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Rasing MJA, Peters M, van Son M, Moerland MA, Eppinga W, van de Pol SMG, Noteboom J, Lagendijk J, van der Voort van Zyp JRN. Recurrence characteristics after focal salvage HDR brachytherapy in prostate cancer. Radiother Oncol 2023; 180:109495. [PMID: 36708924 DOI: 10.1016/j.radonc.2023.109495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 11/01/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Radiorecurrent prostate cancer is often confined to the prostate, predominantly near the index lesion. The purpose of this study was to look at recurrence characteristics in patients treated with focal salvage high dose-rate (HDR) brachytherapy. MATERIALS AND METHODS Patients treated with MRI-guided HDR brachytherapy, with a single fraction of 19 Gy from July 2013 to October 2021 as focal salvage treatment, were prospectively included in the current study. Imaging data were collected regarding the occurrence of local, regional and distant recurrences, including location of local recurrences (LR) in relation to the HDR radiotherapy field. RESULTS One hundred seventy-five patients were included after focal salvage HDR brachytherapy (median follow-up 36 months (IQR 23-50)). Three-years biochemical recurrence-free survival, LR-free survival, in-field LR-free survival, out-of-field LR-free survival, any-recurrence-free survival and ADT-free survival were 43% (95%CI 34%-52%), 51% (41%-61%), 70% (61%-80%), 92% (88%-97%), 42% (32%-52%) and 86% (80%-92%), respectively. Larger GTV-size and shorter PSA doubling time were associated with in-field LR in multivariable analysis. CONCLUSION After focal salvage HDR brachytherapy with a dose of 1x19 Gy for local prostate cancer recurrence, subsequent recurrences are mostly local and in-field.
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Affiliation(s)
- Marnix J A Rasing
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marieke van Son
- Department of Urology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Wietse Eppinga
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Sandrine M G van de Pol
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Juus Noteboom
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jan Lagendijk
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Rasing MJA, Peters M, Moerland MA, Noteboom JL, Lagendijk JJ, van der Voort van Zyp JRN. [Experiences with MRI-guided brachytherapy for radiorecurrent prostate cancer]. Ned Tijdschr Geneeskd 2022; 166:D6966. [PMID: 36300470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
MR-guided brachytherapy offers a focal salvage treatment for the local recurrence in case of isolated locally recurrent prostate cancer in the prostate and/or seminal vesicles after primary radiotherapy. By focusing on only the local recurrence instead of the whole prostate, chances of additional toxicity of the bladder, urethra and rectum can be minimized. In almost all patients, the treatment leads to a good initial treatment response that persists in about half of patients, while others will develop progressive disease later on. For selecting suitable patients, factors such as preexistent urinary- and bowel complaints, localization and size of the recurrence, PSA doubling time and time between primary radiotherapy and development of the recurrence are relevant. MR-guided brachytherapy can provide a suitable salvage strategy, with the aims of deferring androgen deprivation therapy and a chance of cure.
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Affiliation(s)
| | - Max Peters
- UMC Utrecht, Cancer Center, afd. Radiotherapie, Utrecht
- Contact: Max Peters
| | - M A Moerland
- UMC Utrecht, Cancer Center, afd. Radiotherapie, Utrecht
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Willigenburg T, van Son MJ, van de Pol SMG, Eppinga WSC, Lagendijk JJW, de Boer HCJ, Moerland MA, van der Voort van Zyp JRN, Peters M. Development and internal validation of multivariable prediction models for biochemical failure after MRI-guided focal salvage high-dose-rate brachytherapy for radiorecurrent prostate cancer. Clin Transl Radiat Oncol 2021; 30:7-14. [PMID: 34278009 PMCID: PMC8261471 DOI: 10.1016/j.ctro.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/03/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022] Open
Abstract
Background and purpose Magnetic resonance-guided focal salvage high-dose-rate brachytherapy (FS-HDR-BT) for radiorecurrent prostate cancer (PCa) shows low toxicity rates. However, biochemical failure (BF) after treatment occurs frequently. We developed two prediction models for BF (Phoenix definition) with the aim of enhancing patient counselling before FS-HDR-BT and during follow-up. Materials and methods A prospective cohort of 150 radiorecurrent PCa patients treated with FS-HDR-BT between 2013 and 2020 was used for model development and internal validation. Multivariable Cox Proportional Hazards regression was applied. For model 1, only pre-salvage variables were included as candidate predictors. For model 2, additional (post-)salvage characteristics were tested. After calibration, nomograms and webtools were constructed. Finally, three risk groups were identified. Results Sixty-one patients (41%) experienced BF. At baseline (model 1), age, gross tumour volume, pre-salvage PSA, and pre-salvage PSA doubling time (PSADT) were predictive of BF. During follow-up (model 2), age, pre-salvage PSA and PSADT, seminal vesicle involvement, post-salvage time to PSA nadir, and percentage PSA reduction were predictive of BF. The adjusted C-statistics were 0.73 (95% CI: 0.66-0.81) and 0.84 (95% CI: 0.78-0.90), respectively, with acceptable calibration. Estimated 2-year biochemical disease-free survival for the low-, intermediate-, and high-risk groups were 84%, 70%, and 31% (model 1), and 100%, 71%, and 5% (model 2). Conclusion Two models are provided for prediction of BF in patients with radiorecurrent PCa treated with FS-HDR-BT. Based on pre- and post-salvage characteristics, we are able to identify patients with a high risk of BF. These findings can aid patient counselling for FS-HDR-BT.
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Affiliation(s)
- Thomas Willigenburg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J van Son
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sandrine M G van de Pol
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wietse S C Eppinga
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan J W Lagendijk
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans C J de Boer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Moerland MA, van Schelven LJ, van Lier A, Boskovic E, Peters M, van Son MJ, van der Voort van Zyp JRN, Lagendijk JJW. MR compatibility, safety and accuracy of the redesigned UMC Utrecht single needle implant device. Phys Med Biol 2021; 66. [PMID: 34010820 DOI: 10.1088/1361-6560/ac02d5] [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: 12/31/2020] [Accepted: 05/19/2021] [Indexed: 11/11/2022]
Abstract
Purpose. The Utrecht single needle implant device (SNID) was redesigned to increase needle insertion velocity. The purpose of this study is to evaluate the magnetic resonance compatibility, safety and accuracy of the implant device preparing its application in a patient study to investigate the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.Methods. Several experiments were performed to evaluate the mechanical and radiofrequency safety of the needle system, the magnetic field perturbation, the calibration of the implant device in the MR coordinate system, functioning of the implant device during imaging and accuracy of needle insertion.Results. Endurance experiments showed the mechanical safety of the needle system. Magnetic field perturbation was acceptable with induced image distortions smaller than 0.5 mm for clinical MR sequences. Calibration of the implant device in the MR coordinate system was reproducible with average error (mean±standard deviation) of 0.2 ± 0.4 mm, 0.1 ± 0.3 mm and 0.6 ± 0.6 mm in thex,y- andz- direction, respectively. The RF safety measurement showed for clinical MR imaging sequences maximum temperature rises of 0.2 °C at the entry and tip points of the needle. Simultaneous functioning of the implant device and imaging is possible albeit with some intensity band artifacts in the fast field echo images. Finally, phantom measurements showed deviations amounting 2.5-3.6 mm measured as target-to-needle distance at a depth of 12 cm.Conclusions. This preclinical evaluation showed that the MR compatibility, safety and accuracy of the redesigned UMC Utrecht SNID allow its application in a patient study on the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.
