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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Kim JY, Tawk B, Knoll M, Hoegen-Saßmannshausen P, Liermann J, Huber PE, Lifferth M, Lang C, Häring P, Gnirs R, Jäkel O, Schlemmer HP, Debus J, Hörner-Rieber J, Weykamp F. Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS). Cancers (Basel) 2024; 16:1210. [PMID: 38539544 PMCID: PMC10969008 DOI: 10.3390/cancers16061210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE The Ethos (Varian Medical Systems) radiotherapy device combines semi-automated anatomy detection and plan generation for cone beam computer tomography (CBCT)-based daily online adaptive radiotherapy (oART). However, CBCT offers less soft tissue contrast than magnetic resonance imaging (MRI). This work aims to present the clinical workflow of CBCT-based oART with shuttle-based offline MR guidance. METHODS From February to November 2023, 31 patients underwent radiotherapy on the Ethos (Varian, Palo Alto, CA, USA) system with machine learning (ML)-supported daily oART. Moreover, patients received weekly MRI in treatment position, which was utilized for daily plan adaptation, via a shuttle-based system. Initial and adapted treatment plans were generated using the Ethos treatment planning system. Patient clinical data, fractional session times (MRI + shuttle transport + positioning, adaptation, QA, RT delivery) and plan selection were assessed for all fractions in all patients. RESULTS In total, 737 oART fractions were applied and 118 MRIs for offline MR guidance were acquired. Primary sites of tumors were prostate (n = 16), lung (n = 7), cervix (n = 5), bladder (n = 1) and endometrium (n = 2). The treatment was completed in all patients. The median MRI acquisition time including shuttle transport and positioning to initiation of the Ethos adaptive session was 53.6 min (IQR 46.5-63.4). The median total treatment time without MRI was 30.7 min (IQR 24.7-39.2). Separately, median adaptation, plan QA and RT times were 24.3 min (IQR 18.6-32.2), 0.4 min (IQR 0.3-1,0) and 5.3 min (IQR 4.5-6.7), respectively. The adapted plan was chosen over the scheduled plan in 97.7% of cases. CONCLUSION This study describes the first workflow to date of a CBCT-based oART combined with a shuttle-based offline approach for MR guidance. The oART duration times reported resemble the range shown by previous publications for first clinical experiences with the Ethos system.
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Affiliation(s)
- Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Bouchra Tawk
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Maximilian Knoll
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center Heidelberg, 69120 Heidelberg, Germany
| | - Philipp Hoegen-Saßmannshausen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Peter E. Huber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Molecular Radiooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Mona Lifferth
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Clemens Lang
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Peter Häring
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Regula Gnirs
- Division of Radiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Oliver Jäkel
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Molecular Radiooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
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Santoso AP, Vinogradskiy Y, Robin TP, Goodman KA, Schefter TE, Miften M, Jones BL. Clinical and Dosimetric Impact of 2D kV Motion Monitoring and Intervention in Liver Stereotactic Body Radiation Therapy. Adv Radiat Oncol 2024; 9:101409. [PMID: 38298328 PMCID: PMC10828584 DOI: 10.1016/j.adro.2023.101409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/13/2023] [Indexed: 02/02/2024] Open
Abstract
Purpose Positional errors resulting from motion are a principal challenge across all disease sites in radiation therapy. This is particularly pertinent when treating lesions in the liver with stereotactic body radiation therapy (SBRT). To achieve dose escalation and margin reduction for liver SBRT, kV real-time imaging interventions may serve as a potential solution. In this study, we report results of a retrospective cohort of liver patients treated using real-time 2D kV-image guidance SBRT with emphasis on the impact of (1) clinical workflow, (2) treatment accuracy, and (3) tumor dose. Methods and Materials Data from 33 patients treated with 41 courses of liver SBRT were analyzed. During treatment, planar kV images orthogonal to the treatment beam were acquired to determine treatment interventions, namely treatment pauses (ie, adequacy of gating thresholds) or treatment shifts. Patients were shifted if internal markers were >3 mm, corresponding to the PTV margin used, from the expected reference condition. The frequency, duration, and nature of treatment interventions (ie, pause vs shift) were recorded, and the dosimetric impact associated with treatment shifts was estimated using a machine learning dosimetric model. Results Of all fractions delivered, 39% required intervention, which took on average 1.9 ± 1.6 minutes and occurred more frequently in treatments lasting longer than 7 minutes. The median realignment shift was 5.7 mm in size, and the effect of these shifts on minimum tumor dose in simulated clinical scenarios ranged from 0% to 50% of prescription dose per fraction. Conclusion Real-time kV-based imaging interventions for liver SBRT minimally affect clinical workflow and dosimetrically benefit patients. This potential solution for addressing positional errors from motion addresses concerns about target accuracy and may enable safe dose escalation and margin reduction in the context of liver SBRT.
