First Clinical Investigation of Cone Beam Computed Tomography and Deformable Registration for Adaptive Proton Therapy for Lung Cancer

Veiga, Catarina; Janssens, Guillaume; Teng, Ching Ling; Baudier, Thomas; Hotoiu, L.; McClelland, Jamie R.; Royle, G.; Lin, Liyong; Yin, Lingshu; Metz, James M.; Solberg, Timothy D.; Tochner, Zelig; Simone, Charles B.; McDonough, James E.; Teo, Boon K.

doi:10.1016/j.ijrobp.2016.01.055

Cited by 185 publications

(223 citation statements)

References 35 publications

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“…The standard image guidance for positioning in proton therapy is orthogonal X‐ray42 which has limitations for 3D target positioning. More advanced 3D imaging techniques like in‐room and cone‐beam CT become more and more available and might be beneficial,43, 44, 45 also for direct dose recalculations, dose accumulation and treatment adaptations. Estimations for accumulated doses during the treatment course were not feasible here due to the limitation of having only one control CT available.…”

Section: Discussionmentioning

confidence: 99%

Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes

Stützer

Jakobi

Bandurska-Luque

et al. 2017

J Applied Clin Med Phys

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PurposeEvaluation of dose degradation by anatomic changes for head‐and‐neck cancer (HNC) intensity‐modulated proton therapy (IMPT) relative to intensity‐modulated photon therapy (IMRT) and identification of potential indicators for IMPT treatment plan adaptation.MethodsFor 31 advanced HNC datasets, IMPT and IMRT plans were recalculated on a computed tomography scan (CT) taken after about 4 weeks of therapy. Dose parameter changes were determined for the organs at risk (OARs) spinal cord, brain stem, parotid glands, brachial plexus, and mandible, for the clinical target volume (CTV) and the healthy tissue outside planning target volume (PTV). Correlation of dose degradation with target volume changes and quality of rigid CT matching was investigated.ResultsRecalculated IMPT dose distributions showed stronger degradation than the IMRT doses. OAR analysis revealed significant changes in parotid median dose (IMPT) and near maximum dose (D 1ml) of spinal cord (IMPT, IMRT) and mandible (IMPT). OAR dose parameters remained lower in IMPT cases. CTV coverage (V 95%) and overdose (V 107%) deteriorated for IMPT plans to (93.4 ± 5.4)% and (10.6 ± 12.5)%, while those for IMRT plans remained acceptable. Recalculated plans showed similarly decreased PTV conformity, but considerable hotspots, also outside the PTV, emerged in IMPT cases. Lower CT matching quality was significantly correlated with loss of PTV conformity (IMPT, IMRT), CTV homogeneity and coverage (IMPT). Target shrinkage correlated with increased dose in brachial plexus (IMRT, IMPT), hotspot generation outside the PTV (IMPT) and lower PTV conformity (IMRT).ConclusionsThe study underlines the necessity of precise positioning and monitoring of anatomy changes, especially in IMPT which might require adaptation more often. Since OAR doses remained typically below constraints, IMPT plan adaptation will be indicated by target dose degradations.

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Section: Discussionmentioning

confidence: 99%

Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes

Stützer

Jakobi

Bandurska-Luque

et al. 2017

J Applied Clin Med Phys

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“…Owing to the already large irradiation volumes and potential risks of additional elective treatment, elective whole pleural irradiation was not administered. Daily image guidance, inclusive of cone‐beam CT scans as previously reported , was conducted for verification prior to treatment delivery.…”

Section: Methodsmentioning

confidence: 99%

A Novel Prospective Study Assessing the Combination of Photodynamic Therapy and Proton Radiation Therapy: Safety and Outcomes When Treating Malignant Pleural Mesothelioma

