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Trivellato S, Caricato P, Pellegrini R, Daniotti MC, Bianchi S, Bordigoni B, Carminati S, Faccenda V, Panizza D, Montanari G, Arcangeli S, De Ponti E. Lexicographic optimization-based planning for stereotactic radiosurgery of brain metastases. Radiother Oncol 2024; 196:110308. [PMID: 38677330 DOI: 10.1016/j.radonc.2024.110308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
AIM To validate a fully-automated lexicographic optimization-planning system (mCycle, Elekta) for single-(SL) and multiple-(ML, up to 4 metastases) lesions in intracranial stereotactic radiosurgery (SRS, 21 Gy, single fraction). METHODS A pre-determined priority list, Wish-List (WL), represents a dialogue between planner and clinician, establishing strict constraints and pursuing objectives. In order to satisfy the clinical protocol without manual intervention, four patients were required to tweak and fine-tune each WL (SLp, MLp) for coplanar arcs. Thirty-five testing plans (20 SLp, 15 MLp) were automatically re-planned (mCP). Automatic and manual plans were compared including dose constraints, conformality, modulation complexity score (MCS), delivery time, and local gamma analysis (2%/2 mm). To ensure plan clinical acceptability, two radiation oncologists conducted an independent blind plan choice. RESULTS Each WL-tuning took 3 days. Estimated median manual plans and mCP calculation time were 8 and 3 h, respectively. Significant increases in SLp and MLp target coverage and conformity were registered. mCP showed a not significant and clinically acceptable higher median brain V12Gy. SLp registered a -5.8% MU decrease with comparable median delivery time (MP 2.0 min, mCP 1.9 min) while MLp showed a +9.8% MU increase and longer delivery time (MP 3.5 min, mCP 4.4 min). mCP MCS resulted significantly higher without affecting gamma passing rates. At blind choice, mCP were preferred in the majority of cases. CONCLUSIONS Lexicographic optimization produced acceptable SRS plans with coplanar arcs significantly reducing the overall planning time in cases with up to 4 brain metastases. These planning improvements suggest further investigations by setting high-quality non-coplanar arc plans as a reference.
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Affiliation(s)
- Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Paolo Caricato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; Department of Physics, University of Milan, Milan, Italy; Medical Physics Department, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | | | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; Department of Physics, University of Milan, Milan, Italy
| | - Sofia Bianchi
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy; Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Stefano Carminati
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; Department of Physics, University of Milan, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Gianluca Montanari
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy; Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Panizza D, Faccenda V, Daniotti MC, Trivellato S, Lucchini R, Pellegrini R, De Ponti E, Arcangeli S. Dosimetric Impact of Intrafraction Prostate Motion and Interfraction Anatomical Changes in Dose-Escalated Linac-Based SBRT. Int J Radiat Oncol Biol Phys 2023; 117:e703. [PMID: 37786062 DOI: 10.1016/j.ijrobp.2023.06.2192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The aim of this study was to investigate the impact of intrafraction prostate motion and interfraction anatomical changes on dose metrics and the effect of beam gating and motion correction in dose-escalated Linac-based SBRT. MATERIALS/METHODS Thirteen patients (56 fractions) with organ-confined prostate cancer underwent dose-escalated FFF-VMAT SBRT. Accurate patient setup was ensured by CBCT, and real-time 3D prostate motion data were obtained using a novel electromagnetic tracking device. Treatment was interrupted when the signals exceeded a 2 mm threshold in any of the three spatial directions and couch position was corrected unless the offset was transient. Prostate trajectories with and without beam gating and motion correction events were reconstructed and analyzed. Rectum and bladder volumes on each daily CBCT were recorded and compared with volumes at simulation. The prostate motion observed for each fraction was incorporated into the patient original treatment plan with an isocenter shift method. Actually, delivered treatments were then obtained by recalculating the reconstructed motion-encoded plan on deformed CTs reflecting the patient CBCT-anatomy of the day. Non-gated treatments were also simulated using the prostate motion data assuming that no treatment interruptions have occurred. RESULTS Treatment interruptions because of target motion trespassing the predefined threshold occurred in 25 fractions (45%). Rectum and bladder volume changes were relevant in most patients. The mean relative dose differences between actually delivered and planned treatments