Adaptive Planning in Intensity-Modulated Radiation Therapy for Head and Neck Cancers: Single-Institution Experience and Clinical Implications

Ahn, Peter H.; Chen, Chin Cheng; Ahn, A.; Hong, Linda; Scripes, Paola Godoy; Shen, Jin; Lee, Chen Chiao; Miller, Eirwen M.; Garg, Madhur

doi:10.1016/j.ijrobp.2010.03.014

Cited by 121 publications

(124 citation statements)

References 14 publications

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“…Our results coincide with Ahn et al, (18) who studied 23 HNC patients undergoing regular scans and found a loss of PTV coverage at approximately the 11th fraction, which was recovered in the posterior scans.…”

Section: Discussionsupporting

confidence: 92%

“…It should be stressed that it will be necessary to identify which patients in particular would benefit from replanning. For instance Ahn et al (18) indicated that only 15 out of 23 patients (65%) benefitted from a new plan. Recently, Zhao et al (26) showed that nasopharyngeal carcinoma patients who have clinically identified anatomic changes during the course of IMRT might potentially benefit from replanning.…”

Section: Discussionmentioning

confidence: 99%

“…Ahn et al (18) indicated the need for an accurate determination of anatomical changes and their consequent dosimetric parameters as a prime factor in the determination of any subsequent replanning.…”

Section: Introductionmentioning

confidence: 99%

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Dose variations in tumor volumes and organs at risk during IMRT for head‐and‐neck cancer

Beltran

Ramos

Rovira

et al. 2012

J Applied Clin Med Phys

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Many head‐and‐neck cancer (HNC) patients treated with radiotherapy suffer significant anatomical changes due to tumor shrinkage or weight loss. The purpose of this study was to assess dose changes over target volumes and organs at risk during intensity‐modulated radiotherapy for HNC patients. Sixteen HNC IMRT patients, all requiring bilateral neck irradiation, were enrolled in the study. A CTplan was performed and the initial dose distribution was calculated. During the treatment, two subsequent CTs at the 15th (CT15) and 25th (CT25) fractions were acquired. The initial plan was calculated on the CT15 and CT25, and dose‐volume differences related to the CTplan were assessed. For target volumes, mean values of nearmaximun absorbed dose (normalD2%) increased at the 25th fraction, and doses covering 95% and 98% of volume decreased significantly at the 15th fraction. Contralateral and ipsilateral parotid gland mean doses increased by 6.1% (range: ‐5.4, 23.5%) and 4.7% (range: ‐9.1, 22.3%), respectively, at CT25. The normalD2% in the spinal cord increased by 1.8 Gy at CT15. Mean absorbed dose increases at CT15 and CT25 were observed in: the lips, 3.8% and 5.3%; the oral cavity, 3.5% and 2.5%; and lower middle neck structure, 1.9% and 1.6%. Anatomical changes during treatment of HNC patients affect dose distribution and induce a loss of dose coverage to target volumes and an overdosage to critical structures. Appropriate organs at risk have to be contoured and monitored in order to know if the initial plan remains suitable during the course of the treatment. Reported dosimetric data can help to identify patients who could benefit from adaptive radiotherapy.PACS numbers: 87.53.Kn, 87.55.Dk

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

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Dose variations in tumor volumes and organs at risk during IMRT for head‐and‐neck cancer

Beltran

Ramos

Rovira

et al. 2012

J Applied Clin Med Phys

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“…New adaptive plans may also be needed if the immobilization device needs to be adjusted or remade for variety of reasons. For some patients receiving intensity‐modulated radiotherapy (IMRT) or volumetric‐modulated arc therapy (VMAT), the significant benefit of replanning has been demonstrated 4. The frequency of replanning in patients with head and neck cancer was reported to be 32%–70%, depending on criteria 5.…”

Section: Introductionmentioning

confidence: 99%

“…Several investigators have looked for indicators to predict substantial dosimetric change. Although correlations between several parameters (such as weight loss, skin separation, and others) and dose change to target or organ at risk (OAR) were observed,4, 5, 6 no single parameter can be reliably used to decide the time of replanning for patients with head and neck cancer 4. Therefore, decisions on replanning are frequently based on the practical experience of clinicians.…”

Section: Introductionmentioning

confidence: 99%

Feasibility of CBCT‐based dose with a patient‐specific stepwise HU‐to‐density curve to determine time of replanning

