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Vitzthum LK, Surucu M, Gensheimer MF, Kovalchuk N, Han B, Pham D, Chang D, Shirvani SM, Aksoy D, Maniyedath A, Narayanan M, Da Silva AJ, Mazin S, Feghali KAA, Iyengar P, Dan T, Pompos A, Timmerman R, Öz O, Cai B, Garant A. BIOGUIDE-X: A First-in-Human Study of the Performance of Positron Emission Tomography-Guided Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:1172-1180. [PMID: 38147912 DOI: 10.1016/j.ijrobp.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/02/2023] [Accepted: 12/15/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE Positron emission tomography (PET)-guided radiation therapy is a novel tracked dose delivery modality that uses real-time PET to guide radiation therapy beamlets. The BIOGUIDE-X study was performed with sequential cohorts of participants to (1) identify the fluorodeoxyglucose (FDG) dose for PET-guided therapy and (2) confirm that the emulated dose distribution was consistent with a physician-approved radiation therapy plan. METHODS AND MATERIALS This prospective study included participants with at least 1 FDG-avid targetable primary or metastatic tumor (2-5 cm) in the lung or bone. For cohort I, a modified 3 + 3 design was used to determine the FDG dose that would result in adequate signal for PET-guided therapy. For cohort II, PET imaging data were collected on the X1 system before the first and last fractions among patients undergoing conventional stereotactic body radiation therapy. PET-guided therapy dose distributions were modeled on the patient's computed tomography anatomy using the collected PET data at each fraction as input to an "emulated delivery" and compared with the physician-approved plan. RESULTS Cohort I demonstrated adequate FDG activity in 6 of 6 evaluable participants (100.0%) with the first injected dose level of 15 mCi FDG. In cohort II, 4 patients with lung tumors and 5 with bone tumors were enrolled, and evaluable emulated delivery data points were collected for 17 treatment fractions. Sixteen of the 17 emulated deliveries resulted in dose distributions that were accurate with respect to the approved PET-guided therapy plan. The 17th data point was just below the 95% threshold for accuracy (dose-volume histogram score = 94.6%). All emulated fluences were physically deliverable. No toxicities were attributed to multiple FDG administrations. CONCLUSIONS PET-guided therapy is a novel radiation therapy modality in which a radiolabeled tumor can act as its own fiducial for radiation therapy targeting. Emulated therapy dose distributions calculated from continuously acquired real-time PET data were accurate and machine-deliverable in tumors that were 2 to 5 cm in size with adequate FDG signal characteristics.
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Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California.
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Bin Han
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Pham
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Chang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | | | | | | | - Puneeth Iyengar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tu Dan
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Arnold Pompos
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Orhan Öz
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Bin Cai
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Aurelie Garant
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
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Da Silva A, Olcott P, Tian S, Yang X, Sethi I, Shirvani S, Mazin S, Owonikoko T, Bradley J, Schuster D, Higgins K. Feasibility of Using FDG in the Stereotactic Ablative Setting for Tracked Dose Delivery With BgRT: Results from a Prospective Study of Serial Inter-Fraction PET/CTs. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Oderinde OM, Shirvani SM, Olcott PD, Kuduvalli G, Mazin S, Larkin D. The technical design and concept of a PET/CT linac for biology-guided radiotherapy. Clin Transl Radiat Oncol 2021; 29:106-112. [PMID: 34258399 PMCID: PMC8260396 DOI: 10.1016/j.ctro.2021.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/30/2021] [Accepted: 04/07/2021] [Indexed: 12/26/2022] Open
Abstract
This article summarizes the chief technology and concept of the world's first PET/CT Linac for BgRT. BgRT delivery uses annihilation photons emanating from the PET-avid tumor to guide the delivery of beamlets in real-time. BgRT treatment technique opens the avenue to debulking advanced and metastatic disease.
