Stereotactic ablative radiation for pancreatic cancer on a 1.5 Telsa magnetic resonance-linac system

Tringale, Kathryn R.; Tyagi, Neetu; Reyngold, Marsha; Romesser, Paul B.; Wu, Abraham J.; O'Reilly, Eileen Mary; Varghese, Anna M.; Scripes, Paola Godoy; Khalil, Danny N.; Park, Wungki; Yu, Kenneth H.; Crane, Christopher H.

doi:10.1016/j.phro.2022.10.003

Cited by 17 publications

(18 citation statements)

References 31 publications

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“…In contrast, studies using a 0.35-T MRIdian observed 0%–3% grade 3–4 acute toxicity and 3%–5% late toxicity with prescribed BED ranging from 72 Gy to 100 Gy for inoperable PC ( 6 , 11 , 12 ). A recent study using a 1.5 T MR-linac found no grade 3–4 acute and late toxicity with 100-Gy BED prescribed to inoperable pancreatic tumors (summary in Supplementary 7 ) ( 13 ). In line with these studies, we observed minimal grade 3–4 toxicity in the hypofractionation group after including all experienced symptoms, except preexisting.…”

Section: Discussionmentioning

confidence: 99%

“…Beyond local tumor movement, there is difficulty with daily tumor localization, discrimination between the tumor and radiosensitive local organs at risk (OAR), and the possibility to adjust the radiotherapy treatment plan accordingly. Magnetic resonance-guided radiotherapy (MRgRT) may allow for high-precision treatment intensification with the aim of improving clinical outcomes without increasing radiation-induced toxicity ( 6 , 10 – 13 ). By visualizing the tumor and OAR at every fraction and minutes before dose delivery, the treatment plan can be improved by adapting it to the daily anatomy ( 14 , 15 ).…”

Section: Introductionmentioning

confidence: 99%

“…In recent years, MRgRT has been introduced in a growing number of centers worldwide and is increasingly being used to treat tumors in the upper abdomen. However, clinical outcomes have only been reported on a small scale, often retrospective, by single institutes, or in the context of clinical trials, in which patient selection might limit generalization of findings ( 6 , 11 – 13 ). The 1.5 Tesla (T) MR-linac (Unity, Elekta AB, SE) is an MRgRT platform that received CE marking in 2018 and was introduced in multiple clinics around the globe.…”

Section: Introductionmentioning

confidence: 99%

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Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac

Eijkelenkamp,

Grimbergen,

Daamen

et al. 2023

Front. Oncol.

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IntroductionOnline adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT.MethodsWe evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3–12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan–Meier analysis to calculate the cumulative overall survival.ResultsA total of 80 patients were assessed with a median FU of 8 months (range 1–39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3–4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3–4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%.ConclusionOnline adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3–4 toxicity and a stable QoL at 3 months of FU.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac

Eijkelenkamp,

Grimbergen,

Daamen

et al. 2023

Front. Oncol.

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“…To illustrate use of the rtTEM, the publication ‘Stereotactic ablative radiation for pancreatic cancer on a 1.5 Tesla magnetic resonance-linac system’ ( 5 ) reports on 30 patients that were treated with ablative radiation therapy using online magnetic resonance guided adaptive radiation therapy (MRgART). The rtTEM classifies this as a medium strength, safety article.…”

Section: Methodsmentioning

confidence: 99%

The Radiation Therapy Technology Evidence Matrix: a framework to visualize evidence development for innovations in radiation therapy

Edwards,

Luzzara,

Dell’Acqua

et al. 2024

Front. Oncol.