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Affiliation(s)
- M A Moerland
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - L J van Schelven
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, The Netherlands
| | - A van Lier
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - E Boskovic
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, The Netherlands
| | - M Peters
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | - M J van Son
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
| | | | - J J W Lagendijk
- Radiation Oncology Department, University Medical Center Utrecht, The Netherlands
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van Son MJ, Peters M, Moerland MA, van der Voort van Zyp JRN. In Reply to Murgic and Chung. Int J Radiat Oncol Biol Phys 2021; 110:618-619. [PMID: 33989587 DOI: 10.1016/j.ijrobp.2021.01.021] [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: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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van Son MJ, Peters M, Moerland MA, Lagendijk JJW, Eppinga WSC, Shah TT, Ahmed HU, van der Voort van Zyp JRN. MRI-Guided Ultrafocal Salvage High-Dose-Rate Brachytherapy for Localized Radiorecurrent Prostate Cancer: Updated Results of 50 Patients. Int J Radiat Oncol Biol Phys 2020; 107:126-135. [PMID: 32006609 DOI: 10.1016/j.ijrobp.2020.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE Most patients with local prostate cancer recurrence after radiation therapy undergo palliative androgen deprivation therapy because whole-gland salvage treatments have a high risk of severe toxicity. Focal treatment reduces this risk while offering a second opportunity for cure. We report updated outcomes of ultrafocal salvage high-dose-rate brachytherapy (HDR-BT). METHODS AND MATERIALS Prospectively collected data from the first 50 treated patients were analyzed. Disease status was assessed by 3T multiparametric magnetic resonance imaging (MRI), 18F-Choline or 68Ga-prostate-specific membrane antigen positron emission tomography/computed tomography, and systematic or tumor-targeted biopsies. Ultrafocal salvage HDR-BT (1 × 19 Gy) was performed by implanting the clinical target volume (CTV: gross tumor volume + 5 mm margin) under fused transrectal ultrasound/MRI guidance. Follow-up included toxicity grading (using Common Terminology Criteria for Adverse Events 4.0), quality of life assessment, and prostate-specific antigen (PSA) testing. RESULTS Median follow-up was 31 months. Median CTV D95% was 18.8 Gy. We observed 2% grade 3 genitourinary toxicity, no grade 3 gastrointestinal toxicity, and 22% newly developed grade 3 erectile dysfunction. Five of 13 patients (38%) with self-reported pretreatment potency (International Index of Erectile Function >17) remained potent. Clinically relevant quality of life deterioration was reported for only 6 of 31 items and was not statistically significant. Biochemical failure (nadir + 2) occurred in 26 patients. Among intraprostatic recurrences, 73% were in field. After 2.5 years, biochemical disease-free survival was 51% (95% confidence interval, 37%-69%), metastases-free survival was 75% (64%-89%), androgen deprivation therapy-free survival was 90% (82%-99%), and overall survival was 98% (94%-100%). Presalvage PSA, CTV size, and stage ≥T3 were significantly associated with biochemical failure. Higher-risk patients (stage ≥T3, PSA ≥10, or PSA double time ≤9 months) had 25% biochemical disease-free survival at 2.5 years versus 71% for lower-risk patients. CONCLUSIONS At this early stage, MRI-guided ultrafocal HDR-BT seems to be a safe salvage treatment option, with acceptable biochemical control in a well-selected group of patients and potential for effectively postponing androgen deprivation therapy.
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Affiliation(s)
| | - Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, the Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, the Netherlands
| | - Jan J W Lagendijk
- Department of Radiotherapy, University Medical Center Utrecht, the Netherlands
| | - Wietse S C Eppinga
- Department of Radiotherapy, University Medical Center Utrecht, the Netherlands
| | - Taimur T Shah
- Department of Surgery and Cancer, Division of Surgery, Faculty of Medicine, Imperial College London, London, United Kingdom; Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hashim U Ahmed
- Department of Surgery and Cancer, Division of Surgery, Faculty of Medicine, Imperial College London, London, United Kingdom; Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Juliet van Son M, Peters M, Moerland MA, van der Voort van Zyp JR. In Reply to David and Kamrava. Int J Radiat Oncol Biol Phys 2019; 104:1183-1184. [DOI: 10.1016/j.ijrobp.2019.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/03/2019] [Accepted: 05/08/2019] [Indexed: 11/29/2022]
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Beld E, Moerland MA, van der Voort van Zyp JRN, Viergever MA, Lagendijk JJW, Seevinck PR. MRI artifact simulation for clinically relevant MRI sequences for guidance of prostate HDR brachytherapy. Phys Med Biol 2019; 64:095006. [PMID: 30947159 DOI: 10.1088/1361-6560/ab15ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
For the purpose of magnetic resonance imaging (MRI) guidance of prostate high-dose-rate (HDR) brachytherapy, this paper presents a study on the potential of clinically relevant MRI sequences to facilitate tracking or localization of brachytherapy devices (HDR source/titanium needle), and which could simultaneously be used to visualize the anatomy. The tracking or localization involves simulation of the MRI artifact in combination with a template matching algorithm. Simulations of the MRI artifacts induced by an HDR brachytherapy source and a titanium needle were implemented for four types of sequences: spoiled gradient echo, spin echo, balanced steady-state free precession (bSSFP) and bSSFP with spectral attenuated inversion recovery (SPAIR) fat suppression. A phantom study was conducted in which mentioned sequences (in 2D) as well as the volumetric MRI sequences of the current clinical scan protocol were applied to obtain the induced MRI artifacts for an HDR source and a titanium needle. Localization of the objects was performed by a phase correlation based template matching algorithm. The simulated images demonstrated high correspondences with the acquired MR images, and allowed localization of the objects. A comparison between the object positions obtained for all applied MRI sequences showed deviations (from the average position) of 0.2-0.3 mm, proving that all MRI sequences were suitable for localization of the objects, irrespective of their 2D or volumetric nature. This study demonstrated that the MRI artifact induced by an HDR source or a titanium needle could be simulated for the four investigated types of MRI sequences (spoiled gradient echo, spin echo, bSSFP and bSSFP-SPAIR), valuable for real-time object localization in clinical practice. This leads to more flexibility in the choice of MRI sequences for guidance of HDR brachytherapy, as they are suitable for both object localization and anatomy visualization.
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Affiliation(s)
- Ellis Beld
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. Author to whom correspondence may be addressed
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Peters M, van Son MJ, Moerland MA, Kerkmeijer LGW, Eppinga WSC, Meijer RP, Lagendijk JJW, Shah TT, Ahmed HU, van der Voort van Zijp JRN. MRI-Guided Ultrafocal HDR Brachytherapy for Localized Prostate Cancer: Median 4-Year Results of a feasibility study. Int J Radiat Oncol Biol Phys 2019; 104:1045-1053. [PMID: 30926575 DOI: 10.1016/j.ijrobp.2019.03.032] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/15/2019] [Accepted: 03/17/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE For the treatment of localized prostate cancer, focal therapy has the potential to cure with fewer side effects than traditional whole-gland treatments. We report an update on toxicity, quality of life (QoL), and tumor control in our magnetic resonance imaging (MRI)-guided ultrafocal high-dose-rate brachytherapy cohort. METHODS AND MATERIALS Disease status was evaluated by systematic biopsies and 3T multiparametric MRI. The brachytherapy implant procedure under fused transrectal ultrasound/MRI guidance was followed by a 1.5 T MRI for contour adjustments and catheter position verification. A single dose of 19 Gy was delivered to the tumor with a margin of 5 mm. Genitourinary (GU) toxicity, gastrointestinal (GI) toxicity, and erectile dysfunction (ED) were graded with the Common Terminology Criteria for Adverse Events version 4.0. QoL was measured with RAND-36, European Organisation for Research and Treatment of Cancer QLQ-C30 and PR25. International Prostate Symptom Scores and International Index of Erectile Function scores were obtained. Prostate-specific antigen level was monitored, with biochemical recurrence defined as nadir + 2 ng/mL (Phoenix). RESULTS Thirty patients with National Comprehensive Cancer Network low- (13%) to intermediate-risk (87%) prostate cancer were treated between May 2013 and April 2016. Median follow-up was 4 years. Median age was 71 years (interquartile range, 68-73) and median initial prostate-specific antigen level was 7.3 ng/mL (5.2-8.1). Maximum Gleason score was 4 + 3 = 7 (in 2 patients). All tumors were radiologic (MRI) stage T2. No grade >2 GU or >1 GI toxicity occurred. International Prostate Symptom Scores only deteriorated temporarily. Mild pretreatment ED deteriorated to moderate/severe ED in 50% of patients. Long-term clinically relevant QoL deterioration was seen in sexual activity and tiredness, whereas emotional and cognitive functioning improved. At 4 years, biochemical disease-free survival was 70% (95% confidence interval, 52%-93%), metastases-free survival was 93% (85%-100%), and overall survival was 100%. Of intraprostatic recurrences, 7 of 9 were out of field. CONCLUSIONS Ultrafocal high-dose-rate brachytherapy conveys minimal GU or GI toxicity and has a marginal effect on QoL. An early decline in erectile function was seen. Tumor control outcomes are poor (biochemical disease-free survival of 70% [52%-93%] at 4 years), most likely as a result of poor patient selection.
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Affiliation(s)
- Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Marieke J van Son
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Linda G W Kerkmeijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wietse S C Eppinga
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, Netherlands; Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jan J W Lagendijk
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Taimur T Shah
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom; Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Hashim U Ahmed
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom; Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Beld E, Seevinck PR, Schuurman J, Viergever MA, Lagendijk JJ, Moerland MA. Development and Testing of a Magnetic Resonance (MR) Conditional Afterloader for Source Tracking in Magnetic Resonance Imaging-Guided High-Dose-Rate (HDR) Brachytherapy. Int J Radiat Oncol Biol Phys 2018; 102:960-968. [DOI: 10.1016/j.ijrobp.2018.04.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/13/2018] [Accepted: 04/24/2018] [Indexed: 01/18/2023]
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Maenhout M, Peters M, Moerland MA, Meijer RP, van den Bosch MAAJ, Frank SJ, Nguyen PL, van Vulpen M, van der Voort van Zyp JRN. MRI guided focal HDR brachytherapy for localized prostate cancer: Toxicity, biochemical outcome and quality of life. Radiother Oncol 2018; 129:554-560. [PMID: 30131183 DOI: 10.1016/j.radonc.2018.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe toxicity, biochemical outcome and quality of life after MRI guided focal high dose rate brachytherapy (HDR-BT) in a single fraction of 19 Gy for localized prostate cancer. MATERIALS AND METHODS Between May 2013 and April 2016, 30 patients were treated by MRI-guided focal HDR-BT. Patients with visible tumour on MRI were included. All patients were ≥65 years, T-stage <T3, Gleason ≤7, PSA <10 ng/mL and IPSS <15. Focal irradiation was delivered in a single fraction of 19 Gy to the D95 of the clinical target volume. Toxicity was reported using the Common Terminology Criteria for Adverse Events version 4. Biochemical failure was defined according to the Phoenix criteria and quality of life was measured using validated questionnaires. RESULTS Median follow up was 24 months. One patient developed a grade 2 and 3 GU toxicity after treatment. In the other 29 patients, no grade 2 or higher perioperative complications occurred. Five patients developed a biochemical recurrence. For all measured time points, there was no statistically significant deterioration in quality of life. CONCLUSION Focal MRI guided HDR-BT confers low toxicity rates and maintains quality of life. Biochemical recurrence is rather high, 5 patients developed a biochemical recurrence according to the Phoenix definition. Longer evaluation of these patients is necessary and caution is warranted before implementing focal HDR-BT in patients with localized prostate cancer.
