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Lee J, Shin NY, Lee SJ, Cho YJ, Jung IH, Sung JW, Kim SJ, Kim JW. Development of Magnetic Resonance-Compatible Head Immobilization Device and Initial Experience of Magnetic Resonance-Guided Radiation Therapy for Central Nervous System Tumors. Pract Radiat Oncol 2024:S1879-8500(24)00093-6. [PMID: 38697347 DOI: 10.1016/j.prro.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE We aimed to develop and investigate positional reproducibility using a fixation device (Unity Brain tumor Immobilization Device [UBID]) in patients with brain tumor undergoing magnetic resonance (MR)-guided radiation therapy (RT) with a 1.5 Tesla (T) MR-linear accelerator (MR-LINAC) to evaluate its feasibility in clinical practice and report representative cases of patients with central nervous system (CNS) tumor. MATERIALS AND METHODS Quantitative analysis was performed by comparing images obtained by placing only the MR phantom on the couch with those obtained by placing UBID next to the MR phantom. Twenty patients who underwent RT for CNS tumors using 1.5T MR-LINAC between June and October 2022 were retrospectively analyzed. Among them, 5 did not use UBID, whereas 15 used UBID. The positional reproducibility of UBID was evaluated using the median interfractional and intrafractional errors in the first 10 fractions. RESULTS Each MR quality factor of the MR phantom with UBID satisfied the criteria presented by Elekta. Median values of median shifts in the mediolateral, anteroposterior, and craniocaudal axes for interfractional errors were 2.98, 2.35, and 1.40 mm, respectively. For intrafractional errors, the median values were 0.05, 0.03, and 0.06 mm, respectively. The median values of the median rotations in pitch, roll, and yaw for both interfractional and intrafractional rotations were 0.00°. One patient diagnosed with an optic nerve sheath meningioma received RT with motion monitoring during irradiation. In 2 patients, changes in the tumor cavity and residual lesions were observed in the MRI obtained using 1.5T MR-LINAC on the day of the first treatment and immediately before the 21st fraction, respectively; therefore, offline/online adaptation was performed. CONCLUSIONS The reproducible and immobile UBID is clinically feasible in patients with CNS tumors receiving RT with 1.5T MR-LINAC. Based on our initial experience, we developed a workflow for 1.5T MR-LINAC treatment of CNS tumors.
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Affiliation(s)
- Joongyo Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Department of Radiation Oncology, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Na Young Shin
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Seo Jin Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoon Jin Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - In Ho Jung
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Won Sung
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sei Joon Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Ong WL, Stewart J, Sahgal A, Soliman H, Tseng CL, Detsky J, Chen H, Ho L, Das S, Maralani P, Lipsman N, Stanisz G, Perry J, Lim-Fat MJ, Atenafu EG, Lau A, Ruschin M, Myrehaug S. Predictors of Tumor Dynamics Over a 6-Week Course of Concurrent Chemoradiotherapy for Glioblastoma and the Effect on Survival. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00453-X. [PMID: 38561051 DOI: 10.1016/j.ijrobp.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/09/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE We present the final analyses of tumor dynamics and their prognostic significance during a 6-week course of concurrent chemoradiotherapy for glioblastoma in the Glioblastoma Longitudinal Imaging Observational study. METHODS AND MATERIALS This is a prospective serial magnetic resonance imaging study in 129 patients with glioblastoma who had magnetic resonance imaging obtained at radiation therapy (RT) planning (F0), fraction 10 (F10), fraction 20 (F20), and 1-month post-RT. Tumor dynamics assessed included gross tumor volume relative to F0 (Vrel) and tumor migration distance (dmigration). Covariables evaluated included: corpus callosum involvement, extent of surgery, O6-methylguanine-DNA-methyltransferase methylation, and isocitrate dehydrogenase mutation status. RESULTS The median Vrel were 0.85 (range, 0.25-2.29) at F10, 0.79 (range, 0.09-2.22) at F20, and 0.78 (range, 0.13-4.27) at 1 month after completion of RT. The median dmigration were 4.7 mm (range, 1.1-20.4 mm) at F10, 4.7 mm (range, 0.8-20.7 mm) at F20, and 6.1 mm (range, 0.0-45.5 mm) at 1 month after completion of RT. Compared with patients who had corpus callosum involvement (n = 26), those without corpus callosum involvement (n = 103) had significant Vrel reduction at F20 (P = .03) and smaller dmigration at F20 (P = .007). Compared with patients who had biopsy alone (n = 19) and subtotal resection (n = 71), those who had gross total resection (n = 38) had significant Vrel reduction at F10 (P = .001) and F20 (P = .001) and a smaller dmigration at F10 (P = .03) and F20 (P = .002). O6-Methylguanine-DNA-methyltransferase methylation and isocitrate dehydrogenase mutation status were not significantly associated with tumor dynamics. The median progression-free survival and overall survival (OS) were 8.5 months (95% CI, 6.9-9.9) and 20.4 months (95% CI, 17.6-25.2). In multivariable analyses, patients with Vrel ≥ 1.33 at F10 had worse OS (hazard ratio [HR], 4.6; 95% CI, 1.8-11.4; P = .001), and patients with dmigration ≥ 5 mm at 1-month post-RT had worse progression-free survival (HR, 1.76; 95% CI, 1.08-2.87) and OS (HR, 2.2; 95% CI, 1.2-4.0; P = .007). CONCLUSIONS Corpus callosum involvement and extent of surgery are independent predictors of tumor dynamics during RT and can enable patient selection for adaptive RT strategies. Significant tumor enlargement at F10 and tumor migration 1-month post-RT were associated with poorer OS.
