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Clough A, Chuter R, Hales RB, Parker J, McMahon J, Whiteside L, McHugh L, Davies L, Sanders J, Benson R, Nelder C, McDaid L, Choudhury A, Eccles CL. Impact of a contouring atlas on radiographer inter-observer variation in male pelvis radiotherapy. J Med Imaging Radiat Sci 2024:S1939-8654(24)00058-4. [PMID: 38609834 DOI: 10.1016/j.jmir.2024.03.004] [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: 01/11/2024] [Revised: 02/26/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE/OBJECTIVE To determine the impact of a MR-based contouring atlas for male pelvis radiotherapy delineation on inter-observer variation to support radiographer led real-time magnetic resonance image guided adaptive radiotherapy (MRgART). MATERIAL/METHODS Eight RTTs contoured 25 MR images in the Monaco treatment planning system (Monaco 5.40.01), from 5 patients. The prostate, seminal vesicles, bladder, and rectum were delineated before and after the introduction of an atlas developed through multi-disciplinary consensus. Inter-observer contour variations (volume), time to contour and observer contouring confidence were determined at both time-points using a 5-point Likert scale. Descriptive statistics were used to analyse both continuous and categorical variables. Dice similarity coefficient (DSC), Dice-Jaccard coefficient (DJC) and Hausdorff distance were used to calculate similarity between observers. RESULTS Although variation in volume definition decreased for all structures among all observers post intervention, the change was not statistically significant. DSC and DJC measurements remained consistent following the introduction of the atlas for all observers. The highest similarity was found in the bladder and prostate whilst the lowest was the seminal vesicles. The mean contouring time for all observers was reduced by 50% following the introduction of the atlas (53 to 27 minutes, p=0.01). For all structures across all observers, the mean contouring confidence increased significantly from 2.3 to 3.5 out of 5 (p=0.02). CONCLUSION Although no significant improvements were observed in contour variation amongst observers, the introduction of the consensus-based contouring atlas improved contouring confidence and speed; key factors for a real-time RTT-led MRgART.
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Affiliation(s)
- Abigael Clough
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Chuter
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Rosie B Hales
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jacqui Parker
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - John McMahon
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lee Whiteside
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Louise McHugh
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lucy Davies
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Rebecca Benson
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Claire Nelder
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lisa McDaid
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ananya Choudhury
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
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Warren M, Barrett A, Bhalla N, Brada M, Chuter R, Cobben D, Eccles CL, Hart C, Ibrahim E, McClelland J, Rea M, Turtle L, Fenwick JD. Sorting lung tumor volumes from 4D-MRI data using an automatic tumor-based signal reduces stitching artifacts. J Appl Clin Med Phys 2024; 25:e14262. [PMID: 38234116 PMCID: PMC11005973 DOI: 10.1002/acm2.14262] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/30/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
PURPOSE To investigate whether a novel signal derived from tumor motion allows more precise sorting of 4D-magnetic resonance (4D-MR) image data than do signals based on normal anatomy, reducing levels of stitching artifacts within sorted lung tumor volumes. METHODS (4D-MRI) scans were collected for 10 lung cancer patients using a 2D T2-weighted single-shot turbo spin echo sequence, obtaining 25 repeat frames per image slice. For each slice, a tumor-motion signal was generated using the first principal component of movement in the tumor neighborhood (TumorPC1). Signals were also generated from displacements of the diaphragm (DIA) and upper and lower chest wall (UCW/LCW) and from slice body area changes (BA). Pearson r coefficients of correlations between observed tumor movement and respiratory signals were determined. TumorPC1, DIA, and UCW signals were used to compile image stacks showing each patient's tumor volume in a respiratory phase. Unsorted image stacks were also built for comparison. For each image stack, the presence of stitching artifacts was assessed by measuring the roughness of the compiled tumor surface according to a roughness metric (Rg). Statistical differences in weighted means of Rg between any two signals were determined using an exact permutation test. RESULTS The TumorPC1 signal was most strongly correlated with superior-inferior tumor motion, and had significantly higher Pearson r values (median 0.86) than those determined for correlations of UCW, LCW, and BA with superior-inferior tumor motion (p < 0.05). Weighted means of ratios of Rg values in TumorPC1 image stacks to those in unsorted, UCW, and DIA stacks were 0.67, 0.69, and 0.71, all significantly favoring TumorPC1 (p = 0.02-0.05). For other pairs of signals, weighted mean ratios did not differ significantly from one. CONCLUSION Tumor volumes were smoother in 3D image stacks compiled using the first principal component of tumor motion than in stacks compiled with signals based on normal anatomy.
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Affiliation(s)
- Mark Warren
- School of Health Sciences, Institute of Population HealthUniversity of LiverpoolLiverpoolUK
| | | | - Neeraj Bhalla
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
| | - Michael Brada
- Molecular & Clinical Cancer Medicine, Institute of Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Robert Chuter
- Christie Medical Physics and EngineeringThe Christie NHS Foundation TrustManchesterUK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - David Cobben
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
- Department of Health Data Science, Institute of Population HealthUniversity of LiverpoolLiverpoolUK
| | - Cynthia L. Eccles
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- RadiotherapyThe Christie NHS Foundation TrustManchesterUK
| | - Clare Hart
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
| | - Ehab Ibrahim
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
| | - Jamie McClelland
- Department of Medical Physics and BioengineeringUniversity College LondonLondonUK
| | - Marc Rea
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
| | - Louise Turtle
- The Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolUK
| | - John D. Fenwick
- Department of Medical Physics and BioengineeringUniversity College LondonLondonUK
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McDaid L, Clough A, Benson RK, Nelder C, McMahon J, Jackson S, Aznar M, Choudhury AC, van Herk M, Eccles CL. Geometric distortion caused by metallic femoral head prosthesis in prostate cancer imaging on an MR Linac: in-vivo measurements of spatial deformation. Br J Radiol 2024; 97:757-762. [PMID: 38407369 PMCID: PMC11027238 DOI: 10.1093/bjr/tqae044] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVES Metallic implants cause artefacts and distortion on MRI. To ensure accurate dose delivery and plan adaptation on an MR Linac, there is a need to evaluate distortion caused. METHODS Participants were imaged on an MR Linac (Elekta Unity, Elekta AB Stockholm). Three sequences were evaluated. Two vendor supplied (T2W TSE 3D), and one T2W TSE 3D optimized to reduce metal artefact distortions. Images were rigidly registered to CT images by a single observer, using bony anatomy. Three coronal and three axial images were selected, and six paired, adjacent, bony landmarks were identified on each slice. Images bisecting treatment isocentre were included. Difference between landmark coordinates was taken to be measure of distortion. RESULTS Five observers participated. Thirty six pairs of bony landmarks were identified. Median difference in position of landmarks was ≤3 mm (range 0.3-4.4 mm). One-way analysis of variance (ANOVA) between observer means showed no significant variation between sequences or patients (P = 1.26 in plane, P = 0.11 through plane). Interobserver intra class correlation (ICC) was 0.70 in-plane and 0.78 through-plane. Intra-observer ICC for three observers was 0.76, 0.81, 0.83, showing moderate to good reliability on this small cohort. CONCLUSIONS This in-vivo feasibility study suggests distortion due to metallic hip prosthesis is not an obstacle for pelvic radiotherapy on an MR Linac. Research on the impact on plan quality is warranted. ADVANCES IN KNOWLEDGE This work supports feasibility of treating patients with metallic hip prosthesis on an MR Linac.
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Affiliation(s)
- Lisa McDaid
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - Abigael Clough
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - Rebecca K Benson
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - Claire Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - John McMahon
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
| | - Steven Jackson
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Marianne Aznar
- Manchester Academic Health Science Centre, Radiotherapy Related Research, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, M20 4BX, United Kingdom
| | - Ananya C Choudhury
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
- Manchester Academic Health Science Centre, Radiotherapy Related Research, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, M20 4BX, United Kingdom
| | - Marcel van Herk
- Manchester Academic Health Science Centre, Radiotherapy Related Research, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, M20 4BX, United Kingdom
| | - Cynthia L Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
- Manchester Academic Health Science Centre, Radiotherapy Related Research, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, M20 4BX, United Kingdom
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McDaid L, Eccles CL, Yorke J. An evaluation of radiographers' extended practice in the detection of brain metastases on magnetic resonance images. Radiography (Lond) 2024; 30:313-318. [PMID: 38118376 DOI: 10.1016/j.radi.2023.12.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Patients who undergo magnetic resonance (MR) imaging to confirm or rule out metastatic brain disease are required to wait for image review by a radiologist before leaving the department at the institute where this study was carried out. The aim was to evaluate whether radiographers can review images and reduce waiting times in those patients without metastases. METHODS Prospective observational study of MR radiographers (n = 11) was undertaken. Radiographers commented on images to confirm whether the images showed evidence of metastatic disease, pathology but no metastases, or no pathology. Responses were compared to the radiological report (reference standard). Online questionnaires determined the views and opinions of radiographers (n = 8) and consultant radiologists (n = 6) towards radiographers expanding their scope of practice to include the confirmation or exclusion of brain metastases. RESULTS Despite a lack of formal training for image reviewing, overall level of agreement between the radiographer reviews and reference standard was 77.9 % (κ = 0.45). Pooled sensitivity and specificity were 88.6 % & 71.3 % respectively. Kendall's τ = -0.03 (bootstrap 95 % CI -0.73 to 0.61, p = 0.925). Positive predictive value (PPV) was 65.5 % (CI 59.2%-71.4 %) and negative predictive value (NPV) 91.1 % (CI 84.9%-94.9 %). Radiographers and radiologists surveyed demonstrated a willingness to engage with role expansion. CONCLUSION Based on our small study and interdisciplinary survey, local radiographers and radiologists agree, following a program of radiographer training, screening for brain metastases by radiographers could be implemented. IMPLICATIONS FOR PRACTICE With appropriate governance and training support, the introduction of formal radiographer screening for patients referred to exclude brain metastases could provide more efficient working practice.
