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Nelson CL, Nguyen C, Fang R, Court LE, Cardenas CE, Rhee DJ, Netherton TJ, Mumme RP, Gay S, Gay C, Marquez B, El Basha MD, Zhao Y, Gronberg M, Hernandez S, Nealon KA, Martel MK, Yang J. A real-time contouring feedback tool for consensus-based contour training. Front Oncol 2023; 13:1204323. [PMID: 37771435 PMCID: PMC10525705 DOI: 10.3389/fonc.2023.1204323] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
Purpose Variability in contouring structures of interest for radiotherapy continues to be challenging. Although training can reduce such variability, having radiation oncologists provide feedback can be impractical. We developed a contour training tool to provide real-time feedback to trainees, thereby reducing variability in contouring. Methods We developed a novel metric termed localized signed square distance (LSSD) to provide feedback to the trainee on how their contour compares with a reference contour, which is generated real-time by combining trainee contour and multiple expert radiation oncologist contours. Nine trainees performed contour training by using six randomly assigned training cases that included one test case of the heart and left ventricle (LV). The test case was repeated 30 days later to assess retention. The distribution of LSSD maps of the initial contour for the training cases was combined and compared with the distribution of LSSD maps of the final contours for all training cases. The difference in standard deviations from the initial to final LSSD maps, ΔLSSD, was computed both on a per-case basis and for the entire group. Results For every training case, statistically significant ΔLSSD were observed for both the heart and LV. When all initial and final LSSD maps were aggregated for the training cases, before training, the mean LSSD ([range], standard deviation) was -0.8 mm ([-37.9, 34.9], 4.2) and 0.3 mm ([-25.1, 32.7], 4.8) for heart and LV, respectively. These were reduced to -0.1 mm ([-16.2, 7.3], 0.8) and 0.1 mm ([-6.6, 8.3], 0.7) for the final LSSD maps during the contour training sessions. For the retention case, the initial and final LSSD maps of the retention case were aggregated and were -1.5 mm ([-22.9, 19.9], 3.4) and -0.2 mm ([-4.5, 1.5], 0.7) for the heart and 1.8 mm ([-16.7, 34.5], 5.1) and 0.2 mm ([-3.9, 1.6],0.7) for the LV. Conclusions A tool that uses real-time contouring feedback was developed and successfully used for contour training of nine trainees. In all cases, the utility was able to guide the trainee and ultimately reduce the variability of the trainee's contouring.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jinzhong Yang
- *Correspondence: Christopher L. Nelson, ; Jinzhong Yang,
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Martel MK. Past AAPM President: 2007. Med Phys 2023; 50 Suppl 1:137. [PMID: 37428590 DOI: 10.1002/mp.16273] [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: 09/20/2022] [Revised: 09/20/2022] [Accepted: 01/31/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Mary K Martel
- Department of Radiation Physics, Division of Radiation Oncology, UT MD Anderson Cancer Center, Houston, Texas, USA
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Briere TM, Agrusa JE, Martel MK, Jackson A, Olch AJ, Ronckers CM, Kremer LCM, Constine LS, McAleer MF. Acute and Late Pulmonary Effects After Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)00132-8. [PMID: 35525723 DOI: 10.1016/j.ijrobp.2022.01.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Pediatric Normal Tissue Effects in the Clinic (PENTEC) pulmonary task force reviewed dosimetric and clinical factors associated with radiation therapy (RT)-associated pulmonary toxicity in children. METHODS Comprehensive search of PubMed (1965-2020) was conducted to assess available evidence and predictive models of RT-induced lung injury in pediatric cancer patients (<21 years old). Lung dose for radiation pneumonitis (RP) was obtained from dose-volume histogram (DVH) data. RP grade was obtained from standard criteria. Clinical pulmonary outcomes were evaluated using pulmonary function tests (PFTs), clinical assessment, and questionnaires. RESULTS More than 2,400 abstracts were identified; 460 articles had detailed treatment and toxicity data; and 11 articles with both detailed DVH and toxicity data were formally reviewed. Pooled cohorts treated during 1999 to 2016 included 277 and 507 patients age 0.04 to 22.7 years who were evaluable for acute and late RP analysis, respectively. After partial lung RT, there were 0.4% acute and 2.8% late grade 2, 0.4% acute and 0.8% late grade 3, and no grade 4 to 5 RP. RP risk after partial thoracic RT with mean lung dose (MLD) <14 Gy and total lung V20Gy <30% is low. Clinical and self-reported pulmonary outcomes data included 8,628 patients treated during 1970 to 2013, age 0 to 21.9 years. At a median 2.9- to 21.9-year follow-up, patients were often asymptomatic; abnormal PFTs were common and severity correlated with lung dose. At ≥10-year follow-up, multi-institutional studies suggested associations between total or ipsilateral lung doses >10 Gy and pulmonary complications and deaths. After whole lung irradiation (WLI), pulmonary toxicity is higher; no dose response relationship was identified. Bleomycin and other chemotherapeutics at current dose regimens do not contribute substantially to adverse pulmonary outcomes after partial lung irradiation but increase risk with WLI. CONCLUSIONS After partial lung RT, acute pulmonary toxicity is uncommon; grade 2 to 3 RP incidences are <1%. Late toxicities, including subclinical/asymptomatic impaired pulmonary function, are more common (<4%). Incidence and severity appear to increase over time. Upon review of available literature, there appears to be low risk of pulmonary complications in children with MLD < 14 Gy and V20Gy <30% using standard fractionated RT to partial lung volumes. A lack of robust data limit guidance on lung dose/volume constraints, highlighting the need for additional work to define factors associated with RT-induced lung injury.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer E Agrusa
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Arthur J Olch
- Department of Radiation Oncology University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Cécile M Ronckers
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C M Kremer
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Han EY, Cardenas CE, Nguyen C, Hancock D, Xiao Y, Mumme R, Court LE, Rhee DJ, Netherton TJ, Li J, Yeboa DN, Wang C, Briere TM, Balter P, Martel MK, Wen Z. Clinical implementation of automated treatment planning for whole-brain radiotherapy. J Appl Clin Med Phys 2021; 22:94-102. [PMID: 34250715 PMCID: PMC8425887 DOI: 10.1002/acm2.13350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 12/22/2022] Open
Abstract
The purpose of the study was to develop and clinically deploy an automated, deep learning‐based approach to treatment planning for whole‐brain radiotherapy (WBRT). We collected CT images and radiotherapy treatment plans to automate a beam aperture definition from 520 patients who received WBRT. These patients were split into training (n = 312), cross‐validation (n = 104), and test (n = 104) sets which were used to train and evaluate a deep learning model. The DeepLabV3+ architecture was trained to automatically define the beam apertures on lateral‐opposed fields using digitally reconstructed radiographs (DRRs). For the beam aperture evaluation, 1st quantitative analysis was completed using a test set before clinical deployment and 2nd quantitative analysis was conducted 90 days after clinical deployment. The mean surface distance and the Hausdorff distances were compared in the anterior‐inferior edge between the clinically used and the predicted fields. Clinically used plans and deep‐learning generated plans were evaluated by various dose–volume histogram metrics of brain, cribriform plate, and lens. The 1st quantitative analysis showed that the average mean surface distance and Hausdorff distance were 7.1 mm (±3.8 mm) and 11.2 mm (±5.2 mm), respectively, in the anterior–inferior edge of the field. The retrospective dosimetric comparison showed that brain dose coverage (D99%, D95%, D1%) of the automatically generated plans was 29.7, 30.3, and 32.5 Gy, respectively, and the average dose of both lenses was up to 19.0% lower when compared to the clinically used plans. Following the clinical deployment, the 2nd quantitative analysis showed that the average mean surface distance and Hausdorff distance between the predicted and clinically used fields were 2.6 mm (±3.2 mm) and 4.5 mm (±5.6 mm), respectively. In conclusion, the automated patient‐specific treatment planning solution for WBRT was implemented in our clinic. The predicted fields appeared consistent with clinically used fields and the predicted plans were dosimetrically comparable.
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Affiliation(s)
- Eun Young Han
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos E Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Callistus Nguyen
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald Hancock
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yao Xiao
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raymond Mumme
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence E Court
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dong Joo Rhee
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tucker J Netherton
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina M Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Balter
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhifei Wen
- Department of Radiation Oncology, Hoag Hospital, Newport Beach, CA, USA
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Krafft SP, Rao A, Stingo F, Briere TM, Court LE, Liao Z, Martel MK. Erratum: "The utility of quantitative CT radiomics features for improved prediction of radiation pneumonitis" [Med. Phys. Vol. 45(11):5317-5324 (2018)]. Med Phys 2019; 46:1079. [PMID: 30730574 DOI: 10.1002/mp.13327] [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: 01/25/2018] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Shane P Krafft
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Arvind Rao
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Francesco Stingo
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tina Marie Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Pollard-Larkin JM, Paradis KC, Moran JM, Martel MK, Rong Y. Voices for gender equity in medical physics. J Appl Clin Med Phys 2018; 19:6-10. [PMID: 30408312 PMCID: PMC6236816 DOI: 10.1002/acm2.12487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 09/10/2018] [Accepted: 09/10/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Julianne M Pollard-Larkin
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, Huston, TX, USA
| | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, Huston, TX, USA
| | - Yi Rong
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
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7
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Krafft SP, Rao A, Stingo F, Briere TM, Court LE, Liao Z, Martel MK. The utility of quantitative CT radiomics features for improved prediction of radiation pneumonitis. Med Phys 2018; 45:5317-5324. [PMID: 30133809 DOI: 10.1002/mp.1315023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 05/25/2023] Open
Abstract
PURPOSE The purpose of this study was to explore gains in predictive model performance for radiation pneumonitis (RP) using pretreatment CT radiomics features extracted from the normal lung volume. METHODS A total of 192 patients treated for nonsmall cell lung cancer with definitive radiotherapy were considered in the current study. In addition to clinical and dosimetric data, CT radiomics features were extracted from the total lung volume defined using the treatment planning scan. A total of 6851 features (15 clinical, 298 total lung and heart dosimetric, and 6538 image features) were gathered and considered candidate predictors for modeling of RP grade ≥3. Models were built with the least absolute shrinkage and selection operator (LASSO) logistic regression and applied to the set of candidate predictors with 50 iterations of tenfold nested cross-validation. RESULTS In the current cohort, 30 of 192 patients (15.6%) presented with RP grade ≥3. Average cross-validated AUC (CV-AUC) using only the clinical and dosimetric parameters was 0.51. CV-AUC was 0.68 when total lung CT radiomics features were added. Analysis with the entire set of available predictors revealed seven different image features selected in at least 40% of the model fits. CONCLUSIONS We have successfully incorporated CT radiomics features into a framework for building predictive RP models via LASSO logistic regression. Addition of normal lung image features produced superior model performance relative to traditional dosimetric and clinical predictors of RP, suggesting that pretreatment CT radiomics features should be considered in the context of RP prediction.
