Local Control and Toxicity of Adaptive Radiotherapy Using Weekly CT Imaging: Results from the LARTIA Trial in Stage III NSCLC

Ramella, Sara; Fiore, Michele; Silipigni, S.; Zappa, Maria Cristina; Jaus, Massimo Osvaldo; Alberti, Antonio; Matteucci, Paolo; Molfese, E.; Cornacchione, Patrizia; Greco, Carlo; Trodella, Lucio; Ippolito, Edy; D’Angelillo, Rolando Maria

doi:10.1016/j.jtho.2017.03.025

Cited by 56 publications

(40 citation statements)

References 44 publications

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“…We studied 91 stage III patients treated with concurrent chemoradiation. As reported in a previous prospective study of our group [ 18 ], 50 patients with stage IIIA/IIIB NSCLC were enrolled from November 2012 to July 2014 and treated with concurrent chemoradiation at radical dose with adaptive approach.…”

Section: Methodsmentioning

confidence: 99%

A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients

et al. 2018

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The primary goal of precision medicine is to minimize side effects and optimize efficacy of treatments. Recent advances in medical imaging technology allow the use of more advanced image analysis methods beyond simple measurements of tumor size or radiotracer uptake metrics. The extraction of quantitative features from medical images to characterize tumor pathology or heterogeneity is an interesting process to investigate, in order to provide information that may be useful to guide the therapies and predict survival. This paper discusses the rationale supporting the concept of radiomics and the feasibility of its application to Non-Small Cell Lung Cancer in the field of radiation oncology research. We studied 91 stage III patients treated with concurrent chemoradiation and adaptive approach in case of tumor reduction during treatment. We considered 12 statistics features and 230 textural features extracted from the CT images. In our study, we used an ensemble learning method to classify patients’ data into either the adaptive or non-adaptive group during chemoradiation on the basis of the starting CT simulation. Our data supports the hypothesis that a specific signature can be identified (AUC 0.82). In our experience, a radiomic signature mixing semantic and image-based features has shown promising results for personalized adaptive radiotherapy in non-small cell lung cancer.

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Section: Methodsmentioning

confidence: 99%

A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients

et al. 2018

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“…In addition, many prior studies applied additional diagnostic computed tomography (CT) or positron emission tomography with computed tomography (PET/CT) for re-planning (18,(20)(21)(22)(23)(24)(25)(26)(27)(28). The regular application of diagnostic CT, if necessary with additional intravenous contrast agent, is personnel and time-consuming as well as associated with a not negligible additional radiation dose exposure to the patient (29).…”

Section: Introductionmentioning

confidence: 99%

Cone-Beam-CT Guided Adaptive Radiotherapy for Locally Advanced Non-small Cell Lung Cancer Enables Quality Assurance and Superior Sparing of Healthy Lung

et al. 2020

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PurposeTo evaluate the potential of cone-beam-CT (CB-CT) guided adaptive radiotherapy (ART) for locally advanced non-small cell lung cancer (NSCLC) for sparing of surrounding organs-at-risk (OAR).Materials and MethodsIn 10 patients with locally advanced NSCLC, daily CB-CT imaging was acquired during radio- (n = 4) or radiochemotherapy (n = 6) for simulation of ART. Patients were treated with conventionally fractionated intensity-modulated radiotherapy (IMRT) with total doses of 60–66 Gy (pPlan) (311 fraction CB-CTs). OAR were segmented on every daily CB-CT and the tumor volumes were modified weekly depending on tumor changes. Doses actually delivered were recalculated on daily images (dPlan), and voxel-wise dose accumulation was performed using a deformable registration algorithm. For simulation of ART, treatment plans were adapted using the new contours and re-optimized weekly (aPlan).ResultsCB-CT showed continuous tumor regression of 1.1 ± 0.4% per day, leading to a residual gross tumor volume (GTV) of 65.3 ± 13.4% after 6 weeks of radiotherapy (p = 0.005). Corresponding PTVs decreased to 83.7 ± 7.8% (p = 0.005). In the actually delivered plans (dPlan), both conformity (p = 0.005) and homogeneity (p = 0.059) indices were impaired compared to the initial plans (pPlan). This resulted in higher actual lung doses than planned: V20Gy was 34.6 ± 6.8% instead of 32.8 ± 4.9% (p = 0.066), mean lung dose was 19.0 ± 3.1 Gy instead of 17.9 ± 2.5 Gy (p = 0.013). The generalized equivalent uniform dose (gEUD) of the lung was 18.9 ± 3.1 Gy instead of 17.8 ± 2.5 Gy (p = 0.013), leading to an increased lung normal tissue complication probability (NTCP) of 15.2 ± 13.9% instead of 9.6 ± 7.3% (p = 0.017). Weekly plan adaptation enabled decreased lung V20Gy of 31.6 ± 6.2% (−3.0%, p = 0.007), decreased mean lung dose of 17.7 ± 2.9 Gy (−1.3 Gy, p = 0.005), and decreased lung gEUD of 17.6 ± 2.9 Gy (−1.3 Gy, p = 0.005). Thus, resulting lung NTCP was reduced to 10.0 ± 9.5% (−5.2%, p = 0.005). Target volume coverage represented by conformity and homogeneity indices could be improved by weekly plan adaptation (CI: p = 0.007, HI: p = 0.114) and reached levels of the initial plan (CI: p = 0.721, HI: p = 0.333).ConclusionIGRT with CB-CT detects continuous GTV and PTV changes. CB-CT-guided ART for locally advanced NSCLC is feasible and enables superior sparing of healthy lung at high levels of plan conformity.