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Affiliation(s)
- Wee Loon Ong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Australia
| | - James Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sunit Das
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Division of Neurosurgery and Centre for Ethics, St Michael's Hospital, Toronto, Canada; The Arthur and Sonia Labatt Brain Tumour Research Centre, SickKids Hospital, Toronto, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto Canada
| | - Greg Stanisz
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada; Department of Neurosurgery and Paediatric Neurosurgery, Medical University Lublin, Poland
| | - James Perry
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada
| | - Angus Lau
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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Tseng CL, Zeng KL, Mellon EA, Soltys SG, Ruschin M, Lau AZ, Lutsik NS, Chan RW, Detsky J, Stewart J, Maralani PJ, Sahgal A. Evolving concepts in margin strategies and adaptive radiotherapy for glioblastoma: A new future is on the horizon. Neuro Oncol 2024; 26:S3-S16. [PMID: 38437669 PMCID: PMC10911794 DOI: 10.1093/neuonc/noad258] [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] [Indexed: 03/06/2024] Open
Abstract
Chemoradiotherapy is the standard treatment after maximal safe resection for glioblastoma (GBM). Despite advances in molecular profiling, surgical techniques, and neuro-imaging, there have been no major breakthroughs in radiotherapy (RT) volumes in decades. Although the majority of recurrences occur within the original gross tumor volume (GTV), treatment of a clinical target volume (CTV) ranging from 1.5 to 3.0 cm beyond the GTV remains the standard of care. Over the past 15 years, the incorporation of standard and functional MRI sequences into the treatment workflow has become a routine practice with increasing adoption of MR simulators, and new integrated MR-Linac technologies allowing for daily pre-, intra- and post-treatment MR imaging. There is now unprecedented ability to understand the tumor dynamics and biology of GBM during RT, and safe CTV margin reduction is being investigated with the goal of improving the therapeutic ratio. The purpose of this review is to discuss margin strategies and the potential for adaptive RT for GBM, with a focus on the challenges and opportunities associated with both online and offline adaptive workflows. Lastly, opportunities to biologically guide adaptive RT using non-invasive imaging biomarkers and the potential to define appropriate volumes for dose modification will be discussed.
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Affiliation(s)
- Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Oncology, Simcoe Muskoka Regional Cancer Program, Royal Victoria Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Natalia S Lutsik
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Rachel W Chan
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Sahgal A, Chang S. Pushing the boundaries of radiation technology for the management of central nervous system tumors. Neuro Oncol 2024; 26:S1-S2. [PMID: 38437663 PMCID: PMC10911792 DOI: 10.1093/neuonc/noae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Susan Chang
- Department of Neurological Surgery, Division of Neuro Oncology, University of California at San Francisco, San Francisco, California, USA
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5
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [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: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Ocanto A, Torres L, Montijano M, Rincón D, Fernández C, Sevilla B, Gonsalves D, Teja M, Guijarro M, Glaría L, Hernánz R, Zafra-Martin J, Sanmamed N, Kishan A, Alongi F, Moghanaki D, Nagar H, Couñago F. MR-LINAC, a New Partner in Radiation Oncology: Current Landscape. Cancers (Basel) 2024; 16:270. [PMID: 38254760 PMCID: PMC10813892 DOI: 10.3390/cancers16020270] [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: 12/17/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Technological advances in radiation oncology are oriented towards improving treatment precision and tumor control. Among these advances, magnetic-resonance-image-guided radiation therapy (MRgRT) stands out, with technological advances to deliver targeted treatments adapted to a tumor's anatomy on the day while minimizing incidental exposure to organs at risk, offering an unprecedented therapeutic advantage compared to X-ray-based IGRT delivery systems. This new technology changes the traditional workflow in radiation oncology and requires an evolution in team coordination to administer more precise treatments. Once implemented, it paves the way for newer indication for radiation therapy to safely deliver higher doses than ever before, with better preservation of healthy tissues to optimize patient outcomes. In this narrative review, we assess the technical aspects of the novel linear accelerators that can deliver MRgRT and summarize the available published experience to date, focusing on oncological results and future challenges.