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Affiliation(s)
- Shane P Krafft
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Arvind Rao
- Department of Bioinformatics and Computational Biology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Stingo
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Marie Briere
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Krafft SP, Rao A, Stingo F, Briere TM, Court LE, Liao Z, Martel MK. The utility of quantitative CT radiomics features for improved prediction of radiation pneumonitis. Med Phys 2018; 45:5317-5324. [PMID: 30133809 DOI: 10.1002/mp.13150] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The purpose of this study was to explore gains in predictive model performance for radiation pneumonitis (RP) using pretreatment CT radiomics features extracted from the normal lung volume. METHODS A total of 192 patients treated for nonsmall cell lung cancer with definitive radiotherapy were considered in the current study. In addition to clinical and dosimetric data, CT radiomics features were extracted from the total lung volume defined using the treatment planning scan. A total of 6851 features (15 clinical, 298 total lung and heart dosimetric, and 6538 image features) were gathered and considered candidate predictors for modeling of RP grade ≥3. Models were built with the least absolute shrinkage and selection operator (LASSO) logistic regression and applied to the set of candidate predictors with 50 iterations of tenfold nested cross-validation. RESULTS In the current cohort, 30 of 192 patients (15.6%) presented with RP grade ≥3. Average cross-validated AUC (CV-AUC) using only the clinical and dosimetric parameters was 0.51. CV-AUC was 0.68 when total lung CT radiomics features were added. Analysis with the entire set of available predictors revealed seven different image features selected in at least 40% of the model fits. CONCLUSIONS We have successfully incorporated CT radiomics features into a framework for building predictive RP models via LASSO logistic regression. Addition of normal lung image features produced superior model performance relative to traditional dosimetric and clinical predictors of RP, suggesting that pretreatment CT radiomics features should be considered in the context of RP prediction.
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Affiliation(s)
- Shane P Krafft
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.,The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Arvind Rao
- Department of Bioinformatics and Computational Biology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Stingo
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Marie Briere
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Benedict SH, Hoffman K, Martel MK, Abernethy AP, Asher AL, Capala J, Chen RC, Chera B, Couch J, Deye J, Efstathiou JA, Ford E, Fraass BA, Gabriel PE, Huser V, Kavanagh BD, Khuntia D, Marks LB, Mayo C, McNutt T, Miller RS, Moore KL, Prior F, Roelofs E, Rosenstein BS, Sloan J, Theriault A, Vikram B. Overview of the American Society for Radiation Oncology-National Institutes of Health-American Association of Physicists in Medicine Workshop 2015: Exploring Opportunities for Radiation Oncology in the Era of Big Data. Int J Radiat Oncol Biol Phys 2017; 95:873-879. [PMID: 27302503 DOI: 10.1016/j.ijrobp.2016.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 01/24/2023]
Affiliation(s)
| | - Karen Hoffman
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary K Martel
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Anthony L Asher
- American Association of Neurological Surgeons, Rolling Meadows, Illinois
| | - Jacek Capala
- Clinical Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald C Chen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Bhisham Chera
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer Couch
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - James Deye
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jason A Efstathiou
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Ford
- University of Washington, Seattle, Washington
| | | | - Peter E Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vojtech Huser
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Maryland
| | | | | | - Lawrence B Marks
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Todd McNutt
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Kevin L Moore
- University of California, San Diego, La Jolla, California
| | - Fred Prior
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erik Roelofs
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | | | - Bhadrasain Vikram
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Niedzielski JS, Yang J, Mohan R, Titt U, Mirkovic D, Stingo F, Liao Z, Gomez DR, Martel MK, Briere TM, Court LE. Differences in Normal Tissue Response in the Esophagus Between Proton and Photon Radiation Therapy for Non-Small Cell Lung Cancer Using In Vivo Imaging Biomarkers. Int J Radiat Oncol Biol Phys 2017; 99:1013-1020. [PMID: 29063837 DOI: 10.1016/j.ijrobp.2017.07.005] [Citation(s) in RCA: 4] [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] [Received: 01/24/2017] [Revised: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE To determine whether there exists any significant difference in normal tissue toxicity between intensity modulated radiation therapy (IMRT) or proton therapy for the treatment of non-small cell lung cancer. METHODS AND MATERIALS A total of 134 study patients (n=49 treated with proton therapy, n=85 with IMRT) treated in a randomized trial had a previously validated esophageal toxicity imaging biomarker, esophageal expansion, quantified during radiation therapy, as well as esophagitis grade (Common Terminology Criteria for Adverse Events version 3.0), on a weekly basis during treatment. Differences between the 2 modalities were statically analyzed using the imaging biomarker metric value (Kruskal-Wallis analysis of variance), as well as the incidence and severity of esophagitis grade (χ2 and Fisher exact tests, respectively). The dose-response of the imaging biomarker was also compared between modalities using esophageal equivalent uniform dose, as well as delivered dose to an isotropic esophageal subvolume. RESULTS No statistically significant difference in the distribution of esophagitis grade, the incidence of grade ≥3 esophagitis (15 and 11 patients treated with IMRT and proton therapy, respectively), or the esophageal expansion imaging biomarker between cohorts (P>.05) was found. The distribution of imaging biomarker metric values had similar distributions between treatment arms, despite a slightly higher dose volume in the proton arm (P>.05). Imaging biomarker dose-response was similar between modalities for dose quantified as esophageal equivalent uniform dose and delivered esophageal subvolume dose. Regardless of treatment modality, there was high variability in imaging biomarker response, as well as esophagitis grade, for similar esophageal doses between patients. CONCLUSIONS There was no significant difference in esophageal toxicity from either proton- or photon-based radiation therapy as quantified by esophagitis grade or the esophageal expansion imaging biomarker.
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Affiliation(s)
- Joshua S Niedzielski
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas.
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Uwe Titt
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Dragan Mirkovic
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Francesco Stingo
- Department of Statistics, Computer Science, Applications "G. Parenti," University of Florence, Florence, Italy
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Tina M Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
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Briere TM, Krafft S, Liao Z, Martel MK. In Reply to Jin et al. Int J Radiat Oncol Biol Phys 2016; 96:481-482. [DOI: 10.1016/j.ijrobp.2016.06.018] [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: 06/07/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
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Aristophanous M, Suh Y, Chi PC, Whittlesey LJ, LaNeave S, Martel MK. Initial clinical experience with ArcCHECK for IMRT/VMAT QA. J Appl Clin Med Phys 2016; 17:20-33. [PMID: 27685107 PMCID: PMC5874100 DOI: 10.1120/jacmp.v17i5.6118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/31/2016] [Accepted: 03/22/2016] [Indexed: 11/23/2022] Open
Abstract
Many devices designed for the purpose of performing patient‐specific IMRT/VMAT QA are commercially available. In this work we report our experience and initial clinical results with the ArcCHECK. The ArcCHECK consists of a cylindrical array of diode detectors measuring entry and exit doses. The measured result is a cumulative dose displayed as a 2D matrix. The detector array requires both an absolute dose calibration, and a calibration of the detector response, relative to each other. In addition to the calibrations suggested by the manufacturer, various tests were performed in order to assess its stability and performance prior to clinical introduction. Tests of uniformity, linearity, and repetition rate dependence of the detector response were conducted and described in this work. Following initial testing, the ArcCHECK device was introduced in the clinic for routine patient‐specific IMRT QA. The clinical results from one year of use were collected and analyzed. The gamma pass rates at the 3%/3 mm criterion were reported for 3,116 cases that included both IMRT and VMAT treatment plans delivered on 18 linear accelerators. The gamma pass rates were categorized based on the treatment site, treatment technique, type of MLCs, operator, ArcCHECK device, and LINAC model. We recorded the percent of failures at the clinically acceptable threshold of 90%. In addition, we calculated the threshold that encompasses two standard deviations (2 SD) (95%) of QAs (T95) for each category investigated. The commissioning measurements demonstrated that the device performed as expected. The uniformity of the detector response to a constant field arc delivery showed a 1% standard deviation from the mean. The variation in dose with changing repetition rate was within 1 cGy of the mean, while the measured dose showed a linear relation with delivered MUs. Our initial patient QA results showed that, at the clinically selected passing criterion, 4.5% of cases failed. On average T95 was 91%, ranging from 73% for gynecological sites to 96.5% for central nervous system sites. There are statistically significant differences in passing rates between IMRT and VMAT, high‐definition (HD) and non‐HD MLCs, and different LINAC models (p‐values <<0.001). An additional investigation into the failing QAs and a comparison with ion‐chamber measurements reveals that the differences observed in the passing rates between the different studied factors can be largely explained by the field size dependence of the device. Based on our initial experience with the ArcCHECK, our passing rates are, on average, consistent with values reported in the AAPM TG‐119. However, the significant variations between QAs that were observed based on the size of the treatment fields may need to be corrected to improve the specificity and sensitivity of the device. PACS number(s): 87.55.Qr, 87.56.Fc
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Farnia B, Philip N, Georges RH, McAleer MF, Palmer M, Yang J, Allen PK, Martel MK, Mahajan A, McGovern SL. Reirradiation of Recurrent Pediatric Brain Tumors after Initial Proton Therapy. Int J Part Ther 2016; 3:1-12. [PMID: 31772970 PMCID: PMC6871582 DOI: 10.14338/ijpt-15-00036.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 10/20/2015] [Accepted: 03/08/2016] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The use of reirradiation for recurrent pediatric brain tumors has been increasing, but the effect of repeat radiation on critical cranial structures is unknown. METHODS AND MATERIALS Between July 2009 and May 2013, the records of 12 pediatric patients initially treated with proton therapy and then with reirradiation for recurrent brain tumors were retrospectively reviewed for toxicity and outcomes. Initial and repeat radiation dose distributions were deformed and merged to determine the maximum dose to 0.03 cm3 of the optic chiasm, optic nerves, spinal cord, brainstem, cochleae, pituitary, and uninvolved brain, and to 1 cm3 of the brainstem and brain on individual and composite plans. These dosimetric results were compared with auditory, neurocognitive, ophthalmologic, and endocrine outcomes to identify radiation-associated toxicities. RESULTS Median follow-up was 3.5 years from diagnosis. Median ages at initial and repeat radiation were 4.6 and 6.7 years, respectively. All patients initially received proton radiotherapy to a median tumor dose of 55.8 Gy relative biological effectiveness (RBE) (range, 45 to 60 Gy [RBE]). At progression, patients completed a second course of radiation to local fields (n = 7) or the craniospinal axis (n = 5) with a median tumor dose of 40 Gy (RBE) (range, 20 to 54 Gy [RBE]). Median progression-free survival was 22.7 months from the last day of the second radiation course. No patient developed central nervous system necrosis requiring treatment. Of evaluable patients, none developed radiation-related high-grade hearing loss (n = 11), visual pathway deficit (n = 10), or significant change in pre- and post-reirradiation full-scale intelligence quotient (n = 4). Of 11 evaluable patients, 4 (36.4%) developed secondary hypothyroidism and 1 (9.1%) developed growth hormone deficiency. CONCLUSION Repeat radiation for recurrent brain tumors after proton therapy may be performed in the pediatric population with acceptable short- and long-term toxicity.