were -3.0% [-18.5 - 2.8] for CTV D99% and -2.6% [-17.8 - 1.0] for PTV D95% over all 56 fractions. However, the median cumulative CTV coverage with 93% of the prescribed dose turned out to be satisfactory. Urethra sparing was slightly degraded and a mean reduction of rectum and bladder dose was seen in all but two dose metrics: the maximum dose to rectum mucosa and the bladder D40%. Nevertheless, only 2 major deviations in rectum mucosa D0.035cc were observed at the end of the treatment. The greatest contribution to target missing and OARs doses came from the interfraction anatomical variations, while intrafraction prostate motion marginally contributed in gated treatments. In non-gated treatments, further deteriorations by 2.4 - 2.8% in minimum target coverage metrics and by 3.1 - 11.6% in bladder dose parameters would have occurred on average. CONCLUSION The implemented motion management strategy and the strict patient preparation regimen, along with current PTV margins, robustness of original treatment plans, and fast FFF beam delivery, ensured no significant degradations of dose metrics due to both intrafraction motion and interfraction anatomical changes. Non-gated treatments would have more widely deteriorated the dosimetry of some individual fractions. Thus, continuous monitoring, beam gating and motion correction are recommended to safely deliver dose-escalated prostate SBRT.
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Affiliation(s)
- D Panizza
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - V Faccenda
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - M C Daniotti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - S Trivellato
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - R Lucchini
- University of Milan Bicocca - School of Medicine and Surgery, Milan, Italy
| | | | - E De Ponti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - S Arcangeli
- University of Milan Bicocca - School of Medicine and Surgery, Milan, Italy
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Trivellato S, Caricato P, Pellegrini R, Daniotti MC, Panizza D, Montanari G, Faccenda V, Arcangeli S, De Ponti E. Lexicographic Optimization-Based Planning for Single and Multiple Brain Metastasis Radiosurgery with Coplanar Arcs. Int J Radiat Oncol Biol Phys 2023; 117:e728. [PMID: 37786118 DOI: 10.1016/j.ijrobp.2023.06.2244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) This study validated a not yet commercially available fully-automated lexicographic optimization planning system (LOps) for single and multiple lesions intracranial stereotactic radiosurgery (SRS). MATERIALS/METHODS Forty-four consecutive SRS treatment plans (21 Gy/1 fx) delivered between November 2019 and August 2022 were retrospectively selected and automatically re-planned by LOps: 25 of them has 1 lesion, 13 had 2 lesions, 4 had 3 lesions, and 2 had 4 lesions. An a-priori assigned priority list, Wish List (WL), was used to define the sequential LO: 4 patient sets (tuning set) were necessary to tune each WL, for single lesion-plans (SLp) and multiple lesion-plans (MLp). While in manual plans (MP), the arc setup is freely chosen, the WL was tuned to use 2 coplanar arcs of 140° and 360° for SLp and MLp, respectively. A 0° and 90° collimator rotation were set for counter-clockwise and clockwise arcs, respectively. The fluence optimization is followed by a Monte Carlo calculation (MCc) with 1 mm-dose grid and 0.5%-statistical uncertainty. A target coverage as high as possible was requested, with at least 80% of the prescription dose covering 99% of the PTV. The main criteria for SLp approval were a brain V12Gy <10 cm3. In MLp this criterion can be overcome to get the minimum target coverage. The remaining 36 SRS plans (21 SL and 15 MLp) were automatically re-planned (testing set). Testing plans were compared in terms of dose-volume constraints, conformality, and monitor units (MUs). Statistical significance was assessed by performing the Wilcoxon test and plan delivery accuracy was verified by pre-treatment QA. RESULTS WLs-tuning took 3 days. Overall manual and automatic MCc time can be estimated at 8 hours and 3 hours, respectively. Statistically significant increases in SLp and MLp target coverage (GTV_D98%: +3.0% SL, +5.7% ML, PTV_D98%: +4.4% SL, +13.4% ML) and conformity index were registered. Automatic plans showed acceptably higher median brain V12Gy (SL: MP 7.2 cm3, SLp 7.6 cm3; ML: MP 8.7 cm3, MLp 10.3 cm3). The SLp registered a lower median MU number (-4.2%) while MLp were obtained with a higher median number of MU (+9.8%). This not statistically significant difference did not affect gamma passing rates. CONCLUSION The novel LOps produced high-quality clinically acceptable SRS SL and ML plans with coplanar arcs according to institutional-specific planning protocols, significantly reducing the overall planning time from about one working day for one MP to about 3 hours for one automatic plan. Together with comparable OAR sparing, the target coverage was significantly increased and the plan deliverability preserved.