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Affiliation(s)
- Andrew P. Santoso
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler P. Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Karyn A. Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tracey E. Schefter
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Bernard L. Jones
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
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4
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Courtney PT, Valle LF, Raldow AC, Steinberg ML. MRI-Guided Radiation Therapy-An Emerging and Disruptive Process of Care: Healthcare Economic and Policy Considerations. Semin Radiat Oncol 2024; 34:4-13. [PMID: 38105092 DOI: 10.1016/j.semradonc.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
MRI-guided radiation therapy (MRgRT) is an emerging, innovative technology that provides opportunities to transform and improve the current clinical care process in radiation oncology. As with many new technologies in radiation oncology, careful evaluation from a healthcare economic and policy perspective is required for its successful implementation. In this review article, we describe the current evidence surrounding MRgRT, framing it within the context of value within the healthcare system. Additionally, we highlight areas in which MRgRT may disrupt the current process of care, and discuss the evidence thresholds and timeline required for the widespread adoption of this promising technology.
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Affiliation(s)
- P Travis Courtney
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Luca F Valle
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA.
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Hehakaya C, Frederix G, van der Voort van Zyp J, Grobbee D, Verkooijen H. Realizing the value of complex medical technology: Demonstrating cost-effectiveness is not enough. Clin Transl Radiat Oncol 2023; 41:100644. [PMID: 37304169 PMCID: PMC10248500 DOI: 10.1016/j.ctro.2023.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023] Open
Abstract
The main factors driving the value of medical treatments are proven effectiveness and cost-effectiveness. This is different for complex medical technologies that combine scientific disciplines, functions or tools in a single solution-oriented method. This short communication provides three recommendations to realize the value of complex medical technologies. It is important to engage stakeholders before technology implementation to promote its relevance from multiple perspectives, to explore opportunities for professional development and collaboration, and to demonstrate the societal effects over the entire life-cycle.
