Fully automated VMAT treatment planning for advanced-stage NSCLC patients.

PURPOSE: To develop a fully automated procedure for multicriterial volumetric modulated arc therapy (VMAT) treatment planning (autoVMAT) for stage III/IV non-small cell lung cancer (NSCLC) patients treated with curative intent. MATERIALS AND METHODS: After configuring the developed autoVMAT system for NSCLC, autoVMAT plans were compared with manually generated clinically delivered intensity-modulated radiotherapy (IMRT) plans for 41 patients. AutoVMAT plans were also compared to manually generated VMAT plans in the absence of time pressure. For 16 patients with reduced planning target volume (PTV) dose prescription in the clinical IMRT plan (to avoid violation of organs at risk tolerances), the potential for dose escalation with autoVMAT was explored. RESULTS: Two physicians evaluated 35/41 autoVMAT plans (85%) as clinically acceptable. Compared to the manually generated IMRT plans, autoVMAT plans showed statistically significant improved PTV coverage (V95% increased by 1.1% ± 1.1%), higher dose conformity (R50 reduced by 12.2% ± 12.7%), and reduced mean lung, heart, and esophagus doses (reductions of 0.9 Gy ± 1.0 Gy, 1.5 Gy ± 1.8 Gy, 3.6 Gy ± 2.8 Gy, respectively, all p < 0.001). To render the six remaining autoVMAT plans clinically acceptable, a dosimetrist needed less than 10 min hands-on time for fine-tuning. AutoVMAT plans were also considered equivalent or better than manually optimized VMAT plans. For 6/16 patients, autoVMAT allowed tumor dose escalation of 5-10 Gy. CONCLUSION: Clinically deliverable, high-quality autoVMAT plans can be generated fully automatically for the vast majority of advanced-stage NSCLC patients. For a subset of patients, autoVMAT allowed for tumor dose escalation.

Large-scale dose evaluation of deep learning organ contours in head-and-neck radiotherapy by leveraging existing plans.

Background and purpose: Retrospective dose evaluation for organ-at-risk auto-contours has previously used small cohorts due to additional manual effort required for treatment planning on auto-contours. We aimed to do this at large scale, by a) proposing and assessing an automated plan optimization workflow that used existing clinical plan parameters and b) using it for head-and-neck auto-contour dose evaluation. Materials and methods: Our automated workflow emulated our clinic's treatment planning protocol and reused existing clinical plan optimization parameters. This workflow recreated the original clinical plan (POG) with manual contours (PMC) and evaluated the dose effect (POG-PMC) on 70 photon and 30 proton plans of head-and-neck patients. As a use-case, the same workflow (and parameters) created a plan using auto-contours (PAC) of eight head-and-neck organs-at-risk from a commercial tool and evaluated their dose effect (PMC-PAC). Results: For plan recreation (POG-PMC), our workflow had a median impact of 1.0% and 1.5% across dose metrics of auto-contours, for photon and proton respectively. Computer time of automated planning was 25% (photon) and 42% (proton) of manual planning time. For auto-contour evaluation (PMC-PAC), we noticed an impact of 2.0% and 2.6% for photon and proton radiotherapy. All evaluations had a median ΔNTCP (Normal Tissue Complication Probability) less than 0.3%. Conclusions: The plan replication capability of our automated program provides a blueprint for other clinics to perform auto-contour dose evaluation with large patient cohorts. Finally, despite geometric differences, auto-contours had a minimal median dose impact, hence inspiring confidence in their utility and facilitating their clinical adoption.

Five Fraction External Beam Partial Breast Irradiation: A User's Guide.