This is a summary of the design and concept of the RefleXion X1, a system for biology-guided radiotherapy (BgRT). This system is a multi-modal tomography (PET, fan-beam kVCT, and MVD) treatment machine that utilizes imaging and therapy planes for optimized beam delivery of IMRT, SBRT, SRS, and BgRT radiotherapy regimens. For BgRT delivery specifically, annihilation photons emanating outward from a PET-avid tumor are used to guide the delivery of beamlets of radiation to the tumor at sub-second latency. With the integration of PET detectors, rapid beam-station delivery, real-time tracking, and high-frequency multi-leaf collimation, the BgRT system has the potential to deliver a highly conformal treatment to malignant lesions while minimizing dose to surrounding healthy tissues. Furthermore, the potential use of a single radiotracer injection to guide radiotherapy to multiple targets opens avenues for debulking in advanced and metastatic disease states.
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Shirvani SM, Huntzinger CJ, Melcher T, Olcott PD, Voronenko Y, Bartlett-Roberto J, Mazin S. Biology-guided radiotherapy: redefining the role of radiotherapy in metastatic cancer. Br J Radiol 2021; 94:20200873. [PMID: 33112685 PMCID: PMC7774706 DOI: 10.1259/bjr.20200873] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 12/14/2022] Open
Abstract
The emerging biological understanding of metastatic cancer and proof-of-concept clinical trials suggest that debulking all gross disease holds great promise for improving patient outcomes. However, ablation of multiple targets with conventional external beam radiotherapy systems is burdensome, which limits investigation and utilization of complete metastatic ablation in the majority of patients with advanced disease. To overcome this logistical hurdle, technical innovation is necessary. Biology-guided radiotherapy (BgRT) is a new external beam radiotherapy delivery modality combining positron emission tomography-computed tomography (PET-CT) with a 6 MV linear accelerator. The key innovation is continuous response of the linear accelerator to outgoing tumor PET emissions with beamlets of radiotherapy at subsecond latency. This allows the deposited dose to track tumors in real time. Multiple new hardware and algorithmic advances further facilitate this low-latency feedback process. By transforming tumors into their own fiducials after intravenous injection of a radiotracer, BgRT has the potential to enable complete metastatic ablation in a manner efficient for a single patient and scalable to entire populations with metastatic disease. Future trends may further enhance the utility of BgRT in the clinic as this technology dovetails with other innovations in radiotherapy, including novel dose painting and fractionation schemes, radiomics, and new radiotracers.
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Seyedin S, Mawlawi O, Turner L, Mazin S, Voronenko Y, Olcott P, Wages C, Balter P, Chang J, Gomez D, Komaki R, Welsh J. Use of Emission Guided Radiation Therapy Can Better Spare Critical Structures Compared With Intensity Modulated Radiation Therapy, Volumetric Modulated Arc Therapy, or Proton Therapy. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.2110] [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: 10/22/2022]
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Nanduri A, Fan Q, Yang J, Yamamoto T, Graves E, Loo B, Mazin S. TH-E-BRF-11: Dynamic Treatment of Clinical Margins Beyond the PET-Avid Target in Emission Guided Radiation Therapy: A Retrospective Patient Study. Med Phys 2014. [DOI: 10.1118/1.4889675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Fan Q, Nanduri A, Yang J, Yamamoto T, Loo B, Graves E, Zhu L, Mazin S. Toward a planning scheme for emission guided radiation therapy (EGRT): FDG based tumor tracking in a metastatic breast cancer patient. Med Phys 2014; 40:081708. [PMID: 23927305 DOI: 10.1118/1.4812427] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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