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Affiliation(s)
- C. Hehakaya
- Global Public Health & Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G.W.J. Frederix
- Health Economic Evaluation, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - D.E. Grobbee
- Global Public Health & Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H.M. Verkooijen
- Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, The Netherlands
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Ma CMC, Shan G, Hu W, Price RA, Chen L. A new target localization method for image-guided radiation therapy of prostate cancer. Phys Med 2023; 107:102550. [PMID: 36870203 DOI: 10.1016/j.ejmp.2023.102550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/24/2023] [Accepted: 02/18/2023] [Indexed: 03/06/2023] Open
Abstract
In imaged-guided radiation therapy (IGRT), target localization is usually done with rigid-body registration based on anatomy matching. Problems arise when the target volume can only be matched partially due to inter-fractional organ motion and deformation, resulting in deteriorated target coverage and critical structure sparing. A new target localization method is investigated in which the treatment target volume is aligned with the prescription isodose surface. Our study included 15 prostate patients previously treated with intensity-modulated radiation therapy (IMRT). Patient setup and target localization were performed using a CT-on-rails system before and after the IMRT treatment. IMRT plans were generated on the original simulation CTs (15) and the same MUs and leaf sequences were used to compute the dose distributions on post-treatment CTs (98) with the isocenter adjustments based on either anatomical structure matching or prescription isodose surface alignment. When patients were aligned with the traditional anatomy matching method, the dose to 95% of the CTV, D95, received 74.0 - 77.6 Gy and the minimum CTV dose, Dmin, was 61.9 - 71.6 Gy, respectively, in the cumulative dose distributions. The rectal dose-volume constraints were violated in 35.7% of the treatment fractions. When patients were aligned using the new localization method, the dose to 95% of the CTV, D95, received 74.0 - 78.2 Gy and the minimum CTV dose, Dmin, was 68.4 - 71.6 Gy, respectively, in the cumulative dose distributions. The rectal dose-volume constraints were violated in 17.3% of the treatment fractions. Traditional IGRT target localization based on anatomy matching is effective for population-based PTV margins but not ideal for those patients with large inter-fractional prostate rotation/deformation due to large rectal and bladder volume variation. The new method using the prescription isodose surface to align the target volume could improve the target coverage and rectal sparing for these patients, which can be implemented clinically to improve target dose delivery accuracy.
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Affiliation(s)
- C M Charlie Ma
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States.
| | - Guoping Shan
- Department of Radiation Physics, Zhejiang Key Lab of Radiation Oncology, Hangzhou, China
| | - Wei Hu
- Department of Radiation Oncology, Taizhou Central Hospital, Zhejiang, China
| | - Robert A Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Lili Chen
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
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Hogan L, Jameson M, Crawford D, Alvares S, Loo C, Picton M, Moutrie Z, Pagulayan C, Jelen U, Dunkerley N, Twentyman T, de Leon J, Batumalai V. Old dogs, new tricks:
MR‐Linac
training and credentialing of radiation oncologists, radiation therapists and medical physicists. J Med Radiat Sci 2022; 70 Suppl 2:99-106. [PMID: 36502538 PMCID: PMC10122927 DOI: 10.1002/jmrs.640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
The introduction of magnetic resonance (MR) linear accelerators (MR-Linacs) into radiotherapy departments has increased in recent years owing to its unique advantages including the ability to deliver online adaptive radiotherapy. However, most radiation oncology professionals are not accustomed to working with MR technology. The integration of an MR-Linac into routine practice requires many considerations including MR safety, MR image acquisition and optimisation, image interpretation and adaptive radiotherapy strategies. This article provides an overview of training and credentialing requirements for radiation oncology professionals to develop competency and efficiency in delivering treatment safely on an MR-Linac.
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Affiliation(s)
- Louise Hogan
- GenesisCare Alexandria New South Wales Australia
| | - Michael Jameson
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Australia
| | | | | | - Conrad Loo
- GenesisCare Alexandria New South Wales Australia
| | | | - Zoe Moutrie
- GenesisCare Alexandria New South Wales Australia
- Department of Radiation Oncology South West Sydney Local Health District Warwick Farm New South Wales Australia
| | | | - Ursula Jelen
- GenesisCare Alexandria New South Wales Australia
| | | | | | | | - Vikneswary Batumalai
- GenesisCare Alexandria New South Wales Australia
- School of Clinical Medicine, Faculty of Medicine and Health UNSW Sydney Australia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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9
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Rumley CN, Hansen CR, Jameson MG, Trada Y, Johansen J, Gyldenkerne N, Eriksen JG, Aly F, Christensen RL, Lee M, Brink C, Holloway L. Delineation uncertainties of tumour volumes on MRI of head and neck cancer patients. Clin Transl Radiat Oncol 2022. [PMID: 36017132 PMCID: PMC9395751 DOI: 10.1016/j.ctro.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 11/28/2022] Open
Abstract
Role of target delineation uncertainties in head and neck cancer patients. Knowing contouring variations for MRI allows better adaptation of MRLinac for H&N cancers. An interobserver variation for GTV among 8 observers was below 2 mm using MRI. Variability between observers might improve using other imaging modalities.
