The promise of adaptive radiotherapy for pelvic tumors: “too high cost for too little result” or “a low cost for a significant result”?

Fiorino, Claudio; Cozzarini, C.; Passoni, P.

doi:10.1080/0284186x.2016.1203460

Cited by 7 publications

(3 citation statements)

References 24 publications

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“…Implementation issues currently limit the ability for many of these promises to be realised. The cost‐effectiveness of the technology is likely to improve with selection of patients most likely to benefit and incorporation of clinical, anatomical, functional and biological information . While there are technical and clinical challenges to the development of MRgRT including validation of imaging biomarkers and rigorous assessment of benefit and cost‐effectiveness, coordinated approaches are being taken to manage them and develop an evidence base for clinical benefit .…”

Section: Discussionmentioning

confidence: 99%

Magnetic resonance‐guided radiation therapy: A review

et al. 2019

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Summary Magnetic resonance‐guided radiation therapy (MRgRT) is a promising approach to improving clinical outcomes for patients treated with radiation therapy. The roles of image guidance, adaptive planning and magnetic resonance imaging in radiation therapy have been increasing over the last two decades. Technical advances have led to the feasible combination of magnetic resonance imaging and radiation therapy technologies, leading to improved soft‐tissue visualisation, assessment of inter‐ and intrafraction motion, motion management, online adaptive radiation therapy and the incorporation of functional information into treatment. MRgRT can potentially transform radiation oncology by improving tumour control and quality of life after radiation therapy and increasing convenience of treatment by shortening treatment courses for patients. Multiple groups have developed clinical implementations of MRgRT predominantly in the abdomen and pelvis, with patients having been treated since 2014. While studies of MRgRT have primarily been dosimetric so far, an increasing number of trials are underway examining the potential clinical benefits of MRgRT, with coordinated efforts to rigorously evaluate the benefits of the promising technology. This review discusses the current implementations, studies, potential benefits and challenges of MRgRT.

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Section: Discussionmentioning

confidence: 99%

Magnetic resonance‐guided radiation therapy: A review

et al. 2019

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“…On the contrary, in case any causality between high ERI TCP and risk of distant relapses exists (direct or mediated by the immune system), one could try to increase the fraction of responding patients (i.e., with lower ERI TCP ) by intensifying the loco-regional treatment, for instance through dose escalation to the residual tumor; in this case, the response-driven adaptive boosting approach proposed by our group [23] as well as other similar approaches with external beams or brachytherapy [26], [27] could be followed. In any case, dose intensification with personalization of the delivered dose based on ERI TCP , could in principle be effective in increasing the number of complete response, potentially increasing the number of patients who could avoid surgery dramatically, with a consequent relevant impact on their quality of live [20], [22].…”

Section: Discussionmentioning

confidence: 99%

“…Tumor regression during therapy, although less investigated [17], [18], [19], [23], [24], [25], has been shown to be correlated with pathological response as well, with the advantage to give a prediction during the treatment and consequently to increase the potentials of response-driven treatment personalization. Moreover, tumor regression during RCT has also been successfully exploited by our group to implement early-regression guided adaptive boosting therapy [19], [23] with great potentials for treatment intensification aiming to increase the rate of pCR [26], similarly to what recently reported with image-guided brachytherapy boosting [27]. More in general this approach (i.e., escalating the dose on the residual tumor after early response assessed by proper imaging techniques) seems to be highly promising even outside the rectal cancer scenario [28].…”

Section: Introductionmentioning

confidence: 99%

Accurate outcome prediction after neo-adjuvant radio-chemotherapy for rectal cancer based on a TCP-based early regression index

Fiorino

Passoni

Palmisano

et al. 2019

Clinical and Translational Radiation Oncology

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Background and purpose: An early tumor regression index (ERI TCP) was previously introduced and found to predict pathological response after neo-adjuvant radio-chemotherapy of rectal cancer. ERI TCP was tested as a potential biomarker in predicting long-term disease-free survival. Materials and methods: Data of 65 patients treated with an early regression-guided adaptive boosting technique (ART) were available. Overall, loco-regional relapse-free and distant metastasis-free survival (OS, LRFS, DMFS) were considered. Patients received 41.4 Gy in 18 fractions (2.3 Gy/fr), including ART concomitant boost on the residual GTV during the last 6 fractions (3 Gy/fr, D mean : 45.6 Gy). Chemotherapy included oxaliplatin and 5-fluorouracil (5-FU). T2-weighted MRI taken before (MRI pre) and at half therapy (MRI half) were available and GTVs were contoured (V pre , V half). The parameter ERI TCP = Àln[(1 À (V half /V pre)) Vpre ] was calculated for all patients. Cox regression models were assessed considering several clinical and histological variables. Cox models not including/including ERI TCP (CONV_model and REGR_model respectively) were assessed and their discriminative power compared. Results: At a median follow-up of 47 months, OS, LRFS and DMFS were 94%, 95% and 78%. Due to too few events, multivariable analyses focused on DMFS: the resulting CONV_model included pathological complete remission or clinical complete remission followed by surgery refusal (HR: 0.15, p = 0.07) and 5-FU dose >90% (HR: 0.29, p = 0.03) as best predictors, with AUC = 0.75. REGR_model included ERI TCP (HR: 1.019, p < 0.0001) and 5-FU dose >90% (HR: 0.18, p = 0.005); AUC was 0.86, significantly higher than CONV_model (p = 0.05). Stratifying patients according to the best cutoff value for ERI TCP and to 5-FU dose (> vs <90%) resulted in 47-month DMFS equal to 100%/69%/0% for patients with two/one/zero positive factors respectively (p = 0.0002). ERI TCP was also the only variable significantly associated to OS (p = 0.01) and LRFS (p = 0.03). Conclusion: ERI TCP predicts long-term DMFS after radio-chemotherapy for rectal cancer: an independent impact of the 5-FU dose was also found. This result represents a first step toward application of ERI TCP in treatment personalization: additional confirmation on independent cohorts is warranted.

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