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Affiliation(s)
- L McDaid
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK.
| | - C L Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Medicine, Biology and Health University of Manchester, UK
| | - J Yorke
- Department of Quality and Standards, The Christie NHS Foundation Trust, Manchester, UK
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Eccles CL, Dubec M, Cobben D, van Herk M, McDaid L, Nelder C, Whiteside L, Davies LSC, McHugh L, Bridge J, Fendallamaro P, Chuter R, Hoskin P, Huddart RA, Choudhury A. Single Institution Preliminary Evaluation of a National Study for the Development of Daily Online Magnetic Resonance Image Guided Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e663. [PMID: 37785963 DOI: 10.1016/j.ijrobp.2023.06.2101] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) A 4-stage non-comparative prospective feasibility study to assess and develop imaging protocols for MRIgRT was opened at the first two centers using MR Linac technology in the UK. The primary aims of this study were to determine a) the acceptability of MR images for target and organ at risk delineation and registration; b) inter/intra observer registration and delineation variation. This work reports on the initial results from a single center. MATERIALS/METHODS In June 2019, following ethical and regulatory approvals the 2nd UK centre began study recruitment as follows: Stage A: non-patient volunteer imaging to determine sequence suitability for normal tissue in 6 anatomical sites (head & neck (H&N), chest wall/breast, lung/esophagus, abdomen, male and female pelvis). Volunteers were recruited in cohorts of 3 participants per region, and image quality was assessed by 3 independent observers using a visual guidance assessment tool (VGA). Stage B: the most suitable sequences defined in stage A used to assess the visibility of targets/normal tissues in patient volunteers using the same methods as in stage A. Stage C: patient volunteers were imaged using sequences selected from stage B to determine inter and intra observer segmentation and registration variation. Stage D recruitment of patient and non-patient volunteers for further image develop and refinement of MRIgRT workflows. All participants completed experience questionnaires to optimize workflows. Participants were asked to undergo 1-12 imaging sessions, lasting no more than 60. RESULTS To date 151 participants (61 non-patients; 90 patients) have undergone 231 imaging sessions. From stage B, vendor provided, in-workflow sequences have been agreed from 47 completed VGAs by prioritizing high scores in either the tumor (e.g., lung) or organs at risk (e.g., cervix). T2w 3D sequences scored best in cervix, pancreas, prostate, bladder, liver, soft-tissue metastases and rectal cancers; T1w 3D sequences for H&N, and patient a specific approach for lung. No suitable sequences have been selected for partial breast. Research sequences (e.g., diffusion weighted or motion corrected imaging) have been agreed or are in development in stages C & D for H&N, cervix, bladder and prostate cancers. The mean interobserver (n = 8) vector variation in 5 H&N patients was largest (3.6mm) using T1-CT boney registrations and smallest (2.1mm) using T1-T1 soft-tissue registrations (mean observer match confidence 3.7/5). Analyses using MR to CT, MR to MR and CT to CT registrations in lung, pancreas, cervix, bladder, and prostate have also been completed. Interobserver delineation studies are on-going. CONCLUSION Using a 4-stage non-comparative prospective feasibility study has facilitated clinical implementation MRIgRT of multiple treatment sites at our institution.
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Affiliation(s)
- C L Eccles
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - M Dubec
- University of Manchester, Manchester, United Kingdom
| | - D Cobben
- The Clatterbridge Cancer Centre NHS, Liverpool, United Kingdom
| | - M van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - L McDaid
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - C Nelder
- The Christie NHS, Manchester, United Kingdom
| | - L Whiteside
- The Christie NHS FT, Manchester, United Kingdom
| | | | - L McHugh
- The Christie NHS FT, Manchester, United Kingdom
| | - J Bridge
- The Christie NHS FT, Manchester, United Kingdom
| | | | - R Chuter
- The Christie NHS Foundation, Manchester, United Kingdom
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - R A Huddart
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, London, United Kingdom
| | - A Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK, Manchester, United Kingdom
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Dubec MJ, Buckley DL, Berks M, Clough A, Gaffney J, Datta A, McHugh DJ, Porta N, Little RA, Cheung S, Hague C, Eccles CL, Hoskin PJ, Bristow RG, Matthews JC, van Herk M, Choudhury A, Parker GJM, McPartlin A, O'Connor JPB. First-in-human technique translation of oxygen-enhanced MRI to an MR Linac system in patients with head and neck cancer. Radiother Oncol 2023; 183:109592. [PMID: 36870608 DOI: 10.1016/j.radonc.2023.109592] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND AND PURPOSE Tumour hypoxia is prognostic in head and neck cancer (HNC), associated with poor loco-regional control, poor survival and treatment resistance. The advent of hybrid MRI - radiotherapy linear accelerator or 'MR Linac' systems - could permit imaging for treatment adaptation based on hypoxic status. We sought to develop oxygen-enhanced MRI (OE-MRI) in HNC and translate the technique onto an MR Linac system. MATERIALS AND METHODS MRI sequences were developed in phantoms and 15 healthy participants. Next, 14 HNC patients (with 21 primary or local nodal tumours) were evaluated. Baseline tissue longitudinal relaxation time (T1) was measured alongside the change in 1/T1 (termed ΔR1) between air and oxygen gas breathing phases. We compared results from 1.5 T diagnostic MR and MR Linac systems. RESULTS Baseline T1 had excellent repeatability in phantoms, healthy participants and patients on both systems. Cohort nasal concha oxygen-induced ΔR1 significantly increased (p < 0.0001) in healthy participants demonstrating OE-MRI feasibility. ΔR1 repeatability coefficients (RC) were 0.023-0.040 s-1 across both MR systems. The tumour ΔR1 RC was 0.013 s-1 and the within-subject coefficient of variation (wCV) was 25% on the diagnostic MR. Tumour ΔR1 RC was 0.020 s-1 and wCV was 33% on the MR Linac. ΔR1 magnitude and time-course trends were similar on both systems. CONCLUSION We demonstrate first-in-human translation of volumetric, dynamic OE-MRI onto an MR Linac system, yielding repeatable hypoxia biomarkers. Data were equivalent on the diagnostic MR and MR Linac systems. OE-MRI has potential to guide future clinical trials of biology guided adaptive radiotherapy.
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Affiliation(s)
- Michael J Dubec
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK.
| | - David L Buckley
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK; Biomedical Imaging, University of Leeds, Leeds, UK
| | - Michael Berks
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Abigael Clough
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - John Gaffney
- Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Anubhav Datta
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Damien J McHugh
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Nuria Porta
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Ross A Little
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Susan Cheung
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Christina Hague
- Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Cynthia L Eccles
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Peter J Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Robert G Bristow
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Julian C Matthews
- Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Marcel van Herk
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Geoff J M Parker
- Bioxydyn Ltd, Manchester, UK; Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Andrew McPartlin
- Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | - James P B O'Connor
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Radiology, The Christie NHS Foundation Trust, Manchester, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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Hancock A, Hutton D, Roberts D, Whiteside L, Golby C, Eccles CL, Turtle L, McGinn S, Hooton R, Fillingham E, Hudson J, Maguire M, Mackay R. Barriers and facilitators to conducting radiotherapy clinical trials: Findings from a UK survey. Radiography (Lond) 2023; 29:369-378. [PMID: 36758382 DOI: 10.1016/j.radi.2023.01.001] [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: 08/04/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION As an essential component of service delivery, radiotherapy clinical trials were championed within the NHS England service specifications. A call for a 15% increase in research and clinical trial activity, alongside a demand for equity of access for patients with cancer subsequently ensued. National understanding of current radiotherapy clinical trials operational practices is absent, but essential to help establish the current provision required to support the development of a strategic plan for implementation of NHS England's specifications. METHODS A cross-sectional survey was developed by a multi-disciplinary team and distributed to therapeutic radiography clinical trial leads across the UK to ascertain the current provision of radiotherapy clinical trials only, including workforce resources and the trials management processes to establish a benchmark and identify potential barriers, enablers, and opportunities to increase access to clinical trials. RESULTS Thirty-two complete responses were obtained equating to 49% of the total UK NHS departments and 74% of those departments invited. Four key findings were identified: 1) research strategy and systems, 2) participation and activity in radiotherapy clinical trials, 3) access to clinical trials at alternative departments and 4) facilitators & barriers. Overarchingly a lack of radiotherapy clinical trials strategy or supported processes were apparent across the UK, aggravating existing barriers to trial activity. CONCLUSION It is essential for radiotherapy clinical trials to be embedded in to departmental and Trust strategy, this will help to ensure the processes and resources required for trial delivery are not only in place, but also recognised as imperative and important for patients with cancer as radiotherapy treatment delivery. IMPLICATIONS FOR PRACTICE Failure to address the barriers or build upon the facilitators may result in UK radiotherapy departments facing challenges in achieving the 15% increase in radiotherapy clinical trial activity.