PURPOSE Emission guided radiation therapy (EGRT) is a new modality that uses PET emissions in real-time for direct tumor tracking during radiation delivery. Radiation beamlets are delivered along positron emission tomography (PET) lines of response (LORs) by a fast rotating ring therapy unit consisting of a linear accelerator (Linac) and PET detectors. The feasibility of tumor tracking and a primitive modulation method to compensate for attenuation have been demonstrated using a 4D digital phantom in our prior work. However, the essential capability of achieving dose modulation as in conventional intensity modulated radiation therapy (IMRT) treatments remains absent. In this work, the authors develop a planning scheme for EGRT to accomplish sophisticated intensity modulation based on an IMRT plan while preserving tumor tracking. METHODS The planning scheme utilizes a precomputed LOR response probability distribution to achieve desired IMRT planning modulation with effects of inhomogeneous attenuation and nonuniform background activity distribution accounted for. Evaluation studies are performed on a 4D digital patient with a simulated lung tumor and a clinical patient who has a moving breast cancer metastasis in the lung. The Linac dose delivery is simulated using a voxel-based Monte Carlo algorithm. The IMRT plan is optimized for a planning target volume (PTV) that encompasses the tumor motion using the MOSEK package and a Pinnacle3™ workstation (Philips Healthcare, Fitchburg, WI) for digital and clinical patients, respectively. To obtain the emission data for both patients, the Geant4 application for tomographic emission (GATE) package and a commercial PET scanner are used. As a comparison, 3D and helical IMRT treatments covering the same PTV based on the same IMRT plan are simulated. RESULTS 3D and helical IMRT treatments show similar dose distribution. In the digital patient case, compared with the 3D IMRT treatment, EGRT achieves a 15.1% relative increase in dose to 95% of the gross tumor volume (GTV) and a 31.8% increase to 50% of the GTV. In the patient case, EGRT yields a 15.2% relative increase in dose to 95% of the GTV and a 20.7% increase to 50% of the GTV. The organs at risk (OARs) doses are kept similar or lower for EGRT in both cases. Tumor tracking is observed in the presence of planning modulation in all EGRT treatments. CONCLUSIONS As compared to conventional IMRT treatments, the proposed EGRT planning scheme allows an escalated target dose while keeping dose to the OARs within the same planning limits. With the capabilities of incorporating planning modulation and accurate tumor tracking, EGRT has the potential to greatly improve targeting in radiation therapy and enable a practical and effective implementation of 4D radiation therapy for planning and delivery.
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Affiliation(s)
- Qiyong Fan
- Nuclear and Radiological Engineering Program, The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332, USA
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Fan Q, Nanduri A, Yang J, Yamamoto T, Loo B, Graves E, Zhu L, Mazin S. Simultaneous Tracking of Multiple Metastases Using FDG-PET Emission-Guided Radiation Therapy (EGRT) in a Breast Cancer Patient. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.246] [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: 11/24/2022]
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Fan Q, Nanduri A, Yang J, Yamamoto T, Loo B, Graves E, Zhu L, Mazin S. SU-F-500-06: Demonstration of a Planning Scheme for Emission Guided Radiation Therapy (EGRT) in a Metastatic Breast Cancer Patient. Med Phys 2013. [DOI: 10.1118/1.4815196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Yang J, Yamamoto T, Mazin S, Cui J, Graves E, Keall P. TH-A-WAB-09: The Potential of Positron Emission Tomography (PET) for Intra-Treatment Dynamic Tumor Tracking During Radiotherapy: A Phantom Study. Med Phys 2013. [DOI: 10.1118/1.4815703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Fan Q, Nanduri A, Mazin S, Zhu L. Emission guided radiation therapy for lung and prostate cancers: a feasibility study on a digital patient. Med Phys 2012; 39:7140-52. [PMID: 23127105 PMCID: PMC3505203 DOI: 10.1118/1.4761951] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/22/2012] [Accepted: 10/03/2012] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Accurate tumor tracking remains a challenge in current radiation therapy. Many strategies including image guided radiation therapy alleviate the problem to certain extents. The authors propose a new modality called emission guided radiation therapy (EGRT) to accurately and directly track the tumor based on its biological signature. This work is to demonstrate the feasibility of EGRT under two clinical scenarios using a 4D digital patient model. METHODS EGRT uses lines of response (LOR's) from positron emission events to direct beamlets of