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“…Ramella et al prospectively analyzed 50 patients with locally advanced non-smallcell lung cancer treated with concomitant chemoradiotherapy. [18] The patients underwent weekly CT simulation during treatment. Adaptive planning was outlined in cases of tumor regression.…”

Section: Discussionmentioning

confidence: 99%

Case Presentation: The Effect of Volumetric Image Guidance & Adaptive Radiotherapy on Cardiac Dose in A Patient with Esophageal Cancer

Sezen¹

2018

TJ Oncol

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SUMMARYWe present the case of a patient with esophageal cancer whose tumor size regression prompted re-planning to decrease the cardiac dose. A 68-year-old male presented at our outpatient clinic with dysphagia. He was diagnosed with clinical T3N1M0 adenocarcinoma located at the distal esophagus-esophagogastric junction. He was decided to have surgery after receiving neoadjuvant chemoradiotherapy. Following 4-D CT simulation, IG-IMRT with SIB technique was planned as 50 Gy in 25 fractions to iGTV and as 45 Gy to the area identified as the CTV. Daily kV and weekly CBCT were planned at the beginning of the treatment. Concurrent CT with weekly paclitaxel-carboplatin was administered. At the simulation and start of the treatment, the heart was pushed anteriorly due to the mass effect and dilatation in the mid-lower esophagus. The mass and dilatation regressed at the weekly CBCT of the patient. The thirdweek CBCT evaluation revealed the movement of the heart posteriorly into the PTV. Re-simulation was performed to continue with the adaptive planning for the last 10 treatment fractions. The cumulative dose received by the heart was reduced from 96% to 93% for V5Gy, from 79% to 60.8% for V10Gy, from 60% to 43.2% for V15Gy, from 35% to 21% for V20Gy, and from 29.6 to 28 Gy for the mean cardiac dose with the volumetric image-guided adaptive planning. If tumor regression is predicted during radiotherapy to possibly change doses of organs at risk, volumetric image guidance should be encouraged once per week, at least, to consider adaptive treatment when required to ensure the critical organ doses within safe limits.

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Local Control and Toxicity of Adaptive Radiotherapy Using Weekly CT Imaging: Results from the LARTIA Trial in Stage III NSCLC

Abstract: The reduced toxicity and the documented low rate of marginal failures make the adaptive approach a modern option for future randomized studies. The best scenario to confirm its application is probably in neoadjuvant chemoradiation trials.

Cited by 56 publications

References 44 publications

A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients

A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients

Cone-Beam-CT Guided Adaptive Radiotherapy for Locally Advanced Non-small Cell Lung Cancer Enables Quality Assurance and Superior Sparing of Healthy Lung

Case Presentation: The Effect of Volumetric Image Guidance & Adaptive Radiotherapy on Cardiac Dose in A Patient with Esophageal Cancer

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