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Affiliation(s)
- A Hancock
- University of Exeter, UK; Weston Park Cancer Centre, UK.
| | - D Hutton
- Northwest Radiotherapy Operational Delivery Network, UK; University of Liverpool, UK
| | | | | | | | - C L Eccles
- The Christie NHS FT, UK; University of Manchester, UK
| | - L Turtle
- The Clatterbridge Cancer Centre NHS FT, UK
| | - S McGinn
- The Clatterbridge Cancer Centre NHS FT, UK
| | - R Hooton
- The Clatterbridge Cancer Centre NHS FT, UK
| | | | - J Hudson
- Lancashire Teaching Hospitals, UK
| | - M Maguire
- The Clatterbridge Cancer Centre NHS FT, UK
| | - R Mackay
- The Christie NHS FT, UK; University of Manchester, UK
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Whiteside L, McDaid L, Hales RB, Rodgers J, Dubec M, Huddart RA, Choudhury A, Eccles CL. To see or not to see: Evaluation of magnetic resonance imaging sequences for use in MR Linac-based radiotherapy treatment. J Med Imaging Radiat Sci 2022; 53:362-373. [PMID: 35850925 DOI: 10.1016/j.jmir.2022.06.005] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE This work evaluated the suitability of MR derived sequences for use in online adaptive RT workflows on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac). MATERIALS/METHODS Non-patient volunteers were recruited to an ethics approved MR Linac imaging study. Participants attended 1-3 imaging sessions in which a combination of DIXON, 2D and 3D volumetric T1 and T2 weighted images were acquired axially, with volunteers positioned using immobilisation devices typical for radiotherapy to the anatomical region being scanned. Images from each session were appraised by three independent reviewers to determine optimal sequences over six anatomical regions: head and neck, female and male pelvis, thorax (lung), thorax (breast/chest wall) and abdomen. Site specific anatomical structures were graded by the perceived ability to accurately contour a typical organ at risk. Each structure was independently graded on a 4-point Likert scale as 'Very Clear', 'Clear', 'Unclear' or 'Not visible' by observers, consisting of radiographers (therapeutic and diagnostic) and clinicians. RESULTS From July 2019 to September 2019, 18 non-patient volunteers underwent 24 imaging sessions in the following anatomical regions: head and neck (n=3), male pelvis (n=4), female pelvis (n=5), lung/oesophagus (n=5) abdomen (n=4) and chest wall/breast (n=3). T2 sequences were the most preferred for perceived ability to contour anatomy in both male and female pelvis. For all other sites T1 weighted DIXON sequences were most favourable. CONCLUSION This study has determined the preferential sequence selection for organ visualisation, as a pre-requisite to our institution adopting MR-guided radiotherapy for a more diverse range of disease sites.
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Affiliation(s)
- Lee Whiteside
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom.
| | - Lisa McDaid
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - Rosie B Hales
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - John Rodgers
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom
| | - Michael Dubec
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, United Kingdom
| | - Robert A Huddart
- The Institute of Cancer Research, London UK; The Royal Marsden, London, United Kingdom
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Clinical Oncology, The Christie NHS Foundation Trust, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust, Department of Radiotherapy, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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Daly M, McWilliam A, Radhakrishna G, Choudhury A, Eccles CL. Radiotherapy respiratory motion management in hepatobiliary and pancreatic malignancies: a systematic review of patient factors influencing effectiveness of motion reduction with abdominal compression. Acta Oncol 2022; 61:833-841. [PMID: 35611555 DOI: 10.1080/0284186x.2022.2073186] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The effectiveness of abdominal compression for motion management in hepatobiliary-pancreatic (HPB) radiotherapy has not been systematically evaluated. METHODS & MATERIALS A systematic review was carried out using PubMed/Medline, Cochrane Library, Web of Science, and CINAHL databases up to 1 July 2021. No date restrictions were applied. Additional searches were carried out using the University of Manchester digital library, Google Scholar and of retrieved papers' reference lists. Studies conducted evaluating respiratory motion utilising imaging with and without abdominal compression in the same patients available in English were included. Studies conducted in healthy volunteers or majority non-HPB sites, not providing descriptive motion statistics or patient characteristics before and after compression in the same patients or published without peer-review were excluded. A narrative synthesis was employed by tabulating retrieved studies and organising chronologically by abdominal compression device type to help identify patterns in the evidence. RESULTS The inclusion criteria were met by 6 studies with a total of 152 patients. Designs were a mix of retrospective and prospective quantitative designs with chronological, non-randomised recruitment. Abdominal compression reduced craniocaudal respiratory motion in the majority of patients, although in four studies there were increases seen in at least one direction. The influence of patient comorbidities on effectiveness of compression, and/or comfort with compression was not evaluated in any study. CONCLUSION Abdominal compression may not be appropriate for all patients, and benefit should be weighed with potential increase in motion or discomfort in patients with small initial motion (<5 mm). Patient factors including male sex, and high body mass index (BMI) were found to impact the effectiveness of compression, however with limited evidence. High-quality studies are warranted to fully assess the clinical impact of abdominal compression on treatment outcomes and toxicity prospective in comparison to other motion management strategies.
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Affiliation(s)
- Mairead Daly
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
| | | | - Ananya Choudhury
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
| | - Cynthia L Eccles
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
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Pitt E, Clough A, Nelder C, Benson R, McDaid L, Whiteside L, Davies L, Parker J, Awofisoye T, Freear L, Chuter R, Berresford J, Marchant T, Crockett C, Salem A, Faivre-Finn C, Eccles CL. Considerations for the Clinical Implementation of MR-Guided ART for Lung Cancer. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.041] [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] [Indexed: 11/27/2022]
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11
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Pitt E, Clough A, Nelder C, Benson R, McDaid L, Whiteside L, Davies L, Parker J, Awofisoye T, Freear L, Chuter R, Berresford J, Marchant T, McPartlin A, Eccles CL. Considerations for the Clinical Implementation of MR-Guided ART for H&N Cancer. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.025] [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] [Indexed: 11/30/2022]
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12
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McDaid L, Clough A, Benson R, Nelder C, McMahon J, Aznar M, Choudhury A, Jackson S, Eccles CL. Quantifying Distortion on MR Images of Patients with Metallic Hip Prosthesis – Will it Exclude Treatment on an MR Linac? J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.027] [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] [Indexed: 11/29/2022]
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13
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Clough A, Hales R, Choudhury A, Parker J, McMahon J, Whiteside L, McHugh L, Davies L, Sanders J, Benson R, Nelder C, Eccles CL. Impact of the implementation of a Contouring Atlas on Therapeutic Radiographer Inter-observer Contour Variation in Prostate Radiotherapy. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.045] [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] [Indexed: 11/26/2022]
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14
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Clough A, McDaid L, Doherty W, Eccles CL. Development of Competencies to Ensure Safe Image Registration by Radiographers Working on an MR Linac. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.044] [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] [Indexed: 10/18/2022]
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15
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Clough A, Sanders J, Banfill K, Faivre-Finn C, Price G, Eccles CL, Aznar MC, Van Herk M. A novel use for routine CBCT imaging during radiotherapy to detect COVID-19. Radiography (Lond) 2022; 28:17-23. [PMID: 34332857 PMCID: PMC8299223 DOI: 10.1016/j.radi.2021.07.011] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/21/2021] [Accepted: 07/11/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Thoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection. METHODS A tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January-June 2020 to assess the efficiency of the tool and process. RESULTS Three patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs. Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process. CONCLUSION The preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers. IMPLICATIONS FOR PRACTICE This process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.