OBJECTIVE: Mature follow up from multiple randomized trials have demonstrated the safety and efficacy of external beam partial breast irradiation (PBI) for appropriately selected patients with early stage breast cancer. Despite this evidence, external beam PBI remains underutilized. In this user guide we outline patient selection, workflow, and address possible challenges to aid in implementation of evidence-based external beam PBI. MATERIALS AND METHODS: Review of the current guidelines for PBI suitability, surgical considerations, treatment technique, simulation, contouring, and treatment planning, citing the latest published literature to support PBI utilization. RESULTS: Prospective data supports the use of 30 Gy in 5 fractions delivered with intensity modulated radiation therapy on a daily or every other day basis for a significant proportion of early stage breast cancer patients. The surgical cavity must be clearly visualized on treatment planning scan, recommend 3-5 weeks post-operatively, and the recommended clinical target volume expansion on the surgical cavity is 0.5-1.0 cm. A planning target volume expansion, based on motion management and image guidance, of 0.5-1.0 cm should be used. Organ at risk dose constraints of heart V3Gy ≤10% and contralateral breast Dmax ≤1 Gy are often achievable. CONCLUSIONS: Five fraction external beam PBI is a highly effective treatment with very limited toxicity for patients with early stage breast cancer following breast conserving surgery. Commonly utilized intensity modulated treatment planning techniques with plan delivery on standard linear accelerators results significant normal tissue sparing and makes implementation feasible at most radiation oncology centers.

Comparison of visibility of iodinated hydrogel and gadolinium-modified hyaluronic acid spacer gels on computed tomography and onboard imaging.

BACKGROUND AND PURPOSE: In accelerated partial breast irradiation (APBI), accurate definition of the tumour bed is crucial to reduce the risk of local recurrence and the volume of healthy tissue irradiated. Recently, hydrogels have been proposed to improve visibility of the lumpectomy cavity for APBI. The aim of this study was to alter two commercially available hyaluronic acid (HA) gels, with gadopentenate dimeglumine (GD), a magnetic resonance imaging (MRI) contrast agent. We hypothesize that after injection in the surgical cavity, the mixtures will be visible with computed tomography (CT) for improved treatment planning, cone-beam CT (CBCT) for improved patient setup and planar kilovoltage (kV) x-ray for real-time tracking during treatment. MATERIALS AND METHODS: In this ex vivo study, GD was mixed with the two HA gels, and 1 mL of each mixture was injected into fatty and muscular tissue of a pork phantom. Visibility with CT, CBCT and planar x-ray imaging was assessed. Contrast-to-noise ratios (CNR) were measured and compared to commercially available iodinated polyethylene glycol (PEG). RESULTS: The gel mixtures showed increased visibility over HA gels without GD. When comparing CNR of the gel mixtures to that of iodinated PEG on CT, there was a 4-fold increase in muscle for both mixtures and a 1.6-fold to 3.6-fold increase in fat, depending on the HA gel. Gel mixtures showed better visibility with planar kV imaging over iodinated PEG. CONCLUSION: Addition of GD to HA gels increases visibility with CT, CBCT and planar x-ray imaging, indicating potential for improved delineation and positioning in APBI.

Intrafraction motion during partial breast irradiation depends on treatment time.

INTRODUCTION: As the prognosis of early-stage breast cancer patients is excellent, prevention of radiation-induced toxicity has become crucial. Reduction of margins compensating for intrafraction motion reduces non-target dose. We assessed motion of the tumor bed throughout APBI treatment fractions and calculated CTV-PTV margins for breathing and drift. METHODS: This prospective clinical trial included patients treated with APBI on a Cyberknife with fiducial tracking. Paired orthogonal kV images made throughout the entire fraction were used to extract the tumor bed position. The images used for breathing modelling were used to calculate breathing amplitudes. The margins needed to compensate for breathing and drift were calculated according to Engelsman and Van Herk respectively. RESULTS: Twenty-two patients, 110 fractions and 5087 image pairs were analyzed. The margins needed for breathing were 0.3-0.6 mm. The margin for drift increased with time after the first imaging for positioning. For a total fraction duration up to 8 min, a margin of 1.0 mm is sufficient. For a fraction of 32 min, 2.5 mm is needed. Techniques that account for breathing motion can reduce the margin by 0.1 mm. There was a systematic trend in the drift in the caudal, medial and posterior direction. To compensate for this, 0.7 mm could be added to the margins. CONCLUSIONS: The margin needed to compensate for intrafraction motion increased with longer fraction duration due to drifting of the target. It doubled for a fraction of 24 min compared to 8 min. Breathing motion has a limited effect.