Background During the last decade, radiotherapy using MR Linac has gone from research to clinical implementation for different cancer locations. For head and neck cancer (HNC), target delineation based only on MR images is not yet standard, and the utilisation of MRI instead of PET/CT in radiotherapy planning is not well established. We aimed to analyse the inter-observer variation (IOV) in delineating GTV (gross tumour volume) on MR images only for patients with HNC. Material/methods 32 HNC patients from two independent departments were included. Four clinical oncologists from Denmark and four radiation oncologists from Australia had independently contoured primary tumour GTVs (GTV-T) and nodal GTVs (GTV-N) on T2-weighted MR images obtained at the time of treatment planning. Observers were provided with sets of images, delineation guidelines and patient synopsis. Simultaneous truth and performance level estimation (STAPLE) reference volumes were generated for each structure using all observer contours. The IOV was assessed using the DICE Similarity Coefficient (DSC) and mean absolute surface distance (MASD). Results 32 GTV-Ts and 68 GTV-Ns were contoured per observer. The median MASD for GTV-Ts and GTV-Ns across all patients was 0.17 cm (range 0.08–0.39 cm) and 0.07 cm (range 0.04–0.33 cm), respectively. Median DSC relative to a STAPLE volume for GTV-Ts and GTV-Ns across all patients were 0.73 and 0.76, respectively. A significant correlation was seen between median DSCs and median volumes of GTV-Ts (Spearman correlation coefficient 0.76, p < 0.001) and of GTV-Ns (Spearman correlation coefficient 0.55, p < 0.001). Conclusion Contouring GTVs in patients with HNC on MRI showed that the median IOV for GTV-T and GTV-N was below 2 mm, based on observes from two separate radiation departments. However, there are still specific regions in tumours that are difficult to resolve as either malignant tissue or oedema that potentially could be improved by further training in MR-only delineation.
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11
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Damyanovich AZ, Tadic T, Foltz WD, Jelveh S, Bissonnette JP. Time-course assessment of 3D-image distortion on the 1.5 T Marlin/Elekta Unity MR-LINAC. Phys Med 2022; 100:90-98. [PMID: 35777256 DOI: 10.1016/j.ejmp.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/04/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The efficacy of MR-guided radiotherapy on a MR-LINAC (MR-L) is dependent on the geometric accuracy of its MR images over clinically relevant Fields-of-View (FOVs). Our objectives were to: evaluate gradient non-linearity (GNL) on the Elekta Unity MR-L across time via 76 weekly measurements of 3D-distortion over concentrically larger diameter spherical volumes (DSVs); quantify distortion measurement error; and assess the temporal stability of spatial distortion using statistical process control (SPC). METHODS MR-image distortion was assessed using a large-FOV 3D-phantom containing 1932 markers embedded in seven parallel plates, spaced 25 mm × 25 mm in- and 55 mm through-plane. Automatically analyzed T1 images yielded distortions in 200, 300, 400 and 500 mm concentric DSVs. Distortion measurement error was evaluated using median absolute difference analysis of imaging repeatability tests. RESULTS Over the measurement period absolute time-averaged distortion varied between: dr = 0.30 - 0.49 mm, 0.53 - 0.80 mm, 1.0 - 1.4 mm and 2.28 - 2.37 mm, for DSVs 200, 300, 400 and 500 mm at the 98th percentile level. Repeatability tests showed that imaging/repositioning introduces negligible error: mean ≤ 0.02 mm (max ≤ 0.3 mm). SPC analysis showed image distortion was stable across all DSVs; however, noticeable changes in GNL were observed following servicing at the one-year mark. CONCLUSIONS Image distortion on the MR-L is in the sub-millimeter range for DSVs ≤ 300 mm and stable across time, with SPC analysis indicating all measurements remain within control for each DSV.