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Affiliation(s)
- A Clough
- The Christie NHSFT, Manchester, United Kingdom.
| | - J Sanders
- The Christie NHSFT, Manchester, United Kingdom
| | - K Banfill
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - C Faivre-Finn
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - G Price
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - C L Eccles
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - M C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - M Van Herk
- The Christie NHSFT, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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Hales RB, Chuter R, McWilliam A, Salah A, Dubec M, Freear L, McDaid L, Aznar M, van Herk M, McPartlin A, Eccles CL. The impact of gadolinium-based MR contrast on radiotherapy planning for oropharyngeal treatment on the MR Linac. Med Phys 2022; 49:510-520. [PMID: 34741308 DOI: 10.1002/mp.15325] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/08/2021] [Accepted: 10/15/2021] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Gadolinium-based contrast agents (GBCAs) may add value to magnetic resonance (MR)-only radiotherapy (RT) workflows including on hybrid machines such as the MR Linac. The impact of GBCAs on RT dose distributions however have not been well studied. This work used retrospective GBCA-enhanced datasets to assess the dosimetric effect of GBCAs on head and neck plans. METHODS Ten patients with oropharyngeal squamous cell carcinoma receiving RT from November 2018 to April 2020 were included in this study. RT planning included contrast-enhanced computed tomography (CT) and MR scans. A contrast agent "contour" was defined by delineating GBCA-enhanced regions using an agreed window/level threshold, transferred to the planning CT and given a standardized electron density (ED) of 1.149 in the Monaco treatment planning system (Elekta AB). Four plans were per patient calculated and compared using two methods: (1) optimized without contrast (Plan A) then recalculated with ED (Plan B), and (2) optimized with contrast ED (Plan C) then without (Plan D). For target parameters minimum and maximum doses to 1cc of PTVs, D95 values, and percent dose differences were calculated. Dose differences for organs-at-risk (OARs) were calculated as a percentage of the clinical tolerance value. For the purposes of this study, ±2% over the whole treatment course was considered to be a clinically acceptable dose deviation. Wilcoxon-signed rank tests were used to determine any dose differences within and between the two methods of optimization and recalculation (p < 0.05). Pearson's correlations were used to establish the relationship between gadolinium uptake volume in a structure (i.e., proportion of structure covered by a density override) and the resulting dose difference. RESULTS The median percent dose differences for key reportable dosimetric parameters between non-contrast and simulated contrast plans were <1.2% over all fractions over all patients for reportable target parameters (mean 0.34%, range 0.22%-1.02%). The percent dose differences for maximum dose to 1cc of both PTV1 and PTV2 were significantly different after application of density override (p < 0.05) but only in method 2 (Plan C vs. Plan D). For D95 PTV1, there was a statistically significant effect of density override (p < 0.01), however only in method 1 (Plan A vs. Plan B). There were no significant differences between calculation methods of the impact of contrast in most target parameters with the exception of D95 PTV1 (p < 0.01) and for D95 PTV2 (p < 0.05). The median percent dose differences for reportable OAR parameters as a percentage of clinical planning tolerances were <2.0% over a full treatment course (mean 0.65%, range 0.27%-1.62%). There were no significant differences in dose to OARs within or between methods for contrast impact assessment. CONCLUSIONS Dose differences to targets and OARs in oropharyngeal cancer treatment due to the presence of GBCA were minimal, and this work suggests that prospective in vivo evaluations of impact may not be necessary in this clinical site. Accounting for GBCAs may not be needed in daily adaptive workflows on the MR Linac.
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Affiliation(s)
- Rosie B Hales
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Robert Chuter
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Alan McWilliam
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Amal Salah
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Michael Dubec
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Linnéa Freear
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Lisa McDaid
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Marianne Aznar
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Marcel van Herk
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew McPartlin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Cynthia L Eccles
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
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17
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Sargos P, Baumann BC, Faye MD, Fonteyne V, Eccles CL. A Tailored Radiation Therapy Strategy for Older Patients With Localized Bladder Cancer Not Eligible for Curative Treatment. Int J Radiat Oncol Biol Phys 2021; 110:425-428. [PMID: 33989576 DOI: 10.1016/j.ijrobp.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France.
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Mame Daro Faye
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Canada
| | - Véronique Fonteyne
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
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18
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McDaid L, Doherty W, Eccles CL. Development of competencies to ensure safe Image Registration by radiographers working on an MR Linac. J Med Imaging Radiat Sci 2021. [DOI: 10.1016/j.jmir.2021.03.024] [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] [Indexed: 10/21/2022]
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19
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Dubec M, Brown S, Chuter R, Hales R, Whiteside L, Rodgers J, Parker J, Eccles CL, van Herk M, Faivre-Finn C, Cobben D. MRI and CBCT for lymph node identification and registration in patients with NSCLC undergoing radical radiotherapy. Radiother Oncol 2021; 159:112-118. [PMID: 33775713 DOI: 10.1016/j.radonc.2021.03.015] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE This study compared MRI to CBCT for the identification and registration of lymph nodes (LN) in patients with locally advanced (LA)-NSCLC, to assess the suitability of targeting LNs in future MR-image guided radiotherapy (MRgRT) workflows. METHOD Radiotherapy radiographers carried out Visual Grading Analysis (VGA) assessment of image quality, LN registration and graded their confidence in registration for each of the 24 LNs on CBCT and two MR sequences, MR1 (T2w Turbo Spin Echo) and MR2 (T1w DIXON water only image). RESULTS Pre-registration image quality assessment revealed MR1 and MR2 as significantly superior to CBCT in terms of image quality (p ≤ 0.01). No significant differences were noted in interobserver variability for LN registration between CBCT, MR1 and MR2. Observers were more confident in their MR registrations compared to their CBCT based LN registrations (p ≤ 0.02). SUMMARY Interobserver setup correction variability was not found to be significantly different between CBCT and MR. Image quality and registration confidence were found to be superior for MRI sequences. This is a promising step towards MR-guided radiotherapy for the treatment of LA-NSCLC.
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Affiliation(s)
- Michael Dubec
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK.
| | - Sean Brown
- Gloucestershire Oncology Centre, Cheltenham General Hospital, Cheltenham, UK
| | - Robert Chuter
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Rosie Hales
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Lee Whiteside
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - John Rodgers
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Jacqui Parker
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Cynthia L Eccles
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel van Herk
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - David Cobben
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
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20
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McDaid L, Doherty W, Clough A, Eccles CL. Development of an educational framework for radiographers working on an MR Linac. J Med Imaging Radiat Sci 2021. [DOI: 10.1016/j.jmir.2021.03.032] [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] [Indexed: 10/21/2022]
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21
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Speight R, Tyyger M, Schmidt MA, Liney G, Johnstone R, Eccles CL, Dubec M, George B, Henry A, Herbert T, Nyholm T, Mahmood F, Korhonen J, Sims R, Tijssen RHN, Vanhoutte F, Busoni S, Lacornerie T, McCallum H. IPEM Topical Report: an international IPEM survey of MRI use for external beam radiotherapy treatment planning. Phys Med Biol 2021; 66:075007. [PMID: 33631729 DOI: 10.1088/1361-6560/abe9f7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/25/2021] [Indexed: 11/12/2022]
Abstract
Introduction/Background. Despite growing interest in magnetic resonance imaging (MRI), integration in external beam radiotherapy (EBRT) treatment planning uptake varies globally. In order to understand the current international landscape of MRI in EBRT a survey has been performed in 11 countries. This work reports on differences and common themes identified.Methods. A multi-disciplinary Institute of Physics and Engineering in Medicine working party modified a survey previously used in the UK to understand current practice using MRI for EBRT treatment planning, investigate how MRI is currently used and managed as well as identify knowledge gaps. It was distributed electronically within 11 countries: Australia, Belgium, Denmark, Finland, France, Italy, the Netherlands, New Zealand, Sweden, the UK and the USA.Results. The survey response rate within the USA was <1% and hence these results omitted from the analysis. In the other 10 countries the survey had a median response rate of 77% per country. Direct MRI access, defined as either having a dedicated MRI scanner for radiotherapy (RT) or access to a radiology MRI scanner, varied between countries. France, Italy and the UK reported the lowest direct MRI access rates and all other countries reported direct access in ≥82% of centres. Whilst ≥83% of centres in Denmark and Sweden reported having dedicated MRI scanners for EBRT, all other countries reported ≤29%. Anatomical sites receiving MRI for EBRT varied between countries with brain, prostate, head and neck being most common. Commissioning and QA of image registration and MRI scanners varied greatly, as did MRI sequences performed, staffing models and training given to different staff groups. The lack of financial reimbursement for MR was a consistent barrier for MRI implementation for RT for all countries and MR access was a reported important barrier for all countries except Sweden and Denmark.Conclusion. No country has a comprehensive approach for MR in EBRT adoption and financial barriers are present worldwide. Variations between countries in practice, equipment, staffing models, training, QA and MRI sequences have been identified, and are likely to be due to differences in funding as well as a lack of consensus or guidelines in the literature. Access to dedicated MR for EBRT is limited in all but Sweden and Denmark, but in all countries there are financial challenges with ongoing per patient costs. Despite these challenges, significant interest exists in increasing MR guided EBRT planning over the next 5 years.