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Affiliation(s)
- S Trivellato
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - P Caricato
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | | | - M C Daniotti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - D Panizza
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - G Montanari
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - V Faccenda
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - S Arcangeli
- University of Milan Bicocca - School of Medicine and Surgery, Milan, Italy
| | - E De Ponti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
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Faccenda V, Panizza D, Trivellato S, Daniotti MC, Pisoni V, Lucchini R, Arcangeli S, De Ponti E. Dosimetric Impact of Setup Errors in Single-Isocenter VMAT Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e102-e103. [PMID: 37784630 DOI: 10.1016/j.ijrobp.2023.06.873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) In stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) of brain metastases (BM) using single-isocenter VMAT, intra-fraction positioning errors may affect target coverage. This study aims to investigate geometric and dosimetric accuracy in single and multiple BM treatments. MATERIALS/METHODS Seventy patients with single (n = 38) and multiple (n = 32) BM treated with 15-21 Gy in 1 (n = 59) or 27 Gy in 3 (n = 11) fractions using coplanar FFF-VMAT technique were analyzed. PTV was defined by a 2 mm isotropic GTV expansion. Pre-treatment setup errors were evaluated with CBCT and corrected with a robotic six degrees-of-freedom couch. For each fraction, intra-fractional errors were measured by post-treatment CBCT and applied to the planning CT. Plans involving translations and rotations (Fx-plan) were recalculated with Monte Carlo TPS. Original and Fx-plans were compared in terms of target and brain dose parameters, performing the Wilcoxon-Mann-Whitney test (alpha = 0.05). The relationships of the BM volume, maximum dimension, distance-to-isocenter (for multiple BM cases only) and barycenter shift with the difference in target coverage between the two plans were investigated. RESULTS The median post-treatment 3D error and maximum rotational error over all 129 BM were 0.5 mm [0.1-2.7] and 0.3° [0.0-1.3], respectively. The resulting median BM barycenter shift was 0.5 mm [0.1-2.7]. The percentage of fractions in which at least one BM barycenter shifted by more than 2 mm from the planned position was 4% and 1% for single and multiple BM cases, respectively. The median single GTV volume was 0.27 cc [0.01-10.48], while the PTV had a median volume of 1.05 cc [0.12-17.05]. The median BM maximum dimension was 10.7 mm [2.9-34.1] and for multiple BM the median distance-to-isocenter was 5.15 cm [0.89-7.52]. For single BM patients, the GTV D95% was never reduced by > 5%, while PTV D95% reductions > 1% occurred in only 11 (29%) PTV. For multiple BM patients, the target statistics were slightly worse, with dose deficits larger than 5% and 1% occurring respectively in 2 BM and 34 (37%) PTV. Anyway, the majority of single and multiple BM had a loss of coverage for both GTV and PTV below 1% in Fx-plans. Larger than 5% brain V12 Gy (SRS) and V20 Gy (fSRS) increases were observed for only one single BM patient. None of the two dosimetric comparisons resulted statistically significant (p>0.05). The differences in target coverage showed a moderate-to-strong correlation only with the BM barycenter shift in both cases (R2 = 0.70-0.73 for single and R2 = 0.44-0.50 for multiple BM). CONCLUSION Due to the optimal patient setup, as well as the full six degrees-of-freedom corrections, the safety PTV margin, and the fast beam delivery, the dosimetric effects of residual setup and patient motion errors for both single and multiple BM cases were negligible. These findings warrant a potential reduction in the PTV margin with this treatment technique.