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Affiliation(s)
- Benjamin Farnia
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nancy Philip
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Rola H. Georges
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Matthew Palmer
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Pamela K. Allen
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Mary K. Martel
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Susan L. McGovern
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Niedzielski JS, Yang J, Liao Z, Gomez DR, Stingo F, Mohan R, Martel MK, Briere TM, Court LE. (18)F-Fluorodeoxyglucose Positron Emission Tomography Can Quantify and Predict Esophageal Injury During Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:670-8. [PMID: 27681764 DOI: 10.1016/j.ijrobp.2016.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/05/2016] [Accepted: 07/13/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE We sought to investigate the ability of mid-treatment (18)F-fluorodeoxyglucose positron emission tomography (PET) studies to objectively and spatially quantify esophageal injury in vivo from radiation therapy for non-small cell lung cancer. METHODS AND MATERIALS This retrospective study was approved by the local institutional review board, with written informed consent obtained before enrollment. We normalized (18)F-fluorodeoxyglucose PET uptake to each patient's low-irradiated region (<5 Gy) of the esophagus, as a radiation response measure. Spatially localized metrics of normalized uptake (normalized standard uptake value [nSUV]) were derived for 79 patients undergoing concurrent chemoradiation therapy for non-small cell lung cancer. We used nSUV metrics to classify esophagitis grade at the time of the PET study, as well as maximum severity by treatment completion, according to National Cancer Institute Common Terminology Criteria for Adverse Events, using multivariate least absolute shrinkage and selection operator (LASSO) logistic regression and repeated 3-fold cross validation (training, validation, and test folds). This 3-fold cross-validation LASSO model procedure was used to predict toxicity progression from 43 asymptomatic patients during the PET study. Dose-volume metrics were also tested in both the multivariate classification and the symptom progression prediction analyses. Classification performance was quantified with the area under the curve (AUC) from receiver operating characteristic analysis on the test set from the 3-fold analyses. RESULTS Statistical analysis showed increasing nSUV is related to esophagitis severity. Axial-averaged maximum nSUV for 1 esophageal slice and esophageal length with at least 40% of axial-averaged nSUV both had AUCs of 0.85 for classifying grade 2 or higher esophagitis at the time of the PET study and AUCs of 0.91 and 0.92, respectively, for maximum grade 2 or higher by treatment completion. Symptom progression was predicted with an AUC of 0.75. Dose metrics performed poorly at classifying esophagitis (AUC of 0.52, grade 2 or higher mid treatment) or predicting symptom progression (AUC of 0.67). CONCLUSIONS Normalized uptake can objectively, locally, and noninvasively quantify esophagitis during radiation therapy and predict eventual symptoms from asymptomatic patients. Normalized uptake may provide patient-specific dose-response information not discernible from dose.
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Affiliation(s)
- Joshua S Niedzielski
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas.
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Francesco Stingo
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas
| | - Tina M Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas Houston Graduate School of Biomedical Science, Houston, Texas
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Jani AB, Gratzle J, Muresan E, Martel MK. Impact on Late Toxicity of using Transabdominal Ultrasound for Prostate Cancer Patients Treated with Intensity Modulated Radiotherapy. Technol Cancer Res Treat 2016; 4:115-20. [PMID: 15649095 DOI: 10.1177/153303460500400115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
An analysis of the effects of using the B-mode ultrasound Acquisition and Targeting (BAT) system for positioning of prostate cancer patients receiving external beam radiotherapy (EBRT) on late gastrointestinal (GI) and genitourinary (GU) toxicity is provided. The records of 49 consecutive patients treated using the BAT were reviewed; additionally, a comparison (No-BAT) group treated in a similar manner was identified, consisting of 49 patients treated immediately prior to this BAT group. There were no other fundamental differences between the two groups. The daily BAT movements were charted and late toxicity was scored for all patients using established toxicity scales. The results demonstrated similar GU toxicity rates between the two groups, but slightly lower rates of GI toxicity in the BAT group vs. the No-BAT group. However, regression analyses revealed that no factors, including BAT use, were significantly correlated with late GI or GU toxicity. Further efforts, perhaps better undertaken in a multi-institutional setting, are needed to determine whether BAT use can significantly reduce late GI toxicity.
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Affiliation(s)
- Ashesh B Jani
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, 5758 S. Maryland Ave., MC 9006, Chicago, IL 60637 USA.
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Farnia B, Philip N, Georges RH, McAleer MF, Palmer M, Yang J, Allen PK, Martel MK, Mahajan A, McGovern SL. Reirradiation of Recurrent Pediatric Brain Tumors after Initial Proton Therapy. Int J Part Ther 2016. [DOI: 10.14338/ijpt-15-00036] [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: 11/21/2022] Open
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17
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Briere TM, Krafft S, Liao Z, Martel MK. Lung Size and the Risk of Radiation Pneumonitis. Int J Radiat Oncol Biol Phys 2015; 94:377-84. [PMID: 26675062 DOI: 10.1016/j.ijrobp.2015.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 07/07/2015] [Accepted: 10/01/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to identify patient populations treated for non-small cell lung cancer (NSCLC) who may be more at risk of radiation pneumonitis. METHODS AND MATERIALS A total of 579 patients receiving fractionated 3D conformal or intensity modulated radiation therapy (IMRT) for NSCLC were included in the study. Statistical analysis was performed to search for cohorts of patients with higher incidences of radiation pneumonitis. In addition to conventional risk factors, total and spared lung volumes were analyzed. The Lyman-Kutcher-Burman (LKB) and cure models were then used to fit the incidence of radiation pneumonitis as a function of lung dose and other factors. RESULTS Total lung volumes with a sparing of less than 1854 cc at 40 Gy were associated with a significantly higher incidence of radiation pneumonitis at 6 months (38% vs 12% for patients with larger volumes, P<.001). This patient cohort was overwhelmingly female and represented 22% of the total female population of patients and nearly 30% of the cases of radiation pneumonitis. An LKB fit to normal tissue complication probability (NTCP) including volume as a dose modifying factor resulted in a dose that results in a 50% probability of complication for the smaller spared volume cohort that was 9 Gy lower than the fit to all mean lung dose data and improved the ability to predict radiation pneumonitis (P<.001). Using an effective dose parameter of n=0.42 instead of mean lung dose further improved the LKB fit. Fits to the data using the cure model produced similar results. CONCLUSIONS Spared lung volume should be considered when treating NSCLC patients. Separate dose constraints based on smaller spared lung volume should be considered. Smaller spared lung volume patients should be followed closely for signs of radiation pneumonitis.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Shane Krafft
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Chetty IJ, Martel MK, Jaffray DA, Benedict SH, Hahn SM, Berbeco R, Deye J, Jeraj R, Kavanagh B, Krishnan S, Lee N, Low DA, Mankoff D, Marks LB, Ollendorf D, Paganetti H, Ross B, Siochi RAC, Timmerman RD, Wong JW. Technology for Innovation in Radiation Oncology. Int J Radiat Oncol Biol Phys 2015; 93:485-92. [PMID: 26460989 DOI: 10.1016/j.ijrobp.2015.07.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/30/2015] [Accepted: 07/06/2015] [Indexed: 01/18/2023]
Abstract
Radiation therapy is an effective, personalized cancer treatment that has benefited from technological advances associated with the growing ability to identify and target tumors with accuracy and precision. Given that these advances have played a central role in the success of radiation therapy as a major component of comprehensive cancer care, the American Society for Radiation Oncology (ASTRO), the American Association of Physicists in Medicine (AAPM), and the National Cancer Institute (NCI) sponsored a workshop entitled "Technology for Innovation in Radiation Oncology," which took place at the National Institutes of Health (NIH) in Bethesda, Maryland, on June 13 and 14, 2013. The purpose of this workshop was to discuss emerging technology for the field and to recognize areas for greater research investment. Expert clinicians and scientists discussed innovative technology in radiation oncology, in particular as to how these technologies are being developed and translated to clinical practice in the face of current and future challenges and opportunities. Technologies encompassed topics in functional imaging, treatment devices, nanotechnology, and information technology. The technical, quality, and safety performance of these technologies were also considered. A major theme of the workshop was the growing importance of innovation in the domain of process automation and oncology informatics. The technologically advanced nature of radiation therapy treatments predisposes radiation oncology research teams to take on informatics research initiatives. In addition, the discussion on technology development was balanced with a parallel conversation regarding the need for evidence of efficacy and effectiveness. The linkage between the need for evidence and the efforts in informatics research was clearly identified as synergistic.