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Affiliation(s)
- Richard Speight
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Marcus Tyyger
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Maria A Schmidt
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Gary Liney
- Ingham Institute for Applied Medical Research & Liverpool Cancer Therapy Centre, Liverpool, Sydney, NSW 2170, Australia
| | - Robert Johnstone
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust and the University of Manchester, Manchester, United Kingdom
| | - Michael Dubec
- The Christie NHS Foundation Trust and the University of Manchester, Manchester, United Kingdom
| | - Ben George
- University of Oxford and GenesisCare, Oxford, United Kingdom
| | - Ann Henry
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Trina Herbert
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Sweden
| | - Faisal Mahmood
- Odense University Hospital, Laboratory of Radiation Physics, Odense, Denmark and University of Southern Denmark, Department of Clinical Research, Denmark
| | - Juha Korhonen
- Department of Medical Imaging and Radiation Therapy, Kymenlaakso Central Hospital, Kotka, Finland
| | - Rick Sims
- Auckland Radiation Oncology, Epsom, Auckland, New Zealand and Icon Cancer Centres, Cairns, QLD, Australia
| | - Rob H N Tijssen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Simone Busoni
- Department of Health Physics, AOU Careggi (Firenze University Hospital), Firenze, Italy
| | | | - Hazel McCallum
- Translational and Clinical Research Institute, Newcastle University and Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Clough A, Bridge P, Hales R, McDaid L, Choudhury A, Eccles CL. An unusual case of oedematous prostate volumetric changes observed over the course of radiotherapy on the MR linear accelerator. J Med Imaging Radiat Sci 2021; 52:147-151. [PMID: 33342695 DOI: 10.1016/j.jmir.2020.11.019] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The integration of magnetic resonance (MR) imaging into radiotherapy through new technology, including the MR -linear accelerator (MRL), has allowed further advancements into image guided radiotherapy (IGRT). Better soft tissue visualisation has led to some unusual findings. CASE AND OUTCOMES A patient with T1c N0 M0 prostate adenocarcinoma received 60Gy in 20# radiotherapy on the MRL. Radiotherapy planning (RTP) scans were completed on both CT and MR (using T2 and T1 weighted three-dimensional turbo spin echo sequences, reconstructed transaxially (TRA). The MR scans revealed atypical oedema in the right peripheral zone, visualised on T2-weighted (T2w) MR Images as an accumulation of high signal intensity fluid. Daily MRL treatment includes a (T2w 3D Tra) sequence with which oedematous changes could be monitored. The images demonstrated an increase in oedematous volume over fractions 1-10 causing the prostate contour variations from the initial planning scans. Despite the prostate volume variations PTV coverage was never breached and dose constraints were always met for both PTV and surrounding organs at risk (OAR's), excluding the need for oncologist input. A single Therapeutic Radiographer (RTT) experienced in MRL delivery, contoured the prostate and oedematous volumes on the radiotherapy plan (RTP) MR and all on-treatment MR images to assess change over the radiotherapy course. The initial volumes were 53.4 cm3 and 8.3 cm3 for the prostate plus oedema and oedema alone respectively. The most significant change was seen for both the prostate and oedema on fraction nine (68.0 cm3 and 10.1 cm3, respectively). Reductions were noted after this with final (fraction 20) volumes of 55.2 cm3 and 0.58 cm3 respectively. DISCUSSION The ability to visualise prostatic oedema was new to the radiotherapy treatment team due to better soft tissue visualisation than standard radiotherapy. The results from contouring the prostate and oedema volumes confirmed radiographer observations and demonstrated how oedema impacted the overall prostate volume by quantifying the oedematous variations over time. The changes in oedema volume are presumed to be in response to radiotherapy. CONCLUSION Further adaptive radiotherapy work-flow developments, utilising an "Adapt to Shape" model will allow real-time re-contouring of the prostate to ensure tumour control is not compromised. Further work investigating the frequency and impact of oedemotous changes to external beam prostate patients will help to inform practice.
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Affiliation(s)
| | - Pete Bridge
- The University of Liverpool, Liverpool, United Kingdom
| | - Rosie Hales
- The Christie NHSFT, Manchester, United Kingdom
| | - Lisa McDaid
- The Christie NHSFT, Manchester, United Kingdom
| | - Ananya Choudhury
- The Christie NHSFT, Manchester, United Kingdom; The University of Manchester, Manchester, United Kingdom
| | - Cynthia L Eccles
- The Christie NHSFT, Manchester, United Kingdom; The University of Manchester, Manchester, United Kingdom.
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Speight R, Dubec M, Eccles CL, George B, Henry A, Herbert T, Johnstone RI, Liney GP, McCallum H, Schmidt MA. IPEM topical report: guidance on the use of MRI for external beam radiotherapy treatment planning . Phys Med Biol 2021; 66:055025. [PMID: 33450742 DOI: 10.1088/1361-6560/abdc30] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022]
Abstract
This document gives guidance for multidisciplinary teams within institutions setting up and using an MRI-guided radiotherapy (RT) treatment planning service. It has been written by a multidisciplinary working group from the Institute of Physics and Engineering in Medicine (IPEM). Guidance has come from the experience of the institutions represented in the IPEM working group, in consultation with other institutions, and where appropriate references are given for any relevant legislation, other guidance documentation and information in the literature. Guidance is only given for MRI acquired for external beam RT treatment planning in a CT-based workflow, i.e. when MRI is acquired and registered to CT with the purpose of aiding delineation of target or organ at risk volumes. MRI use for treatment response assessment, MRI-only RT and other RT treatment types such as brachytherapy and gamma radiosurgery are not considered within the scope of this document. The aim was to produce guidance that will be useful for institutions who are setting up and using a dedicated MR scanner for RT (referred to as an MR-sim) and those who will have limited time on an MR scanner potentially managed outside of the RT department, often by radiology. Although not specifically covered in this document, there is an increase in the use of hybrid MRI-linac systems worldwide and brief comments are included to highlight any crossover with the early implementation of this technology. In this document, advice is given on introducing a RT workload onto a non-RT-dedicated MR scanner, as well as planning for installation of an MR scanner dedicated for RT. Next, practical guidance is given on the following, in the context of RT planning: training and education for all staff working in and around an MR scanner; RT patient set-up on an MR scanner; MRI sequence optimisation for RT purposes; commissioning and quality assurance (QA) to be performed on an MR scanner; and MRI to CT registration, including commissioning and QA.
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Affiliation(s)
- Richard Speight
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Michael Dubec
- The Christie NHS Foundation Trust and the University of Manchester, Manchester, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust and the University of Manchester, Manchester, United Kingdom
| | - Ben George
- University of Oxford and GenesisCare, Oxford, United Kingdom
| | - Ann Henry
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Trina Herbert
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Gary P Liney
- Ingham Institute for Applied Medical Research and Liverpool Cancer Therapy Centre, Liverpool, Sydney, NSW 2170, Australia
| | - Hazel McCallum
- Translational and Clinical Research Institute, Newcastle University and Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Maria A Schmidt
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
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Hales RB, Rodgers J, Whiteside L, McDaid L, Berresford J, Budgell G, Choudhury A, Eccles CL. Therapeutic Radiographers at the Helm: Moving Towards Radiographer-Led MR-Guided Radiotherapy. J Med Imaging Radiat Sci 2020; 51:364-372. [PMID: 32600981 DOI: 10.1016/j.jmir.2020.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Magnetic resonance-guided adaptive radiotherapy (MRgART) has the potential to improve treatment processes and outcomes for a variety of tumour sites; however, it requires significant clinical resources. Magnetic resonance linear accelerator (MR-linac) treatments require a daily multidisciplinary presence for delivery. To facilitate sustainable MRgART models, agreed protocols facilitating therapeutic radiographer (RTT)-led delivery must be developed to establish a service similar to conventional image-guided radiotherapy (IGRT). This work provides a clinical perspective on the implementation of a protocol-driven 'clinician-lite' MRgART workflow at one institution. METHODS To identify knowledge, skills, and competence required at each step in the MRgART workflow, an interdisciplinary informal survey and needs assessment were undertaken to identify additional or enhanced skills required for MRgART, over and above those required for conventional cone-beam computed tomography-based IGRT. The MRgART pathway was critically evaluated by relevant professionals to encourage multidisciplinary input and discussion, allowing an iterative development of the RTT-led workflow. Starting with the simplest online adaptation strategy, consisting of a virtual couch shift and online replanning, clear guidelines were established for the delivery of radical prostate radiotherapy with a reduction in staff numbers present. RESULTS The MRgART-specific skills identified included MRI safety and screening, MR image acquisition, MRI-based anatomy, multimodality image interpretation and registration, and treatment plan evaluation. These skills were developed in RTTs via tutorials, workshops, focussed self-directed reading, teaching of colleagues, and end-to-end workflow testing. After initial treatments and discussions, roles and responsibilities of the three professional groups (clinicians, RTTs, and physicists) have evolved to achieve a 'clinician-lite' workflow for simple radical prostate treatments. DISCUSSION Through applying a definitive framework and establishing agreed threshold and action levels for action within anticipated treatment scenarios similar to those in cone-beam computed tomography-based IGRT, we have implemented a 'clinician-lite' workflow for simple adaptive treatments on the MR-linac. The responsibility for online plan evaluation and approval now rests with physicists and RTTs to streamline MRgART. Early evaluation of the framework after treatment of 10 patients has required minimal online clinician input (1.5% of 200 fractions delivered). CONCLUSION A 'clinician-lite' prostate treatment workflow has been successfully introduced on the MR-linac at our institution and will serve as a model for other tumour sites, using more complex adaptive strategies. Early indications are that this framework has the potential to improve patient throughput and efficiency. Further identification and validation of roles and responsibilities such as online contouring, and more interactive online planning, will facilitate RTTs to fully lead in the online workflow as adaptive radiotherapy becomes ever more complex.
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Affiliation(s)
- Rosie B Hales
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - John Rodgers
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Lee Whiteside
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Lisa McDaid
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - Joseph Berresford
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Geoff Budgell
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Cynthia L Eccles
- Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK.
