Image guidance in radiation therapy for better cure of cancer

Grégoire, Vincent; Gückenberger, Matthias; Haustermans, Karin; Lagendijk, J J W; Ménard, Cynthia; Pötter, Richard; Slotman, Ben J.; Tanderup, Kari; Thorwarth, Daniela; Herk, Marcel van; Zips, Daniel

doi:10.1002/1878-0261.12751

Cited by 82 publications

(72 citation statements)

References 135 publications

(152 reference statements)

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“…Tumor margin prescriptions were developed to account for the differences between the radiation dose distribution and the patient’s anatomy based on patient positioning errors, anatomical changes, and intrafraction motion ( 1 ). In-room imaging went a long way to reduce the margins needed to account for positioning and anatomical changes, but intrafraction motion remained a challenge due to the lack of real-time internal imaging of soft tissues ( 2 , 3 ). This limitation was solved with the recent development of magnetic resonance (MR)-guided RT, defined as the integration of a radiation-delivery machine and an MR scanner ( 4 , 5 ).…”

Section: Introductionmentioning

confidence: 99%

Technical Challenges of Real-Time Adaptive MR-Guided Radiotherapy

Thorwarth

Low

2021

Front. Oncol.

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In the past few years, radiotherapy (RT) has experienced a major technological innovation with the development of hybrid machines combining magnetic resonance (MR) imaging and linear accelerators. This new technology for MR-guided cancer treatment has the potential to revolutionize the field of adaptive RT due to the opportunity to provide high-resolution, real-time MR imaging before and during treatment application. However, from a technical point of view, several challenges remain which need to be tackled to ensure safe and robust real-time adaptive MR-guided RT delivery. In this manuscript, several technical challenges to MR-guided RT are discussed. Starting with magnetic field strength tradeoffs, the potential and limitations for purely MR-based RT workflows are discussed. Furthermore, the current status of real-time 3D MR imaging and its potential for real-time RT are summarized. Finally, the potential of quantitative MR imaging for future biological RT adaptation is highlighted.

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Section: Introductionmentioning

confidence: 99%

Technical Challenges of Real-Time Adaptive MR-Guided Radiotherapy

Thorwarth

Low

2021

Front. Oncol.

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“…However, hypoxia level images together with the radiation response curve in Figure 1 C enable construction of radioresistance images that most likely would be more appropriate. In addition, combined devices of MR imaging and linear accelerators (MR-linacs) are on the way into clinical routine [ 179 ]. MR-based methods to image hypoxia levels during radiation treatment might facilitate dose-painting with these machines, and development of such methods are likely to be pursued in the coming years.…”

Section: Perspectivesmentioning

confidence: 99%

Tumor Hypoxia as a Barrier in Cancer Therapy: Why Levels Matter

Hompland

Fjeldbo

Lyng

2021

Cancers

102

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Hypoxia arises in tumor regions with insufficient oxygen supply and is a major barrier in cancer treatment. The distribution of hypoxia levels is highly heterogeneous, ranging from mild, almost non-hypoxic, to severe and anoxic levels. The individual hypoxia levels induce a variety of biological responses that impair the treatment effect. A stronger focus on hypoxia levels rather than the absence or presence of hypoxia in our investigations will help development of improved strategies to treat patients with hypoxic tumors. Current knowledge on how hypoxia levels are sensed by cancer cells and mediate cellular responses that promote treatment resistance is comprehensive. Recently, it has become evident that hypoxia also has an important, more unexplored role in the interaction between cancer cells, stroma and immune cells, influencing the composition and structure of the tumor microenvironment. Establishment of how such processes depend on the hypoxia level requires more advanced tumor models and methodology. In this review, we describe promising model systems and tools for investigations of hypoxia levels in tumors. We further present current knowledge and emerging research on cellular responses to individual levels, and discuss their impact in novel therapeutic approaches to overcome the hypoxia barrier.