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Affiliation(s)
- V Faccenda
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - D Panizza
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - S Trivellato
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - M C Daniotti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
| | - V Pisoni
- Fondazione IRCCS San Gerardo dei Tintori - Radiation Oncology Department, Monza, Italy
| | - R Lucchini
- University of Milan Bicocca - School of Medicine and Surgery, Milan, Italy
| | - S Arcangeli
- University of Milan Bicocca - School of Medicine and Surgery, Milan, Italy
| | - E De Ponti
- Fondazione IRCCS San Gerardo dei Tintori - Medical Physics Department, Monza, Italy
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Caricato P, Trivellato S, Pellegrini R, Montanari G, Daniotti MC, Bordigoni B, Faccenda V, Panizza D, Meregalli S, Bonetto E, Voet P, Arcangeli S, De Ponti E. Updating approach for lexicographic optimization-based planning to improve cervical cancer plan quality. Discov Oncol 2023; 14:180. [PMID: 37775613 PMCID: PMC10541351 DOI: 10.1007/s12672-023-00800-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND To investigate the capability of a not-yet commercially available fully automated lexicographic optimization (LO) planning algorithm, called mCycle (Elekta AB, Stockholm, Sweden), to further improve the plan quality of an already-validated Wish List (WL) pushing on the organs-at-risk (OAR) sparing without compromising target coverage and plan delivery accuracy. MATERIAL AND METHODS Twenty-four mono-institutional consecutive cervical cancer Volumetric-Modulated Arc Therapy (VMAT) plans delivered between November 2019 and April 2022 (50 Gy/25 fractions) have been retrospectively selected. In mCycle the LO planning algorithm was combined with the a-priori multi-criterial optimization (MCO). Two versions of WL have been defined to reproduce manual plans (WL01), and to improve the OAR sparing without affecting minimum target coverage and plan delivery accuracy (WL02). Robust WLs have been tuned using a subset of 4 randomly selected patients. The remaining plans have been automatically re-planned by using the designed WLs. Manual plans (MP) and mCycle plans (mCP01 and mCP02) were compared in terms of dose distributions, complexity, delivery accuracy, and clinical acceptability. Two senior physicians independently performed a blind clinical evaluation, ranking the three competing plans. Furthermore, a previous defined global quality index has been used to gather into a single score the plan quality evaluation. RESULTS The WL tweaking requests 5 and 3 working days for the WL01 and the WL02, respectively. The re-planning took in both cases 3 working days. mCP01 best performed in terms of target coverage (PTV V95% (%): MP 98.0 [95.6-99.3], mCP01 99.2 [89.7-99.9], mCP02 96.9 [89.4-99.5]), while mCP02 showed a large OAR sparing improvement, especially in the rectum parameters (e.g., Rectum D50% (Gy): MP 41.7 [30.2-47.0], mCP01 40.3 [31.4-45.8], mCP02 32.6 [26.9-42.6]). An increase in plan complexity has been registered in mCPs without affecting plan delivery accuracy. In the blind comparisons, all automated plans were considered clinically acceptable, and mCPs were preferred over MP in 90% of cases. Globally, automated plans registered a plan quality score at least comparable to MP. CONCLUSIONS This study showed the flexibility of the Lexicographic approach in creating more demanding Wish Lists able to potentially minimize toxicities in RT plans.
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Affiliation(s)
- Paolo Caricato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
- Department of Physics, University of Milan, Milan, Italy.
| | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | | | - Gianluca Montanari
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milano Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Sofia Meregalli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elisa Bonetto
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Peter Voet
- Research Clinical Liaison, Elekta AB, Stockholm, Sweden
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Faccenda V, Panizza D, Pisoni V, Trivellato S, Daniotti MC, Bianchi SP, De Ponti E, Arcangeli S. Single-Isocenter Linac-Based Radiosurgery for Brain Metastases with Coplanar Arcs: A Dosimetric and Clinical Analysis. Cancers (Basel) 2023; 15:4496. [PMID: 37760466 PMCID: PMC10526167 DOI: 10.3390/cancers15184496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of linac-based SRS/fSRS treatments using the single-isocenter coplanar FFF-VMAT technique for both single and multiple BM was investigated. Seventy patients (129 BM) treated with 15-21 Gy in 1 (n = 59) or 27 Gy in 3 (n = 11) fractions were analyzed. For each fraction, plans involving the intra-fractional errors measured by post-treatment CBCT were recalculated. The relationships of BM size, distance-to-isocenter, and barycenter shift with the difference in target coverage were evaluated. Clinical outcomes were assessed using logistic regression and Kaplan-Meier analysis. The median delivery time was 3.78 min (range, 1.83-9.25). The median post-treatment 3D error was 0.5 mm (range, 0.1-2.7) and the maximum rotational error was 0.3° (range, 0.0-1.3). In single BM patients, the GTV D95% was never reduced by >5%, whereas PTV D95% reductions >1% occurred in only 11 cases (29%). In multiple BM patients, dose deficits >5% and >1% occurred in 2 GTV (2%) and 34 PTV (37%), respectively. The differences in target coverage showed a moderate-to-strong correlation only with barycenter shift. Local failure of at least one treated BM occurred in 13 (21%) patients and the 1-year and 2-year local control rates for all lesions were 94% and 90%, respectively. The implemented workflow ensured that the degradation of target and brain dose metrics in delivered treatments was negligible. Along with encouraging clinical outcomes, these findings warrant a reduction in the PTV margins at our institution.
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Affiliation(s)
- Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Valerio Pisoni
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Sofia Paola Bianchi
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
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Faccenda V, Panizza D, Daniotti MC, Pellegrini R, Trivellato S, Caricato P, Lucchini R, De Ponti E, Arcangeli S. Dosimetric Impact of Intrafraction Prostate Motion and Interfraction Anatomical Changes in Dose-Escalated Linac-Based SBRT. Cancers (Basel) 2023; 15:cancers15041153. [PMID: 36831496 PMCID: PMC9954235 DOI: 10.3390/cancers15041153] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
The dosimetric impact of intrafraction prostate motion and interfraction anatomical changes and the effect of beam gating and motion correction were investigated in dose-escalated linac-based SBRT. Fifty-six gated fractions were delivered using a novel electromagnetic tracking device with a 2 mm threshold. Real-time prostate motion data were incorporated into the patient's original plan with an isocenter shift method. Delivered dose distributions were obtained by recalculating these motion-encoded plans on deformed CTs reflecting the patient's CBCT daily anatomy. Non-gated treatments were simulated using the prostate motion data assuming that no treatment interruptions have occurred. The mean relative dose differences between delivered and planned treatments were -3.0% [-18.5-2.8] for CTV D99% and -2.6% [-17.8-1.0] for PTV D95%. The median cumulative CTV coverage with 93% of the prescribed dose was satisfactory. Urethra sparing was slightly degraded, with the maximum dose increased by only 1.0% on average, and a mean reduction in the rectum and bladder doses was seen in almost all dose metrics. Intrafraction prostate motion marginally contributed in gated treatments, while in non-gated treatments, further deteriorations in the minimum target coverage and bladder dose metrics would have occurred on average. The implemented motion management strategy and the strict patient preparation regimen, along with other treatment optimization strategies, ensured no significant degradations of dose metrics in delivered treatments.