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Rodgers J, Hales R, Whiteside L, Parker J, McHugh L, Cree A, van Herk M, Choudhury A, Hoskin P, McWilliam A, Eccles CL. Comparison of radiographer interobserver image registration variability using cone beam CT and MR for cervix radiotherapy. Br J Radiol 2020; 93:20200169. [PMID: 32543946 PMCID: PMC7446016 DOI: 10.1259/bjr.20200169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the consistency of therapy radiographers performing image registration using cone beam computed tomography (CBCT)-CT, magnetic resonance (MR)-CT, and MR-MR image guidance for cervix cancer radiotherapy and to assess that MR-based image guidance is not inferior to CBCT standard practice. METHODS 10 patients receiving cervix radiation therapy underwent daily CBCT guidance and magnetic resonance (MR) imaging weekly during treatment. Offline registration of each MR image, and corresponding CBCT, to planning CT was performed by five radiographers. MR images were also registered to the earliest MR interobserver variation was assessed using modified Bland-Altman analysis with clinically acceptable 95% limits of agreement (LoA) defined as ±5.0 mm. RESULTS 30 CBCT-CT, 30 MR-CT and 20 MR-MR registrations were performed by each observer. Registration variations between CBCT-CT and MR-CT were minor and both strategies resulted in 95% LoA over the clinical threshold in the anteroposterior direction (CBCT-CT ±5.8 mm, MR-CT ±5.4 mm). MR-MR registrations achieved a significantly improved 95% LoA in the anteroposterior direction (±4.3 mm). All strategies demonstrated similar results in lateral and longitudinal directions. CONCLUSION The magnitude of interobserver variations between CBCT-CT and MR-CT were similar, confirming that MR-CT radiotherapy workflows are comparable to CBCT-CT image-guided radiotherapy. Our results suggest MR-MR radiotherapy workflows may be a superior registration strategy. ADVANCES IN KNOWLEDGE This is the first publication quantifying interobserver registration of multimodality image registration strategies for cervix radical radiotherapy patients.
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Affiliation(s)
- John Rodgers
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK,
| | - Rosie Hales
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK,
| | - Lee Whiteside
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK,
| | - Jacqui Parker
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK,
| | - Louise McHugh
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK,
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Chin S, Eccles CL, McWilliam A, Chuter R, Walker E, Whitehurst P, Berresford J, Van Herk M, Hoskin PJ, Choudhury A. Magnetic resonance-guided radiation therapy: A review. J Med Imaging Radiat Oncol 2020; 64:163-177. [PMID: 31646742 DOI: 10.1111/1754-9485.12968] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
Magnetic resonance-guided radiation therapy (MRgRT) is a promising approach to improving clinical outcomes for patients treated with radiation therapy. The roles of image guidance, adaptive planning and magnetic resonance imaging in radiation therapy have been increasing over the last two decades. Technical advances have led to the feasible combination of magnetic resonance imaging and radiation therapy technologies, leading to improved soft-tissue visualisation, assessment of inter- and intrafraction motion, motion management, online adaptive radiation therapy and the incorporation of functional information into treatment. MRgRT can potentially transform radiation oncology by improving tumour control and quality of life after radiation therapy and increasing convenience of treatment by shortening treatment courses for patients. Multiple groups have developed clinical implementations of MRgRT predominantly in the abdomen and pelvis, with patients having been treated since 2014. While studies of MRgRT have primarily been dosimetric so far, an increasing number of trials are underway examining the potential clinical benefits of MRgRT, with coordinated efforts to rigorously evaluate the benefits of the promising technology. This review discusses the current implementations, studies, potential benefits and challenges of MRgRT.
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Affiliation(s)
- Stephen Chin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Cynthia L Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Alan McWilliam
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Robert Chuter
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Emma Walker
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Philip Whitehurst
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Joseph Berresford
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel Van Herk
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Peter J Hoskin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
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Speight R, Schmidt MA, Liney GP, Johnstone RI, Eccles CL, Dubec M, George B, Henry A, McCallum H. IPEM Topical Report: A 2018 IPEM survey of MRI use for external beam radiotherapy treatment planning in the UK. Phys Med Biol 2019; 64:175021. [PMID: 31239419 DOI: 10.1088/1361-6560/ab2c7c] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The benefits of integrating MRI into the radiotherapy pathway are well published, however there is little consensus in guidance on how to commission or implement its use. With a view to developing consensus guidelines for the use of MRI in external beam radiotherapy (EBRT) treatment planning in the UK, a survey was undertaken by an Institute of Physics and Engineering in Medicine (IPEM) working-party to assess the current landscape of MRI use in EBRT in the UK. A multi-disciplinary working-party developed a survey to understand current practice using MRI for EBRT treatment planning; investigate how MRI is currently used and managed; and identify knowledge gaps. The survey was distributed electronically to radiotherapy service managers and physics leads in 71 UK radiotherapy (RT) departments (all NHS and private groups). The survey response rate was 87% overall, with 89% of NHS and 75% of private centres responding. All responding centres include EBRT in some RT pathways: 94% using Picture Archiving and Communication System (PACS) images potentially acquired without any input from RT departments, and 69% had some form of MRI access for planning EBRT. Most centres reporting direct access use a radiology scanner within the same hospital in dedicated (26%) or non-dedicated (52%) RT scanning sessions. Only two centres reported having dedicated RT MRI scanners in the UK, lower than reported in other countries. Six percent of radiotherapy patients in England (data not publically available outside of England) have MRI as part of their treatment, which again is lower than reported elsewhere. Although a substantial number of centres acquire MRI scans for treatment planning purposes, most centres acquire less than five patient scans per month for each treatment site. Commissioning and quality assurance of both image registration and MRI scanners was found to be variable across the UK. In addition, staffing models and training given to different staff groups varied considerably across the UK, reflecting the current lack of national guidelines. The primary barriers reported to MRI implementation in EBRT planning included costs (e.g. lack of a national tariff for planning MRI), lack of MRI access and/or capacity within hospitals. Despite these challenges, significant interest remains in increasing MRI-assisted EBRT planning over the next five years.
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Affiliation(s)
- Richard Speight
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. Author to whom correspondence should be addressed
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Eccles CL, Campbell M. Keeping Up with the Hybrid Magnetic Resonance Linear Accelerators: How Do Radiation Therapists Stay Current in the Era of Hybrid Technologies? J Med Imaging Radiat Sci 2019; 50:195-198. [PMID: 31064719 DOI: 10.1016/j.jmir.2019.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 03/18/2019] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 01/09/2023]
Abstract
The benefits of integrating magnetic resonance imaging (MRI) into radiotherapy planning have long been extolled, first appearing in the literature as early as 1986. Most often described as a tool to be used when registered to a planning computed tomography to improve target and organ at risk delineation, the use of MRI for on-board image guidance and as a sole imaging modality throughout the entire radiotherapy pathway is quickly becoming a reality for appropriately selected patient populations in academic centres throughout the world. With the commercialization of these integrated magnetic resonance - radiotherapy delivery systems, an MRI-only workflow will prove beneficial, with MRI being used for treatment planning, localization, and on-treatment plan adaptation. Despite these technological advancements, recent surveys indicate uptake of MRI in radiotherapy as a routine practice has proven challenging. Reasons cited for this slow uptake were primarily related to health economics and/or accessibility. Furthermore, these surveys, like much of the academic literature, shy away from focusing on safe, sustainable staffing models enabled by comprehensive and appropriate education and training. In stark contrast to conebeam computed tomography guided therapy, magnetic resonance - radiotherapy systems are currently being operated by teams of physicians, radiographers, and physicists because of the diverse and complex tasks required to deliver treatment. The pace of innovation in RT remains high and unfortunately the window of opportunity to implement appropriate education continues to narrow. It is vital that we establish a framework to future-proof our profession. In the era of magnetic resonance-guided radiotherapy, we have yet to address the question of how to devise a consensus on the requisite knowledge, skills, and competence for radiation therapists and therapy radiographers using and/or operating MRI that provides guidance, without becoming prohibitively costly or time consuming.
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Affiliation(s)
- Cynthia L Eccles
- Department of Radiotherapy, The Christie NHS Foundation Trust and Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
| | - Mikki Campbell
- Radiation Treatment Program, Odette Cancer Centre at Sunnybrook Health Sciences Centre, Toronto, Canada
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Pathmanathan AU, McNair HA, Schmidt MA, Brand DH, Delacroix L, Eccles CL, Gordon A, Herbert T, van As NJ, Huddart RA, Tree AC. Comparison of prostate delineation on multimodality imaging for MR-guided radiotherapy. Br J Radiol 2019; 92:20180948. [PMID: 30676772 PMCID: PMC6540870 DOI: 10.1259/bjr.20180948] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE: With increasing incorporation of MRI in radiotherapy, we investigate two MRI sequences for prostate delineation in radiographer-led image guidance. METHODS: Five therapeutic radiographers contoured the prostate individually on CT, T2 weighted (T2W) and T2* weighted (T2*W) imaging for 10 patients. Contours were analysed with Monaco ADMIRE (research v. 2.0) to assess interobserver variability and accuracy by comparison with a gold standard clinician contour. Observers recorded time taken for contouring and scored image quality and confidence in contouring. RESULTS: There is good agreement when comparing radiographer contours to the gold-standard for all three imaging types with Dice similarity co-efficient 0.91-0.94, Cohen's κ 0.85-0.91, Hausdorff distance 4.6-7.6 mm and mean distance between contours 0.9-1.2 mm. In addition, there is good concordance between radiographers across all imaging modalities. Both T2W and T2*W MRI show reduced interobserver variability and improved accuracy compared to CT, this was statistically significant for T2*W imaging compared to CT across all four comparison metrics. Comparing MRI sequences reveals significantly reduced interobserver variability and significantly improved accuracy on T2*W compared to T2W MRI for DSC and Cohen's κ. Both MRI sequences scored significantly higher compared to CT for image quality and confidence in contouring, particularly T2*W. This was also reflected in the shorter time for contouring, measuring 15.4, 9.6 and 9.8 min for CT, T2W and T2*W MRI respectively. Conclusion: Therapeutic radiographer prostate contours are more accurate, show less interobserver variability and are more confidently and quickly outlined on MRI compared to CT, particularly using T2*W MRI. Advances in knowledge: Our work is relevant for MRI sequence choice and development of the roles of the interprofessional team in the advancement of MRI-guided radiotherapy.