Rice

Busch

et al. 2018

Photochem & Photobiology

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Malignant pleural mesothelioma remains difficult to treat, with high failure rates despite optimal therapy. We present a novel prospective trial combining proton therapy (PT) and photodynamic therapy (PDT) and the largest-ever mesothelioma PT experience (n = 10). PDT photosensitizers included porfimer sodium (2 mg-kg−1; 24 h drug-light interval) or 2-[1-hexylox-yethyl]-2-devinyl pyropheophorbide-a (HPPH) (4 mg m−2; 48 h) with wavelengths of 630 nm to 60Jcm−2 and 665 nm to 15–45Jcm−2, respectively. With a median age of 69 years, patients were predominantly male (90%) with epithelioid histology (100%) and stage III-IV disease (100%). PT was delivered to a median of 55.0 CGE/1.8–2.0 CGE (range 50–75 CGE) adjuvantly (n = 8) or as salvage therapy (n = 2) following extended pleurectomy/decortication (ePD)/PDT. Two-year local control was 90%, with distant and regional failure rates of 50% and 30%, respectively. All patients received chemotherapy, and four received immunotherapy. Surgical complications included atrial fibrillation (n = 3), pneumonia (n = 2), and deep vein thrombosis (n = 2). Median survival from PT completion was 19.5 months (30.3 months from diagnosis), and 1-and 2-year survival rates were 58% and 29%. No patient experienced CTCAEv4 grade ≥2 acute or late toxicity. Our prolonged survival in very advanced-stage patients compares favorably to survival for PT without PDT and photon therapy with PDT, suggesting possible spatial or systemic cooperativity and immune effect.

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“…There are current developments to improve the image quality of CBCT; only time will tell if the improved CBCT images can rival those of the CT-on-rails. Moreover, CBCT does not have sufficient cephalad-caudad coverage, though here have been recent studies on the use of “synthetic” CT, in which deformable registration is used to map the Hounsfield units from the simulation CT onto the CBCT to provide the missing anatomical information [54]. …”

Section: Physics and Biological Effectiveness Related Challenges Imentioning

confidence: 99%

Empowering Intensity Modulated Proton Therapy Through Physics and Technology: An Overview

Mohan

Das

Ling

2017

International Journal of Radiation Oncology*Biology*Physics

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Considering the clinical potential of protons attributable to their physical characteristics, interest in proton therapy has increased greatly in this century as has the number of proton therapy installations. Until recently, passively scattered proton therapy (PSPT) was used almost entirely. Notably, overall clinical results to date have not shown convincing benefit protons over photons. A rapid transition is now occurring with the implementation of the most advanced form of proton therapy, the intensity-modulated proton therapy (IMPT). IMPT is superior to PSPT and IMRT dosimetrically. However, numerous limitations exist in the present IMPT methods. In particular, compared to IMRT, IMPT is highly vulnerable to various uncertainties. In this overview we identify three major areas of current limitations of IMPT: treatment planning, treatment delivery, and motion management, and discuss current and future efforts for improvement. For treatment planning, we need to reduce uncertainties in proton range and in computed dose distributions, improve robust planning and optimization, enhance adaptive treatment planning and delivery, and consider how to exploit the variability in the relative biological effectiveness (RBE) of protons for clinical benefit. The quality of proton therapy also depends on the characteristics of the IMPT delivery systems and image-guidance. Efforts are needed to optimize the beamlet spot size for both improved dose conformality and faster delivery. For the latter, faster energy switching time and increased dose-rate are also needed. Real-time in-room volumetric imaging for guiding IMPT is in its early stages with CBCT and CT-on-rails, and continued improvements are anticipated. In addition, imaging of the proton beams themselves using, for instance, prompt gamma emissions, is being developed to determine the proton range and to reduce range uncertainty. With the realization of the advances described above, we posit that IMPT, thus empowered, will lead to substantially improved clinical results.

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First Clinical Investigation of Cone Beam Computed Tomography and Deformable Registration for Adaptive Proton Therapy for Lung Cancer

Abstract: A proton therapy workflow based on CBCT provided clinical indicators similar to those using rCT for patients with lung cancer with considerable anatomic changes.

Cited by 185 publications

References 35 publications

Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes

Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes

A Novel Prospective Study Assessing the Combination of Photodynamic Therapy and Proton Radiation Therapy: Safety and Outcomes When Treating Malignant Pleural Mesothelioma

Empowering Intensity Modulated Proton Therapy Through Physics and Technology: An Overview

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