Evaluation of the palliative radiotherapy pathway in a single institute: Can an MR Linac improve efficiency?

Benson, R.; Clough, Abigael; Nelder, Claire; Pitt, E.; Portner, R.; Vassiliou, Maria; McDaid, Lisa; Choudhury, Ananya; Rembielak, Agata; Eccles, C.

doi:10.1016/j.jmir.2021.11.010

Cited by 8 publications

(6 citation statements)

References 22 publications

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“…Finally, similar palliative RT workflows are being evaluated on magnetic resonance linear accelerator systems, with the potential for improved visualization of soft tissue tumors compared to a CBCT-based workflow. 30,31 Future work should provide additional insights to determine the strengths and weaknesses of both approaches.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a workflow for cone‐beam CT‐guided online adaptive palliative radiotherapy planned using diagnostic CT scans

Nelissen

Versteijne

Senan

et al. 2022

J Applied Clin Med Phys

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Purpose Single‐visit radiotherapy (RT) is beneficial for patients requiring pain control and can limit interruptions to systemic treatments. However, the requirement for a dedicated planning CT (pCT)‐scan can result in treatment delays. We developed a workflow involving preplanning on available diagnostic CT (dCT) imaging, followed by online plan adaption using a cone‐beam CT (CBCT)‐scan prior to RT‐delivery, in order to account for any changes in anatomy and target position. Methods Patients previously treated with palliative RT for bone metastases were selected from our hospital database. Patient dCT‐images were deformed to treatment CBCTs in the Ethos platform (Varian Medical Systems) and a synthetic CT (sCT) generated. Treatment quality was analyzed by comparing a coverage of the V95% of the planning/clinical target volume and different organ‐at‐risk (OAR) doses between adapted and initial clinical treatment plans. Doses were recalculated on the CBCT and sCT in a separate treatment planning system. Adapted plan doses were measured on‐couch using an anthropomorphic phantom with a Gafchromic EBT3 dosimetric film and compared to dose calculations. Results All adapted treatment plans met the clinical goals for target and OARs and outperformed the original treatment plans calculated on the (daily) sCT. Differences in V95% of the target volume coverage between the initial and adapted treatments were <0.2%. Dose recalculations on CBCT and sCT were comparable, and the average gamma pass rate (3%/2 mm) of dosimetric measurements was 98.8%. Conclusions Online daily adaptive RT using dCTs instead of a dedicated pCT is feasible using the Ethos platform. This workflow has now been implemented clinically.

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Section: Discussionmentioning

confidence: 99%

Evaluation of a workflow for cone‐beam CT‐guided online adaptive palliative radiotherapy planned using diagnostic CT scans

Nelissen

Versteijne

Senan

et al. 2022

J Applied Clin Med Phys

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“…Second, this case demonstrates the value of the MR-Linac for palliative radiotherapy if target changes are expected, or unpredictable, over a course of treatment. The feasibility of palliative MR-Linac treatments have been explored to improve treatment efficiencies and reduce wait times ( 27 ). The unexpectedly large target response and positive cancer and toxicity outcomes supersedes the challenges related to longer treatment sessions and increased resource allocation associated with the MR-Linac.…”

Section: Discussionmentioning

confidence: 99%

Case Report: MR-Guided Adaptive Radiotherapy, Some Room to Maneuver

Winter

Padayachee

et al. 2022

Front. Oncol.

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BackgroundA magnetic resonance linear accelerator (MR-Linac) provides superior soft tissue contrast to evaluate inter- and intra-fraction motion and facilitate online adaptive radiation therapy (ART). We present here an unusual case of locally advanced castrate-resistant prostate cancer treated with high-dose palliative ultra-hypofractionated radiation therapy on the MR-Linac with significant inter-fraction tumor regression.Case PresentationThe patient was a 65-year-old man diagnosed with metastatic prostate cancer to bone and pelvic lymph nodes 7 years prior. At diagnosis, he presented with a PSA of 23 ng/ml and was commenced on a luteinizing hormone-releasing hormone agonist, achieving a PSA nadir of 4.68 ng/ml at 12 months. The patient subsequently had progressive lower urinary tract symptoms, his PSA increased to 47 ng/ml, and there was a markedly enlarged pelvic mass involving the prostate with gross extra-capsular disease and invasion into the posterior bladder wall. The patient was referred for palliative radiation to the pelvic mass due to urinary symptoms, pain, and lower limb paraesthesia. Treatment was planned to be delivered on the MR-Linac with a schedule of 36 Gy over 6 weekly factions allowing for maximal target dose delivery while minimizing surrounding organs at risk (OARs) radiation exposure. Unexpectedly, the target volume had a marked 49% (453 cc to 233 cc) reduction that was accounted for in the online adaptive process. A new reference plan was generated after 3 fractions to add sacral plexus as an OAR, previously not visible due to mass encroachment. The patient reported ongoing reduction in urinary symptoms, pelvic pain, and lower limb paresthesia by the end of treatment.ConclusionUsing daily MR-guided ART, improved visualization of the changing target and OARs ensured safe dose escalation. The unexpected positive response of the target and improved patient outcomes demonstrated the added value of the MR-Linac for online adaptive radiotherapy in this setting.

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“…On the other hand, the PROMPTS study showed that patients with asymptomatic MSCC from prostate cancer can safely avoid radiotherapy and thereby toxicity of esophagitis [26] . The use of MR-LINAC based treatment could be a way to improve efficacy of palliative radiotherapy with scan, plan and treat approach without the need of a planning CT [27] . This would also allow oesophageal avoidance with online adaptation, however compromises to the PTV would still be required with this approach.…”

Section: Discussionmentioning

confidence: 99%

Reduction of oesophageal toxicity with VMAT dose-sparing radiotherapy in thoracic metastatic spinal cord compression: A feasibility study

Gram

Persson

et al. 2022

Technical Innovations & Patient Support in Radiation Oncolo

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Evaluation of the palliative radiotherapy pathway in a single institute: Can an MR Linac improve efficiency?

Cited by 8 publications

References 22 publications

Evaluation of a workflow for cone‐beam CT‐guided online adaptive palliative radiotherapy planned using diagnostic CT scans

Evaluation of a workflow for cone‐beam CT‐guided online adaptive palliative radiotherapy planned using diagnostic CT scans

Case Report: MR-Guided Adaptive Radiotherapy, Some Room to Maneuver

Reduction of oesophageal toxicity with VMAT dose-sparing radiotherapy in thoracic metastatic spinal cord compression: A feasibility study

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