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Affiliation(s)
| | - Helen A McNair
- The Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, United Kingdom
| | | | | | - Louise Delacroix
- The Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, United Kingdom
| | | | - Alexandra Gordon
- The Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, United Kingdom
| | - Trina Herbert
- The Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, United Kingdom
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Eccles CL, Nill S, Herbert T, Scurr E, McNair HA. Blurring the lines for better visualisation. Radiography (Lond) 2019; 25:91-93. [PMID: 30599837 DOI: 10.1016/j.radi.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/30/2018] [Accepted: 08/12/2018] [Indexed: 11/16/2022]
Abstract
On-treatment imaging in radiotherapy has evolved over the last 60 years, bringing with it changes in the roles of radiographers, radiologists and oncologists. The ability to acquire and interpret high quality images (2D kilovoltage and megavoltage imaging and 3D CT and cone-beam CT) for radiotherapy planning and delivery requires therapy radiographers to have skills and knowledge that overlap with those of diagnostic radiographers. With the implementation of MRI-guided radiotherapy, treatment radiographers and clinical oncologists are exploring new territory, requiring truly collaborative working practices with their radiology partners. This short communication introduces the first images acquired using the hybrid MR Linac at our institution.
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Affiliation(s)
- C L Eccles
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, UK.
| | - S Nill
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - T Herbert
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, UK
| | - E Scurr
- Department of Radiology, Royal Marsden NHS Foundation Trust, London, UK
| | - H A McNair
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, UK
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Eccles CL, McNair HA, Armstrong SEA, Helyer SJ, Scurr ED. In response to Westbrook - Opening the debate on MRI practitioner education. Radiography (Lond) 2017; 23 Suppl 1:S75-S76. [PMID: 28780958 DOI: 10.1016/j.radi.2017.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/14/2017] [Indexed: 11/22/2022]
Affiliation(s)
- C L Eccles
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, UK.
| | - H A McNair
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, UK
| | - S E A Armstrong
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, UK
| | - S J Helyer
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, UK
| | - E D Scurr
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, UK
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Eccles CL, Tse RV, Hawkins MA, Lee MT, Moseley DJ, Dawson LA. Intravenous contrast-enhanced cone beam computed tomography (IVCBCT) of intrahepatic tumors and vessels. Adv Radiat Oncol 2016; 1:43-50. [PMID: 28740872 PMCID: PMC5506729 DOI: 10.1016/j.adro.2016.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/18/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose Liver tumors are challenging to visualize on cone beam computed tomography (CBCT) without intravenous (IV) contrast. Image guidance for liver cancer stereotactic body ablative radiation therapy (SABR) could be improved with the direct visualization of hepatic tumors and vasculature. This study investigated the feasibility of the use of IV contrast-enhanced CBCT (IV-CBCT) as a means to improve liver target visualization. Methods and Materials Patients on a liver SABR protocol underwent IV-CBCT before 1 or more treatment fractions in addition to a noncontrast CBCT. Image acquisition was initiated 0 to 30 seconds following injection and acquired over 60 to 120 seconds. “Stop and go” exhale breath-hold CBCT scans were used whenever feasible. Changes in mean CT number in regions of interest within visible vasculature, tumor, and adjacent liver were quantified between CBCT and IV-CBCT. Results Twelve pairs of contrast and noncontrast CBCTs were obtained in 7 patients. Intravenous-CBCT improved hepatic tumor visibility in breath-hold scans only for 3 patients (2 metastases, 1 hepatocellular carcinoma). Visible tumors ranged in volume from 124 to 564 mL. Small tumors in free-breathing patients did not show enhancement on IVCBT. Conclusions Intravenous-CBCT may enhance the visibility of hepatic vessels and tumor in CBCT scans obtained during breath hold. Optimization of IV contrast timing and reduction of artifacts to improve tumor visualization warrant further investigation.
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Affiliation(s)
- Cynthia L Eccles
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.,C.L.E. and M.A.H. are currently at the CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Regina V Tse
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.,R.V.T. is currently at the Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Maria A Hawkins
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.,C.L.E. and M.A.H. are currently at the CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Mark T Lee
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.,M.T.L. is currently at Cancer Therapy Centre, Liverpool Hospital, University of New South Wales, Australia
| | - Douglas J Moseley
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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Abstract
PURPOSE Endobiliary stents can be used as surrogates for pancreatic localization when using cone-beam computed tomography (CBCT) during external-beam radiotherapy (EBRT). This work reports on interfraction stent position changes during EBRT for locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Six patients with endobiliary stents who underwent EBRT for LAPC were assessed. Measurements from the most superior aspect of the stent (sup stent) and the most inferior aspect of the stent (inf stent) to the most inferior, posterior aspect of the L1 vertebra central spinous process were determined from daily treatment CBCTs and compared with those determined from the planning computed tomography (CT) scan. Changes in stent-L1 measurements were interpreted as changes in relative stent position. RESULTS Three patients showed mean interfraction stent position changes of ≥1 cm when treatment measurements were compared with planning measurements. The sup stent for patient A moved to the right (2.66 ± 2.77 cm) and inferiorly (3.0 ± 3.12 cm), and the inf stent moved to the right (1.92 ± 2.02 cm) inferiorly (3.23 ± 3.34 cm) and posteriorly (1.41 ± 1.43 cm). The inf stent for patient B moved superiorly (2.23 ± 0.49 cm) and posteriorly (1.72 ± 0.59 cm). The sup and inf stent for patient F moved inferiorly (0.98 ± 0.35 cm and 1.21 ± 0.38 cm, respectively). The remaining three patients C, D, and E showed interfraction position changes of <1 cm. CONCLUSION Endobiliary stent migration and deformation were observed in a small subset of patients. Further investigation is required before confirming their use as surrogates for LAPC target localization during image-guided EBRT.
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Affiliation(s)
- Kwun-Ye Chu
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom ; Radiotherapy Department, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Cynthia L Eccles
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom ; Radiotherapy Department, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Thomas B Brunner
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom ; Department of Radiation Oncology, University of Freiburg, Freiburg im Breisgau, Germany
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Warren S, Partridge M, Fokas E, Eccles CL, Brunner TB. Comparing dose-volume histogram and radiobiological endpoints for ranking intensity-modulated arc therapy and 3D-radiotherapy treatment plans for locally-advanced pancreatic cancer. Acta Oncol 2013; 52:1573-8. [PMID: 23957620 DOI: 10.3109/0284186x.2013.813072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Samantha Warren
- The Gray Institute of Radiation Oncology and Biology, Department of Oncology, University of Oxford , Old Road Campus Research Building, Oxford , UK
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Eccles CL, Lindsay PE, Craig TD, Kim JJ, Dawson LA. Dosimetric Impact of Image-Guided Radiotherapy in Liver Stereotactic Radiotherapy. J Med Imaging Radiat Sci 2013; 44:5-13. [DOI: 10.1016/j.jmir.2012.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 08/29/2012] [Accepted: 09/06/2012] [Indexed: 11/28/2022]
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Lee MT, Purdie TG, Eccles CL, Sharpe MB, Dawson LA. Comparison of simple and complex liver intensity modulated radiotherapy. Radiat Oncol 2010; 5:115. [PMID: 21114865 PMCID: PMC3003186 DOI: 10.1186/1748-717x-5-115] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/30/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Intensity-modulated radiotherapy (IMRT) may allow improvement in plan quality for treatment of liver cancer, however increasing radiation modulation complexity can lead to increased uncertainties and requirements for quality assurance. This study assesses whether target coverage and normal tissue avoidance can be maintained in liver cancer intensity-modulated radiotherapy (IMRT) plans by systematically reducing the complexity of the delivered fluence. METHODS An optimal baseline six fraction individualized IMRT plan for 27 patients with 45 liver cancers was developed which provided a median minimum dose to 0.5 cc of the planning target volume (PTV) of 38.3 Gy (range, 25.9-59.5 Gy), in 6 fractions, while maintaining liver toxicity risk <5% and maximum luminal gastrointestinal structure doses of 30 Gy. The number of segments was systematically reduced until normal tissue constraints were exceeded while maintaining equivalent dose coverage to 95% of PTV (PTVD95). Radiotherapy doses were compared between the plans. RESULTS Reduction in the number of segments was achieved for all 27 plans from a median of 48 segments (range 34-52) to 19 segments (range 6-30), without exceeding normal tissue dose objectives and maintaining equivalent PTVD95 and similar PTV Equivalent Uniform Dose (EUD(-20)) IMRT plans with fewer segments had significantly less monitor units (mean, 1892 reduced to 1695, p = 0.012), but also reduced dose conformity (mean, RTOG Conformity Index 1.42 increased to 1.53 p = 0.001). CONCLUSIONS Tumour coverage and normal tissue objectives were maintained with simplified liver IMRT, at the expense of reduced conformity.