Fiducial marker motion relative to the tumor bed has a significant impact on PTV margins in partial breast irradiation.

INTRODUCTION: With the introduction of accelerated partial breast irradiation (APBI) and the trend of reducing the number of fractions, the geometric accuracy of treatment delivery becomes critical. APBI patient setup is often based on fiducials, as the seroma is frequently not visible on pretreatment imaging. We assessed the motion of fiducials relative to the tumor bed between planning CT and treatment, and calculated margins to compensate for this motion. METHODS: A cohort of seventy patients treated with APBI on a Cyberknife was included. Planning and in-room pretreatment CT scans were registered on the tumor bed. Residual motion of the centers of mass of surgical clips and interstitial gold markers was calculated. We calculated the margins required per desired percentage of patients with 100% CTV coverage, and the systematic and random errors for fiducial motion. RESULTS: For a single fraction treatment, a margin of 1.8 mm would ensure 100% CTV coverage in 90% of patients when using surgical clips for patient set-up. When using interstitial markers, the margin should be 2.2 mm. The systematic and random errors were 0.46 mm for surgical clip motion and 0.60 mm for interstitial marker motion. No clinical factors were found predictive for fiducial motion. CONCLUSIONS: Fiducial motion relative to the tumor bed between planning CT and APBI treatment is non-negligible and should be included in the PTV margin calculation to prevent geographical miss. Systematic and random errors of fiducial motion were combined with other geometric uncertainties to calculate comprehensive PTV margins for different treatment techniques.

Estimation of Annual Secondary Lung Cancer Deaths Using Various Adjuvant Breast Radiotherapy Techniques for Early-Stage Cancers.

PURPOSE: Secondary lung cancer (SLC) can offset the benefit of adjuvant breast radiotherapy (RT), and risks compound sharply after 25 to 30 years. We hypothesized that SLC risk is mainly an issue for early-stage breast cancer, and that lives could be saved using different RT techniques. PATIENTS AND METHODS: The SEER database was used to extract breast patient age, stage survival, and radiotherapy utilization over time and per stage and to assess the factors associated with increased SLC risk with a multivariable competing risk Cox model. The number of SLC was calculated using the BEIR model modified with patient survival, age, and use of RT from the SEER database. Stage distribution and number of new breast cancer cases were obtained from the NAACCR. Mean lung dose for various irradiation techniques was obtained from measurement or literature. RESULTS: Out of the 765,697 non-metastatic breast cancers in the SEER database from 1988 to 2012, 49.8% received RT. RT significantly increased the SLC risk for longer follow-up (HR=1.58), early stage including DCIS, stage I and IIA (HR = 1.11), and younger age (HR=1.061) (all p<0.001). More advanced stages did not have significantly increased risk. In 2019, 104,743 early-stage breast patients received radiotherapy, and an estimated 3,413 will develop SLC (3.25%) leading to an excess of 2,900 deaths (2.77%). VMAT would reduce this mortality by 9.9%, hypofractionation 26 Gy in five fractions by 38.8%, a prone technique by 70.3%, 3D-CRT APBI by 43.3%, HDR brachytherapy by 71.1%, LDR by 80.7%, and robotic 4π APBI by 85.2%. CONCLUSIONS: SLC after breast RT remains a clinically significant issue for early-stage breast cancers. This mortality could be significantly reduced using a prone technique or APBI.

Reducing the Risk of Secondary Lung Cancer in Treatment Planning of Accelerated Partial Breast Irradiation.