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Affiliation(s)
- Andrei Z Damyanovich
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada.
| | - Tony Tadic
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada
| | - Warren D Foltz
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada
| | - Salomeh Jelveh
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Jean-Pierre Bissonnette
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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12
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Li W, Winter J, Padayachee J, Dang J, Kong V, Chung P. Case Report: MR-Guided Adaptive Radiotherapy, Some Room to Maneuver. Front Oncol 2022; 12:877452. [PMID: 35494044 PMCID: PMC9047540 DOI: 10.3389/fonc.2022.877452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
Abstract
Background A magnetic resonance linear accelerator (MR-Linac) provides superior soft tissue contrast to evaluate inter- and intra-fraction motion and facilitate online adaptive radiation therapy (ART). We present here an unusual case of locally advanced castrate-resistant prostate cancer treated with high-dose palliative ultra-hypofractionated radiation therapy on the MR-Linac with significant inter-fraction tumor regression. Case Presentation The patient was a 65-year-old man diagnosed with metastatic prostate cancer to bone and pelvic lymph nodes 7 years prior. At diagnosis, he presented with a PSA of 23 ng/ml and was commenced on a luteinizing hormone-releasing hormone agonist, achieving a PSA nadir of 4.68 ng/ml at 12 months. The patient subsequently had progressive lower urinary tract symptoms, his PSA increased to 47 ng/ml, and there was a markedly enlarged pelvic mass involving the prostate with gross extra-capsular disease and invasion into the posterior bladder wall. The patient was referred for palliative radiation to the pelvic mass due to urinary symptoms, pain, and lower limb paraesthesia. Treatment was planned to be delivered on the MR-Linac with a schedule of 36 Gy over 6 weekly factions allowing for maximal target dose delivery while minimizing surrounding organs at risk (OARs) radiation exposure. Unexpectedly, the target volume had a marked 49% (453 cc to 233 cc) reduction that was accounted for in the online adaptive process. A new reference plan was generated after 3 fractions to add sacral plexus as an OAR, previously not visible due to mass encroachment. The patient reported ongoing reduction in urinary symptoms, pelvic pain, and lower limb paresthesia by the end of treatment. Conclusion Using daily MR-guided ART, improved visualization of the changing target and OARs ensured safe dose escalation. The unexpected positive response of the target and improved patient outcomes demonstrated the added value of the MR-Linac for online adaptive radiotherapy in this setting.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- *Correspondence: Winnie Li,
| | - Jeff Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jerusha Padayachee
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jennifer Dang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vickie Kong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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13
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Dunkerley DAP, Hyer DE, Snyder JE, St-Aubin JJ, Anderson CM, Caster JM, Smith MC, Buatti JM, Yaddanapudi S. Clinical Implementational and Site-Specific Workflows for a 1.5T MR-Linac. J Clin Med 2022; 11:jcm11061662. [PMID: 35329988 PMCID: PMC8954784 DOI: 10.3390/jcm11061662] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 01/27/2023] Open
Abstract
MR-guided adaptive radiotherapy (MRgART) provides opportunities to benefit patients through enhanced use of advanced imaging during treatment for many patients with various cancer treatment sites. This novel technology presents many new challenges which vary based on anatomic treatment location, technique, and potential changes of both tumor and normal tissue during treatment. When introducing new treatment sites, considerations regarding appropriate patient selection, treatment planning, immobilization, and plan-adaption criteria must be thoroughly explored to ensure adequate treatments are performed. This paper presents an institution’s experience in developing a MRgART program for a 1.5T MR-linac for the first 234 patients. The paper suggests practical treatment workflows and considerations for treating with MRgART at different anatomical sites, including imaging guidelines, patient immobilization, adaptive workflows, and utilization of bolus.