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Affiliation(s)
- Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - David A Jaffray
- Departments of Radiation Oncology and Medical Biophysics, Princess Margaret Hospital, Toronto, Ontario
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California - Davis Cancer Center, Sacramento, California
| | - Stephen M Hahn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ross Berbeco
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - James Deye
- Radiation Research Programs, National Cancer Institute, Bethesda, Maryland
| | - Robert Jeraj
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
| | - Brian Kavanagh
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Sunil Krishnan
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel A Low
- Department of Radiation Oncology, University of California - Los Angeles, Los Angeles, California
| | - David Mankoff
- Department of Radiology, University of Washington Medical School, Seattle, Washington
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Daniel Ollendorf
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Proton Therapy Center, Boston, Massachusetts
| | - Brian Ross
- Department of Radiology, University of Michigan Health Systems, Ann Arbor, Michigan
| | | | - Robert D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical School, Dallas, Texas
| | - John W Wong
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland
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Brennan D, Schubert L, Diot Q, Castillo R, Castillo E, Guerrero T, Martel MK, Linderman D, Gaspar LE, Miften M, Kavanagh BD, Vinogradskiy Y. Clinical validation of 4-dimensional computed tomography ventilation with pulmonary function test data. Int J Radiat Oncol Biol Phys 2015; 92:423-9. [PMID: 25817531 DOI: 10.1016/j.ijrobp.2015.01.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/09/2015] [Accepted: 01/13/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE A new form of functional imaging has been proposed in the form of 4-dimensional computed tomography (4DCT) ventilation. Because 4DCTs are acquired as part of routine care for lung cancer patients, calculating ventilation maps from 4DCTs provides spatial lung function information without added dosimetric or monetary cost to the patient. Before 4DCT-ventilation is implemented it needs to be clinically validated. Pulmonary function tests (PFTs) provide a clinically established way of evaluating lung function. The purpose of our work was to perform a clinical validation by comparing 4DCT-ventilation metrics with PFT data. METHODS AND MATERIALS Ninety-eight lung cancer patients with pretreatment 4DCT and PFT data were included in the study. Pulmonary function test metrics used to diagnose obstructive lung disease were recorded: forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity. Four-dimensional CT data sets and spatial registration were used to compute 4DCT-ventilation images using a density change-based and a Jacobian-based model. The ventilation maps were reduced to single metrics intended to reflect the degree of ventilation obstruction. Specifically, we computed the coefficient of variation (SD/mean), ventilation V20 (volume of lung ≤20% ventilation), and correlated the ventilation metrics with PFT data. Regression analysis was used to determine whether 4DCT ventilation data could predict for normal versus abnormal lung function using PFT thresholds. RESULTS Correlation coefficients comparing 4DCT-ventilation with PFT data ranged from 0.63 to 0.72, with the best agreement between FEV1 and coefficient of variation. Four-dimensional CT ventilation metrics were able to significantly delineate between clinically normal versus abnormal PFT results. CONCLUSIONS Validation of 4DCT ventilation with clinically relevant metrics is essential. We demonstrate good global agreement between PFTs and 4DCT-ventilation, indicating that 4DCT-ventilation provides a reliable assessment of lung function. Four-dimensional CT ventilation enables exciting opportunities to assess lung function and create functional avoidance radiation therapy plans. The present work provides supporting evidence for the integration of 4DCT-ventilation into clinical trials.
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Affiliation(s)
| | - Leah Schubert
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Quentin Diot
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Richard Castillo
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas
| | - Edward Castillo
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Thomas Guerrero
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Derek Linderman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado.
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Hunter LA, Krafft S, Stingo F, Choi H, Martel MK, Kry SF, Court LE. High quality machine-robust image features: identification in nonsmall cell lung cancer computed tomography images. Med Phys 2014; 40:121916. [PMID: 24320527 DOI: 10.1118/1.4829514] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE For nonsmall cell lung cancer (NSCLC) patients, quantitative image features extracted from computed tomography (CT) images can be used to improve tumor diagnosis, staging, and response assessment. For these findings to be clinically applied, image features need to have high intra and intermachine reproducibility. The objective of this study is to identify CT image features that are reproducible, nonredundant, and informative across multiple machines. METHODS Noncontrast-enhanced, test-retest CT image pairs were obtained from 56 NSCLC patients imaged on three CT machines from two institutions. Two machines ("M1" and "M2") used cine 4D-CT and one machine ("M3") used breath-hold helical 3D-CT. Gross tumor volumes (GTVs) were semiautonomously segmented then pruned by removing voxels with CT numbers less than a prescribed Hounsfield unit (HU) cutoff. Three hundred and twenty eight quantitative image features were extracted from each pruned GTV based on its geometry, intensity histogram, absolute gradient image, co-occurrence matrix, and run-length matrix. For each machine, features with concordance correlation coefficient values greater than 0.90 were considered reproducible. The Dice similarity coefficient (DSC) and the Jaccard index (JI) were used to quantify reproducible feature set agreement between machines. Multimachine reproducible feature sets were created by taking the intersection of individual machine reproducible feature sets. Redundant features were removed through hierarchical clustering based on the average correlation between features across multiple machines. RESULTS For all image types, GTV pruning was found to negatively affect reproducibility (reported results use no HU cutoff). The reproducible feature percentage was highest for average images (M1 = 90.5%, M2 = 94.5%, M1∩M2 = 86.3%), intermediate for end-exhale images (M1 = 75.0%, M2 = 71.0%, M1∩M2 = 52.1%), and lowest for breath-hold images (M3 = 61.0%). Between M1 and M2, the reproducible feature sets generated from end-exhale images were relatively machine-sensitive (DSC = 0.71, JI = 0.55), and the reproducible feature sets generated from average images were relatively machine-insensitive (DSC = 0.90, JI = 0.87). Histograms of feature pair correlation distances indicated that feature redundancy was machine-sensitive and image type sensitive. After hierarchical clustering, 38 features, 28 features, and 33 features were found to be reproducible and nonredundant for M1∩M2 (average images), M1∩M2 (end-exhale images), and M3, respectively. When blinded to the presence of test-retest images, hierarchical clustering showed that the selected features were informative by correctly pairing 55 out of 56 test-retest images using only their reproducible, nonredundant feature set values. CONCLUSIONS Image feature reproducibility and redundancy depended on both the CT machine and the CT image type. For each image type, the authors found a set of cross-machine reproducible, nonredundant, and informative image features that would be useful for future image-based models. Compared to end-exhale 4D-CT and breath-hold 3D-CT, average 4D-CT derived image features showed superior multimachine reproducibility and are the best candidates for clinical correlation.
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Affiliation(s)
- Luke A Hunter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Centre, 1515 Holcombe, Houston, Texas 77030
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21
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Tucker SL, Liao Z, Dinh J, Bian SX, Mohan R, Martel MK, Grosshans DR. Is there an impact of heart exposure on the incidence of radiation pneumonitis? Analysis of data from a large clinical cohort. Acta Oncol 2014; 53:590-6. [PMID: 23992110 DOI: 10.3109/0284186x.2013.831185] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The goal of the present study was to determine, in a large clinical cohort, whether incidental radiation exposure to the heart during definitive radiotherapy of inoperable non-small cell lung cancer (NSCLC) detectably increased the risk of radiation pneumonitis (RP) beyond that resulting from radiation exposure to lung. MATERIAL AND METHODS Data were analyzed from all patients who received definitive three-dimensional (3D) concurrent radiotherapy or intensity-modulated radiotherapy for the treatment of NSCLC over a 10-year period at our institution, except those who had previous lung cancer or for whom radiation treatment plans were unavailable for calculation of heart and lung dose-volume histograms (DVHs). Parameters computed from heart and lung DVHs included mean lung dose (MLD), effective lung dose computed using volume parameter n = 0.5 (Deff), mean heart dose (MHD), percentage of heart receiving > 65 Gy (V65), and minimum dose to the hottest 10% of heart (D10). Univariate and multivariate normal-tissue complication probability (NTCP) models were used to analyze incidence of Grade ≥ 2 or Grade ≥ 3 RP as a function of these and other parameters. RESULTS The study cohort included 629 patients, with crude rates of Grade ≥ 2 RP and Grade ≥ 3 RP of N = 263 (42%) and N = 124 (20%), respectively. Univariate NTCP models based on dosimetric lung parameters (MLD and Deff) fit the data better than models based on univariate heart parameters (heart D10, heart V65 or MHD). In multivariate modeling, incorporation of heart parameters did not significantly improve the fit of RP risk models based on lung parameters alone (p > 0.38 in each case). CONCLUSIONS In this large clinical cohort, there was no evidence that incidental heart exposure during radiotherapy of NSCLC had a detectable impact on the occurrence of moderate or severe RP.
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Affiliation(s)
- Susan L Tucker
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
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Allen Li X, Alber M, Deasy JO, Jackson A, Ken Jee KW, Marks LB, Martel MK, Mayo C, Moiseenko V, Nahum AE, Niemierko A, Semenenko VA, Yorke ED. The use and QA of biologically related models for treatment planning: short report of the TG-166 of the therapy physics committee of the AAPM. Med Phys 2013; 39:1386-409. [PMID: 22380372 DOI: 10.1118/1.3685447] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Treatment planning tools that use biologically related models for plan optimization and/or evaluation are being introduced for clinical use. A variety of dose-response models and quantities along with a series of organ-specific model parameters are included in these tools. However, due to various limitations, such as the limitations of models and available model parameters, the incomplete understanding of dose responses, and the inadequate clinical data, the use of biologically based treatment planning system (BBTPS) represents a paradigm shift and can be potentially dangerous. There will be a steep learning curve for most planners. The purpose of this task group is to address some of these relevant issues before the use of BBTPS becomes widely spread. In this report, the authors (1) discuss strategies, limitations, conditions, and cautions for using biologically based models and parameters in clinical treatment planning; (2) demonstrate the practical use of the three most commonly used commercially available BBTPS and potential dosimetric differences between biologically model based and dose-volume based treatment plan optimization and evaluation; (3) identify the desirable features and future directions in developing BBTPS; and (4) provide general guidelines and methodology for the acceptance testing, commissioning, and routine quality assurance (QA) of BBTPS.