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Affiliation(s)
- Abrahams Ocanto
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Lisselott Torres
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Miguel Montijano
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Diego Rincón
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Beatriz Sevilla
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Daniela Gonsalves
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Macarena Teja
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Marcos Guijarro
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Luis Glaría
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Raúl Hernánz
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Juan Zafra-Martin
- Group of Translational Research in Cancer Immunotherapy, Centro de Investigaciones Médico-Sanitarias (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain;
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Noelia Sanmamed
- Department of Radiation Oncology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA;
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar, Italy;
- University of Brescia, 25121 Brescia, Italy
| | - Drew Moghanaki
- UCLA Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
- GenesisCare, 28043 Madrid, Spain
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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).
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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..
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8
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Bryant JM, Doniparthi A, Weygand J, Cruz-Chamorro R, Oraiqat IM, Andreozzi J, Graham J, Redler G, Latifi K, Feygelman V, Rosenberg SA, Yu HHM, Oliver DE. Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions. Cancers (Basel) 2023; 15:5200. [PMID: 37958374 PMCID: PMC10649155 DOI: 10.3390/cancers15215200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Magnetic resonance imaging (MRI) provides excellent visualization of central nervous system (CNS) tumors due to its superior soft tissue contrast. Magnetic resonance-guided radiotherapy (MRgRT) has historically been limited to use in the initial treatment planning stage due to cost and feasibility. MRI-guided linear accelerators (MRLs) allow clinicians to visualize tumors and organs at risk (OARs) directly before and during treatment, a process known as online MRgRT. This novel system permits adaptive treatment planning based on anatomical changes to ensure accurate dose delivery to the tumor while minimizing unnecessary toxicity to healthy tissue. These advancements are critical to treatment adaptation in the brain and spinal cord, where both preliminary MRI and daily CT guidance have typically had limited benefit. In this narrative review, we investigate the application of online MRgRT in the treatment of various CNS malignancies and any relevant ongoing clinical trials. Imaging of glioblastoma patients has shown significant changes in the gross tumor volume over a standard course of chemoradiotherapy. The use of adaptive online MRgRT in these patients demonstrated reduced target volumes with cavity shrinkage and a resulting reduction in radiation dose to uninvolved tissue. Dosimetric feasibility studies have shown MRL-guided stereotactic radiotherapy (SRT) for intracranial and spine tumors to have potential dosimetric advantages and reduced morbidity compared with conventional linear accelerators. Similarly, dosimetric feasibility studies have shown promise in hippocampal avoidance whole brain radiotherapy (HA-WBRT). Next, we explore the potential of MRL-based multiparametric MRI (mpMRI) and genomically informed radiotherapy to treat CNS disease with cutting-edge precision. Lastly, we explore the challenges of treating CNS malignancies and special limitations MRL systems face.