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14
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Pham TT, Whelan B, Oborn BM, Delaney GP, Vinod S, Brighi C, Barton M, Keall P. Magnetic resonance imaging (MRI) guided proton therapy: A review of the clinical challenges, potential benefits and pathway to implementation. Radiother Oncol 2022; 170:37-47. [DOI: 10.1016/j.radonc.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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16
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Nowee ME, van Pelt VWJ, Walraven I, Simões R, Liskamp CP, Lambregts DMJ, Heijmink S, Schaake E, van der Heide UA, Janssen TM. The impact of image acquisition time on registration, delineation and image quality for magnetic resonance guided radiotherapy of prostate cancer patients. Phys Imaging Radiat Oncol 2021; 19:85-89. [PMID: 34355071 PMCID: PMC8325094 DOI: 10.1016/j.phro.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/03/2021] [Accepted: 07/01/2021] [Indexed: 12/22/2022]
Abstract
Background and Purpose Magnetic resonance (MR) guided radiotherapy utilizes MR images for (online) plan adaptation and image guidance. The aim of this study was to investigate the impact of variation in MR acquisition time and scan resolution on image quality, interobserver variation in contouring and interobserver variation in registration. Materials and Methods Nine patients with prostate cancer were included. Four T2-weighted 3D turbo spin echo (T2w 3D TSE) sequences were acquired with different acquisition times and resolutions. Two radiologists assessed image quality, conspicuity of the capsule, peripheral zone and central gland architecture and motion artefacts on a 5 point scale. Images were delineated by two radiation oncologists and interobserver variation was assessed by the 95% Hausdorff distance. Seven observers registered the MR images on the planning CT. Registrations were compared on systematic offset and interobserver variation. Results Acquisition times ranged between 1.3 and 6.3 min. Overall image quality and capsule definition were significantly worse for the MR sequence with an acquisition time of 1.3 min compared to the other sequences. Median 95% Hausdorff distance showed no significant differences in interobserver variation of contouring. Systematic offset and interobserver variation in registration were small (<1 mm) and of no clinical significance. Conclusions Our results can be used to effectively shorten overall fraction time for online adaptive MR guided radiotherapy by optimising the imaging sequence used for registration. From the sequences studied, a sequence of 3.1 min with anisotropic voxels of 1.2 × 1.2 × 2.4 mm3 provided the shortest acquisition time without compromising image quality.
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Affiliation(s)
- M E Nowee
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - V W J van Pelt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - I Walraven
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R Simões
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C P Liskamp
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - D M J Lambregts
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S Heijmink
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E Schaake
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - U A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - T M Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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17
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Shelley CE, Barraclough LH, Nelder CL, Otter SJ, Stewart AJ. Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation. Clin Oncol (R Coll Radiol) 2021; 33:579-590. [PMID: 34247890 DOI: 10.1016/j.clon.2021.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.
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Affiliation(s)
- C E Shelley
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | - L H Barraclough
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - C L Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Otter
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - A J Stewart
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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18
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Hehakaya C, van der Voort van Zyp JRN, Vanneste BGL, Grutters JPC, Grobbee DE, Verkooijen HM, Frederix GWJ. Early health economic analysis of 1.5 T MRI-guided radiotherapy for localized prostate cancer: Decision analytic modelling. Radiother Oncol 2021; 161:74-82. [PMID: 34089754 DOI: 10.1016/j.radonc.2021.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE 1.5 Tesla magnetic resonance imaging radiotherapy linear accelerator (MR-Linac) is gaining interest for treatment of localized prostate cancer. Clinical evidence is lacking and it therefore remains uncertain whether MR-Linac is cost-effective. An early health economic analysis was performed to calculate the necessary relative reduction in complications and the maximum price of MR-Linac (5 fractions) to be cost-effective compared to 5, 20 and 39 fractionation schedules of external beam radiotherapy (EBRT) and low-dose-rate (LDR) brachytherapy. MATERIALS AND METHODS A state transition model was developed for men with localized prostate cancer. Complication rates such as grade ≥2 urinary, grade ≥2 bowel and sexual complications, and utilities were based on systematic literature searches. Costs were estimated from a Dutch healthcare perspective. Threshold analyses were performed to identify the thresholds of complications and costs for MR-Linac to be cost-effective, while holding other outcomes such as biochemical progression and mortality constant. One-way sensitivity analyses were performed to outline uncertainty outcomes. RESULTS At €6460 per patient, no reductions in complications were needed to consider MR-Linac cost-effective compared to EBRT 20 and 39 fractions. Compared to EBRT 5 fractions and LDR brachytherapy, MR-Linac was found to be cost-effective when complications are relatively reduced by 54% and 66% respectively. Results are highly sensitive to the utilities of urinary, bowel and sexual complications and the probability of biochemical progression. CONCLUSIONS MR-Linac is found to be cost-effective compared to 20 and 39 fractions EBRT at baseline. For MR-Linac to become cost-effective over 5 fractions EBRT and LDR brachytherapy, it has to reduce complications substantially or be offered at lower costs.