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Affiliation(s)
- X Allen Li
- Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Briere TM, Tucker SL, Liao Z, Martel MK. TU-G-108-03: Small Lung Size Increases the Risk of Radiation Pneumonitis in Lung Cancer Patients. Med Phys 2013. [DOI: 10.1118/1.4815452] [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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Court LE, Tucker SL, Gomez D, Liao Z, Zhang J, Kry S, Dong L, Martel MK. A technique to use CT images for in vivo detection and quantification of the spatial distribution of radiation-induced esophagitis. J Appl Clin Med Phys 2013; 14:4195. [PMID: 23652249 PMCID: PMC5714418 DOI: 10.1120/jacmp.v14i3.4195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/31/2013] [Accepted: 01/09/2013] [Indexed: 12/25/2022] Open
Abstract
The purpose of the study was to examine whether CT imaging can be used to quantify radiation‐induced injury to the esophagus. Weekly CT images for 14 patients receiving proton therapy for thoracic tumors were retrospectively reviewed. The images were registered with the original treatment planning CT image using deformable registration techniques, and the esophageal contours from the treatment plan were automatically mapped to the weekly images. The relative change in the size of the esophagus was calculated for each CT slice as the ratio of the cross‐sectional area of the esophagus (minus air) in the weekly CT image to the same area in the planning CT image. The maximum relative change in cross‐sectional area for each CT image was calculated and examined for correlation with the clinical toxicity score for all the patients. The average maximum relative expansion of the esophagus at the end of treatment was 1.41±0.26,1.68±0.36, and 2.10±0.18 for patients with grade 0, 2, and 3 esophagitis, respectively. An unpaired t‐test, with the level of significance corrected with a Bonferroni correction, showed that the difference between grade 3 and 0 was significant, but the differences between grade 0 and 2, and 2 and 3 were not. The timing of changes in esophageal expansion closely matched that of clinically noted changes in patient symptoms. Expansion of the esophagus on CT images has potential as an objective measure of toxicity. The ability to quantify objectively the spatial distribution of radiation‐induced injury will be a useful tool in understanding the impact of partial esophageal sparing on the probability of esophagitis. PACS number: 87.55.dh
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Affiliation(s)
- Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston TX 77030, USA.
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Vinogradskiy Y, Tucker SL, Liao Z, Martel MK. Balancing radiation pneumonitis versus locoregional tumor control in non-small-cell lung cancer. J Thorac Oncol 2013; 8:e47-8. [PMID: 23584304 DOI: 10.1097/jto.0b013e31828cb6fa] [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: 02/03/2023]
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Vinogradskiy Y, Castillo R, Castillo E, Tucker SL, Liao Z, Guerrero T, Martel MK. Use of 4-dimensional computed tomography-based ventilation imaging to correlate lung dose and function with clinical outcomes. Int J Radiat Oncol Biol Phys 2013; 86:366-71. [PMID: 23474113 DOI: 10.1016/j.ijrobp.2013.01.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/30/2012] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Four-dimensional computed tomography (4DCT)-based ventilation is an emerging imaging modality that can be used in the thoracic treatment planning process. The clinical benefit of using ventilation images in radiation treatment plans remains to be tested. The purpose of the current work was to test the potential benefit of using ventilation in treatment planning by evaluating whether dose to highly ventilated regions of the lung resulted in increased incidence of clinical toxicity. METHODS AND MATERIALS Pretreatment 4DCT data were used to compute pretreatment ventilation images for 96 lung cancer patients. Ventilation images were calculated using 4DCT data, deformable image registration, and a density-change based algorithm. Dose-volume and ventilation-based dose function metrics were computed for each patient. The ability of the dose-volume and ventilation-based dose-function metrics to predict for severe (grade 3+) radiation pneumonitis was assessed using logistic regression analysis, area under the curve (AUC) metrics, and bootstrap methods. RESULTS A specific patient example is presented that demonstrates how incorporating ventilation-based functional information can help separate patients with and without toxicity. The logistic regression significance values were all lower for the dose-function metrics (range P=.093-.250) than for their dose-volume equivalents (range, P=.331-.580). The AUC values were all greater for the dose-function metrics (range, 0.569-0.620) than for their dose-volume equivalents (range, 0.500-0.544). Bootstrap results revealed an improvement in model fit using dose-function metrics compared to dose-volume metrics that approached significance (range, P=.118-.155). CONCLUSIONS To our knowledge, this is the first study that attempts to correlate lung dose and 4DCT ventilation-based function to thoracic toxicity after radiation therapy. Although the results were not significant at the .05 level, our data suggests that incorporating ventilation-based functional imaging can improve prediction for radiation pneumonitis. We present an important first step toward validating the use of 4DCT-based ventilation imaging in thoracic treatment planning.
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Affiliation(s)
- Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Evans JD, Gomez DR, Amini A, Rebueno N, Allen PK, Martel MK, Rineer JM, Ang KK, McAvoy S, Cox JD, Komaki R, Welsh JW. Aortic dose constraints when reirradiating thoracic tumors. Radiother Oncol 2013; 106:327-32. [PMID: 23453540 DOI: 10.1016/j.radonc.2013.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/30/2013] [Accepted: 02/09/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Improved radiation delivery and planning has allowed, in some instances, for the retreatment of thoracic tumors. We investigated the dose limits of the aorta wherein grade 5 aortic toxicity was observed after reirradiation of lung tumors. MATERIAL AND METHODS In a retrospective analysis, 35 patients were identified, between 1993 and 2008, who received two rounds of external beam irradiation that included the aorta in the radiation fields of both the initial and retreatment plans. We determined the maximum cumulative dose to 1 cm(3) of the aorta (the composite dose) for each patient, normalized these doses to 1.8 Gy/fraction, and corrected them for long-term tissue recovery between treatments (NIDR). RESULTS The median time interval between treatments was 30 months (range, 1-185 months). The median follow-up of patients alive at analysis was 42 months (range, 14-70 months). Two of the 35 patients (6%) were identified as having grade 5 aortic toxicities. There was a 25% rate of grade 5 aortic toxicity for patients receiving composite doses ≥120.0 Gy (vs. 0% for patients receiving <120.0 Gy) (P=0.047). CONCLUSIONS Grade 5 aortic toxicities were observed with composite doses ≥120.0 Gy (NIDR ≥90.0 Gy) to 1cm(3) of the aorta.
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Affiliation(s)
- Jaden D Evans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
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Tucker SL, Mohan R, Liengsawangwong R, Martel MK, Liao Z. Predicting pneumonitis risk: a dosimetric alternative to mean lung dose. Int J Radiat Oncol Biol Phys 2013; 85:522-7. [PMID: 22580121 DOI: 10.1016/j.ijrobp.2012.03.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/21/2012] [Accepted: 03/22/2012] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine whether the association between mean lung dose (MLD) and risk of severe (grade ≥3) radiation pneumonitis (RP) depends on the dose distribution pattern to normal lung among patients receiving 3-dimensional conformal radiation therapy for non-small-cell lung cancer. METHODS AND MATERIALS Three cohorts treated with different beam arrangements were identified. One cohort (2-field boost [2FB]) received 2 parallel-opposed (anteroposterior-posteroanterior) fields per fraction initially, followed by a sequential boost delivered using 2 oblique beams. The other 2 cohorts received 3 or 4 straight fields (3FS and 4FS, respectively), ie, all fields were irradiated every day. The incidence of severe RP was plotted against MLD in each cohort, and data were analyzed using the Lyman-Kutcher-Burman (LKB) model. RESULTS The incidence of grade ≥3 RP rose more steeply as a function of MLD in the 2FB cohort (N=120) than in the 4FS cohort (N=138), with an intermediate slope for the 3FS group (N=99). The estimated volume parameter from the LKB model was n=0.41 (95% confidence interval, 0.15-1.0) and led to a significant improvement in fit (P=.05) compared to a fit with volume parameter fixed at n=1 (the MLD model). Unlike the MLD model, the LKB model with n=0.41 provided a consistent description of the risk of severe RP in all three cohorts (2FB, 3FS, 4FS) simultaneously. CONCLUSIONS When predicting risk of grade ≥3 RP, the mean lung dose does not adequately take into account the effects of high doses. Instead, the effective dose, computed from the LKB model using volume parameter n=0.41, may provide a better dosimetric parameter for predicting RP risk. If confirmed, these findings support the conclusion that for the same MLD, high doses to small lung volumes ("a lot to a little") are worse than low doses to large volumes ("a little to a lot").
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Affiliation(s)
- Susan L Tucker
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77230-1402, USA.
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Gomez DR, Tucker SL, Martel MK, Mohan R, Balter PA, Lopez Guerra JL, Liu H, Komaki R, Cox JD, Liao Z. Predictors of high-grade esophagitis after definitive three-dimensional conformal therapy, intensity-modulated radiation therapy, or proton beam therapy for non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2012; 84:1010-6. [PMID: 22920974 DOI: 10.1016/j.ijrobp.2012.01.071] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 01/20/2012] [Accepted: 01/24/2012] [Indexed: 12/25/2022]
Abstract
INTRODUCTION We analyzed the ability of various patient- and treatment-related factors to predict radiation-induced esophagitis (RE) in patients with non-small cell lung cancer (NSCLC) treated with three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), or proton beam therapy (PBT). METHODS AND MATERIALS Patients were treated for NSCLC with 3D-CRT, IMRT, or PBT at MD Anderson from 2000 to 2008 and had full dose-volume histogram (DVH) data available. The endpoint was severe (grade≥3) RE. The Lyman-Kutcher-Burman (LKB) model was used to analyze RE as a function of the fractional esophageal DVH, with clinical variables included as dose-modifying factors. RESULTS Overall, 652 patients were included: 405 patients were treated with 3D-CRT, 139 with IMRT, and 108 with PBT; corresponding rates of grade≥3 RE were 8%, 28%, and 6%, respectively, with a median time to onset of 42 days (range, 11-93 days). A fit of the fractional DVH LKB model demonstrated that the fractional effective dose was significantly different (P=.046) than 1 (fractional mean dose) indicating that high doses to small volumes are more predictive than mean esophageal dose. The model fit was better for 3D-CRT and PBT than for IMRT. Including receipt of concurrent chemotherapy as a dose-modifying factor significantly improved the LKB model (P=.005), and the model was further improved by including a variable representing treatment with >30 fractions. Examining individual types of chemotherapy agents revealed a trend toward receipt of concurrent taxanes and increased risk of RE (P=.105). CONCLUSIONS Fractional dose (dose rate) and number of fractions (total dose) distinctly affect the risk of severe RE, estimated using the LKB model, and concurrent chemotherapy improves the model fit. This risk of severe RE is underestimated by this model in patients receiving IMRT.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77054, USA.
