Adaptive Radiation Therapy Physician Guidelines: Recommendations From an Expert Users’ Panel

Kim, Hyun; Lee, Percy; Tree, A.; Chuong, Michael D.; Raldow, A.; Kishan, Amar U.; Fuller, C.D.; Rosenberg, Stephen A.; Hall, William A.; Chie, Eui Kyu; Portelance, Lorraine

doi:10.1016/j.prro.2022.05.007

Cited by 10 publications

(5 citation statements)

References 20 publications

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“…Although our study focused on the technical aspects of safely commissioning adaptive radiotherapy, clinics should also give careful consideration to procedures and guidelines for contouring and evaluating adaptive plans. A recent paper by Kim et al provides some guidance from physicians for ART prescriptions and on-treatment decision-making, 30 whereas a publication by Shepherd et al details an approach to train-ing advanced adapters and implementing an adaptive workflow. 31 A limitation of this work is that this series of tests is non-exhaustive and could be expanded to include other scenarios that clinics may encounter with online adaptation.…”

Section: Discussionmentioning

confidence: 99%

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Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations

Kisling

Keiper

Branco

et al. 2022

J Applied Clin Med Phys

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Online adaptive radiotherapy platforms present a unique challenge for commissioning as guidance is lacking and specialized adaptive equipment, such as deformable phantoms, are rare. We designed a novel adaptive commissioning process consisting of end‐to‐end tests using standard clinical resources. These tests were designed to simulate anatomical changes regularly observed at patient treatments. The test results will inform users of the magnitude of uncertainty from on‐treatment changes during the adaptive workflow and the limitations of their systems. We implemented these tests for the cone‐beam computed tomography (CT)‐based Varian Ethos online adaptive platform. Many adaptive platforms perform online dose calculation on a synthetic CT (synCT). To assess the impact of the synCT generation and online dose calculation on dosimetric accuracy, we conducted end‐to‐end tests using commonly available equipment: a CIRS IMRT Thorax phantom, PinPoint ionization chamber, Gafchromic film, and bolus. Four clinical scenarios were evaluated: weight gain and weight loss were simulated by adding and removing bolus, internal target shifts were simulated by editing the CTV during the adaptive workflow to displace it, and changes in gas were simulated by removing and reinserting rods in varying phantom locations. The effect of overriding gas pockets during planning was also assessed. All point dose measurements agreed within 2.7% of the calculated dose, with one exception: a scenario simulating gas present in the planning CT, not overridden during planning, and dissipating at treatment. Relative film measurements passed gamma analysis (3%/3 mm criteria) for all scenarios. Our process validated the Ethos dose calculation for online adapted treatment plans. Based on our results, we made several recommendations for our clinical adaptive workflow. This commissioning process used commonly available equipment and, therefore, can be applied in other clinics for their respective online adaptive platforms.

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Section: Discussionmentioning

confidence: 99%

“…A recent paper by Kim et al. provides some guidance from physicians for ART prescriptions and on‐treatment decision‐making, 30 whereas a publication by Shepherd et al. details an approach to training advanced adapters and implementing an adaptive workflow 31 …”

Section: Discussionmentioning

confidence: 99%

Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations

Kisling

Keiper

Branco

et al. 2022

J Applied Clin Med Phys

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“…At present, our institution holds a monthly adaptive working group meeting where involved members present and refine novel workflow and trial concepts, enabling stream-lined team teaching and group involvement in the development of new disease site applications. When “doctor-of-the-day” style coverage is utilized for daily ART procedural coverage, communication of clinical intent between team members is also essential; we utilize a well-described adaptive guideline approach, in which a detailed written hand-off guides the covering physician to meet the prescribing physician’s clinical goals for individual ART patients [48] . Reassessment of clinical use following major technologic upgrades is also critical for evolution of ART use.…”

Section: Discussionmentioning

confidence: 99%

Initial clinical experience building a dual CT- and MR-guided adaptive radiotherapy program

Price

Schiff

Laugeman

et al. 2023

Clinical and Translational Radiation Oncology

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“…In the last 10 years, three adaptive radiation therapy (ART) platforms—Ethos (Varian Medical Systems, Palo Alto, CA, USA), MRIdian (ViewRay Inc., Mountain View, CA, USA), and Unity (Elekta AB, Stockholm, Sweden)—have been introduced for clinical application. These platforms utilize onboard imaging-based deformable auto-segmentation of structure sets [ 28 ]. However, the accuracy of deformable image registration (DIR) depends on factors like the interface areas of deformation, the transformation framework (asymmetric or symmetric), the registration algorithm, and the mapping direction (forward or backward) [ 29 ].…”

Section: Introductionmentioning

confidence: 99%

“…As a result, manual adjustments might be necessary for these outcomes, potentially consuming a significant amount of time. Additionally, the implementation of online ART carries the risk of unintended modifications to the treatment plan, thereby increasing the demand for radiation oncologists to evaluate and approve plans in real-time [ 28 ].…”

Section: Introductionmentioning

confidence: 99%

Feasibility of artificial intelligence-driven interfractional monitoring of organ changes by mega-voltage computed tomography in intensity-modulated radiotherapy of prostate cancer

Lee,

Choi,

Kim

et al. 2023

Radiat Oncol J

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Purpose: High-dose radiotherapy (RT) for localized prostate cancer requires careful consideration of target position changes and adjacent organs-at-risk (OARs), such as the rectum and bladder. Therefore, daily monitoring of target position and OAR changes is crucial in minimizing interfractional dosimetric uncertainties. For efficient monitoring of the internal condition of patients, we assessed the feasibility of an auto-segmentation of OARs on the daily acquired images, such as megavoltage computed tomography (MVCT), via a commercial artificial intelligence (AI)-based solution in this study. Materials and Methods: We collected MVCT images weekly during the entire course of RT for 100 prostate cancer patients treated with the helical TomoTherapy system. Based on the manually contoured body outline, the bladder including prostate area, and rectal balloon regions for the 100 MVCT images, we trained the commercially available fully convolutional (FC)-DenseNet model and tested its auto-contouring performance. Results: Based on the optimally determined hyperparameters, the FC-DenseNet model successfully auto-contoured all regions of interest showing high dice similarity coefficient (DSC) over 0.8 and a small mean surface distance (MSD) within 1.43 mm in reference to the manually contoured data. With this well-trained AI model, we have efficiently monitored the patient's internal condition through six MVCT scans, analyzing DSC, MSD, centroid, and volume differences.Conclusion: We have verified the feasibility of utilizing a commercial AI-based model for auto-segmentation with low-quality daily MVCT images. In the future, we will establish a fast and accurate auto-segmentation and internal organ monitoring system for efficiently determining the time for adaptive replanning.

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Adaptive Radiation Therapy Physician Guidelines: Recommendations From an Expert Users’ Panel

Cited by 10 publications

References 20 publications

Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations

Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations

Initial clinical experience building a dual CT- and MR-guided adaptive radiotherapy program

Feasibility of artificial intelligence-driven interfractional monitoring of organ changes by mega-voltage computed tomography in intensity-modulated radiotherapy of prostate cancer

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