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Affiliation(s)
- Metha Maenhout
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Max Peters
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Marinus A Moerland
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Richard P Meijer
- University Medical Center Utrecht, Department of Urology, the Netherlands
| | | | - Steven J Frank
- The University of Texas MD Anderson Cancer Center, Department of Radiotherapy, Houston, USA
| | - Paul L Nguyen
- Dana-Farber Cancer Institute, Department of Radiotherapy, Boston, USA
| | - Marco van Vulpen
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
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Abstract
For the purpose of MR-guided high-dose-rate (HDR) brachytherapy, a method for real-time localization of an HDR brachytherapy source was developed, which requires high spatial and temporal resolutions. MR-based localization of an HDR source serves two main aims. First, it enables real-time treatment verification by determination of the HDR source positions during treatment. Second, when using a dummy source, MR-based source localization provides an automatic detection of the source dwell positions after catheter insertion, allowing elimination of the catheter reconstruction procedure. Localization of the HDR source was conducted by simulation of the MR artifacts, followed by a phase correlation localization algorithm applied to the MR images and the simulated images, to determine the position of the HDR source in the MR images. To increase the temporal resolution of the MR acquisition, the spatial resolution was decreased, and a subpixel localization operation was introduced. Furthermore, parallel imaging (sensitivity encoding) was applied to further decrease the MR scan time. The localization method was validated by a comparison with CT, and the accuracy and precision were investigated. The results demonstrated that the described method could be used to determine the HDR source position with a high accuracy (0.4-0.6 mm) and a high precision (⩽0.1 mm), at high temporal resolutions (0.15-1.2 s per slice). This would enable real-time treatment verification as well as an automatic detection of the source dwell positions.
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Affiliation(s)
- E Beld
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
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Van Son MJ, Peters M, Moerland MA, Noteboom JL, Eppinga WS, Davila Fajardo R, Lagendijk J, Van der Voort van Zyp JR. Re-salvage MRI-guided Focal High-dose-rate Brachytherapy for Locally Recurrent Prostate Cancer. Cureus 2018; 10:e2429. [PMID: 29876151 PMCID: PMC5988341 DOI: 10.7759/cureus.2429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Prostate cancer recurrences are common, even with twenty-first-century primary prostate cancer treatment modalities. The most common salvage treatment is (delayed) hormonal therapy, which is often associated with serious side-effects. Due to the risk of significant toxicity, whole-gland targeted salvage treatments remain unpopular. Consequently, developments in focal therapies have arisen. Magnetic resonance imaging (MRI)-guided focal salvage high-dose-rate brachytherapy (HDR-BT) is a novel treatment aiming for minimal toxicity in recurrent prostate cancer patients. Repeating focal treatment could, therefore, be possible in case of post-salvage recurrence. We report the case of a 77-year-old man who underwent repeat focal HDR-BT.
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Maenhout M, van der Voort van Zyp JR, Borot de Battisti M, Peters M, van Vulpen M, van den Bosch M, Moerland MA. The effect of catheter displacement and anatomical variations on the dose distribution in MRI-guided focal HDR brachytherapy for prostate cancer. Brachytherapy 2018; 17:68-77. [DOI: 10.1016/j.brachy.2017.04.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/08/2017] [Accepted: 04/17/2017] [Indexed: 01/20/2023]
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Maenhout M, Peters M, van Vulpen M, Moerland MA, Meijer RP, van den Bosch MAAJ, Nguyen PL, Frank SJ, van der Voort van Zyp JRN. Focal MRI-Guided Salvage High-Dose-Rate Brachytherapy in Patients With Radiorecurrent Prostate Cancer. Technol Cancer Res Treat 2017; 16:1194-1201. [PMID: 29333958 PMCID: PMC5762090 DOI: 10.1177/1533034617741797] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Whole-gland salvage treatment of radiorecurrent prostate cancer has a high rate of severe toxicity. The standard of care in case of a biochemical recurrence is androgen deprivation treatment, which is associated with morbidity and negative effects on quality of life. A salvage treatment with acceptable toxicity might postpone the start of androgen deprivation treatment, might have a positive influence on the patients’ quality of life, and might even be curative. Here, toxicity and biochemical outcome are described after magnetic resonance imaging–guided focal salvage high-dose-rate brachytherapy in patients with radiorecurrent prostate cancer. Materials and Methods: Seventeen patients with pathologically proven locally recurrent prostate cancer were treated with focal high-dose-rate brachytherapy in a single 19-Gy fraction using magnetic resonance imaging for treatment guidance. Primary radiotherapy consisted of external beam radiotherapy or low-dose-rate brachytherapy. Tumors were delineated with Ga-68–prostate-specific membrane antigen or F18-choline positron emission tomography in combination with multiparametric magnetic resonance imaging. All patients had a prostate-specific antigen level of less than 10 ng/mL at the time of recurrence and a prostate-specific antigen doubling time of ≥12 months. Toxicity was measured by using the Common Terminology Criteria for Adverse Events version 4. Results: Eight of 17 patients had follow-up interval of at least 1 year. At a median follow-up interval of 10 months (range 3-40 months), 1 patient experienced a biochemical recurrence according to the Phoenix criteria, and prostate-specific membrane antigen testing revealed that this was due to a distant nodal metastasis. One patient had a grade 3 urethral stricture at 2 years after treatment. Conclusion: Focal salvage high-dose-rate brachytherapy in patients with radiorecurrent prostate cancer showed grade 3 toxicity in 1 of 17 patients and a distant nodal metastasis in another patient. Whether this treatment option leads to cure in a subset of patients or whether it can successfully postpone androgen deprivation treatment needs further investigation.
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Affiliation(s)
- Metha Maenhout
- 1 Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Max Peters
- 1 Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marco van Vulpen
- 2 Department of Urology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marinus A Moerland
- 1 Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard P Meijer
- 1 Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Paul L Nguyen
- 3 Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Steven J Frank
- 4 Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Raaymakers BW, Jürgenliemk-Schulz IM, Bol GH, Glitzner M, Kotte ANTJ, van Asselen B, de Boer JCJ, Bluemink JJ, Hackett SL, Moerland MA, Woodings SJ, Wolthaus JWH, van Zijp HM, Philippens MEP, Tijssen R, Kok JGM, de Groot-van Breugel EN, Kiekebosch I, Meijers LTC, Nomden CN, Sikkes GG, Doornaert PAH, Eppinga WSC, Kasperts N, Kerkmeijer LGW, Tersteeg JHA, Brown KJ, Pais B, Woodhead P, Lagendijk JJW. First patients treated with a 1.5 T MRI-Linac: clinical proof of concept of a high-precision, high-field MRI guided radiotherapy treatment. ACTA ACUST UNITED AC 2017; 62:L41-L50. [PMID: 29135471 DOI: 10.1088/1361-6560/aa9517] [Citation(s) in RCA: 346] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Peters M, Moerland MA, van der Voort van Zyp JR. Salvage brachytherapy for radiorecurrent prostate cancer: Searching for safety and success. Brachytherapy 2017; 16:1099-1100. [DOI: 10.1016/j.brachy.2017.08.008] [Citation(s) in RCA: 2] [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: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/26/2022]
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Peters M, Kanthabalan A, Shah TT, McCartan N, Moore CM, Arya M, van der Voort van Zyp JR, Moerland MA, Hindley RG, Emberton M, Ahmed HU. Development and internal validation of prediction models for biochemical failure and composite failure after focal salvage high intensity focused ultrasound for local radiorecurrent prostate cancer: Presentation of risk scores for individual patient prognoses. Urol Oncol 2017; 36:13.e1-13.e10. [PMID: 28927782 DOI: 10.1016/j.urolonc.2017.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 04/29/2017] [Revised: 07/29/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Patient selection for focal salvage remains difficult. Therefore, we developed and internally validated prediction models for biochemical failure (BF) and a composite endpoint (CE) following focal salvage high intensity focused ultrasound (HIFU) for radiorecurrent prostate cancer. MATERIALS AND METHODS A prospective HIFU registry identified 150 cases (November 2006-August 2015). Recurrence was assessed with multiparametric magnetic resonance imaging (MRI) combined with template prostate mapping biopsies, targeted biopsies, or systematic transrectal ultrasound-guided biopsies. Metastatic disease was ruled out with a positron emission tomography-computed tomography and a bone scan. Focal salvage HIFU consisted of quadrant-ablation, hemi-ablation, or index-lesion ablation. Cox-regression was used for BF (Phoenix-definition) and CE (BF/MRI+/biopsies+/local or systemic treatment/metastases+/prostate cancer specific mortality+). Internal validation was performed using bootstrap resampling (500 datasets) after which C-statistic and hazard ratios were adjusted. Models were calibrated and risk scores created. RESULTS Median follow-up was 35 months (interquartile range: 22-52). Median biochemical disease-free survival (DFS) was 33 months (95% CI: 23-45). Median CE-free survival was 24 months (95% CI: 21-35). After multivariable analysis, DFS interval after primary radiotherapy, presalvage prostate-specific antigen (PSA), PSA-doubling time, prostatic volume, and T-stage (both MRI based) predicted BF. For the CE, PSA-doubling time was not predictive but additionally, primary Gleason score was. The adjusted C-statistics were 0.68 and 0.64 for BF and CE, respectively. Calibration was accurate until 48 months. The risk scores showed 3 groups, with biochemical DFS of 60%, 35%, and 7% and CE-free survival of 40%, 24%, and 0% at 4 years. CONCLUSION Our model, once externally validated, could allow for better selection of patients for focal salvage HIFU.