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Vinogradskiy YY, Castillo R, Castillo E, Chandler A, Martel MK, Guerrero T. Use of weekly 4DCT-based ventilation maps to quantify changes in lung function for patients undergoing radiation therapy. Med Phys 2012; 39:289-98. [PMID: 22225299 DOI: 10.1118/1.3668056] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE A method has been proposed to calculate ventilation maps from four-dimensional computed tomography (4DCT) images. Weekly 4DCT data were acquired throughout the course of radiation therapy for patients with lung cancer. The purpose of our work was to use ventilation maps calculated from weekly 4DCT data to study how ventilation changed throughout radiation therapy. METHODS Quantitative maps representing ventilation were generated for six patients. Deformable registration was used to link corresponding lung volume elements between the inhale and exhale phases of the 4DCT dataset. Following spatial registration, corresponding Hounsfield units were input into a density-change-based model for quantifying the local ventilation. The ventilation data for all weeks were registered to the pretreatment ventilation image set. We quantitatively analyzed the data by defining regions of interest (ROIs) according to dose (V(20)) and lung lobe and by tracking the weekly ventilation of each ROI throughout treatment. The slope of the linear fit to the weekly ventilation data was used to evaluate the change in ventilation throughout treatment. A positive slope indicated an increase in ventilation, a negative slope indicated a decrease in ventilation, and a slope of 0 indicated no change. The dose ROI ventilation and slope data were used to study how ventilation changed throughout treatment as a function of dose. The lung lobe ROI ventilation data were used to study the impact of the presence of tumor on pretreatment ventilation. In addition, the lobe ROI data were used to study the impact of tumor reduction on ventilation change throughout treatment. RESULTS Using the dose ROI data, we found that three patients had an increase in weekly ventilation as a function of dose (slopes of 1.1, 1.4, and 1.5) and three patients had no change or a slight decrease in ventilation as a function of dose (slopes of 0.3, -0.6, -0.5). Visually, pretreatment ventilation appeared to be lower in the lobes that contained tumor. Pretreatment ventilation was 39% for lobes that contained tumor and 54% for lobes that did not contain tumor. The difference in ventilation between the two groups was statistically significant (p = 0.017). When the weekly lobe ventilation data were qualitatively observed, two distinct patterns emerged. When the tumor volume in a lobe was reduced, ventilation increased in the lobe. When the tumor volume was not reduced, the ventilation distribution did not change. The average slope of the group of lobes that contained tumors that shrank was 1.18, while the average slope of the group that did not contain tumors (or contained tumors that did not shrink) was -0.32. The slopes for the two groups were significantly different (p = 0.014). CONCLUSIONS We did not find a consistent pattern of ventilation change as a function of radiation dose. Pretreatment ventilation was significantly lower for lobes that contained tumor, due to occlusion of the central airway. The weekly lobe ventilation data indicated that when tumor volume shrinks, ventilation increases, and when the thoracic anatomy is not visibly changed, ventilation is likely to remain unchanged.
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Affiliation(s)
- Yevgeniy Y Vinogradskiy
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Vinogradskiy Y, Tucker SL, Liao Z, Martel MK. Investigation of the Relationship Between Gross Tumor Volume Location and Pneumonitis Rates Using a Large Clinical Database of Non-Small-Cell Lung Cancer Patients. Int J Radiat Oncol Biol Phys 2012; 82:1650-8. [DOI: 10.1016/j.ijrobp.2011.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/14/2011] [Accepted: 02/09/2011] [Indexed: 10/18/2022]
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Vinogradskiy Y, Tucker SL, Liao Z, Martel MK. A Novel Method to Incorporate the Spatial Location of the Lung Dose Distribution into Predictive Radiation Pneumonitis Modeling. Int J Radiat Oncol Biol Phys 2012; 82:1549-55. [DOI: 10.1016/j.ijrobp.2011.05.007] [Citation(s) in RCA: 10] [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] [Received: 10/13/2010] [Revised: 04/06/2011] [Accepted: 05/10/2011] [Indexed: 11/28/2022]
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Jiang ZQ, Yang K, Komaki R, Wei X, Tucker SL, Zhuang Y, Martel MK, Vedam S, Balter P, Zhu G, Gomez D, Lu C, Mohan R, Cox JD, Liao Z. Long-term clinical outcome of intensity-modulated radiotherapy for inoperable non-small cell lung cancer: the MD Anderson experience. Int J Radiat Oncol Biol Phys 2011; 83:332-9. [PMID: 22079735 DOI: 10.1016/j.ijrobp.2011.06.1963] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 05/10/2011] [Accepted: 06/14/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE In 2007, we published our initial experience in treating inoperable non-small-cell lung cancer (NSCLC) with intensity-modulated radiation therapy (IMRT). The current report is an update of that experience with long-term follow-up. METHODS AND MATERIALS Patients in this retrospective review were 165 patients who began definitive radiotherapy, with or without chemotherapy, for newly diagnosed, pathologically confirmed NSCLC to a dose of ≥60 Gy from 2005 to 2006. Early and late toxicities assessed included treatment-related pneumonitis (TRP), pulmonary fibrosis, esophagitis, and esophageal stricture, scored mainly according to the Common Terminology Criteria for Adverse Events 3.0. Other variables monitored were radiation-associated dermatitis and changes in body weight and Karnofsky performance status. The Kaplan-Meier method was used to compute survival and freedom from radiation-related acute and late toxicities as a function of time. RESULTS Most patients (89%) had Stage III to IV disease. The median radiation dose was 66 Gy given in 33 fractions (range, 60-76 Gy, 1.8-2.3 Gy per fraction). Median overall survival time was 1.8 years; the 2-year and 3-year overall survival rates were 46% and 30%. Rates of Grade ≥3 maximum TRP (TRP(max)) were 11% at 6 months and 14% at 12 months. At 18 months, 86% of patients had developed Grade ≥1 maximum pulmonary fibrosis (pulmonary fibrosis(max)) and 7% Grade ≥2 pulmonary fibrosis(max). The median times to maximum esophagitis (esophagitis(max)) were 3 weeks (range, 1-13 weeks) for Grade 2 and 6 weeks (range, 3-13 weeks) for Grade 3. A higher percentage of patients who experienced Grade 3 esophagitis(max) later developed Grade 2 to 3 esophageal stricture. CONCLUSIONS In our experience, using IMRT to treat NSCLC leads to low rates of pulmonary and esophageal toxicity, and favorable clinical outcomes in terms of survival.
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Affiliation(s)
- Zhi-Qin Jiang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Du W, Yang JN, Chang EL, Luo D, McAleer MF, Shiu A, Martel MK. A quality assurance procedure to evaluate cone-beam CT image center congruence with the radiation isocenter of a linear accelerator. J Appl Clin Med Phys 2010; 11:3297. [PMID: 21081890 PMCID: PMC5720414 DOI: 10.1120/jacmp.v11i4.3297] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 04/07/2010] [Accepted: 05/07/2010] [Indexed: 11/23/2022] Open
Abstract
A quality assurance (QA) procedure was developed to evaluate the congruence between the cone‐beam computed tomography (CBCT) image center and the radiation isocenter on a Varian Trilogy linac. In contrast to the published QA procedures, this method did not require a ball bearing (BB) phantom to be placed exactly at the radiation isocenter through precalibrated room lasers or light field crosshairs. The only requirement was that the BB phantom be in a stationary position near the radiation isocenter during the image acquisition process. The radiation isocenter was determined with respect to the center of the BB using a Winston‐Lutz test. The CBCT image center was found to have excellent short‐term positional reproducibility (i.e., less than 0.1 mm of wobble in each of the x (lateral), y (vertical), and z (longitudinal) directions) in 10 consecutive acquisitions. Measured over a seven‐month period, the CBCT image center deviated from the radiation isocenter by 0.40±0.12mm(x),0.43±0.04mm(y), and 0.34±0.14mm(z). The z displacement of the 3D CBCT image center was highly correlated (ρ=0.997) with that of the 2D kV portal image center. The correlation coefficients in the x and y directions were poor (ρ=0.66 and ‐0.35, respectively). Systematic discrepancies were found between the CBCT image center and the 2D MV, kV portal image centers. For the linear accelerator studied, we detected a 0.8 mm discrepancy between the CBCT image center and the MV EPID image center in the anterior‐posterior direction. This discrepancy was demonstrated in a clinical case study where the patient was positioned with CBCT followed by MV portal verification. The results from the new QA procedure are useful for guiding high‐precision patient positioning in stereotactic body radiation therapy. PACS number: 87.55.Qr
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Affiliation(s)
- Weiliang Du
- Department of Radiation Physics, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
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Mayo C, Martel MK, Marks LB, Flickinger J, Nam J, Kirkpatrick J. Radiation dose-volume effects of optic nerves and chiasm. Int J Radiat Oncol Biol Phys 2010; 76:S28-35. [PMID: 20171514 DOI: 10.1016/j.ijrobp.2009.07.1753] [Citation(s) in RCA: 305] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 07/10/2009] [Accepted: 07/15/2009] [Indexed: 02/07/2023]
Abstract
Publications relating radiation toxicity of the optic nerves and chiasm to quantitative dose and dose-volume measures were reviewed. Few studies have adequate data for dose-volume outcome modeling. The risk of toxicity increased markedly at doses >60 Gy at approximately 1.8 Gy/fraction and at >12 Gy for single-fraction radiosurgery. The evidence is strong that radiation tolerance is increased with a reduction in the dose per fraction. Models of threshold tolerance were examined.
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Affiliation(s)
- Charles Mayo
- Department of Radiation Oncology, University of Massachusetts School of Medicine, Worcester, MA 01655, USA.
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Marks LB, Ten Haken RK, Martel MK. Guest editor's introduction to QUANTEC: a users guide. Int J Radiat Oncol Biol Phys 2010; 76:S1-2. [PMID: 20171501 DOI: 10.1016/j.ijrobp.2009.08.075] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 08/28/2009] [Indexed: 12/31/2022]
Affiliation(s)
- Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC 27514, USA.