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Affiliation(s)
- Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- Department of Physics, University of Milan, 20133 Milan, Italy
| | | | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Paolo Caricato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Raffaella Lucchini
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- Correspondence:
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Trivellato S, Caricato P, Pellegrini R, Montanari G, Daniotti MC, Bordigoni B, Faccenda V, Panizza D, Meregalli S, Bonetto E, Arcangeli S, De Ponti E. Comprehensive dosimetric and clinical evaluation of lexicographic optimization-based planning for cervical cancer. Front Oncol 2022; 12:1041839. [PMID: 36465394 PMCID: PMC9709287 DOI: 10.3389/fonc.2022.1041839] [Citation(s) in RCA: 1] [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: 09/11/2022] [Accepted: 10/25/2022] [Indexed: 11/01/2023] Open
Abstract
AIM In this study, a not yet commercially available fully-automated lexicographic optimization (LO) planning algorithm, called mCycle (Elekta AB, Stockholm, Sweden), was validated for cervical cancer. MATERIAL AND METHODS Twenty-four mono-institutional consecutive treatment plans (50 Gy/25 fx) delivered between November 2019 and April 2022 were retrospectively selected. The automatic re-planning was performed by mCycle, implemented in the Monaco TPS research version (v5.59.13), in which the LO and Multicriterial Optimization (MCO) are coupled with Monte Carlo calculation. mCycle optimization follows an a priori assigned priority list, the so-called Wish List (WL), representing a dialogue between the radiation oncologist and the planner, setting hard constraints and following objectives. The WL was tuned on a patient subset according to the institution's clinical protocol to obtain an optimal plan in a single optimization. This robust WL was then used to automatically re-plan the remaining patients. Manual plans (MP) and mCycle plans (mCP) were compared in terms of dose distributions, complexity (modulation complexity score, MCS), and delivery accuracy (perpendicular diode matrices, gamma analysis-passing ratio, PR). Their clinical acceptability was assessed through the blind choice of two radiation oncologists. Finally, a global quality score index (SI) was defined to gather into a single number the plan evaluation process. RESULTS The WL tuning requested four patients. The 20 automated re-planning tasks took three working days. The median optimization and calculation time can be estimated at 4 h and just over 1 h per MP and mCP, respectively. The dose comparison showed a comparable organ-at-risk spare. The planning target volume coverage increased (V95%: MP 98.0% [95.6-99.3]; mCP 99.2%[89.7-99.9], p >0.05). A significant increase has been registered in MCS (MP 0.29 [0.24-0.34]; mCP 0.26 [0.23-0.30], p <0.05) without affecting delivery accuracy (PR (3%/3mm): MP 97.0% [92.7-99.2]; mCP 97.1% [95.0-98.6], p >0.05). In the blind choice, all mCP results were clinically acceptable and chosen over MP in more than 75% of cases. The median SI score was 0.69 [0.41-0.84] and 0.73 [0.51-0.82] for MP and mCP, respectively (p >0.05). CONCLUSIONS mCycle plans were comparable to clinical manual plans, more complex but accurately deliverable and registering a similar SI. Automated plans outperformed manual plans in blinded clinical choice.
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Affiliation(s)
- Sara Trivellato
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Paolo Caricato
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | | | - Gianluca Montanari
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Bianca Bordigoni
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Denis Panizza
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Sofia Meregalli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Elisa Bonetto
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
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Panizza D, Faccenda V, Lucchini R, Daniotti MC, Trivellato S, Caricato P, Pisoni V, De Ponti E, Arcangeli S. Intrafraction Prostate Motion Management During Dose-Escalated Linac-Based Stereotactic Body Radiation Therapy. Front Oncol 2022; 12:883725. [PMID: 35463373 PMCID: PMC9021501 DOI: 10.3389/fonc.2022.883725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Extreme hypofractionation requires tight planning margins, high dose gradients, and strict adherence to planning criteria in terms of patient positioning and organ motion mitigation. This study reports the first clinical experience worldwide using a novel electromagnetic (EM) tracking device for intrafraction prostate motion management during dose-escalated linac-based stereotactic body radiation therapy (SBRT). Methods Thirteen patients with organ-confined prostate cancer underwent dose-escalated SBRT using flattening filter-free (FFF) volumetric modulated arc therapy (VMAT). The EM tracking device consisted of an integrated Foley catheter with a transmitter. Patients were simulated and treated with a filled bladder and an empty rectum. Setup accuracy was achieved by ConeBeam-CT (CBCT) matching, and motion was tracked during all the procedure. Treatment was interrupted when the signals exceeded a 2 mm threshold in any of the three spatial directions and, unless the offset was transient, target position was re-defined by repeating CBCT. Moreover, the displacements that would have occurred without any intrafraction organ motion management (i.e. no interruptions and repositionings) were simulated. Results In 31 out of 56 monitored fractions (55%), no intervention was required to correct the target position. In 25 (45%) a correction was mandated, but only in 10 (18%), the beam delivery was interrupted. Total treatment time lasted on average 10.2 minutes, 6.7 minutes for setup, and 3.5 minutes for beam delivery. Without any intrafraction motion management, the overall mean treatment time and the mean delivery time would have been 6.9 minutes and 3.2 minutes, respectively. The prostate would have been found outside the tolerance in 8% of the total session time, in 4% of the time during the setup, and in 14% during the beam-on phase. Predominant motion pattern was posterior and its probability increased with time, with a mean motion ≤ 2 mm occurring within 10 minutes. Conclusions EM real-time tracking was successfully implemented for intrafraction motion management during dose-escalated prostate SBRT. Results showed that most of the observed displacements were < 2 mm in any direction; however, there were a non-insignificant number of fractions with motion exceeding the predefined threshold, which would have otherwise gone undetected without intrafraction motion management.