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“…To this end, integrating a 1.5 T scanner with a linear accelerator led to the development of MR-Linac (MRL), which can be considered a novel deflection point in radiation oncology [ 3 , 4 ]. This integration builds on the idea that safe radiation therapy is predicated on well focused tumor treatment without markedly injuring the neighboring healthy tissues, since therapeutic radiation doses required to destroy cancerous lesions mostly exceed the tolerable threshold by healthy tissues [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Prospective Image Quality and Lesion Assessment in the Setting of MR-Guided Radiation Therapy of Prostate Cancer on an MR-Linac at 1.5 T: A Comparison to a Standard 3 T MRI

Almansour

Afat

Fritz

et al. 2021

Cancers

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The objective of this study is to conduct a qualitative and a quantitative image quality and lesion evaluation in patients undergoing MR-guided radiation therapy (MRgRT) for prostate cancer on a hybrid magnetic resonance imaging and linear accelerator system (MR-Linac or MRL) at 1.5 Tesla. This prospective study was approved by the institutional review board. A total of 13 consecutive patients with biopsy-confirmed prostate cancer and an indication for MRgRT were included. Prior to radiation therapy, each patient underwent an MR-examination on an MRL and on a standard MRI scanner at 3 Tesla (MRI3T). Three readers (two radiologists and a radiation oncologist) conducted an independent qualitative and quantitative analysis of T2-weighted (T2w) and diffusion-weighted images (DWI). Qualitative outcome measures were as follows: zonal anatomy, capsule demarcation, resolution, visibility of the seminal vesicles, geometric distortion, artifacts, overall image quality, lesion conspicuity, and diagnostic confidence. All ratings were performed on an ordinal 4-point Likert scale. Lesion conspicuity and diagnostic confidence were firstly analyzed only on MRL. Afterwards, these outcome parameters were analyzed in consensus with the MRI3T. Quantitative outcome measures were as follows: anteroposterior and right left diameter of the prostate, lesion size, PI-RADS score (Prostate Imaging—Reporting and Data System) and apparent diffusion coefficient (ADC) of the lesions. Intergroup comparisons were computed using the Wilcoxon-sign rank test and t tests. A post-hoc regression analysis was computed for lesion evaluation. Finally, inter-/intra-reader agreement was analyzed using the Fleiss kappa and intraclass correlation coefficient. For T2w images, the MRL showed good results across all quality criteria (median 3 and 4). Furthermore, there were no significant differences between MRL and MRI3T regarding capsule demarcation or geometric distortion. For the DWI, the MRL performed significantly less than MRI3T across most image quality criteria with a median ranging between 2 and 3. However, there were no significant differences between MRL and MRI3T regarding geometric distortion. In terms of lesion conspicuity and diagnostic confidence, inter-reader agreement was fair for MRL alone (Kappa = 0.42) and good for MRL in consensus with MRI3T (Kappa = 0.708). Thus, lesion conspicuity and diagnostic confidence could be significantly improved when reading MRL images in consensus with MRI3T (Odds ratio: 9- to 11-fold for the T2w images and 5- to 8–fold for the DWI) (p < 0.001). For measures of lesion size, anterior-posterior and right-left prostate diameter, inter-reader and intersequence agreement were excellent (ICC > 0.90) and there were no significant differences between MRL and MRI3T among all three readers. In terms of Prostate Imaging Reporting and Data System (PIRADS) scoring, no significant differences were observed between MRL and MRI3T. Finally, there was a significant positive linear relationship between lesion ADC measurements (r = 0.76, p < 0.01) between the ADC values measured on both systems. In conclusion, image quality for T2w was comparable and diagnostic even without administration of spasmolytic- or contrast agents, while DWI images did not reach diagnostic level and need to be optimized for further exploitation in the setting of MRgRT. Diagnostic confidence and lesion conspicuity were significantly improved by reading MRL in consensus with MRI3T which would be advisable for a safe planning and treatment workflow. Finally, ADC measurements of lesions on both systems were comparable indicating that, lesion ADC as measured on the MRL could be used as a biomarker for evaluation of treatment response, similar to examinations using MRI3T.

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Image guidance in radiation therapy for better cure of cancer

Cited by 82 publications

References 135 publications

Technical Challenges of Real-Time Adaptive MR-Guided Radiotherapy

Technical Challenges of Real-Time Adaptive MR-Guided Radiotherapy

Tumor Hypoxia as a Barrier in Cancer Therapy: Why Levels Matter

Prospective Image Quality and Lesion Assessment in the Setting of MR-Guided Radiation Therapy of Prostate Cancer on an MR-Linac at 1.5 T: A Comparison to a Standard 3 T MRI

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