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Affiliation(s)
- Mark T Lee
- Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
- Radiation Oncology Department, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Thomas G Purdie
- Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia L Eccles
- CRUK/MRC Gray Institute for Radiation Oncology and Biology, University of Oxford, Oxford Cancer Centre, Churchill Hospital, Oxford, UK
| | - Michael B Sharpe
- Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
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Velec M, Moseley JL, Eccles CL, Craig T, Sharpe MB, Dawson LA, Brock KK. Effect of breathing motion on radiotherapy dose accumulation in the abdomen using deformable registration. Int J Radiat Oncol Biol Phys 2010; 80:265-72. [PMID: 20732755 DOI: 10.1016/j.ijrobp.2010.05.023] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 05/26/2010] [Accepted: 05/29/2010] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate the effect of breathing motion and dose accumulation on the planned radiotherapy dose to liver tumors and normal tissues using deformable image registration. METHODS AND MATERIALS Twenty-one free-breathing stereotactic liver cancer radiotherapy patients, planned on static exhale computed tomography (CT) for 27-60 Gy in six fractions, were included. A biomechanical model-based deformable image registration algorithm retrospectively deformed each exhale CT to inhale CT. This deformation map was combined with exhale and inhale dose grids from the treatment planning system to accumulate dose over the breathing cycle. Accumulation was also investigated using a simple rigid liver-to-liver registration. Changes to tumor and normal tissue dose were quantified. RESULTS Relative to static plans, mean dose change (range) after deformable dose accumulation (as % of prescription dose) was -1 (-14 to 8) to minimum tumor, -4 (-15 to 0) to maximum bowel, -4 (-25 to 1) to maximum duodenum, 2 (-1 to 9) to maximum esophagus, -2 (-13 to 4) to maximum stomach, 0 (-3 to 4) to mean liver, and -1 (-5 to 1) and -2 (-7 to 1) to mean left and right kidneys. Compared to deformable registration, rigid modeling had changes up to 8% to minimum tumor and 7% to maximum normal tissues. CONCLUSION Deformable registration and dose accumulation revealed potentially significant dose changes to either a tumor or normal tissue in the majority of cases as a result of breathing motion. These changes may not be accurately accounted for with rigid motion.
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Affiliation(s)
- Michael Velec
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Canada.
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Case RB, Moseley DJ, Sonke JJ, Eccles CL, Dinniwell RE, Kim J, Bezjak A, Milosevic M, Brock KK, Dawson LA. Interfraction and intrafraction changes in amplitude of breathing motion in stereotactic liver radiotherapy. Int J Radiat Oncol Biol Phys 2010; 77:918-25. [PMID: 20207501 DOI: 10.1016/j.ijrobp.2009.09.008] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Revised: 08/12/2009] [Accepted: 09/14/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE Interfraction and intrafraction changes in amplitude of liver motion were assessed in patients with liver cancer treated with kV cone beam computed tomography (CBCT)-guided stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS A total of 314 CBCTs obtained with the patient in the treatment position immediately before and after each fraction, and 29 planning 4DCTs were evaluated in 29 patients undergoing six-fraction SBRT for unresectable liver cancer, with (n = 15) and without (n = 14) abdominal compression. Offline, the CBCTs were sorted into 10 bins, based on phase of respiration. Liver motion amplitude was measured using liver-to-liver alignment from the end-exhale and end-inhale CBCT and four-dimensional CT reconstructions. Inter- and intrafraction amplitude changes were measured from the difference between the pre-SBRT CBCTs relative to the planning four-dimensional CT, and from the pre-SBRT and post-SBRT CBCTs, respectively. RESULTS Mean liver motion amplitude for all patients (range) was 1.8 (0.1-7.0), 8.0 (0.1-18.8), and 4.3 (0.1-12.1) mm in the mediolateral (ML), craniocaudal (CC), and anteroposterior (AP) directions, respectively. Mean absolute inter- and intrafraction liver motion amplitude changes were 1.0 (ML), 1.7 (CC), and 1.6 (AP) mm and 1.3 (ML), 1.6 (CC), and 1.9 (AP) mm, respectively. No significant correlations were found between intrafraction amplitude change and intrafraction time (range, 4:56-25:37 min:sec), and between inter- and intrafraction amplitude changes and liver motion amplitude. Intraobserver reproducibility (sigma, n = 29 fractions) was 1.3 (ML), 1.4 (CC), and 1.4 (AP) mm. CONCLUSIONS For the majority of liver SBRT patients, the change in liver motion amplitude was minimal over the treatment course and showed no apparent relationships with the magnitude of liver motion and intrafraction time.
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Affiliation(s)
- Robert B Case
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada
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Eccles CL, Haider EA, Haider MA, Fung S, Lockwood G, Dawson LA. Change in diffusion weighted MRI during liver cancer radiotherapy: preliminary observations. Acta Oncol 2010; 48:1034-43. [PMID: 19634060 DOI: 10.1080/02841860903099972] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate diffusion weighted magnetic resonance imaging (DWI) in liver and liver cancers during and following conformal radiotherapy (RT). To determine the feasibility of using changes in apparent diffusion coefficients (ADC) as a potential surrogate for tumour control or normal tissue injury. MATERIALS AND METHODS Patients on a six-fraction conformal liver RT protocol underwent DW-MRI at the time of treatment planning, during RT (week one and two) and one month following RT. Diffusion weighted MR images were acquired in exhale breath hold, using b-values of 0 and 600. Regions of interest (ROIs) corresponding to maximal tumour dose, high-dose peri-tumour liver, irradiated normal liver, non-irradiated liver, and spleen were analyzed on ADC maps. RESULTS Eleven patients (four hepatocellular carcinoma, five liver metastases, two cholangiocarcinoma) were evaluated. The baseline median tumour ADC of 1.56 x 10(-3)mm(2)/sec increased to 1.89 x 10(-3)mm(2)/sec at RT week one, to 1.91 x 10(-3)mm(2)/sec during week two and to 2.01 x 10(-3)mm(2)/sec at one month following treatment (p < 0.0001). Early increases in mean ADC were correlated with higher dose and sustained tumour response, whereas RECIST and volume changes on T2 images were not. Peri-tumour mean ADC also increased, from 1.40 x 10(-3)mm(2)/sec (baseline) to 1.55 x 10(-3)mm(2)/sec (RT week 2) and 1.64 x 10(-3)mm(2)/sec (follow-up). Small ADC changes were seen in the irradiated liver, and no significant changes were seen in the un-irradiated liver. CONCLUSIONS Changes in tumour ADC were seen during RT. Larger increases were correlated with higher doses and increased likelihood of response.
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Eccles CL, Bissonnette JP, Craig T, Taremi M, Wu X, Dawson LA. Treatment planning study to determine potential benefit of intensity-modulated radiotherapy versus conformal radiotherapy for unresectable hepatic malignancies. Int J Radiat Oncol Biol Phys 2008; 72:582-8. [PMID: 18793961 DOI: 10.1016/j.ijrobp.2008.06.1496] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 06/12/2008] [Accepted: 06/15/2008] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare intensity-modulated radiotherapy (IMRT) with conformal RT (CRT) for hypofractionated isotoxicity liver RT and explore dose escalation using IMRT for the same/improved nominal risk of liver toxicity in a treatment planning study. METHODS AND MATERIALS A total of 26 CRT plans were evaluated. Prescription doses (24-54 Gy within six fractions) were individualized on the basis of the effective liver volume irradiated maintaining < or =5% risk of radiation-induced liver disease. The dose constraints included bowel (0.5 cm(3)) and stomach (0.5 cm(3)) to < or =30 Gy, spinal cord to < or =25 Gy, and planning target volume (PTV) to < or =140% of the prescribed dose. Two groups were evaluated: (1) PTV overlapping or directly adjacent to serial functioning normal tissues (n = 14), and (2) the liver as the dose-limiting normal tissue (n = 12). IMRT plans using direct machine parameter optimization maintained the CRT plan beam arrangements, an estimated radiation-induced liver disease risk of 5%, and underwent dose escalation, if all normal tissue constraints were maintained. RESULTS IMRT improved PTV coverage in 19 of 26 plans (73%). Dose escalation was feasible in 9 cases by an average of 3.8 Gy (range, 0.6-13.2) in six fractions. Three of seven plans without improved PTV coverage had small gross tumor volumes (< or =105 cm(3)) already receiving 54 Gy, the maximal prescription dose allowed. In the remaining cases, the PTV range was 9.6-689 cm(3); two had overlapped organs at risk; and one had four targets. IMRT did not improve these plans owing to poor target coverage (n = 2) and nonliver (n = 2) dose limits. CONCLUSION Direct machine parameter optimization IMRT improved PTV coverage while maintaining normal tissue tolerances in most CRT liver plans. Dose escalation was possible in a minority of patients.
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Affiliation(s)
- Cynthia L Eccles
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
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