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Affiliation(s)
- John Michael Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ajay Doniparthi
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA;
| | - Joseph Weygand
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ruben Cruz-Chamorro
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ibrahim M. Oraiqat
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jacqueline Andreozzi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jasmine Graham
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Daniel E. Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
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9
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Smith D, Knight K, Sim J, Lim Joon D, Foroudi F, Khoo V. A planning-based feasibility study of MR-Linac treatment for anal cancer radiation therapy. Med Dosim 2023; 48:267-272. [PMID: 37507334 DOI: 10.1016/j.meddos.2023.07.001] [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: 04/24/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
The hybrid magnetic resonance image (MRI) scanner and radiation therapy linear accelerator (MR-Linac) has the potential to enhance clinical outcomes for anal cancer (AC) patients with improved soft tissue visualization and daily plan adaption but has planning and delivery limitations due to the incorporation of MRI. We aimed to identify if Elekta Unity MR-Linac-based radiation therapy is feasible for anal cancer. Ten prospectively enrolled AC patients treated with radical chemoradiotherapy were replanned for MR-Linac treatment using departmental planning criteria. For comparison, and to reduce interobserver variability, volumetric modulated arc radiation therapy (VMAT) plans were also created for each patient by the same single senior radiation therapist. Plans were compared using departmental dosimetric plan criteria, as well as conformity and homogeneity indices, monitor units (MUs) and measured plan delivery (beam-on) time. Results were deemed clinically acceptable. Target and organ at risk (OAR) doses were comparable between MR-Linac plans and VMAT plans, although PTV45Gy D98% coverage was compromised in 3 of 10 MR-Linac plans due to caudocranial length exceeding the limits of the MR-Linac. MR-Linac plans had lower MUs, median of 689.1 vs 849.65 (p = 0.002), but took over twice as long to deliver, 529.5s vs 224s (p = <0.0001) as VMAT plans. MR-Linac planning and treatment of AC is feasible for a subset of patients. The current physical limitations of the Elekta Unity system mean patients with large caudocranial elective PTV45Gy target volumes may not be covered dosimetrically to the required clinical standard. Longer image verification and treatment delivery times of the MR-Linac also mean patient selection and intrafractional IGRT are likely to be integral to ensuring high quality clinical outcomes in this rare cancer.
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Affiliation(s)
- Drew Smith
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia.
| | - Kellie Knight
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Jenny Sim
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Vincent Khoo
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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10
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Trivedi AG, Kim SH, Ramesh KK, Giuffrida AS, Weinberg BD, Mellon EA, Kleinberg LR, Barker PB, Han H, Shu HKG, Shim H, Schreibmann E. Applying a Radiation Therapy Volume Analysis Pipeline to Determine the Utility of Spectroscopic MRI-Guided Adaptive Radiation Therapy for Glioblastoma. Tomography 2023; 9:1052-1061. [PMID: 37218946 PMCID: PMC10204497 DOI: 10.3390/tomography9030086] [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: 04/20/2023] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023] Open
Abstract
Accurate radiation therapy (RT) targeting is crucial for glioblastoma treatment but may be challenging using clinical imaging alone due to the infiltrative nature of glioblastomas. Precise targeting by whole-brain spectroscopic MRI, which maps tumor metabolites including choline (Cho) and N-acetylaspartate (NAA), can quantify early treatment-induced molecular changes that other traditional modalities cannot measure. We developed a pipeline to determine how spectroscopic MRI changes during early RT are associated with patient outcomes to provide insight into the utility of adaptive RT planning. Data were obtained from a study (NCT03137888) where glioblastoma patients received high-dose RT guided by the pre-RT Cho/NAA twice normal (Cho/NAA ≥ 2x) volume, and received spectroscopic MRI scans pre- and mid-RT. Overlap statistics between pre- and mid-RT scans were used to quantify metabolic activity changes after two weeks of RT. Log-rank tests were used to quantify the relationship between imaging metrics and patient overall and progression-free survival (OS/PFS). Patients with lower Jaccard/Dice coefficients had longer PFS (p = 0.045 for both), and patients with lower Jaccard/Dice coefficients had higher OS trending towards significance (p = 0.060 for both). Cho/NAA ≥ 2x volumes changed significantly during early RT, putting healthy tissue at risk of irradiation, and warranting further study into using adaptive RT planning.