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Affiliation(s)
- Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Abi Kanthabalan
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Taimur T Shah
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK; Department of Urology, Whittington Hospital NHS Trust, London, UK
| | - Neil McCartan
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Department of Urology, UCLH NHS Foundation Trust, London, UK; Department of Urology, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | | | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard G Hindley
- Department of Urology, Basingstoke Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, Whittington Hospital NHS Trust, London, UK; NIHR UCLH/UCL Comprehensive Biomedical Research Center, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Imperial Urology, Imperial Healthcare NHS Trust, London, UK
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Zijlstra F, Moerland MA, van der Voort van Zyp JRN, Noteboom JL, Viergever MA, Seevinck PR. Challenges in MR-only seed localization for postimplant dosimetry in permanent prostate brachytherapy. Med Phys 2017; 44:5051-5060. [PMID: 28777451 DOI: 10.1002/mp.12505] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 04/18/2017] [Revised: 07/17/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022] Open
Abstract
PURPOSE An MR-only postimplant dosimetry workflow for low dose rate (LDR) brachytherapy could reduce patient burden, improve accuracy, and improve cost efficiency. However, localization of brachytherapy seeds on MRI scans remains a major challenge for this type of workflow. In this study, we propose and validate an MR-only seed localization method and identify remaining challenges. METHODS AND MATERIALS The localization method was based on template matching of simulations of complex-valued imaging artifacts around metal brachytherapy seeds. The method was applied to MRI scans of 25 prostate cancer patients who underwent LDR brachytherapy and for whom postimplant dosimetry was performed after 4 weeks. The seed locations found with the MR-only method were validated against the seed locations found on CT. The circumstances in which detection errors were made were classified to gain an insight in the nature of the errors. RESULTS A total of 1490 of 1557 (96%) seeds were correctly detected, while 67 false-positive errors were made. The correctly detected seed locations had a high spatial accuracy with an average error of 0.8 mm compared with CT. A majority of the false positives occurred near other seeds. Most false negatives were found in either stranded configurations without spacers or near other seeds. CONCLUSIONS The low detection error rate and high localization accuracy obtained by the complex-valued template matching approach are promising for future clinical application of MR-only dosimetry. The most important remaining challenge is robustness with regard to configurations of multiple seeds in close vicinity, such as in strands of seeds without spacers. This issue could potentially be resolved by simulating specific configurations of multiple seeds or by constraining the treatment planning to avoid these configurations, which could make the proposed method competitive with CT-based seed localization.
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Affiliation(s)
- Frank Zijlstra
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Juus L Noteboom
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter R Seevinck
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
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Borot de Battisti M, Denis de Senneville B, Hautvast G, Binnekamp D, Lagendijk JJW, Maenhout M, Moerland MA. A novel adaptive needle insertion sequencing for robotic, single needle MR-guided high-dose-rate prostate brachytherapy. Phys Med Biol 2017; 62:4031-4045. [PMID: 28287399 DOI: 10.1088/1361-6560/aa664b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
MR-guided high-dose-rate (HDR) brachytherapy has gained increasing interest as a treatment for patients with localized prostate cancer because of the superior value of MRI for tumor and surrounding tissues localization. To enable needle insertion into the prostate with the patient in the MR bore, a single needle MR-compatible robotic system involving needle-by-needle dose delivery has been developed at our institution. Throughout the intervention, dose delivery may be impaired by: (1) sub-optimal needle positioning caused by e.g. needle bending, (2) intra-operative internal organ motion such as prostate rotations or swelling, or intra-procedural rectum or bladder filling. This may result in failure to reach clinical constraints. To assess the first aforementioned challenge, a recent study from our research group demonstrated that the deposited dose may be greatly improved by real-time adaptive planning with feedback on the actual needle positioning. However, the needle insertion sequence is left to the doctor and therefore, this may result in sub-optimal dose delivery. In this manuscript, a new method is proposed to determine and update automatically the needle insertion sequence. This strategy is based on the determination of the most sensitive needle track. The sensitivity of a needle track is defined as its impact on the dose distribution in case of sub-optimal positioning. A stochastic criterion is thus presented to determine each needle track sensitivity based on needle insertion simulations. To assess the proposed sequencing strategy, HDR prostate brachytherapy was simulated on 11 patients with varying number of needle insertions. Sub-optimal needle positioning was simulated at each insertion (modeled by typical random angulation errors). In 91% of the scenarios, the dose distribution improved when the needle was inserted into the most compared to the least sensitive needle track. The computation time for sequencing was less than 6 s per needle track. The proposed needle insertion sequencing can therefore assist in delivering an optimal dose in HDR prostate brachytherapy.
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Affiliation(s)
- M Borot de Battisti
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
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21
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Westendorp H, Surmann K, van de Pol SM, Hoekstra CJ, Kattevilder RA, Nuver TT, Moerland MA, Slump CH, Minken AW. Dosimetric impact of contouring and image registration variability on dynamic 125 I prostate brachytherapy. Brachytherapy 2017; 16:572-578. [DOI: 10.1016/j.brachy.2017.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
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22
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Westendorp H, Hoekstra CJ, Immerzeel JJ, van de Pol SMG, Niël CGHJ, Kattevilder RAJ, Nuver TT, Minken AW, Moerland MA. Cone-beam CT-based adaptive planning improves permanent prostate brachytherapy dosimetry: An analysis of 1266 patients. Med Phys 2017; 44:1257-1267. [PMID: 28192614 DOI: 10.1002/mp.12156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 07/05/2016] [Revised: 01/12/2017] [Accepted: 02/08/2017] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate adaptive planning for permanent prostate brachytherapy and to identify the prostate regions that needed adaptation. METHODS AND MATERIALS After the implantation of stranded seeds, using real-time intraoperative planning, a transrectal ultrasound (TRUS)-scan was obtained and contoured. The positions of seeds were determined on a C-arm cone-beam computed tomography (CBCT)-scan. The CBCT-scan was registered to the TRUS-scan using fiducial gold markers. If dose coverage on the combined image-dataset was inadequate, an intraoperative adaptation was performed by placing remedial seeds. CBCT-based intraoperative dosimetry was analyzed for the prostate (D90, V100, and V150) and the urethra (D30). The effects of the adaptive dosimetry procedure for Day 30 were separately assessed. RESULTS We analyzed 1266 patients. In 17.4% of the procedures, an adaptation was performed. Without the dose contribution of the adaptation Day 30 V100 would be < 95% for half of this group. On Day 0, the increase due to the adaptation was 11.8 ± 7.2% (1SD) for D90 and 9.0 ± 6.4% for V100. On Day 30, we observed an increase in D90 of 12.3 ± 6.0% and in V100 of 4.2 ± 4.3%. For the total group, a D90 of 119.6 ± 9.1% and V100 of 97.7 ± 2.5% was achieved. Most remedial seeds were placed anteriorly near the base of the prostate. CONCLUSION CBCT-based adaptive planning enables identification of implants needing adaptation and improves prostate dose coverage. Adaptations were predominantly performed near the anterior base of the prostate.
