blezer
- Division of Imaging, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Ananya Choudhury
- The University of Manchester and The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | | | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lois A Daamen
- Division of Imaging, University Medical Center Utrecht, Utrecht, Netherlands
| | - Corinne Faivre-Finn
- The University of Manchester and The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Clifton D Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center Houston, Houston, Texas
| | | | - Shaista Hafeez
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Uulke A van der Heide
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Robert A Huddart
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anna M Kirby
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Susan Lalondrelle
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Claire McCann
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, Ontario
| | - Bruce D Minsky
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center Houston, Houston, Texas
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marlies E Nowee
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Uwe Oelfke
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | | | | | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, Ontario
| | - Christopher J Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robbert J H A Tersteeg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob H N Tijssen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer, London, United Kingdom
| | - Baukelien van Triest
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, Ontario
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Helena M Verkooijen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands; Division of Imaging, University Medical Center Utrecht, Utrecht, Netherlands.
| |
Collapse
|