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Affiliation(s)
- Anuradha G. Trivedi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Su Hyun Kim
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Karthik K. Ramesh
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Alexander S. Giuffrida
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Brent D. Weinberg
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Eric A. Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 45056, USA
| | - Lawrence R. Kleinberg
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Peter B. Barker
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Hui Han
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Hui-Kuo G. Shu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hyunsuk Shim
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Eduard Schreibmann
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
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11
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La Rosa A, Mittauer KE, Rzepczynski AE, Chuong MD, Kutuk T, Bassiri N, McAllister NC, Hall MD, McCulloch J, Alvarez D, Herrera R, Gutierrez AN, Tolakanahalli R, Odia Y, Ahluwalia MS, Mehta MP, Kotecha R. Treatment of glioblastoma using MRIdian® A3i BrainTx™: Imaging and treatment workflow demonstration. Med Dosim 2023:S0958-3947(23)00019-5. [PMID: 36966049 DOI: 10.1016/j.meddos.2023.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 03/27/2023]
Abstract
For patients with newly diagnosed glioblastoma, the current standard-of-care includes maximal safe resection, followed by concurrent chemoradiotherapy and adjuvant temozolomide, with tumor treating fields. Traditionally, diagnostic imaging is performed pre- and post-resection, without additional dedicated longitudinal imaging to evaluate tumor volumes or other treatment-related changes. However, the recent introduction of MR-guided radiotherapy using the ViewRay MRIdian A3i system includes a dedicated BrainTx package to facilitate the treatment of intracranial tumors and provides daily MR images. We present the first reported case of a glioblastoma imaged and treated using this workflow. In this case, a 67-year-old woman underwent adjuvant chemoradiotherapy after gross total resection of a left frontal glioblastoma. The radiotherapy treatment plan consisted of a traditional two-phase design (46 Gy followed by a sequential boost to a total dose of 60 Gy at 2 Gy/fraction). The treatment planning process, institutional workflow, treatment imaging, treatment timelines, and target volume changes visualized during treatment are presented. This case example using our institutional A3i system workflow successfully allows for imaging and treatment of primary brain tumors and has the potential for margin reduction, detection of early disease progression, or to detect the need for dose adaptation due to interfraction tumor volume changes.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Amy E Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nicole C McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - James McCulloch
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Diane Alvarez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yazmin Odia
- Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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12
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Guerini AE, Nici S, Magrini SM, Riga S, Toraci C, Pegurri L, Facheris G, Cozzaglio C, Farina D, Liserre R, Gasparotti R, Ravanelli M, Rondi P, Spiazzi L, Buglione M. Adoption of Hybrid MRI-Linac Systems for the Treatment of Brain Tumors: A Systematic Review of the Current Literature Regarding Clinical and Technical Features. Technol Cancer Res Treat 2023; 22:15330338231199286. [PMID: 37774771 PMCID: PMC10542234 DOI: 10.1177/15330338231199286] [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: 04/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Possible advantages of magnetic resonance (MR)-guided radiation therapy (MRgRT) for the treatment of brain tumors include improved definition of treatment volumes and organs at risk (OARs) that could allow margin reductions, resulting in limited dose to the OARs and/or dose escalation to target volumes. Recently, hybrid systems integrating a linear accelerator and an magnetic resonance imaging (MRI) scan (MRI-linacs, MRL) have been introduced, that could potentially lead to a fully MRI-based treatment workflow. METHODS We performed a systematic review of the published literature regarding the adoption of MRL for the treatment of primary or secondary brain tumors (last update November 3, 2022), retrieving a total of 2487 records; after a selection based on title and abstracts, the full text of 74 articles was analyzed, finally resulting in the 52 papers included in this review. RESULTS AND DISCUSSION Several solutions have been implemented to achieve a paradigm shift from CT-based radiotherapy to MRgRT, such as the management of geometric integrity and the definition of synthetic CT models that estimate electron density. Multiple sequences have been optimized to acquire images with adequate quality with on-board MR scanner in limited times. Various sophisticated algorithms have been developed to compensate the impact of magnetic field on dose distribution and calculate daily adaptive plans in a few minutes with satisfactory dosimetric parameters for the treatment of primary brain tumors and cerebral metastases. Dosimetric studies and preliminary clinical experiences demonstrated the feasibility of treating brain lesions with MRL. CONCLUSIONS The adoption of an MRI-only workflow is feasible and could offer several advantages for the treatment of brain tumors, including superior image quality for lesions and OARs and the possibility to adapt the treatment plan on the basis of daily MRI. The growing body of clinical data will clarify the potential benefit in terms of toxicity and response to treatment.
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Affiliation(s)
- Andrea Emanuele Guerini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Co-first authors
| | - Stefania Nici
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
- Co-first authors
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Stefano Riga
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Cristian Toraci
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Ludovica Pegurri
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Giorgio Facheris
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Claudia Cozzaglio
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Davide Farina
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Roberto Liserre
- Department of Radiology, Neuroradiology Unit, ASST Spedali Civili University Hospital, Brescia, Italy
| | - Roberto Gasparotti
- Neuroradiology Unit, Department of Medical-Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Paolo Rondi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Spiazzi
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
- Co-last author
| | - Michela Buglione
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Co-last author
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