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Affiliation(s)
- Hendrik Westendorp
- Department of Medical Physics, Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Carel J Hoekstra
- Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Jos J Immerzeel
- Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Sandrine M G van de Pol
- Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Charles G H J Niël
- Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Robert A J Kattevilder
- Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Tonnis T Nuver
- Department of Medical Physics, Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - André W Minken
- Department of Medical Physics, Department of Radiation Oncology, Radiotherapiegroep behandellocatie Deventer, Nico Bolkesteinlaan 85, 7416 SE, Deventer, The Netherlands
| | - Marinus A Moerland
- Department of Medical Physics, Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Peters M, Smit Duijzentkunst DA, Westendorp H, van de Pol SMG, Kattevilder R, Schellekens A, van der Voort van Zyp JRN, Moerland MA, van Vulpen M, Hoekstra CJ. Adaptive cone-beam CT planning improves long-term biochemical disease-free survival for 125I prostate brachytherapy. Brachytherapy 2017; 16:282-290. [PMID: 28110899 DOI: 10.1016/j.brachy.2016.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 08/25/2016] [Revised: 11/11/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Determining the independent effect of additional intraoperative adaptive C-arm cone-beam CT (CBCT) planning vs. transrectal ultrasound (TRUS)-guided interactive planning alone in 125I brachytherapy for prostate cancer (PCa) on biochemical disease-free survival (BDFS). METHODS AND MATERIALS T1/T2-stage PCa patients receiving TRUS-guided brachytherapy from 2000 to 2014 were analyzed. From October 2006, patients received additional intraoperative adaptive CBCT planning for dosimetric evaluation and subsequent remedial seed placement in underdosed areas. Patients were stratified according to the National Comprehensive Cancer Network (NCCN) risk classification. Kaplan-Meier analysis was used to estimate BDFS (primary outcome), overall survival, and PCa-specific survival (secondary outcomes). Cox regression was used to assess the relation between CBCT use and biochemical failure (BF) and overall mortality. RESULTS In all, 1623 patients were included. Median followup was 99 months (interquartile range 70-115) for TRUS patients (n = 613) and 51 months (interquartile range 29-70) for CBCT patients (n = 1010). BF occurred 203 times and 206 patients died, 26 from PCa. For TRUS and CBCT patients, 7-year BDFS was 87.2% vs. 93.5% (log rank: p = 0.04) for low, 75.9% vs. 88.5% (p < 0.001) for intermediate, and 57.1% vs. 85.0% for high-risk patients (p < 0.001). For TRUS and CBCT patients, 7-year PCa-specific survival was 96.0% vs. 100% (p < 0.0001). After Cox regression, CBCT patients had lower hazard of BF: hazard ratio (HR) 0.25 (95% confidence interval [CI]: 0.18-0.33; p < 0.0001). Corrected for confounders, CBCT remained a predictor of BF: HR 0.51 (95% CI: 0.31-0.86; p = 0.01) but not for overall mortality: HR 0.66 (95% CI: 0.40-1.07; p = 0.09). CONCLUSIONS Additional intraoperative adaptive CBCT planning in 125I prostate brachytherapy leads to a significant increase in BDFS in all NCCN risk groups.
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Affiliation(s)
- M Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - H Westendorp
- Department of Radiotherapy, Radiotherapiegroep Deventer, Deventer, The Netherlands
| | - S M G van de Pol
- Department of Radiotherapy, Radiotherapiegroep Deventer, Deventer, The Netherlands
| | - R Kattevilder
- Department of Radiotherapy, Radiotherapiegroep Deventer, Deventer, The Netherlands
| | - A Schellekens
- Department of Radiotherapy, Radiotherapiegroep Deventer, Deventer, The Netherlands
| | | | - M A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C J Hoekstra
- Department of Radiotherapy, Radiotherapiegroep Deventer, Deventer, The Netherlands
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Peters M, Moerland MA, Noteboom JL, Eppinga WS, Lagendijk JJ, van der Voort van Zyp JRN. [MRI-guided brachytherapy in prostate cancer]. Ned Tijdschr Geneeskd 2017; 161:D1708. [PMID: 29303088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The number of patients treated for prostate cancer by radiotherapy treatment has increased substantially over recent decades. However, after both external radiotherapy and brachytherapy, a subset of patients still develops recurrent disease during follow-up. In many patients these recurrences are often limited to one localisation in the prostate. In the past, on diagnosis of a recurrence, palliative hormonal treatment was started. Medical imaging by means of a CT scan was not adequate for delineating the recurrent lesion or for excluding metastases. In case where radiotherapy was considered the best treatment for the recurrence, this often resulted in serious adverse effects. Due to improvements in both imaging and radiotherapy techniques, it is now possible to target the local recurrent lesion only. In recurring prostate cancer this technique is known as focal salvage.
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Affiliation(s)
- M Peters
- Universitair Medisch Centrum Utrecht, Cancer Center, afd. Radiotherapie, Utrecht
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Borot de Battisti M, Denis de Senneville B, Maenhout M, Lagendijk JJW, van Vulpen M, Hautvast G, Binnekamp D, Moerland MA. Fiber Bragg gratings-based sensing for real-time needle tracking during MR-guided brachytherapy. Med Phys 2016; 43:5288. [DOI: 10.1118/1.4961743] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Westendorp H, Nuver TT, Hoekstra CJ, Moerland MA, Minken AW. Edema and Seed Displacements Affect Intraoperative Permanent Prostate Brachytherapy Dosimetry. Int J Radiat Oncol Biol Phys 2016; 96:197-205. [DOI: 10.1016/j.ijrobp.2016.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/10/2016] [Accepted: 04/11/2016] [Indexed: 11/25/2022]
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Beld E, Seevinck PR, Lagendijk JJW, Viergever MA, Moerland MA. Monte Carlo study of the impact of a magnetic field on the dose distribution in MRI-guided HDR brachytherapy using Ir-192. Phys Med Biol 2016; 61:6791-6807. [PMID: 27580406 DOI: 10.1088/0031-9155/61/18/6791] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Borot de Battisti M, Denis de Senneville B, Maenhout M, Hautvast G, Binnekamp D, Lagendijk JJW, Van Vulpen M, Moerland MA. TU-H-CAMPUS-JeP3-05: Adaptive Determination of Needle Sequence HDR Prostate Brachytherapy with Divergent Needle-By-Needle Delivery. Med Phys 2016. [DOI: 10.1118/1.4957703] [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: 11/07/2022] Open
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Borot de Battisti M, Denis de Senneville B, Maenhout M, Hautvast G, Binnekamp D, Lagendijk JJW, Van Vulpen M, Moerland MA. WE-AB-BRA-10: Assessment of Fiber Bragg Grating (FBG)-Based Sensing for Real-Time Needle Tracking During MR-Guided Brachytherapy. Med Phys 2016. [DOI: 10.1118/1.4957739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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30
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Borot de Battisti M, Denis de Senneville B, Maenhout M, Hautvast G, Binnekamp D, Lagendijk JJW, van Vulpen M, Moerland MA. Adaptive planning strategy for high dose rate prostate brachytherapy—a simulation study on needle positioning errors. Phys Med Biol 2016; 61:2177-95. [PMID: 26907732 DOI: 10.1088/0031-9155/61/5/2177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The development of magnetic resonance (MR) guided high dose rate (HDR) brachytherapy for prostate cancer has gained increasing interest for delivering a high tumor dose safely in a single fraction. To support needle placement in the limited workspace inside the closed-bore MRI, a single-needle MR-compatible robot is currently under development at the University Medical Center Utrecht (UMCU). This robotic device taps the needle in a divergent way from a single rotation point into the prostate. With this setup, it is warranted to deliver the irradiation dose by successive insertions of the needle. Although robot-assisted needle placement is expected to be more accurate than manual template-guided insertion, needle positioning errors may occur and are likely to modify the pre-planned dose distribution.In this paper, we propose a dose plan adaptation strategy for HDR prostate brachytherapy with feedback on the needle position: a dose plan is made at the beginning of the interventional procedure and updated after each needle insertion in order to compensate for possible needle positioning errors. The introduced procedure can be used with the single needle MR-compatible robot developed at the UMCU. The proposed feedback strategy was tested by simulating complete HDR procedures with and without feedback on eight patients with different numbers of needle insertions (varying from 4 to 12). In of the cases tested, the number of clinically acceptable plans obtained at the end of the procedure was larger with feedback compared to the situation without feedback. Furthermore, the computation time of the feedback between each insertion was below 100 s which makes it eligible for intra-operative use.
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Peters M, van der Voort van Zyp JRN, Moerland MA, Hoekstra CJ, van de Pol S, Westendorp H, Maenhout M, Kattevilder R, Verkooijen HM, van Rossum PSN, Ahmed HU, Shah TT, Emberton M, van Vulpen M. Development and internal validation of a multivariable prediction model for biochemical failure after whole-gland salvage iodine-125 prostate brachytherapy for recurrent prostate cancer. Brachytherapy 2016; 15:296-305. [PMID: 26948662 DOI: 10.1016/j.brachy.2016.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/18/2016] [Accepted: 01/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Localized recurrent prostate cancer after primary radiotherapy can be curatively treated using salvage iodine-125 ((125)I) brachytherapy. Selection is hampered by a lack of predictive factors for cancer control. This study aims to develop and internally validate a prognostic model for biochemical failure (BF) after salvage (125)I brachytherapy. METHODS AND MATERIALS Whole-gland salvage (125)I brachytherapy patients were treated between 1993 and 2010 in two radiotherapy centers in the Netherlands. Multivariable Cox regression was performed to assess the predictive value of clinical parameters related to BF (Phoenix-definition [prostate-specific antigen [PSA]-nadir + 2.0 ng/mL]). Missing data were handled by multiple imputation. The model's discriminatory ability was assessed with Harrell's C-statistic. Internal validation was performed using bootstrap resampling (2000 data sets). Goodness-of-fit was evaluated with calibration plots. All analyses were performed using the recently published TRIPOD (Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) statement. RESULTS After median followup of 74 months (range 5-138), 43 of a total 62 patients developed BF. In multivariable analysis, disease-free survival interval (DFSI) after primary therapy and pre-salvage prostate-specific antigen doubling time (PSADT) were predictors of BF: corrected hazard ratio (HR) 0.99 (95% confidence interval 0.97-0.999; p = 0.04) and 0.94 (95% confidence interval 0.89-0.99; p = 0.03), both for a 1-month increase (optimism-adjusted C-statistic 0.70). Calibration was accurate up to 36 months. Of patients with PSADT >30 months and DFSI >60 months, 36-month biochemical disease-free survival was >75%. Every 12-month increase in DFSI will allow 3-month decrease in PSADT while maintaining the same biochemical recurrence-free rates. CONCLUSIONS We have presented results from a cohort of patients undergoing salvage (125)I-brachytherapy. Our data show that better selection of patients is possible with the DFSI and PSADT.