therapeutic radiation through the emission sites inside a tumor. This is accomplished by a radiation delivery system consisting of a Linac and positron emission tomography (PET) detectors on a fast rotating closed-ring gantry. During the treatment of radiotracer-administrated cancer patients, PET detectors collect LOR's from tumor uptake sites and the Linac responds in nearly real-time with beamlets of radiation along the same LOR paths. Moving tumors are therefore treated with a high targeting accuracy. Based on the EGRT concept, the authors design a treatment method with additional modulation algorithms including attenuation correction and an integrated boost scheme. Performance is evaluated using simulations of a lung tumor case with 3D motion and a prostate tumor case with setup errors. The emission process is simulated by Geant4 Application for Tomographic Emission package (GATE) and Linac dose delivery is simulated using a voxel-based Monte Carlo algorithm (VMC++). RESULTS In the lung case with attenuation correction, compared to a conventional helical treatment, EGRT achieves a 41% relative increase in dose to 95% of the gross tumor volume (GTV) and a 55% increase to 50% of the GTV. All dose distributions are normalized for the same dose to the lung. In the prostate case with the integrated boost and no setup error, EGRT yields a 19% and 55% relative dose increase to 95% and 50% of the GTV, respectively, when all methods are normalized for the same dose to the rectum. In the prostate case with integrated boost where setup error is present, EGRT contributes a 21% and 52% relative dose increase to 95% and 50% of the GTV, respectively. CONCLUSIONS As a new radiation therapy modality with inherent tumor tracking, EGRT has the potential to substantially improve targeting in radiation therapy in the presence of intrafractional and interfractional motion.
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Affiliation(s)
- Qiyong Fan
- Georgia Institute of Technology, Atlanta, GA, USA
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Fan Q, Nanduri A, Zhu L, Mazin S. TU-G-BRA-04: Emission Guided Radiation Therapy: A Simulation Study of Lung Cancer Treatment with Automatic Tumor Tracking Using a 4D Digital Patient Model. Med Phys 2012. [DOI: 10.1118/1.4736008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Mazin S, Nanduri A, Yang J, Yamamoto T, Loo B, Graves E. TU-A-BRA-05: Lung Cancer Patient Feasibility Study for Emission Guided Radiation Therapy. Med Phys 2012. [DOI: 10.1118/1.4735873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Yang J, Yamamoto T, Thielemans K, Mazin S, Graves E, Keall P. SU-E-J-156: A Feasibility Study for Real-Time Tumor Tracking Using Positron Emission Tomography (PET). Med Phys 2011. [DOI: 10.1118/1.3611924] [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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Rakow-Penner R, Gold G, Daniel B, Stevens K, Rosenberg J, Mazin S, Pauly J, Glover GH. Reduction of truncation artifacts in rapid 3D articular cartilage imaging. J Magn Reson Imaging 2008; 27:860-5. [PMID: 18383247 DOI: 10.1002/jmri.21312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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: 11/07/2022] Open
Abstract
PURPOSE To reduce Gibbs ringing artifact in three-dimensional (3D) articular knee cartilage imaging with linear prediction (LP). MATERIALS AND METHODS A reconstruction method using LP in 3D was applied to truncated data sets of six healthy knees. The technique first linearizes the data before applying the prediction algorithm. Three radiologists blindly reviewed and ranked images of the full, truncated, and predicted data sets. Statistical analysis of the radiologists' reviews was performed for image quality, clinical acceptability of the images, and equivalence with the gold standard. RESULTS LP applied to 3D knee cartilage imaging allows for 40% decreased scan time while providing image quality with statistical equivalence to a full data set. CONCLUSION 3D spoiled gradient echo imaging (SPGR) knee cartilage imaging requires significant scan time. This 40% reduction in scan time will allow such scans to be more feasible without sacrificing clinical acceptability.
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Affiliation(s)
- Rebecca Rakow-Penner
- Department of Radiology, School of Medicine, Stanford University, Stanford, California 94305-5488, USA.
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