The Usefulness of Adaptative Radiotherapy in Prostate Cancer: How, When, and Who?

The aim of this study was to develop a deformable image registration (DIR)-based offline ART protocol capable of identifying significant dosimetric changes in the first treatment fractions to determine when adaptive replanning is needed. A total of 240 images (24 planning CT (pCT) and 216 kilovoltage cone-beam CT (CBCT)) were prospectively acquired from 24 patients with prostate adenocarcinoma during the first three weeks of their treatment (76 Gy in 38 fractions). This set of images was used to plan a hypofractionated virtual treatment (57.3 Gy in 15 fractions); correlation with the DIR of pCT and each CBCT allowed to translate planned doses to each CBCT, and finally mapped back to the pCT to compare with those actually administered. In 37.5% of patients, doses administered in 50% of the rectum (D50) would have exceeded the dose limitation to 50% of the rectum (R50). We first observed a significant variation of the planned rectal volume in the CBCTs of fractions 1, 3, and 5. Then, we found a significant relationship between the D50 accumulated in fractions 1, 3, and 5 and the lack of compliance with the R50. Finally, we found that a D50 variation rate [100 × (administered D50 − planned D50/planned D50)] > 1% in fraction three can reliably identify variations in administered doses that will lead to exceeding rectal dose constraint.

Patterns of practice for adaptive and real-time radiation therapy (POP-ART RT) part II: Offline and online plan adaption for interfractional changes.

PURPOSE: The POP-ART RT study aims to determine to what extent and how intrafractional real-time respiratory motion management (RRMM), and plan adaptation for interfractional anatomical changes (ART) are used in clinical practice and to understand barriers to implementation. Here we report on part II: ART using more than one plan per target per treatment course. MATERIALS AND METHODS: A questionnaire on the current practice of ART, wishes for expansion or implementation, and barriers to implementation was distributed worldwide. Four types of ART were discriminated: daily online replanning, online plan library, protocolled offline replanning (all three based on a protocol), and ad-hoc offline replanning. RESULTS: The questionnaire was completed by 177 centres from 40 countries. ART was used by 61% of respondents (31% with protocol) for a median (range) of 3 (1-8) tumour sites. CBCT/MVCT was the main imaging modality except for online daily replanning (11 users) where 10 users used MR. Two thirds of respondents wished to implement ART for a new tumour site; 40% of these had plans to do it in the next 2 years. Human/material resources and technical limitations were the main barriers to further use and implementation. CONCLUSIONS: ART was used for a broad range of tumour sites, mainly with ad-hoc offline replanning and for a median of 3 tumour sites. There was a large interest in implementing ART for more tumour sites, mainly limited by human/material resources and technical limitations. Daily online replanning was primarily performed on MR-linacs.

Statistical process control for electron beam monitoring.

PURPOSE: To assess the electron beam monitoring statistical process control (SPC) in linear accelerator (linac) daily quality control. We present a long-term record of our measurements and evaluate which SPC-led conditions are feasible for maintaining control. METHODS: We retrieved our linac beam calibration, symmetry, and flatness daily records for all electron beam energies from January 2008 to December 2013, and retrospectively studied how SPC could have been applied and which of its features could be used in the future. A set of adjustment interventions designed to maintain these parameters under control was also simulated. RESULTS: All phase I data was under control. The dose plots were characterized by rising trends followed by steep drops caused by our attempts to re-center the linac beam calibration. Where flatness and symmetry trends were detected they were less-well defined. The process capability ratios ranged from 1.6 to 9.3 at a 2% specification level. Simulated interventions ranged from 2% to 34% of the total number of measurement sessions. We also noted that if prospective SPC had been applied it would have met quality control specifications. CONCLUSIONS: SPC can be used to assess the inherent variability of our electron beam monitoring system. It can also indicate whether a process is capable of maintaining electron parameters under control with respect to established specifications by using a daily checking device, but this is not practical unless a method to establish direct feedback from the device to the linac can be devised.

Validation of a deformable image registration produced by a commercial treatment planning system in head and neck.

In recent years one of the areas of interest in radiotherapy has been adaptive radiation therapy (ART), with the most efficient way of performing ART being the use of deformable image registration (DIR). In this paper we use the distances between points of interest (POIs) in the computed tomography (CT) and the cone beam computed tomography (CBCT) acquisition images and the inverse consistence (IC) property to validate the RayStation treatment planning system (TPS) DIR algorithm. This study was divided into two parts: Firstly the distance-accuracy of the TPS DIR algorithm was ascertained by placing POIs on anatomical features in the CT and CBCT images from five head and neck cancer patients. Secondly, a method was developed for studying the implication of these distances on the dose by using the IC. This method compared the dose received by the structures in the CT, and the structures that were quadruply-deformed. The accuracy of the TPS was 1.7 ± 0.8 mm, and the distance obtained with the quadruply-deformed IC method was 1.7 ± 0.9 mm, i.e. the difference between the IC method multiplied by two, and that of the TPS validation method, was negligible. Moreover, the IC method shows very little variation in the dose-volume histograms when comparing the original and quadruply-deformed structures. This indicates that this algorithm is useful for planning adaptive radiation treatments using CBCT in head and neck cancer patients, although these variations must be taken into account when making a clinical decision to adapt a treatment plan.

Study of DQE dependence with beam quality on GE essential mammography flat panel.

This paper deals with the analysis of the behavior of objective image quality parameters for the new GE Senographe Essential FFDM system, in particular its dependence with beam quality. The detector consists of an indirect conversion a-Si flat panel coupled to a CsI:Tl scintillator. The system under study has gone through a series of relevant modifications in flat panel with respect to the previous model (GE Senographe DS 2000). These changes in the detector modify its performance and are intended to favor advanced applications like tomosynthesis, which uses harder beam spectra and lower doses per exposure than conventional FFDM. Although our system does not have tomosynthesis implemented, we noticed that most clinical explorations were performed by automatically selecting a harder spectrum than that of typical use in FFDM (Rh/Rh 28-30 kV instead of Mo/Mo 28 kV). Since flat-panel optimization for tomosynthesis influences the usual FFDM clinical performance, the new detector behavior needed to be investigated. Therefore, the aim of our study is evaluating the dependence of the detector performance for different beam spectra and exposure levels. In this way, we covered the clinical beam quality range (Rh/Rh 28-30 kV) and we extended the study to even harder spectra (Rh/Rh 34 kV). Detector performance is quantified by means of modulation transfer function (MTF), normalized noise power spectrum (NNPS) and detective quantum efficiency (DQE). We found that flat-panel optimization results in slightly - but statistically significant - higher DQE values as beam quality increases, which is contrary to the expected behavior. This positive correlation between beam quality and DQE is also diametrically opposite to that of the previous model by the same manufacturer. As a direct consequence, usual FFDM takes advantage of the changes in the detector, as less exposure is needed to achieve the same DQE if harder beams are used.