Online Adaptive Radiation Therapy: Implementation of a New Process of Care

Abstract

Onboard magnetic resonance imaging (MRI) guided radiotherapy is now clinically available in nine centers in the world. This technology has facilitated the clinical implementation of online adaptive radiotherapy (OART), or the ability to alter the daily treatment plan based on tumor and anatomical changes in real-time while the patient is on the treatment table. However, due to the time sensitive nature of OART, implementation in a large and busy clinic has many potential obstacles as well as patient-related safety considerations. In this work, we have described the implementation of this new process of care in the Department of Radiation Oncology at the University of California, Los Angeles (UCLA). We describe the rationale, the initial challenges such as treatment time considerations, technical issues during the process of re-contouring, re-optimization, quality assurance, as well as our current solutions to overcome these challenges. In addition, we describe the implementation of a coverage system with a physician of the day as well as online planners (physicists or dosimetrists) to oversee each OART treatment with patient-specific ‘hand-off’ directives from the patient’s treating physician. The purpose of this effort is to streamline the process without compromising treatment quality and patient safety. As more MRI-guided radiotherapy programs come online, we hope that our experience can facilitate successful adoption of OART in a way that maximally benefits the patient.

Automated Hypofractionated IMRT treatment planning for early-stage breast Cancer

“…To date, automated workflow has been developed and implemented in various businesses but the pace of applying automation into health care is not as fast as expected. In the recent two decades, the rapid progress in computerized radiotherapy treatment planning systems has led to great interest in the possibility of automating radiotherapy workflow, which includes automated target delineation (auto-segmentation), automated treatment planning, automated real-time adaptive radiotherapy and automated quality assurance [20][21][22][23][24][25]. This study presents a well-designed fully automated planning algorithm for standardized whole-breast radiotherapy treatment plan generation with a large cohort of 99 patients.…”

A novel MRI segmentation method using CNN‐based correction network for MRI‐guided adaptive radiotherapy

“…Reported by Lamb et al. after studying 80 online MR‐IGART cases, the median time of the adaptive process prior to beam delivery was 54 min, with the re‐contouring process requiring up to 22 min. Although the ViewRay treatment planning and delivery system can automatically propagate planning contours based on deformable image registration (DIR), Lamb et al.…”

Technical Note: Acceleration of online adaptive replanning with automation and parallel operations

“…It is clear that OLAR success depends on how fast the replanning process may be performed and the overall efficiency of the human resource. Because OLAR requires strong expertise and treatment decisions need to be made quickly, it is ideal that both the radiation oncologist and physicist perform OLAR together . Our institution policy requires that a team consisting of at least a radiation oncologist, a physicist and two therapists (three recommended for complicated cases) with adequate contour‐editing training be present during OLAR.…”

“…It has been reported that with MRgRT, the time required to execute OLAR can be more than 60 min with a median time of approximately 30 min. [9][10][11][12] Such long time duration renders the routine OLAR impractical and causes concern with intrafraction motions while waiting for the OLAR. One of the major causes for the prolonged OLAR process is the time required for various human interventions and manual operations.…”