Impact of deviations in target volume delineation – Time for a new RTQA approach?

Cox, Samantha; Cleves, Anne; Clementel, E.; Miles, Elizabeth; Staffurth, John; Gwynne, S.

doi:10.1016/j.radonc.2019.04.012

Cited by 28 publications

(20 citation statements)

References 29 publications

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“…Our systematic review focused on peer review of TVD and physics plans in the non-trial setting, yet its findings align with those of Cox et al [7], which addressed quality assurance in radiotherapy clinical trials.…”

Section: Discussionsupporting

confidence: 62%

“…Standardised, evidence-based RTQA procedures for clinical trials are championed by the Global Quality Assurance of Radiation Therapy Clinical Trials Harmonisation Group, but as noted by Cox et al [7], these procedures tend to focus on prescriptions, dosimetry or other technical planning issues, rather than TVD accuracy. Their review recommends incorporation of a new approach to TVD quality assurance as part of radiotherapy clinical trial quality assurance, to facilitate assessment of its impact on clinical outcomes, and accelerate the evidence base for the best RTQA approach to TVD assessment.…”

Section: Discussionmentioning

confidence: 99%

“…Protocol deviations observed included the geographical miss of primary tumours, inadequate margins applied to treatment volumes and partial treatment of elective volumes [6]. A recent review by Cox et al [7] of TVD assessment as part of radiation therapy quality assurance (RTQA) for clinical trials proposed a new approach to RTQA. They recommended prospective TVD reviews for novel or complex techniques and consistent reporting of RTQA programme outcomes to enable an assessment of the impact of TVD deviations on clinical outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Structure and Processes of Existing Practice in Radiotherapy Peer Review: A Systematic Review of the Literature

et al. 2021

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Peer review in radiotherapy is an essential step in clinical quality assurance to avoid planning-related errors that can impact on patient safety and treatment outcomes. Despite recommendations that radiotherapy centres should include peer review in their regular quality assurance pathway, adoption of the practice has not been universal, and to date there have been no formal guidelines set out to standardise the process. We undertook a systematic review of the literature to determine existing practice in radiotherapy peer review internationally, with respect to meeting structure and processes, in order to define a standardised framework. A PubMed and Web of Science search identified 17 articles detailing peer review practice. The results revealed significant variation in peer review processes between institutions, and a lack of consensus on documentation and reporting. Variations in the grading of outcomes of peer review were also noted. Taking into account the results of this review, a framework for standardising the process and outcome documentation for peer review has been developed. This can be utilised by radiotherapy centres introducing or updating peer review practice, and can facilitate meaningful evaluation of the clinical impact of peer review in the future.

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Section: Discussionsupporting

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Structure and Processes of Existing Practice in Radiotherapy Peer Review: A Systematic Review of the Literature

et al. 2021

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“…On the other hand, in times of global increase of research costs, financing academic trials becomes a real challenge. We therefore recommend for future benchmark analyses an evaluation on the impact on dosimetry and clinical outcome as part of every trial initiation package [34].…”

Section: Discussionmentioning

confidence: 99%

Quality assurance of radiotherapy in the ongoing EORTC 1420 “Best of” trial for early stage oropharyngeal, supraglottic and hypopharyngeal carcinoma: results of the benchmark case procedure

Stelmes

Grégoire

et al. 2021

Radiat Oncol

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Introduction The current phase III EORTC 1420 Best-of trial (NCT02984410) compares the swallowing function after transoral surgery versus intensity modulated radiotherapy (RT) in patients with early-stage carcinoma of the oropharynx, supraglottis and hypopharynx. We report the analysis of the Benchmark Case (BC) procedures before patient recruitment with special attention to dysphagia/aspiration related structures (DARS). Materials and methods Submitted RT volumes and plans from participating centers were analyzed and compared against the gold-standard expert delineations and dose distributions. Descriptive analysis of protocol deviations was conducted. Mean Sorensen-Dice similarity index (mDSI) and Hausdorff distance (mHD) were applied to evaluate the inter-observer variability (IOV). Results 65% (23/35) of the institutions needed more than one submission to achieve Quality assurance (RTQA) clearance. OAR volume delineations were the cause for rejection in 53% (40/76) of cases. IOV could be improved in 5 out of 12 OARs by more than 10 mm after resubmission (mHD). Despite this, final IOV for critical OARs in delineation remained significant among DARS by choosing an aleatory threshold of 0.7 (mDSI) and 15 mm (mHD). Conclusions This is to our knowledge the largest BC analysis among Head and neck RTQA programs performed in the framework of a prospective trial. Benchmarking identified non-common OARs and target delineations errors as the main source of deviations and IOV could be reduced in a significant number of cases after this process. Due to the substantial resources involved with benchmarking, future benchmark analyses should assess fully the impact on patients’ clinical outcome.

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“…It is, therefore recommended to use more than one metric to quantify interobserver variation (17). A qualitative assessment can also be performed whereby an expert or expert panel visually evaluates the contours and classify these as acceptable or unacceptable according to a consensus delineation protocol (9,16,18). The limitation of the latter approach is that it is subjective and time consuming (19).…”

Section: Quantifying Interobserver Variationmentioning

confidence: 99%

Challenges in the target volume definition of lung cancer radiotherapy

Mercieca

Belderbos

Herk

2021

Transl Lung Cancer Res

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Radiotherapy, with or without systemic treatment has an important role in the management of lung cancer. In order to deliver the treatment accurately, the clinician must precisely outline the gross tumour volume (GTV), mostly on computed tomography (CT) images. However, due to the limited contrast between tumour and non-malignant changes in the lung tissue, it can be difficult to distinguish the tumour boundaries on CT images leading to large interobserver variation and differences in interpretation.Therefore the definition of the GTV has often been described as the weakest link in radiotherapy with its inaccuracy potentially leading to missing the tumour or unnecessarily irradiating normal tissue. In this article, we review the various techniques that can be used to reduce delineation uncertainties in lung cancer.The findings of this review indicate that to date, it is still not possible to eliminate interobserver variation in the definition of GTV. Positron Emission Tomography (PET-CT) has an important role in improving the staging accuracy and the definition of the tumour. Various autosegmentation tools have also been proposed to fully or partially automate the delineation process. However, their development is currently hindered by the unavailability of absolute gold standards that can be used to train and validate these algorithms. Hence, manual delineation is still considered to be the gold standard. Nevertheless, auto-segmented contours can provide a good starting point, eventually reducing the delineation time and interobserver variation.Improvements in image quality can also reduce the delineation uncertainty in some cases. The main factor leading to interobserver variation is image interpretation differences between clinicians. Therefore, protocols, training and peer review checks of delineated contours are essential to address this challenge. The development of the MR-linac will also present new challenges and opportunities in optimising the definition of the target volume as well as in the development of adaptive radiotherapy strategies.

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Impact of deviations in target volume delineation – Time for a new RTQA approach?

Cited by 28 publications

References 29 publications

Structure and Processes of Existing Practice in Radiotherapy Peer Review: A Systematic Review of the Literature

Structure and Processes of Existing Practice in Radiotherapy Peer Review: A Systematic Review of the Literature

Quality assurance of radiotherapy in the ongoing EORTC 1420 “Best of” trial for early stage oropharyngeal, supraglottic and hypopharyngeal carcinoma: results of the benchmark case procedure

Challenges in the target volume definition of lung cancer radiotherapy

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