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Liao ZX, Komaki RR, Thames HD, Liu HH, Tucker SL, Mohan R, Martel MK, Wei X, Yang K, Kim ES, Blumenschein G, Hong WK, Cox JD. Influence of technologic advances on outcomes in patients with unresectable, locally advanced non-small-cell lung cancer receiving concomitant chemoradiotherapy. Int J Radiat Oncol Biol Phys 2009; 76:775-81. [PMID: 19515503 DOI: 10.1016/j.ijrobp.2009.02.032] [Citation(s) in RCA: 206] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 11/15/2008] [Accepted: 02/17/2009] [Indexed: 12/17/2022]
Abstract
PURPOSE In 2004, our institution began using four-dimensional computed tomography (4DCT) simulation and then intensity-modulated radiotherapy (IMRT) (4DCT/IMRT) instead of three-dimensional conformal radiotherapy (3DCRT) for the standard treatment of non-small-cell lung cancer (NSCLC). This retrospective study compares disease outcomes and toxicity in patients treated with concomitant chemotherapy and either 4DCT/IMRT or 3DCRT. METHODS AND MATERIALS A total of 496 NSCLC patients have been treated at M. D. Anderson Cancer Center between 1999 and 2006 with concomitant chemoradiotherapy. Among these, 318 were treated with CT/3DCRT and 91 with 4DCT/IMRT. Both groups received a median dose of 63 Gy. Disease end points were locoregional progression (LRP), distant metastasis (DM), and overall survival (OS). Disease covariates were gross tumor volume (GTV), nodal status, and histology. The toxicity end point was Grade >or=3 radiation pneumonitis; toxicity covariates were GTV, smoking status, and dosimetric factors. Data were analyzed using Cox proportional hazards models. RESULTS Mean follow-up times in the 4DCT/IMRT and CT/3DCRT groups were 1.3 (range, 0.1-3.2) and 2.1 (range, 0.1-7.9) years, respectively. The hazard ratios for 4DCT/IMRT were <1 for all disease end points; the difference was significant only for OS. The toxicity rate was significantly lower in the IMRT/4DCT group than in the CT/3DCRT group. V20 was significantly higher in the 3DCRT group and was a significant factor in determining toxicity. Freedom from DM was nearly identical in both groups. CONCLUSIONS Treatment with 4DCT/IMRT was at least as good as that with 3DCRT in terms of the rates of freedom from LRP and DM. There was a significant reduction in toxicity and a significant improvement in OS.
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Affiliation(s)
- Zhongxing X Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Belderbos JS, Kepka L, Kong FM(S, Martel MK, Videtic GM, Jeremic B. Elective Nodal Irradiation (ENI) in Locally Advanced Non–Small-Cell Lung Cancer (NSCLC): Evidence Versus Opinion? Int J Radiat Oncol Biol Phys 2009; 74:322; author reply 322-3. [DOI: 10.1016/j.ijrobp.2008.12.065] [Citation(s) in RCA: 2] [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] [Received: 12/01/2008] [Accepted: 12/31/2008] [Indexed: 10/20/2022]
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Tucker SL, Liu HH, Liao Z, Wei X, Wang S, Jin H, Komaki R, Martel MK, Mohan R. Analysis of radiation pneumonitis risk using a generalized Lyman model. Int J Radiat Oncol Biol Phys 2008; 72:568-74. [PMID: 18793959 DOI: 10.1016/j.ijrobp.2008.04.053] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 04/18/2008] [Accepted: 04/24/2008] [Indexed: 01/28/2023]
Abstract
PURPOSE To introduce a version of the Lyman normal-tissue complication probability (NTCP) model adapted to incorporate censored time-to-toxicity data and clinical risk factors and to apply the generalized model to analysis of radiation pneumonitis (RP) risk. METHODS AND MATERIALS Medical records and radiation treatment plans were reviewed retrospectively for 576 patients with non-small cell lung cancer treated with radiotherapy. The time to severe (Grade >/=3) RP was computed, with event times censored at last follow-up for patients not experiencing this endpoint. The censored time-to-toxicity data were analyzed using the standard and generalized Lyman models with patient smoking status taken into account. RESULTS The generalized Lyman model with patient smoking status taken into account produced NTCP estimates up to 27 percentage points different from the model based on dose-volume factors alone. The generalized model also predicted that 8% of the expected cases of severe RP were unobserved because of censoring. The estimated volume parameter for lung was not significantly different from n = 1, corresponding to mean lung dose. CONCLUSIONS NTCP models historically have been based solely on dose-volume effects and binary (yes/no) toxicity data. Our results demonstrate that inclusion of nondosimetric risk factors and censored time-to-event data can markedly affect outcome predictions made using NTCP models.
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Affiliation(s)
- Susan L Tucker
- Department of Bioinformatics and Computational Biology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Jin H, Tucker SL, Liu HH, Wei X, Yom SS, Wang S, Komaki R, Chen Y, Martel MK, Mohan R, Cox JD, Liao Z. Dose-volume thresholds and smoking status for the risk of treatment-related pneumonitis in inoperable non-small cell lung cancer treated with definitive radiotherapy. Radiother Oncol 2008; 91:427-32. [PMID: 18937989 DOI: 10.1016/j.radonc.2008.09.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2008] [Revised: 09/08/2008] [Accepted: 09/12/2008] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify clinical risk factors and dose-volume thresholds for treatment-related pneumonitis (TRP) in patients with non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Data were retrospectively collected from patients with inoperable NSCLC treated with radiotherapy with or without chemotherapy. TRP was graded according to Common Terminology Criteria for Adverse Events, version 3.0, with time to grade > or = 3 TRP calculated from start of radiotherapy. Clinical factors and dose-volume parameters were analyzed for their association with risk of TRP. RESULTS Data from 576 patients (75% with stage III NSCLC) were included in this study. The Kaplan-Meier estimate of the incidence of grade > or = 3 TRP at 12 months was 22%. An analysis of dose-volume parameters identified a threshold dose-volume histogram (DVH) curve defined by V(20) < or = 25%, V(25) < or = 20%, V(35) < or = 15%, and V(50) < or = 10%. Patients with lung DVHs satisfying these constraints had only 2% incidence of grade > or = 3 TRP. Smoking status was the only clinical factor that affected the risk of TRP independent of dosimetric factors. CONCLUSIONS The risk of TRP varied significantly, depending on radiation dose-volume parameters and patient smoking status. Further studies are needed to identify biological basis of smoking effect and methods to reduce the incidence of TRP.
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Affiliation(s)
- Hekun Jin
- Department of Radiation Oncology, Hunan Tumor Hospital and Institution, Hunan, China
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Videtic GM, Belderbos JS, (Spring) Kong FM, Kepka L, Martel MK, Jeremic B. Report From the International Atomic Energy Agency (IAEA) Consultants' Meeting on Elective Nodal Irradiation in Lung Cancer: Small-Cell Lung Cancer (SCLC). Int J Radiat Oncol Biol Phys 2008; 72:327-34. [PMID: 18793952 DOI: 10.1016/j.ijrobp.2008.03.075] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 03/25/2008] [Accepted: 03/26/2008] [Indexed: 10/21/2022]
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Aristophanous M, Penney BC, Martel MK, Pelizzari CA. A Gaussian mixture model for definition of lung tumor volumes in positron emission tomography. Med Phys 2007; 34:4223-35. [DOI: 10.1118/1.2791035] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [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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43
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Jani AB, Gratzle J, Muresan E, Farrey K, Martel MK. Analysis of acute toxicity with use of transabdominal ultrasonography for prostate positioning during intensity-modulated radiotherapy. Urology 2005; 65:504-8. [PMID: 15780365 DOI: 10.1016/j.urology.2004.09.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2004] [Accepted: 09/30/2004] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To analyze the effects of the B-mode ultrasound acquisition and targeting (BAT) system for positioning of patients with prostate cancer receiving intensity-modulated radiotherapy on acute gastrointestinal (GI) and genitourinary (GU) toxicity. METHODS The records of 50 consecutive patients treated using the BAT system were reviewed. Additionally, a comparison (no-BAT) group (ie, a group without a BAT study) treated in a similar manner was identified. The no-BAT group consisted of 49 patients treated immediately before the BAT group. For the two groups, the target definitions and dose prescriptions were identical, the treatment plan acceptance criteria were identical, and intensity-modulated radiotherapy was used for all patients. The daily BAT movements were charted in each of the three principal directions. Acute toxicity was scored for all patients according to the Radiation Therapy Oncology Group GI and GU acute toxicity scales. RESULTS The GU toxicity rates for the BAT versus no-BAT groups were grade 0 in 20% versus 14%; grade 1 in 38% versus 47%; grade 2 in 38% versus 39%; and grade 3 in 4% versus 0%, respectively (P = 0.284). The corresponding GI toxicity rates were grade 0 in 42% versus 27%; grade 1 in 28% versus 29%; and grade 2 in 30% versus 45% (P = 0.040). The incidence of GU and GI toxicity did not correlate with the directions or size of the BAT moves. Regression analysis revealed that for acute GI toxicity, the only variable reaching statistical significance was BAT use; no variable, including BAT use, reached statistical significance for acute GU toxicity. CONCLUSIONS The use of the BAT system did not change the rate of acute GU toxicity but did reduce the rate of acute GI toxicity.
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Affiliation(s)
- Ashesh B Jani
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, Chicago, Illinois 60637, USA.
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44
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Narayan S, Henning GT, Ten Haken RK, Sullivan MA, Martel MK, Hayman JA. Results following treatment to doses of 92.4 or 102.9 Gy on a phase I dose escalation study for non-small cell lung cancer. Lung Cancer 2004; 44:79-88. [PMID: 15013586 DOI: 10.1016/j.lungcan.2003.09.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Revised: 09/10/2003] [Accepted: 09/15/2003] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE The University of Michigan lung dose escalation study has increased the dose of external beam radiation for non-small cell lung cancer based on the volume of normal lung irradiated. The results of patients treated to either 92.4 or 102.9 Gy are reported. MATERIALS AND METHODS Seventeen patients have completed treatment to 92.4 or 102.9 Gy and have been followed for at least 6 months. The treatment planning goal was to minimize the effective volume (V(eff)) of total lung irradiated as computed using the Kutcher-Burman DVH reduction scheme. Dose was escalated independently within each of five V(eff) bins. Toxicity, freedom from local progression (FFLP), overall survival (OS) and cause specific survival (CSS) are reported. RESULTS Thirteen patients were Stage I, one was Stage II and three were Stage III. V(eff) ranged from 0.06 to 0.21. The median pretreatment FEV(1) was 1.24 L or 44% of predicted. Median follow-up for survivors was 37.9 months. No patient had significant pulmonary toxicity. One patient each had grades 2 and 3 esophagitis. Median percent change in FEV1 was -11%. Two- and three-year actuarial FFLP and OS rates for the entire group were 68 and 58% and 51 and 26%, respectively. For Stage I patients, the 2 and 3 year FFLP, OS and CSS rates were 82 and 68%, 54 and 33%, 76 and 48% respectively. CONCLUSIONS These results suggest that doses of radiation of 92.4 and 102.9 Gy can be delivered safely to limited lung volumes with minimal toxicity.
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Affiliation(s)
- Samir Narayan
- Department of Radiation Oncology, University of California Davis Medical Center, 4501 X Street, G126, Sacramento, CA 95817, USA.