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Affiliation(s)
- Charisma Hehakaya
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands; Julius Clinical, Zeist, The Netherlands.
| | | | - Ben G L Vanneste
- Department of Radiation Oncology, MAASTRO Clinic, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Diederick E Grobbee
- Julius Clinical, Zeist, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands; Utrecht University, The Netherlands
| | - Helena M Verkooijen
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands; Utrecht University, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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Cuccia F, Corradini S, Mazzola R, Spiazzi L, Rigo M, Bonù ML, Ruggieri R, Buglione di Monale E Bastia M, Magrini SM, Alongi F. MR-Guided Hypofractionated Radiotherapy: Current Emerging Data and Promising Perspectives for Localized Prostate Cancer. Cancers (Basel) 2021; 13:1791. [PMID: 33918650 DOI: 10.3390/cancers13081791] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary The biological features of prostate cancer as a tumor with a low alpha beta ratio have led clinicians to consider the use of higher doses per fraction, thus gaining an advantage both in terms of clinical outcomes and of logistic opportunities. To date, moderate hypofractionated schedules are supported by several international clinical guidelines. The subsequent step was represented by the adoption of extreme hypofractionated schedules, for which recent literature data report non-inferiority results for the five-fractions regimens. In this scenario, the recent introduction of MR-guided daily adaptive radiotherapy is a potential paradigm shift, given the ability to increase the resolution of the pelvis anatomy and to take into account of the daily variations in shape and size of the nearby healthy structures. Abstract In this review we summarize the currently available evidence about the role of hybrid machines for MR-guided radiotherapy for prostate stereotactic body radiotherapy. Given the novelty of this technology, to date few data are accessible, but they all report very promising results in terms of tolerability and preliminary clinical outcomes. Most of the studies highlight the favorable impact of on-board magnetic resonance imaging as a means to improve target and organs at risk identification with a consequent advantage in terms of dosimetric results, which is expected to relate to a more favorable toxicity pattern. Still, the longer treatment time per session may potentially affect the patient’s compliance to the treatment, although first quality of life assessment studies have reported substantial tolerability and no major impact on quality of life. Finally, in this review we hypothesize some future scenarios of further investigation, based on the possibility to explore the superior anatomy visualization and the role of daily adapted treatments provided by hybrid MR-Linacs.
