To fly or not to fly: Stereotactic MR-guided adaptive radiotherapy effectively treats ultracentral lung tumors with favorable long-term outcomes

Regnery, Sebastian; Katsigiannopulos, Efthimios; Hoegen, Philipp; Weykamp, Fabian; Sandrini, Elisabetta; Held, T.; Deng, Maximilian; Eichkorn, Tanja; Buchele, Carolin; Rippke, Carolin; Renkamp, C. Katharina; König, Laila; Lang, Kristin; Thomas, Michael; Winter, Hauke; Adeberg, Sebastian; Klüter, Sebastian; Debus, Jürgen; Hörner-Rieber, Juliane

doi:10.1016/j.lungcan.2023.03.011

Cited by 11 publications

(6 citation statements)

References 36 publications

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“…Moreover, by nature of its design, real-time imaging during beam-on time cannot be performed in this system, in comparison to the MR–Linac and its cine-MRI feature, which allows for tumor tracking during the radiotherapy session [ 33 , 34 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS)

Kim,

Tawk,

Knoll

et al. 2024

Cancers

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Purpose: The Ethos (Varian Medical Systems) radiotherapy device combines semi-automated anatomy detection and plan generation for cone beam computer tomography (CBCT)-based daily online adaptive radiotherapy (oART). However, CBCT offers less soft tissue contrast than magnetic resonance imaging (MRI). This work aims to present the clinical workflow of CBCT-based oART with shuttle-based offline MR guidance. Methods: From February to November 2023, 31 patients underwent radiotherapy on the Ethos (Varian, Palo Alto, CA, USA) system with machine learning (ML)-supported daily oART. Moreover, patients received weekly MRI in treatment position, which was utilized for daily plan adaptation, via a shuttle-based system. Initial and adapted treatment plans were generated using the Ethos treatment planning system. Patient clinical data, fractional session times (MRI + shuttle transport + positioning, adaptation, QA, RT delivery) and plan selection were assessed for all fractions in all patients. Results: In total, 737 oART fractions were applied and 118 MRIs for offline MR guidance were acquired. Primary sites of tumors were prostate (n = 16), lung (n = 7), cervix (n = 5), bladder (n = 1) and endometrium (n = 2). The treatment was completed in all patients. The median MRI acquisition time including shuttle transport and positioning to initiation of the Ethos adaptive session was 53.6 min (IQR 46.5–63.4). The median total treatment time without MRI was 30.7 min (IQR 24.7–39.2). Separately, median adaptation, plan QA and RT times were 24.3 min (IQR 18.6–32.2), 0.4 min (IQR 0.3–1,0) and 5.3 min (IQR 4.5–6.7), respectively. The adapted plan was chosen over the scheduled plan in 97.7% of cases. Conclusion: This study describes the first workflow to date of a CBCT-based oART combined with a shuttle-based offline approach for MR guidance. The oART duration times reported resemble the range shown by previous publications for first clinical experiences with the Ethos system.

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Section: Discussionmentioning

confidence: 99%

Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS)

Kim,

Tawk,

Knoll

et al. 2024

Cancers

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“…Different hypofractionated schedules have been utilized for ultracentral tumors ( Supplementary Table S1 ) [ 9 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], but treatment-related toxicities remain concerning ( Figure 3 ) [ 9 , 13 , 14 , 15 , 16 , 17 , 18 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 3...…”

Section: Discussionmentioning

confidence: 99%

“…Sandoval et al reported no acute toxicities in the 38 patients they treated (the most common fractionation schedules were 60 Gy in 8 and 60 Gy in 15 fractions), while in a study by Regnery et al, the most common fractionation schedule was 50–60 Gy in 10 fractions, and 91% [277/303] of the total fractions needed to be adapted. They reported 2 patients (of 16) with Grade 3+ toxicity, including 1 esophagitis G3 and 1 bronchial bleeding G4 [ 40 , 42 ]. In our case, no acute Grade 3+ toxicity was seen.…”

Section: Discussionmentioning

confidence: 99%

“…Different hypofractionated schedules have been utilized for ultracentral tumors (Supplementary Table S1) [9,, but treatment-related toxicities remain concerning (Figure 3) [9,[13][14][15][16][17][18]20,21,[23][24][25][26][27][28][29][30][31][32][33][34]36,38,40,42,43]. Notably, two prior retrospective series detailed their experience with a more conservative hypofractionation schedule, administering a total of 60 Gy in 12 fractions (5 Gy per fraction), utilizing daily cone-beam computerized tomography (CBCT) for online setup and position verification.…”

Section: Discussionmentioning

confidence: 99%

“… Treatment-related toxicities associated with hypofractionated schedules from this study and other case series, showing the median total dose and median number of fractions for each study [ 9 , 13 , 14 , 15 , 16 , 17 , 18 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 38 , 40 , 42 , 43 ]. * Current study.…”

Section: Figurementioning

confidence: 99%

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Accelerated Hypofractionated Magnetic Resonance Guided Adaptive Radiation Therapy for Ultracentral Lung Tumors

La Rosa,

Mittauer,

Bassiri

et al. 2024

Tomography

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Radiotherapy for ultracentral lung tumors represents a treatment challenge, considering the high rates of high-grade treatment-related toxicities with stereotactic body radiation therapy (SBRT) or hypofractionated schedules. Accelerated hypofractionated magnetic resonance-guided adaptive radiation therapy (MRgART) emerged as a potential game-changer for tumors in these challenging locations, in close proximity to central organs at risk, such as the trachea, proximal bronchial tree, and esophagus. In this series, 13 consecutive patients, predominantly male (n = 9), with a median age of 71 (range (R): 46–85), underwent 195 MRgART fractions (all 60 Gy in 15 fractions) to metastatic (n = 12) or primary ultra-central lung tumors (n = 1). The median gross tumor volumes (GTVs) and planning target volumes (PTVs) were 20.72 cc (R: 0.54–121.65 cc) and 61.53 cc (R: 3.87–211.81 cc), respectively. The median beam-on time per fraction was 14 min. Adapted treatment plans were generated for all fractions, and indications included GTV/PTV undercoverage, OARs exceeding tolerance doses, or both indications in 46%, 18%, and 36% of fractions, respectively. Eight patients received concurrent systemic therapies, including immunotherapy (four), chemotherapy (two), and targeted therapy (two). The crude in-field loco-regional control rate was 92.3%. No CTCAE grade 3+ toxicities were observed. Our results offer promising insights, suggesting that MRgART has the potential to mitigate toxicities, enhance treatment precision, and improve overall patient care in the context of ultracentral lung tumors.

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Magnetresonanz-geführte adaptive stereotaktische Radiotherapie von Lungentumoren in ultrazentraler Lokalisation (MAGELLAN, ARO 2021-3)

Regnery,

Hoegen-Saßmannshausen,

Weykamp

et al. 2024

Onkologie

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To fly or not to fly: Stereotactic MR-guided adaptive radiotherapy effectively treats ultracentral lung tumors with favorable long-term outcomes

Cited by 11 publications

References 36 publications

Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS)

Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS)

Accelerated Hypofractionated Magnetic Resonance Guided Adaptive Radiation Therapy for Ultracentral Lung Tumors

Magnetresonanz-geführte adaptive stereotaktische Radiotherapie von Lungentumoren in ultrazentraler Lokalisation (MAGELLAN, ARO 2021-3)

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