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Abstract
Great technologic progress has been made in the last decade in the radiation treatment of lung cancer. In particular, the widespread use of 3D conformal therapy has the potential to escalate the dose to the tumor while sparing dose to normal tissue. Current technology, however, has yet to impact local control and survival. It could be hypothesized that this is due to geographic misses because of poor target definition, movement of the tumor due to respiration, and dose/ fractionation levels. Several emerging technologies that are described in this article have the potential to address these problems, with results expected in the near future. The technical delivery of radiation has not reached its limit.
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Affiliation(s)
- Mary K Martel
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, 5758 South Maryland Avenue, Room MC9006, Chicago, IL 60637, USA.
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Abstract
PURPOSE To examine the ability of standard dose-volume metrics to predict pulmonary function changes as measured by pulmonary function tests (PFTs) in a group of patients with non-small-cell lung cancer treated with nonconventional beam arrangements on a Phase I dose-escalation study. In addition, we wanted to examine the correlation between these metrics. MATERIALS AND METHODS Forty-three patients received a median treatment dose of 76.9 Gy (range 63-102.9). Eight patients also received induction chemotherapy with cisplatin and vinorelbine. They all had pre- and posttreatment PFTs >/=3 months (median 6.2) after treatment. The volume of normal lung treated to >20 Gy, effective volume, and mean lung dose were calculated for both lungs for all patients. Linear regression analysis was performed to determine whether correlations existed between the metrics and changes in the PFTs. Additionally, the three metrics were compared with each other to assess the degree of intermetric correlation. RESULTS No correlation was found between the volume of normal lung treated to >20 Gy, effective volume, and mean lung dose and changes in the PFTs. Subgroup analyses of patients without atelectasis before irradiation, Stage I and II disease, or treatment without induction chemotherapy were also performed. Again, no correlation was found between the dose-volume metrics and the PFT changes. The intermetric correlation was good among all three dose-volume metrics. CONCLUSIONS In this relatively small series of patients, dose-volume metrics that correlate with the risk of pneumonitis did not provide a good model to predict early changes in pulmonary function as measured with PFTs.
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Affiliation(s)
- A M Allen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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Seppenwoolde Y, Lebesque JV, de Jaeger K, Belderbos JSA, Boersma LJ, Schilstra C, Henning GT, Hayman JA, Martel MK, Ten Haken RK. Comparing different NTCP models that predict the incidence of radiation pneumonitis. Normal tissue complication probability. Int J Radiat Oncol Biol Phys 2003; 55:724-35. [PMID: 12573760 DOI: 10.1016/s0360-3016(02)03986-x] [Citation(s) in RCA: 355] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE To compare different normal tissue complication probability (NTCP) models to predict the incidence of radiation pneumonitis on the basis of the dose distribution in the lung. METHODS AND MATERIALS The data from 382 breast cancer, malignant lymphoma, and inoperable non-small-cell lung cancer patients from two centers were studied. Radiation pneumonitis was scored using the Southwestern Oncology Group criteria. Dose-volume histograms of the lungs were calculated from the dose distributions that were corrected for dose per fraction effects. The dose-volume histogram of each patient was reduced to a single parameter using different local dose-effect relationships. Examples of single parameters were the mean lung dose (MLD) and the volume of lung receiving more than a threshold dose (V(Dth)). The parameters for the different NTCP models were fit to patient data using a maximum likelihood analysis. RESULTS The best fit resulted in a linear local dose-effect relationship, with the MLD as the resulting single parameter. The relationship between the MLD and NTCP could be described with a median toxic dose (TD(50)) of 30.8 Gy and a steepness parameter m of 0.37. The best fit for the relationship between the V(Dth) and the NTCP was obtained with a D(th) of 13 Gy. The MLD model was found to be significantly better than the V(Dth) model (p <0.03). However, for 85% of the studied patients, the difference in NTCP calculated with both models was <10%, because of the high correlation between the two parameters. For dose distributions outside the range of the studied dose-volume histograms, the difference in NTCP, using the two models could be >35%. For arbitrary dose distributions, an estimate of the uncertainty in the NTCP could be determined using the probability distribution of the parameter values of the Lyman-Kutcher-Burman model. CONCLUSION The maximum likelihood method revealed that the underlying local dose-effect relation for radiation pneumonitis was linear (the MLD model), rather than a step function (the V(Dth) model). Thus, for the studied patient population, the MLD was the most accurate predictor for the incidence of radiation pneumonitis.
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Affiliation(s)
- Yvette Seppenwoolde
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Pierce LJ, Butler JB, Martel MK, Normolle DP, Koelling T, Marsh RB, Lichter AS, Fraass BA. Postmastectomy radiotherapy of the chest wall: dosimetric comparison of common techniques. Int J Radiat Oncol Biol Phys 2002; 52:1220-30. [PMID: 11955732 DOI: 10.1016/s0360-3016(01)02760-2] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare seven techniques for irradiation of the postmastectomy chest wall (CW) using normal tissue complication probability (NTCP) predictions for pneumonitis and ischemic heart disease and dose-volume histogram analyses for normal and target tissues. METHODS AND MATERIALS Plan comparisons were performed for 20 left-sided postmastectomy CW RT cases using target volumes based on clinical delineation of standard field borders. Seven common treatment techniques were planned for each case, using a prescription of 50 Gy in 25 fractions to the CW and internal mammary node (IMN) targets. NTCP model metrics were used to quantify the risks of pneumonitis and ischemic heart disease, supplemented by dose-volume metrics to assess the target coverage to the CW and IMNs, as well as normal tissue dose (lung and heart). RESULTS Overlap in the distributions of the CW mean dose for all plans was found, except cobalt, which was significantly less than the remaining techniques (global F test, F = 21.90, p <0.0001). Standard tangents produced a significantly lower IMN mean dose than all other methods, as expected (F = 59.55, p < 0.0001); the reverse hockey stick and cobalt techniques were lower than the other methods, which were statistically similar. Cobalt produced a significantly higher percentage of the heart that received >30 Gy (V30) than the other methods (F = 49.76, p <0.0001). Use of partially wide tangent fields (PWTFs) resulted in the smallest heart V30. Use of cobalt fields resulted in a significantly greater NTCP estimate for ischemic heart disease than all the remaining techniques (F = 70.39, p <0.0001). Standard tangents resulted in a percentage of the lung receiving >20 Gy (V20) significantly less than with PWTFs, 30/70 and 20/80 photon/electron mix, and reverse hockey stick techniques. NTCP estimates for pneumonitis revealed significantly better results with standard tangents (F = 6.57, p <0.0001). CONCLUSION No one technique studied combines the best CW and IMN coverage with minimal lung and heart complication probabilities. The choice of technique should be based on clinical discretion and the technical expertise available to implement these complex plans. Of the seven techniques studied, this analysis supports PWTFs as the most appropriate balance of target coverage and normal tissue sparing when irradiating the CW and IMN.
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Affiliation(s)
- Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI 48109-0010, USA.
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Abstract
Multileaf collimator (MLC) systems are available on most commercial linear accelerators, and many of these MLC systems utilize a design with rounded leaf ends and linear motion of the leaves. In this kind of system, the agreement between the digital MLC position readouts and the light field or radiation field edges must be achieved with software, since the leaves do not move in a focused motion like that used for most collimator jaw systems. In this work we address a number of the calibration and quality assurance issues associated with the acceptance, commissioning, and routine clinical use of this type of MLC system. These issues are particularly important for MLCs used for various types of intensity modulated radiation therapy (IMRT) and small, conformal fields. For rounded leaf end MLCs, it is generally not possible to make both the light and radiation field edges agree with the digital readout, so differences between the two kinds of calibrations are illustrated in this work using one vendor's MLC system. It is increasingly critical that the MLC leaf calibration be very consistent with the radiation field edges, so in this work a methodology for performing accurate radiation field size calibration is discussed. A system external to the vendor's MLC control system is used to correct or handle limitations in the MLC control system. When such a system of corrections is utilized, it is found that the MLC radiation field size can be defined with an accuracy of approximately 0.3 mm, much more accurate than most vendor's specifications for MLC accuracy. Quality assurance testing for such a calibration correction system is also demonstrated.
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Affiliation(s)
- M N Graves
- Department of Radiation Oncology, University of Michigan Medical Center Ann Arbor, Michigan 48109-0010, USA.
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50
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Hayman JA, Martel MK, Ten Haken RK, Normolle DP, Todd RF, Littles JF, Sullivan MA, Possert PW, Turrisi AT, Lichter AS. Dose escalation in non-small-cell lung cancer using three-dimensional conformal radiation therapy: update of a phase I trial. J Clin Oncol 2001; 19:127-36. [PMID: 11134205 DOI: 10.1200/jco.2001.19.1.127] [Citation(s) in RCA: 270] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE High-dose radiation may improve outcomes in non-small-cell lung cancer (NSCLC). By using three-dimensional conformal radiation therapy and limiting the target volume, we hypothesized that the dose could be safely escalated. MATERIALS AND METHODS A standard phase I design was used. Five bins were created based on the volume of normal lung irradiated, and dose levels within bins were chosen based on the estimated risk of radiation pneumonitis. Starting doses ranged from 63 to 84 Gy given in 2.1-Gy fractions. Target volumes included the primary tumor and any nodes >or= 1 cm on computed tomography. Clinically uninvolved nodal regions were not included purposely. More recently, selected patients received neoadjuvant cisplatin and vinorelbine. RESULTS At the time of this writing, 104 patients had been enrolled. Twenty-four had stage I, four had stage II, 43 had stage IIIA, 26 had stage IIIB, and seven had locally recurrent disease. Twenty-five received chemotherapy, and 63 were assessable for escalation. All bins were escalated at least twice. Although grade 2 radiation pneumonitis occurred in five patients, grade 3 radiation pneumonitis occurred in only two. The maximum-tolerated dose was only established for the largest bin, at 65.1 Gy. Dose levels for the four remaining bins were 102.9, 102.9, 84 and 75.6 Gy. The majority of patients failed distantly, though a significant proportion also failed in the target volume. There were no isolated failures in clinically uninvolved nodal regions. CONCLUSION Dose escalation in NSCLC has been accomplished safely in most patients using three-dimensional conformal radiation therapy, limiting target volumes, and segregating patients by the volume of normal lung irradiated.
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Affiliation(s)
- J A Hayman
- Department of Radiation Oncology, Division of Hematology/Oncology, University of Michigan Health System, Ann Arbor, MI, USA.
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