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Almansour H, Afat S, Fritz V, Schick F, Nachbar M, Thorwarth D, Zips D, Müller AC, Nikolaou K, Othman AE, Wegener D. Prospective Image Quality and Lesion Assessment in the Setting of MR-Guided Radiation Therapy of Prostate Cancer on an MR-Linac at 1.5 T: A Comparison to a Standard 3 T MRI. Cancers (Basel) 2021; 13:1533. [PMID: 33810410 DOI: 10.3390/cancers13071533] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary High-precision MR-guided radiotherapy (MRgRT) constitutes the state-of-the-art in the sphere of personalized prostate cancer treatment. To this end, integrating a 1.5 T scanner with a linear accelerator led to the development of MR-Linac (MRL), which could be considered a novel deflection point in radiation oncology. Since the success of both diagnosis and radiation treatment is highly dependent on image quality, geometric integrity, and lesion conspicuity, it is important to investigate the quality of these sequences in comparison to the current diagnostic gold standard multiparametric MRI at 3T (MRI3T), which has not been done before. The purpose of this study is to conduct a qualitative and a quantitative analysis of MRL-images at 1.5 T in patients undergoing MRgRT planning for prostate cancer. Results from this study pave the way for developing safer and more efficient planning workflows in patients with prostate cancer undergoing MR-guided radiotherapy. Abstract The objective of this study is to conduct a qualitative and a quantitative image quality and lesion evaluation in patients undergoing MR-guided radiation therapy (MRgRT) for prostate cancer on a hybrid magnetic resonance imaging and linear accelerator system (MR-Linac or MRL) at 1.5 Tesla. This prospective study was approved by the institutional review board. A total of 13 consecutive patients with biopsy-confirmed prostate cancer and an indication for MRgRT were included. Prior to radiation therapy, each patient underwent an MR-examination on an MRL and on a standard MRI scanner at 3 Tesla (MRI3T). Three readers (two radiologists and a radiation oncologist) conducted an independent qualitative and quantitative analysis of T2-weighted (T2w) and diffusion-weighted images (DWI). Qualitative outcome measures were as follows: zonal anatomy, capsule demarcation, resolution, visibility of the seminal vesicles, geometric distortion, artifacts, overall image quality, lesion conspicuity, and diagnostic confidence. All ratings were performed on an ordinal 4-point Likert scale. Lesion conspicuity and diagnostic confidence were firstly analyzed only on MRL. Afterwards, these outcome parameters were analyzed in consensus with the MRI3T. Quantitative outcome measures were as follows: anteroposterior and right left diameter of the prostate, lesion size, PI-RADS score (Prostate Imaging—Reporting and Data System) and apparent diffusion coefficient (ADC) of the lesions. Intergroup comparisons were computed using the Wilcoxon-sign rank test and t tests. A post-hoc regression analysis was computed for lesion evaluation. Finally, inter-/intra-reader agreement was analyzed using the Fleiss kappa and intraclass correlation coefficient. For T2w images, the MRL showed good results across all quality criteria (median 3 and 4). Furthermore, there were no significant differences between MRL and MRI3T regarding capsule demarcation or geometric distortion. For the DWI, the MRL performed significantly less than MRI3T across most image quality criteria with a median ranging between 2 and 3. However, there were no significant differences between MRL and MRI3T regarding geometric distortion. In terms of lesion conspicuity and diagnostic confidence, inter-reader agreement was fair for MRL alone (Kappa = 0.42) and good for MRL in consensus with MRI3T (Kappa = 0.708). Thus, lesion conspicuity and diagnostic confidence could be significantly improved when reading MRL images in consensus with MRI3T (Odds ratio: 9- to 11-fold for the T2w images and 5- to 8–fold for the DWI) (p < 0.001). For measures of lesion size, anterior-posterior and right-left prostate diameter, inter-reader and intersequence agreement were excellent (ICC > 0.90) and there were no significant differences between MRL and MRI3T among all three readers. In terms of Prostate Imaging Reporting and Data System (PIRADS) scoring, no significant differences were observed between MRL and MRI3T. Finally, there was a significant positive linear relationship between lesion ADC measurements (r = 0.76, p < 0.01) between the ADC values measured on both systems. In conclusion, image quality for T2w was comparable and diagnostic even without administration of spasmolytic- or contrast agents, while DWI images did not reach diagnostic level and need to be optimized for further exploitation in the setting of MRgRT. Diagnostic confidence and lesion conspicuity were significantly improved by reading MRL in consensus with MRI3T which would be advisable for a safe planning and treatment workflow. Finally, ADC measurements of lesions on both systems were comparable indicating that, lesion ADC as measured on the MRL could be used as a biomarker for evaluation of treatment response, similar to examinations using MRI3T.
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