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Affiliation(s)
- Denis Panizza
- Medical Physics Department, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Valeria Faccenda
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | - Raffaella Lucchini
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,Radiation Oncology Department, ASST Monza, Monza, Italy
| | - Martina Camilla Daniotti
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | | | - Paolo Caricato
- Medical Physics Department, ASST Monza, Monza, Italy.,Department of Physics, University of Milan, Milan, Italy
| | | | - Elena De Ponti
- Medical Physics Department, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,Radiation Oncology Department, ASST Monza, Monza, Italy
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Lucchini R, Panizza D, Colciago RR, Vernier V, Daniotti MC, Faccenda V, Arcangeli S. Treatment outcome and compliance to dose-intensified linac-based SBRT for unfavorable prostate tumors using a novel real-time organ-motion tracking. Radiat Oncol 2021; 16:180. [PMID: 34535168 PMCID: PMC8447697 DOI: 10.1186/s13014-021-01908-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/07/2021] [Indexed: 01/04/2023] Open
Abstract
PURPOSE/OBJECTIVES To report preliminary data on treatment outcome and compliance to dose-intensified organ sparing SBRT for prostate cancer using a novel electromagnetic transmitter-based tracking system (RayPilotÒ System) to account for intra-fractional organ motion. MATERIAL/METHODS Thirteen patients with intermediate unfavorable (9) and selected high-risk (4) prostate cancer underwent dose-escalated SBRT in 4 or 5 fractions (BED1.5 = 279 Gy and 253 Gy, respectively). The VMAT treatment consisted in two 6FFF or 10FFF full arcs optimized to have the 95% isodose covering at least 95% of the PTV (2 mm isotropic expansion of the CTV). Whenever the real-time tracking registered a displacement that exceeded 2 mm during the setup and/or the beam delivery, the treatment was interrupted and the prostate motion was promptly corrected. The incidence of treatment-related genitourinary (GU) and gastrointestinal (GI) toxicity, patient QoL and PSA outcomes were computed from the start of treatment to the last follow-up date. RESULTS All patients completed the treatment in the expected time (10.2 +/- 4.2 minutes) and their compliance to the procedure was excellent. No clinically significant acute Grade 2 or higher GI (rectal) and GU side effects were observed within 90 days from the treatment completion. The median IPSS increased from 8 at baseline to 12 one-month after treatment and settled to 6 at 3 months. EPIC-26 scores in the urinary domain decreased from a median baseline of 86 pre-treatment to 79 at one-month and returned to baseline at a later timepoint (median score of 85 at 3 months). EPIC-26 scores in the bowel domains did not show significant changes within 3 months following RT. The prostate was found within 1 mm from its initial position in 78% of the beam-on time, between 1 and 2 mm in 20%, and exceeded 2 mm only in 2%, after correction for motion which was performed in 45% of the fractions, either during setup or beam delivery. CONCLUSIONS Our preliminary findings show that dose intensified SBRT for unfavorable prostate tumors does not come at the cost of an increased toxicity, provided that a reliable technique for real time prostate monitoring is ensured. Fast FFF beams contributed to reduce intra-fractional motion. These observations need to be confirmed on a larger scale and a longer follow up.
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Affiliation(s)
- Raffaella Lucchini
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Radiation Oncology Department, ASST Monza, Monza, Italy
| | - Denis Panizza
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Medical Physics Department, ASST Monza, Monza, Italy
| | - Riccardo Ray Colciago
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.
- Radiation Oncology Department, ASST Monza, Monza, Italy.
| | - Veronica Vernier
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | | | - Valeria Faccenda
- Medical Physics Department, ASST Monza, Monza, Italy
- Department of Physics, University of Milan, Milan, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Radiation Oncology Department, ASST Monza, Monza, Italy
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