Chen

Mutaf

et al. 2017

J Applied Clin Med Phys

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Purpose(a) To investigate the accuracy of cone‐beam computed tomography (CBCT)–derived dose distributions relative to fanbeam–based simulation CT‐derived dose distributions; and (b) to study the feasibility of CBCT dosimetry for guiding the appropriateness of replanning.Methods and materialsImage data corresponding to 40 patients (10 head and neck [HN], 10 lung, 10 pancreas, 10 pelvis) who underwent radiation therapy were randomly selected. Each patient had both intensity‐modulated radiation therapy and volumetric‐modulated arc therapy plans; these 80 plans were subsequently recomputed on the CBCT images using a patient‐specific stepwise curve (Hounsfield units‐to‐density). Planning target volumes (PTVs; D98%, D95%, D2%), mean dose, and V95% were compared between simulation‐CT–derived treatment plans and CBCT‐based plans. Gamma analyses were performed using criterion of 3%/3 mm for three dose zones (>90%, 70%~90%, and 30%~70% of maximum dose). CBCT‐derived doses were then used to evaluate the appropriateness of replanning decisions in 12 additional HN patients whose plans were previously revised during radiation therapy because of anatomic changes; replanning in these cases was guided by the conventional observed source‐to‐skin‐distance change‐derived approach.ResultsFor all disease sites, the difference in PTV mean dose was 0.1% ± 1.1%, D2% was 0.7% ± 0.1%, D95% was 0.2% ± 1.1%, D98% was 0.2% ± 1.0%, and V95% was 0.3% ± 0.8%; For 3D dose comparison, 99.0% ± 1.9%, 97.6% ± 4.4%, and 95.3% ± 6.0% of points passed the 3%/3 mm criterion of gamma analysis in high‐, medium‐, and low‐dose zones, respectively. The CBCT images achieved comparable dose distributions. In the 12 previously replanned 12 HN patients, CBCT‐based dose predicted well changes in PTV D2% (Pearson linear correlation coefficient = 0.93; P < 0.001). If 3% of change is used as the replanning criteria, 7/12 patients could avoid replanning.Conclusions CBCT‐based dose calculations produced accuracy comparable to that of simulation CT. CBCT‐based dosimetry can guide the decision to replan during the course of treatment.

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Weekly Adaptive Radiotherapy vs Standard Intensity-Modulated Radiotherapy for Improving Salivary Function in Patients With Head and Neck Cancer

et al. 2023

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ImportanceXerostomia is a major toxic effect associated with intensity-modulated radiotherapy (IMRT) for oropharyngeal cancers.ObjectiveTo assess whether adaptive radiotherapy (ART) improves salivary function compared with IMRT in patients with head and neck cancer.Design, Setting, and ParticipantsThis phase 3 randomized clinical trial was conducted in 11 French centers. Patients aged 18 to 75 years with stage III-IVB squamous cell oropharyngeal cancer treated with chemoradiotherapy were enrolled between July 5, 2013, and October 1, 2018. Data were analyzed from November 2021 to May 2022.InterventionsThe patients were randomly assigned (1:1) to receive standard IMRT (without replanning) or ART (systematic weekly replanning).Main Outcomes and MeasuresThe primary end point was the frequency of xerostomia, measured by stimulating salivary flow with paraffin. Secondary end points included salivary gland excretory function measured using technetium-99m pertechnetate scintigraphy, patient-reported outcomes (Eisbruch xerostomia-specific questionnaire and the MD Anderson Symptom Inventory for Head and Neck Cancer questionnaire), early and late toxic effects, disease control, and overall and cancer-specific survival.ResultsA total of 132 patients were randomized, and after 1 exclusion in the ART arm, 131 were analyzed: 66 in the ART arm (mean [SD] age at inclusion, 60 [8] years; 57 [86.4%] male) and 65 in the standard IMRT arm (mean [SD] age at inclusion, 60 [8] years; 57 [87.7%] male). The median follow-up was 26.4 months (IQR, 1.2-31.3 months). The mean (SD) salivary flow (paraffin) at 12 months was 630 (450) mg/min in the ART arm and 584 (464) mg/min in the standard arm (P = .64). The mean (SD) excretory function of the parotid gland at 12 months, measured by scintigraphy, improved in the ART arm (48% [17%]) compared with the standard arm (41% [17%]) (P = .02). The 2-year-overall survival was 76.9% (95% CI, 64.7%-85.4%) in both arms.Conclusions and RelevanceThis randomized clinical trial did not demonstrate a benefit of ART in decreasing xerostomia compared with standard IMRT. No significant differences were found in secondary end points except for parotid gland excretory function, as assessed by scintigraphy, or in survival rates.Trial RegistrationClinicalTrials.gov Identifier: NCT01874587

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Adaptive Planning in Intensity-Modulated Radiation Therapy for Head and Neck Cancers: Single-Institution Experience and Clinical Implications

Cited by 121 publications

References 14 publications

Dose variations in tumor volumes and organs at risk during IMRT for head‐and‐neck cancer

Dose variations in tumor volumes and organs at risk during IMRT for head‐and‐neck cancer

Feasibility of CBCT‐based dose with a patient‐specific stepwise HU‐to‐density curve to determine time of replanning

Weekly Adaptive Radiotherapy vs Standard Intensity-Modulated Radiotherapy for Improving Salivary Function in Patients With Head and Neck Cancer

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