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Affiliation(s)
- M Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - M A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C J Hoekstra
- Department of Radiation Oncology, Radiotherapeutic Institute RISO, Deventer, The Netherlands
| | - S van de Pol
- Department of Radiation Oncology, Radiotherapeutic Institute RISO, Deventer, The Netherlands
| | - H Westendorp
- Department of Radiation Oncology, Radiotherapeutic Institute RISO, Deventer, The Netherlands
| | - M Maenhout
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Kattevilder
- Department of Radiation Oncology, Radiotherapeutic Institute RISO, Deventer, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Center Utrecht, The Netherlands
| | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H U Ahmed
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, University College London Hospitals, National Health Service (UCLH NHS) Foundation Trust, London, UK
| | - T T Shah
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, University College London Hospitals, National Health Service (UCLH NHS) Foundation Trust, London, UK; Department of Urology, Whittington Hospital NHS Trust, London, UK
| | - M Emberton
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, University College London Hospitals, National Health Service (UCLH NHS) Foundation Trust, London, UK; National Institute for Health Research (NIHR) University College London Hospitals (UCLH/UCL) Comprehensive Biomedical Research Centre, London, UK
| | - M van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Peters M, van der Voort van Zyp JRN, Moerland MA, Hoekstra CJ, van de Pol S, Westendorp H, Maenhout M, Kattevilder R, Verkooijen HM, van Rossum PSN, Ahmed HU, Shah TT, Emberton M, van Vulpen M. Multivariable model development and internal validation for prostate cancer specific survival and overall survival after whole-gland salvage Iodine-125 prostate brachytherapy. Radiother Oncol 2016; 119:104-10. [PMID: 26897512 DOI: 10.1016/j.radonc.2016.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 10/28/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whole-gland salvage Iodine-125-brachytherapy is a potentially curative treatment strategy for localised prostate cancer (PCa) recurrences after radiotherapy. Prognostic factors influencing PCa-specific and overall survival (PCaSS & OS) are not known. The objective of this study was to develop a multivariable, internally validated prognostic model for survival after whole-gland salvage I-125-brachytherapy. MATERIALS AND METHODS Whole-gland salvage I-125-brachytherapy patients treated in the Netherlands from 1993-2010 were included. Eligible patients had a transrectal ultrasound-guided biopsy-confirmed localised recurrence after biochemical failure (clinical judgement, ASTRO or Phoenix-definition). Recurrences were assessed clinically and with CT and/or MRI. Metastases were excluded using CT/MRI and technetium-99m scintigraphy. Multivariable Cox-regression was used to assess the predictive value of clinical characteristics in relation to PCa-specific and overall mortality. PCa-specific mortality was defined as patients dying with distant metastases present. Missing data were handled using multiple imputation (20 imputed sets). Internal validation was performed and the C-statistic calculated. Calibration plots were created to visually assess the goodness-of-fit of the final model. Optimism-corrected survival proportions were calculated. All analyses were performed according to the TRIPOD statement. RESULTS Median total follow-up was 78months (range 5-139). A total of 62 patients were treated, of which 28 (45%) died from PCa after mean (±SD) 82 (±36) months. Overall, 36 patients (58%) patients died after mean 84 (±40) months. PSA doubling time (PSADT) remained a predictive factor for both types of mortality (PCa-specific and overall): corrected hazard ratio's (HR's) 0.92 (95% CI: 0.86-0.98, p=0.02) and 0.94 (95% CI: 0.90-0.99, p=0.01), respectively (C-statistics 0.71 and 0.69, respectively). Calibration was accurate up to 96month follow-up. Over 80% of patients can survive 8years if PSADT>24months (PCaSS) and >33months (OS). Only approximately 50% survival is achieved with a PSADT of 12months. CONCLUSION A PSADT of respectively >24months and >33months can result in >80% probability of PCa- specific and overall survival 8years after whole-gland salvage I-125-brachytherapy. Survival should be weighed against toxicity from a salvage procedure. Larger series and external validation are necessary.
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Affiliation(s)
- Max Peters
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands.
| | | | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | | | | | | | - Metha Maenhout
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | | | | | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, UCLH NHS Foundation Trust, UK
| | - Taimur T Shah
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, UCLH NHS Foundation Trust, UK; Department of Urology, Whittington Hospital NHS Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, UK; Department of Urology, UCLH NHS Foundation Trust, UK; NIHR UCLH/UCL Comprehensive Biomedical Research Centre, London, UK
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
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Borot de Battisti M, Maenhout M, Denis de Senneville B, Hautvast G, Binnekamp D, Lagendijk JJW, van Vulpen M, Moerland MA. An automated optimization tool for high-dose-rate (HDR) prostate brachytherapy with divergent needle pattern. Phys Med Biol 2015; 60:7567-83. [PMID: 26378657 DOI: 10.1088/0031-9155/60/19/7567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Focal high-dose-rate (HDR) for prostate cancer has gained increasing interest as an alternative to whole gland therapy as it may contribute to the reduction of treatment related toxicity. For focal treatment, optimal needle guidance and placement is warranted. This can be achieved under MR guidance. However, MR-guided needle placement is currently not possible due to space restrictions in the closed MR bore. To overcome this problem, a MR-compatible, single-divergent needle-implant robotic device is under development at the University Medical Centre, Utrecht: placed between the legs of the patient inside the MR bore, this robot will tap the needle in a divergent pattern from a single rotation point into the tissue. This rotation point is just beneath the perineal skin to have access to the focal prostate tumor lesion. Currently, there is no treatment planning system commercially available which allows optimization of the dose distribution with such needle arrangement. The aim of this work is to develop an automatic inverse dose planning optimization tool for focal HDR prostate brachytherapy with needle insertions in a divergent configuration. A complete optimizer workflow is proposed which includes the determination of (1) the position of the center of rotation, (2) the needle angulations and (3) the dwell times. Unlike most currently used optimizers, no prior selection or adjustment of input parameters such as minimum or maximum dose or weight coefficients for treatment region and organs at risk is required. To test this optimizer, a planning study was performed on ten patients (treatment volumes ranged from 8.5 cm(3)to 23.3 cm(3)) by using 2-14 needle insertions. The total computation time of the optimizer workflow was below 20 min and a clinically acceptable plan was reached on average using only four needle insertions.
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Affiliation(s)
- M Borot de Battisti
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Westendorp H, Nuver TT, Moerland MA, Minken AW. An automated, fast and accurate registration method to link stranded seeds in permanent prostate implants. Phys Med Biol 2015; 60:N391-403. [DOI: 10.1088/0031-9155/60/20/n391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Charaghvandi RK, den Hartogh MD, van Ommen AMLN, de Vries WJH, Scholten V, Moerland MA, Philippens MEP, Schokker RI, van Vulpen M, van Asselen B, van den Bongard DHJG. MRI-guided single fraction ablative radiotherapy for early-stage breast cancer: a brachytherapy versus volumetric modulated arc therapy dosimetry study. Radiother Oncol 2015; 117:477-82. [PMID: 26438972 DOI: 10.1016/j.radonc.2015.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 01/19/2015] [Revised: 09/01/2015] [Accepted: 09/20/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE A radiosurgical treatment approach for early-stage breast cancer has the potential to minimize the patient's treatment burden. The dosimetric feasibility for single fraction ablative radiotherapy was evaluated by comparing volumetric modulated arc therapy (VMAT) with an interstitial multicatheter brachytherapy (IMB) approach. METHODS AND MATERIALS The tumors of 20 patients with early-stage breast cancer were delineated on a preoperative contrast-enhanced planning CT-scan, co-registered with a contrast-enhanced magnetic resonance imaging (MRI), both in radiotherapy supine position. A dose of 15 Gy was prescribed to the planned target volume of the clinical target volume (PTVCTV), and 20 Gy integrated boost to the PTV of the gross tumor volume (PTVGTV). Treatment plans for IMB and VMAT were optimized for adequate target volume coverage and minimal organs at risk (OAR) dose. RESULTS The median PTVGTV/CTV receiving at least 95% of the prescribed dose was ⩾99% with both techniques. The median PTVCTV unintentionally receiving 95% of the prescribed PTVGTV dose was 65.4% and 4.3% with IMB and VMAT, respectively. OAR doses were comparable with both techniques. CONCLUSION MRI-guided single fraction radiotherapy with an integrated ablative boost to the GTV is dosimetrically feasible with both techniques. We perceive IMB less suitable for clinical implementation due to PTVCTV overdosage. Future studies have to confirm the clinical feasibility of the single fraction ablative approach.