Purpose: Adjuvant accelerated partial breast irradiation (APBI) results in low local recurrence risks. However, the survival benefit of adjuvant radiotherapy APBI for low-risk breast cancer might partially be offset by the risk of radiation-induced lung cancer. Reducing the lung dose mitigates this risk, but this could result in higher doses to the ipsilateral breast. Different external beam APBI techniques are equally conformal and homogenous, but the intermediate to low dose distribution differs. Thus, the risk of toxicity is different. The purpose of this study is to quantify the trade-off between secondary lung cancer risk and breast dose in treatment planning and to compare an optimal coplanar and non-coplanar technique. Methods: A total of 440 APBI treatment plans were generated using automated treatment planning for a coplanar VMAT beam-setup and a non-coplanar robotic stereotactic radiotherapy beam-setup. This enabled an unbiased comparison of two times 11 Pareto-optimal plans for 20 patients, gradually shifting priority from maximum lung sparing to maximum ipsilateral breast sparing. The excess absolute risks of developing lung cancer and breast fibrosis were calculated using the Schneider model for lung cancer and the Avanzo model for breast fibrosis. Results: Prioritizing lung sparing reduced the mean lung dose from 2.2 Gy to as low as 0.3 Gy for the non-coplanar technique and from 1.9 Gy to 0.4 Gy for the coplanar technique, corresponding to a 7- and 4-fold median reduction of secondary lung cancer risk, respectively, compared to prioritizing breast sparing. The increase in breast dose resulted in a negligible 0.4% increase in fibrosis risk. The use of non-coplanar beams resulted in lower secondary cancer and fibrosis risks (p < 0.001). Lung sparing also reduced the mean heart dose for both techniques. Conclusions: The risk of secondary lung cancer of external beam APBI can be dramatically reduced by prioritizing lung sparing during treatment planning. The associated increase in breast dose did not lead to a relevant increase in fibrosis risk. The use of non-coplanar beams systematically resulted in the lowest risks of secondary lung cancer and fibrosis. Prioritizing lung sparing during treatment planning could increase the overall survival of early-stage breast cancer patients by reducing mortality due to secondary lung cancer and cardiovascular toxicity.

Injection of radiopaque hydrogel at time of lumpectomy improves the target definition for adjuvant radiotherapy.

BACKGROUND AND PURPOSE: During oncoplastic breast-conserving surgery (BCS), the surgical cavity is closed to reduce seroma formation. This makes the radiotherapy target definition using clips challenging, leading to poor inter-observer agreement and potentially geographical misses. We hypothesize that injecting a radiopaque hydrogel in the lumpectomy cavity before closure improves radiotherapy target definition and agreement between observers. MATERIALS AND METHODS: Women undergoing BCS in a single university hospital were prospectively accrued in the study. Three to 9 ml of iodined PolyEthylene Glycol (PEG) hydrogel and clips were inserted in the lumpectomy cavity. A CT-scan was performed at 4 to 6 weeks. CT images of BCS patients with standard clips only were used as control group, matched on age, specimen weight, and distance between clips. Six radiation oncologists delineated the tumor bed volumes and rated the cavity visualization scores (CVS). The primary endpoint was the agreement between observers measured using a Conformity Index (Cx). RESULTS: Forty-two patients were included, 21 hydrogel procedures and 21 controls, resulting in 315 observer pairs. The feasibility of the intervention was 100%. The median Cx was higher in the intervention group (Cx = 0.70, IQR [0.54-0.79]) than in the control group (Cx = 0.54, IQR [0.42-0.66]), p < 0.00, as were the CVS (3.5 [2.5-4.5] versus 2.5 [2-3.5], p < 0.001). The rate of surgical site infections was similar to literature. CONCLUSIONS: The use of radiopaque PEG enables to identify the lumpectomy cavity, resulting in a high inter-observer agreement for radiotherapy target definition. This intervention is easy to perform and blend well into current practice.

Economic evaluation of folic acid food fortification in The Netherlands.