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Clinical evidence is crucial in enabling the judicious adoption of technological innovations in radiation therapy (RT). Pharmaceutical evidence development frameworks are not useful for understanding how technical advances are maturing. In this paper, we introduce a new framework, the Radiation Therapy Technology Evidence Matrix (rtTEM), that helps visualize how the clinical evidence supporting new technologies is developing. The matrix is a unique 2D model based on the R-IDEAL clinical evaluation framework. It can be applied to clinical hypothesis testing trials, as well as publications reporting clinical treatment. We present the rtTEM and illustrate its application, using emerging and mature RT technologies as examples. The model breaks down the type of claim along the vertical axis and the strength of the evidence for that claim on the horizontal axis, both of which are inherent in clinical hypothesis testing. This simplified view allows for stakeholders to understand where the evidence is and where it is heading. Ultimately, the value of an innovation is typically demonstrated through superiority studies, which we have divided into three key categories – administrative, toxicity and control, to enable more detailed visibility of evidence development in that claim area. We propose the rtTEM can be used to track evidence development for new interventions in RT. We believe it will enable researchers and sponsors to identify gaps in evidence and to further direct evidence development. Thus, by highlighting evidence looked for by key policy decision makers, the rtTEM will support wider, timely patient access to high value technological advances.

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“…The T1-weighted scan with fat suppression provides sufficient image contrast for the delineation of the OARs (duodenum-stomach and small bowel), but it remains difficult to accurately define the GTV for pancreatic cancer in some cases due to the low contrast between the tumor and adjacent tissue. In clinical practice, both T1-weighted and T2-weighted image contrasts were used synergistically to define the GTV during treatment planning (Tringale et al 2022). However, it is time inefficient to acquire T2-weighted image contrast for real-time motion tracking with the MRSIGMA framework due to the need for long TR and TE.…”

Section: Image Contrastmentioning

confidence: 99%

Real-time 4D MRI using MR signature matching (MRSIGMA) on a 1.5T MR-Linac system

Wu,

Murray,

Siddiq

et al. 2023

Phys. Med. Biol.

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Objective: To develop real-time 4D MRI using MR signature matching (MRSIGMA) for volumetric motion imaging in patients with pancreatic cancer on a 1.5T MR-Linac system.Approach: Two consecutive MRI scans with 3D golden-angle radial stack-of-stars acquisitions were performed on ten patients with inoperable pancreatic cancer. The complete first scan (905 angles) was used to compute a 4D motion dictionary including ten pairs of 3D motion images and signatures. The second scan was used for real-time imaging, where each angle (275 ms) was processed separately to match it to one of the dictionary entries. The complete second scan was also used to compute a 4D reference to assess motion tracking performance. Dice coefficients of the gross tumor volume (GTV) and two organs-at-risk (duodenum-stomach and small bowel) were calculated between signature matching and reference. In addition, volume changes, displacements, center of mass shifts, and Dice scores over time were calculated to characterize motion. Main Results: Total imaging latency of MRSIGMA (acquisition + matching) was less than 300 ms. The Dice coefficients were 0.87±0.06 (GTV), 0.86±0.05 (duodenum-stomach), and 0.85±0.05 (small bowel), which indicate high accuracy (high mean value) and low uncertainty (low standard deviation) of MRSIGMA for real-time motion tracking. The center of mass shift was 3.1±2.0 mm (GTV), 5.3±3.0 mm (duodenum-stomach), and 3.4±1.5 mm (small bowel). The Dice scores over time (0.97± [0.01-0.03]) were similarly high for MRSIGMA and reference scans in all the three contours.Significance: This work demonstrates the feasibility of real-time 4D MRI using MRSIGMA for volumetric motion tracking on a 1.5T MR-Linac system. The high accuracy and low uncertainty of real-time MRSIGMA is an essential step towards continuous treatment adaptation of tumors affected by real-time respiratory motion and could ultimately improve treatment safety by optimizing ablative dose delivery near gastrointestinal organs.

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Stereotactic ablative radiation for pancreatic cancer on a 1.5 Telsa magnetic resonance-linac system

Cited by 17 publications

References 31 publications

Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac

Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac

The Radiation Therapy Technology Evidence Matrix: a framework to visualize evidence development for innovations in radiation therapy

Real-time 4D MRI using MR signature matching (MRSIGMA) on a 1.5T MR-Linac system

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