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Affiliation(s)
| | | | | | | | - Vincent Scholten
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | | | - Rogier I Schokker
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | - Bram van Asselen
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
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Podder TK, Beaulieu L, Caldwell B, Cormack RA, Crass JB, Dicker AP, Fenster A, Fichtinger G, Meltsner MA, Moerland MA, Nath R, Rivard MJ, Salcudean T, Song DY, Thomadsen BR, Yu Y. AAPM and GEC-ESTRO guidelines for image-guided robotic brachytherapy: report of Task Group 192. Med Phys 2015; 41:101501. [PMID: 25281939 DOI: 10.1118/1.4895013] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In the last decade, there have been significant developments into integration of robots and automation tools with brachytherapy delivery systems. These systems aim to improve the current paradigm by executing higher precision and accuracy in seed placement, improving calculation of optimal seed locations, minimizing surgical trauma, and reducing radiation exposure to medical staff. Most of the applications of this technology have been in the implantation of seeds in patients with early-stage prostate cancer. Nevertheless, the techniques apply to any clinical site where interstitial brachytherapy is appropriate. In consideration of the rapid developments in this area, the American Association of Physicists in Medicine (AAPM) commissioned Task Group 192 to review the state-of-the-art in the field of robotic interstitial brachytherapy. This is a joint Task Group with the Groupe Européen de Curiethérapie-European Society for Radiotherapy & Oncology (GEC-ESTRO). All developed and reported robotic brachytherapy systems were reviewed. Commissioning and quality assurance procedures for the safe and consistent use of these systems are also provided. Manual seed placement techniques with a rigid template have an estimated in vivo accuracy of 3-6 mm. In addition to the placement accuracy, factors such as tissue deformation, needle deviation, and edema may result in a delivered dose distribution that differs from the preimplant or intraoperative plan. However, real-time needle tracking and seed identification for dynamic updating of dosimetry may improve the quality of seed implantation. The AAPM and GEC-ESTRO recommend that robotic systems should demonstrate a spatial accuracy of seed placement ≤1.0 mm in a phantom. This recommendation is based on the current performance of existing robotic brachytherapy systems and propagation of uncertainties. During clinical commissioning, tests should be conducted to ensure that this level of accuracy is achieved. These tests should mimic the real operating procedure as closely as possible. Additional recommendations on robotic brachytherapy systems include display of the operational state; capability of manual override; documented policies for independent check and data verification; intuitive interface displaying the implantation plan and visualization of needle positions and seed locations relative to the target anatomy; needle insertion in a sequential order; robot-clinician and robot-patient interactions robustness, reliability, and safety while delivering the correct dose at the correct site for the correct patient; avoidance of excessive force on radioactive sources; delivery confirmation of the required number or position of seeds; incorporation of a collision avoidance system; system cleaning, decontamination, and sterilization procedures. These recommendations are applicable to end users and manufacturers of robotic brachytherapy systems.
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Affiliation(s)
- Tarun K Podder
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, Ohio 44122
| | - Luc Beaulieu
- Department of Radiation Oncology, Centre Hospitalier Univ de Quebec, Quebec G1R 2J6, Canada
| | - Barrett Caldwell
- Schools of Industrial Engineering and Aeronautics and Astronautics, Purdue University, West Lafayette, Indiana 47907
| | - Robert A Cormack
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts 02115
| | - Jostin B Crass
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee 37232
| | - Adam P Dicker
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Aaron Fenster
- Department of Imaging Research, Robarts Research Institute, London, Ontario N6A 5K8, Canada
| | - Gabor Fichtinger
- School of Computer Science, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | | | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, 3508 GA, The Netherlands
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut 06520
| | - Mark J Rivard
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts 02111
| | - Tim Salcudean
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Danny Y Song
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21231
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin 53705
| | - Yan Yu
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107
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de Battisti MB, Maenhout M, de Senneville BD, Hautvast G, Binnekamp D, Lagendijk JJW, Van Vulpen M, Moerland MA. TU-AB-201-05: Automatic Adaptive Per-Operative Re-Planning for HDR Prostate Brachytherapy - a Simulation Study On Errors in Needle Positioning. Med Phys 2015. [DOI: 10.1118/1.4925543] [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: 11/07/2022] Open
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Abstract
Magnetic resonance imaging (MRI) has a number of benefits for the planning of radiotherapy (RT), but its uptake into clinical practice has often been restricted to specialist research sites. There is often a lack of detailed MRI knowledge within the RT community and an apprehension of geometric distortions, both of which prevent its best utilization and merit the introduction of a standardized approach and common guidelines. This review sets out to address some of the issues involved in acquiring MRI scans for RT planning in the context of a number of clinical sites of interest and concludes with recommendations for its best practice in terms of imaging protocol and quality assurance. The article is of particular interest to the growing number of cancer therapy centers that are embarking on MRI simulation on either existing systems or their own dedicated scanners.
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Affiliation(s)
- Gary P Liney
- Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia; Department of Medical Physics, University of Wollongong, Wollongong, New South Wales, Australia.
| | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Affiliation(s)
- Jan J W Lagendijk
- Department of Radiotherapy, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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Peters M, Maenhout M, van der Voort van Zyp JRN, Moerland MA, Moman MR, Steuten LMG, van Deursen MJH, van Vulpen M. Focal salvage iodine-125 brachytherapy for prostate cancer recurrences after primary radiotherapy: a retrospective study regarding toxicity, biochemical outcome and quality of life. Radiother Oncol 2014; 112:77-82. [PMID: 24998704 DOI: 10.1016/j.radonc.2014.06.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [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: 02/20/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Whole-gland salvage for recurrent prostate cancer (PCa) shows high failure and toxicity rates. Early and adequate localization of recurrences enables focal salvage, thereby potentially improving functional outcomes, while maintaining cancer control. MATERIALS AND METHODS Retrospective analysis yielded 20 focal salvage I125 brachytherapy patients for locally recurrent PCa after primary radiotherapy. Tumor was defined by multiparametric MRI and correspondence with transrectal biopsies. Dose data were obtained intra-operatively. The tumor was prescribed ⩾144 Gy. Toxicity was scored by the Common Terminology Criteria for Adverse Events version 4 (CTCAE-4). Biochemical failure (BF) was defined using the Phoenix criteria (PSA-nadir + 2.0 ng/ml). Quality of life (QoL) was measured by SF-36 Health Survey and European Organization of Research and Treatment of Cancer (EORTC) C30+3 and PR25 questionnaires. RESULTS With a median follow-up of 36 months (range 10-45), six patients experienced BF, of which three had no initial response. Grade 3 genitourinary (GU) toxicity occurred in one patient (a urethral stricture). The five previously potent patients retained erectile function. QoL remained decreased with regard to urinary symptoms. CONCLUSION Focal salvage I125 brachytherapy showed one grade 3 GU toxicity in the 20 treated patients. Biochemical response and QoL were acceptable.
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Affiliation(s)
- Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | - Metha Maenhout
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | | | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Maaike R Moman
- Department of Radiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Lotte M G Steuten
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | | | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
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Seevinck P, van den Berg CAT, Moerland MA, Philippens M, Lagendijk J. SU-E-J-131: Automatic Detection of Gold Fiducial Markers On MR Images Using the RASOR Technique. Med Phys 2014. [DOI: 10.1118/1.4888184] [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: 11/07/2022] Open
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Moerland MA, Maenhout M, van der Voort van Zyp JR, Noteboom JL, Eppinga WS, van Vulpen M, Monninkhof EM, Verkooijen HM. In Regard to Genebes et al. Int J Radiat Oncol Biol Phys 2014; 89:436-7. [DOI: 10.1016/j.ijrobp.2014.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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Lever FM, Lips IM, Crijns SPM, Reerink O, van Lier ALHMW, Moerland MA, van Vulpen M, Meijer GJ. Quantification of esophageal tumor motion on cine-magnetic resonance imaging. Int J Radiat Oncol Biol Phys 2013; 88:419-24. [PMID: 24321785 DOI: 10.1016/j.ijrobp.2013.10.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/21/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE To quantify the movement of esophageal tumors noninvasively on cine-magnetic resonance imaging (MRI) by use of a semiautomatic method to visualize tumor movement directly throughout multiple breathing cycles. METHODS AND MATERIALS Thirty-six patients with esophageal tumors underwent MRI. Tumors were located in the upper (8), middle (7), and lower (21) esophagus. Cine-MR images were collected in the coronal and sagittal plane during 60 seconds at a rate of 2 Hz. An adaptive correlation filter was used to automatically track a previously marked reference point. Tumor movement was measured in the craniocaudal (CC), left-right (LR), and anteroposterior (AP) directions and its relationship along the longitudinal axis of the esophagus was investigated. RESULTS Tumor registration within the individual images was typically done at a millisecond time scale. The mean (SD) peak-to-peak displacements in the CC, AP, and LR directions were 13.3 (5.2) mm, 4.9 (2.5) mm, and 2.7 (1.2) mm, respectively. The bandwidth to cover 95% of excursions from the mean position (c95) was also calculated to exclude outliers caused by sporadic movements. The mean (SD) c95 values were 10.1 (3.8) mm, 3.7 (1.9) mm, and 2.0 (0.9) mm in the CC, AP, and LR dimensions. The end-exhale phase provided a stable position in the respiratory cycle, compared with more variety in the end-inhale phase. Furthermore, lower tumors showed more movement than did higher tumors in the CC and AP directions. CONCLUSIONS Intrafraction tumor movement was highly variable between patients. Tumor position proved the most stable during the respiratory cycle in the end-exhale phase. A better understanding of tumor motion makes it possible to individualize radiation delivery strategies accordingly. Cine-MRI is a successful noninvasive modality to analyze motion for this purpose in the future.