BACKGROUND: Folic acid intake before and during pregnancy reduces neural tube defects (NTD). Therefore, several countries have enriched bulk food with folic acid resulting in a 26-48% decrease in the prevalence of NTDs. In 2000, the Dutch Health Council advised against folic acid enrichment based on literature research; yet formal cost-effectiveness information was absent. We designed our study to estimate cost-effectiveness of folic acid food fortification in the Netherlands. METHOD: Prevalence of NTD at birth, life-time costs of care, and folic acid fortification costs were estimated using Dutch registrations, Dutch guidelines for costing, (inter)national literature and expert opinions. Both net cost per discounted life year gained and net cost per discounted quality adjusted life year (QALY) gained were estimated for the base case and sensitivity analyses. RESULTS: In the base case and most sensitivity analyses, folic acid enrichment was estimated to be cost-saving. Bulk food fortification with folic acid remains cost-effective as long as enrichment costs do not exceed euro5.5 million (threshold at euro20 000 per QALY). CONCLUSION: Our model suggests that folic acid fortification of bulk food to prevent cases of NTD in newborns might be a cost-saving intervention in the Netherlands. Additionally, besides the evidence that folic acid reduces the number of NTDs, there are indications that folic acid is associated with the prevention of other birth defects, cardiovascular diseases and cancer. Our model did not yet include these possibly beneficial effects.

Long-term risks of secondary cancer for various whole and partial breast irradiation techniques.

INTRODUCTION: For early stage breast cancer patients, non-breast cancer mortality including secondary cancers and cardiac events can overshadow the benefit of adjuvant radiotherapy. This study evaluates the excess risk of secondary cancer for various breast radiotherapy techniques including accelerated partial breast irradiation (APBI). METHODS: Secondary cancers Lifetime Attributable Risks (LAR) were calculated using a modified BEIR-VII formalism to account for the specific survival of breast cancer patients. Those survivals were extracted from the SEER database. Doses scattered to various organs were measured into a Rando phantom with custom-made breast phantoms. Treatments delivered typical doses of brachytherapy APBI (34 Gy in 10 fractions), external beam APBI (38.5 Gy in 10 fractions) using 3D-conformal, Cyberknife stereotactic (CK), or VMAT, as well as whole breast irradiation (WBI) delivering 42.5 Gy in 16 fractions. RESULTS: WBI resulted in the highest total LAR, with 4.3% excess risk of secondary cancer for a patient treated at age 50 years. Lung cancers accounted for 75-97% of secondary malignancies. For a typical early stage patient irradiated at 50, the excess risks of secondary lung cancer were 1.1% for multicatheter HDR, between 2.2% and 2.5% for 3D-CRT or CK, 3.5% for VMAT APBI, and 3.8% for WBI. CONCLUSIONS: APBI reduces the risk of secondary cancer 2-4 fold compared to WBI. These techniques are well suited for long-living early stage breast cancer patients. HDR brachytherapy and 3D-conformal APBI achieve mean lung doses between 1 and 1.5 Gy, which could serve as reference.

Supine MRI for regional breast radiotherapy: imaging axillary lymph nodes before and after sentinel-node biopsy.

Regional radiotherapy (RT) is increasingly used in breast cancer treatment. Conventionally, computed tomography (CT) is performed for RT planning. Lymph node (LN) target levels are delineated according to anatomical boundaries. Magnetic resonance imaging (MRI) could enable individual LN delineation. The purpose was to evaluate the applicability of MRI for LN detection in supine treatment position, before and after sentinel-node biopsy (SNB). Twenty-three female breast cancer patients (cTis-3N0M0) underwent 1.5 T MRI, before and after SNB, in addition to CT. Endurance for MRI was monitored. Axillary levels were delineated. LNs were identified and delineated on MRI from before and after SNB, and on CT, and compared by Wilcoxon signed-rank tests. LN locations and LN-based volumes were related to axillary delineations and associated volumes. Although postoperative effects were visible, LN numbers on postoperative MRI (median 26 LNs) were highly reproducible compared to preoperative MRI when adding excised sentinel nodes, and higher than on CT (median 11, p < 0.001). LN-based volumes were considerably smaller than respective axillary levels. Supine MRI of LNs is feasible and reproducible before and after SNB. This may lead to more accurate RT target definition compared to CT, with potentially lower toxicity. With the MRI techniques described here, initiation of novel MRI-guided RT strategies aiming at individual LNs could be possible.