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Affiliation(s)
- Frederiek M Lever
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Irene M Lips
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd P M Crijns
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Onne Reerink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Astrid L H M W van Lier
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marinus A Moerland
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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de Leeuw H, Moerland MA, van Vulpen M, Seevinck PR, Bakker CJG. A dual-plane co-RASOR technique for accurate and rapid tracking and position verification of an Ir-192 source for single fraction HDR brachytherapy. Phys Med Biol 2013; 58:7829-39. [DOI: 10.1088/0031-9155/58/21/7829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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De Brabandere M, Al-Qaisieh B, De Wever L, Haustermans K, Kirisits C, Moerland MA, Oyen R, Rijnders A, Van den Heuvel F, Siebert FA. CT- and MRI-based seed localization in postimplant evaluation after prostate brachytherapy. Brachytherapy 2013; 12:580-8. [PMID: 23876358 DOI: 10.1016/j.brachy.2013.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [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: 01/04/2013] [Revised: 02/12/2013] [Accepted: 06/07/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the uncertainties in CT- and MRI-based seed reconstruction in postimplant evaluation after prostate seed brachytherapy in terms of interobserver variability and quantify the impact of seed detection variability on a selection of dosimetric parameters for three postplan techniques: (1) CT, (2) MRI-T1 weighted fused with MRI-T2 weighted, and (3) CT fused with MRI-T2 weighted. METHODS AND MATERIALS Seven physicists reconstructed the seed positions on postimplant CT and MRI-T1 images of three patients. For each patient and imaging modality, the interobserver variability was calculated with respect to a reference seed set. The effect of this variability on dosimetry was calculated for CT and CT + MRI-T2 (CT-based seed reconstruction), as well as for MRI-T1 + MRI-T2 (MRI-T1-based seed reconstruction), using fixed CT and MRI-T2 prostate contours. RESULTS Averaged over three patients, the interobserver variability in CT-based seed reconstruction was 1.1 mm (1 SDref, i.e., standard deviation with respect to the reference value). The D90 (dose delivered to 90% of the target) variability was 1.5% and 1.3% (1 SDref) for CT and CT + MRI-T2, respectively. The mean interobserver variability in MRI-based seed reconstruction was 3.0 mm (1 SDref), and the impact of this variability on D90 was 6.6% for MRI-T1 + MRI-T2. CONCLUSIONS Seed reconstruction on MRI-T1-weighted images was less accurate than on CT. This difference in uncertainties should be weighted against uncertainties due to contouring and image fusion when comparing the overall reliability of postplan techniques.
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Affiliation(s)
- Marisol De Brabandere
- Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven, Belgium.
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Nomden CN, de Leeuw AA, Moerland MA, Roesink JM, Tersteeg RJ, Jürgenliemk-Schulz IM. Clinical Use of the Utrecht Applicator for Combined Intracavitary/Interstitial Brachytherapy Treatment in Locally Advanced Cervical Cancer. Int J Radiat Oncol Biol Phys 2012; 82:1424-30. [DOI: 10.1016/j.ijrobp.2011.04.044] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/15/2011] [Accepted: 04/19/2011] [Indexed: 12/01/2022]
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De Leeuw AA, Van de Kamer JB, Moerland MA, Philippens ME, Jürgenliemk-Schulz IM. The effect of alternative biological modelling parameters (α/β and half time of repair T1/2) on reported EQD2 values in the treatment of advanced cervical cancer. Radiother Oncol 2011; 101:337-42. [DOI: 10.1016/j.radonc.2011.05.087] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 02/09/2011] [Accepted: 05/31/2011] [Indexed: 10/18/2022]
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van den Bosch MR, de Leeuw H, Zwanenburg JJM, Lagendijk JJW, Moerland MA. Single shot MR tagging to quantify local tissue deformation during MRI-guided needle interventions: a feasibility study. Med Phys 2011; 38:5321-9. [PMID: 21992350 DOI: 10.1118/1.3633906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE In MRI-guided needle interventions, such as biopsies and brachytherapy, tissue deformation caused by needle movement may result in localization errors and thus hamper the outcome of the procedure. Monitoring the local tissue deformation provides the ability to compensate for it, e.g., by increasing the needle insertion depth. Fast MR scans are useful to track the needle, but cannot be used to quantify local tissue deformation, in case anatomical landmarks are missing. Artificial landmarks can be created by MR tagging. This method provides a spatial saturation pattern (tag) in the tissue. Deformation of this pattern reflects the tissue motion between tag creation and tag imaging. As the needle movement is nonperiodic, k-space cannot be acquired with a multishot approach, like is usually done for cardiac imaging. Hence, a single shot MR tagging sequence is needed, which entails tag creation, needle movement and tag acquisition. In this study, the feasibility of single shot MR tagging for MRI-guided needle interventions in phantom and volunteer experiments is shown. METHODS Four different experiments were performed on a 1.5 T MR scanner: the first to quantify translations, the second to quantify rotations, the third to mimic a needle intervention, and the fourth to investigate the tag persistence in a volunteer. The tag pattern is created by a 1331 composite pulse. A balanced steady state free precession sequence is used for imaging. To minimize undesired changes in contrast or sharpness of the tag pattern, we chose a relatively small flip angle and a short imaging time in all experiments. In the volunteer experiments, we modified the sequence to also be able to inspect the influence of the used k-space sampling profile and the flip angle on the temporal persistence of image contrast and tag pattern. In all scans, head or surface coils were used for signal reception. RESULTS In all experiments, the tag pattern was clearly visible and could be used to quantify the local tissue deformation caused by (needle) movement. Strong correlations between the actual and measured (angular) phantom motions were obtained. In the needle intervention experiment, the tag lines were perfectly horizontal when there was no needle movement. With needle movement, local tissue displacements up to 5 mm were observed. Volunteer's anatomy could be discriminated, despite the tag pattern. The tag pattern in the prostate, for example, could still be read in all tagging images acquired 2 s after creating the tag pattern. With optimized scan parameters the tag persistence was even longer. The best image tag contrast was obtained using a large flip angle and the profile order low-high, although the image was slightly blurred. CONCLUSIONS This study demonstrates that single shot MR tagging can be used to quantify tissue deformation caused by needle movement. The in-vivo tag persistence is sufficient to enable the application of the tagging sequence during MRI-guided needle interventions in patients.
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Affiliation(s)
- Michiel R van den Bosch
- Department of Radiotherapy, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands.
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Roeloffzen EM, Battermann JJ, van Deursen MJ, Monninkhof EM, Visscher MI, Moerland MA, van Vulpen M. Influence of Dose on Risk of Acute Urinary Retention After Iodine-125 Prostate Brachytherapy. Int J Radiat Oncol Biol Phys 2011; 80:1072-9. [DOI: 10.1016/j.ijrobp.2010.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 03/11/2010] [Accepted: 03/17/2010] [Indexed: 11/29/2022]
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van Haaren PMA, van't Riet A, Moerland MA, Koedooder C, Westendorp H. Dose to fingertips of staff preparing stranded iodine-125 seeds for permanent prostate implants. Radiat Prot Dosimetry 2011; 145:61-65. [PMID: 21112885 DOI: 10.1093/rpd/ncq377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The aim of this study is to measure radiation dose to the fingertips of occupationally exposed workers handling stranded iodine-125 seeds during prostate implants. The doses were measured by thermoluminescence dosimetry at the nail of the index finger of both hands in three hospitals in the Netherlands. In all hospitals, measurements were carried out during the preparation of stranded IBt seeds, type Intersource(®) 1251L. The fingertip doses per procedure (mean ± SD) to the fingertip for workers from the three hospitals were estimated to be 0.29 ± 0.15 mSv (n = 6), <0.03 ± <0.02 mSv (n = 8) and 0.31 ± 0.16 mSv (n=16), respectively. The lower doses found for the hospital 2 workers are presumably related to the heavier shielding and longer utensils used in that hospital. Even in the case of hundreds of implant procedures per year, dose to the fingertips for occupationally exposed workers preparing stranded seeds is expected to be well below the annual limit for extremities of 500 mSv.
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Affiliation(s)
- P M A van Haaren
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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