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. 2016 Dec 1;96(5):1078-1086.
doi: 10.1016/j.ijrobp.2016.08.036. Epub 2016 Aug 31.

Simulated Online Adaptive Magnetic Resonance-Guided Stereotactic Body Radiation Therapy for the Treatment of Oligometastatic Disease of the Abdomen and Central Thorax: Characterization of Potential Advantages

Lauren Henke  1 , Rojano Kashani  1 , Deshan Yang  1 , Tianyu Zhao  1 , Olga Green  1 , Lindsey Olsen  1 , Vivian Rodriguez  1 , H Omar Wooten  1 , H Harold Li  1 , Yanle Hu  1 , Jeffrey Bradley  1 , Clifford Robinson  1 , Parag Parikh  1 , Jeff Michalski  1 , Sasa Mutic  1 , Jeffrey R Olsen  2
Affiliations

Simulated Online Adaptive Magnetic Resonance-Guided Stereotactic Body Radiation Therapy for the Treatment of Oligometastatic Disease of the Abdomen and Central Thorax: Characterization of Potential Advantages

Lauren Henke et al. Int J Radiat Oncol Biol Phys. .

Abstract

Purpose: To characterize potential advantages of online-adaptive magnetic resonance (MR)-guided stereotactic body radiation therapy (SBRT) to treat oligometastatic disease of the non-liver abdomen and central thorax.

Methods and materials: Ten patients treated with RT for unresectable primary or oligometastatic disease of the non-liver abdomen (n=5) or central thorax (n=5) underwent imaging throughout treatment on a clinical MR image guided RT system. The SBRT plans were created on the basis of tumor/organ at risk (OAR) anatomy at initial computed tomography simulation (PI), and simulated adaptive plans were created on the basis of observed MR image set tumor/OAR "anatomy of the day" (PA). Each PA was planned under workflow constraints to simulate online-adaptive RT. Prescribed dose was 50 Gy/5 fractions, with goal coverage of 95% planning target volume (PTV) by 95% of the prescription, subject to hard OAR constraints. The PI was applied to each MR dataset and compared with PA to evaluate changes in dose delivered to tumor/OARs, with dose escalation when possible.

Results: Hard OAR constraints were met for all PIs based on anatomy from initial computed tomography simulation, and all PAs based on anatomy from each daily MR image set. Application of the PI to anatomy of the day caused OAR constraint violation in 19 of 30 cases. Adaptive planning increased PTV coverage in 21 of 30 cases, including 14 cases in which hard OAR constraints were violated by the nonadaptive plan. For 9 PA cases, decreased PTV coverage was required to meet hard OAR constraints that would have been violated in a nonadaptive setting.

Conclusions: Online-adaptive MRI-guided SBRT may allow PTV dose escalation and/or simultaneous OAR sparing compared with nonadaptive SBRT. A prospective clinical trial is underway at our institution to evaluate clinical outcomes of this technique.

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Conflict of interest statement

Conflict of Interest Statement The authors listed below report the following financial relationships (authors not listed reported no relevant financial relationships):

Dr. Bradley reports departmental funding for clinical trials from ViewRay, and honoraria paid to Washington University by ViewRay for lectures he has given, outside of the submitted work.

Dr. Green reports honoraria from ViewRay, inc, outside the submitted work.

Dr. Henke reports grants from ViewRay Inc, outside the submitted work.

Dr. Jeffrey Olsen reports grants, personal fees and other from ViewRay, Inc, outside the submitted work.

Dr. Lindsey Olsen reports grants from Varian Medical Systems, outside the submitted work.

Dr. Kashani reports grants and personal fees from ViewRay Inc, outside the submitted work.

Dr. Mutic reports grants and other from ViewRay, Inc, grants and other from Varian Medical Systems, other from Philips Healthcare, other from Siemens, other from TreatSafely, LLC, and other from Radialogica, LLC, outside the submitted work.

Dr. Parikh reports grants from Philips Healthcare, grants and other from Varian Medical Systems, other from Holaira, Inc, other from Medtronic/Covidien, outside the submitted work.

Dr. Robinson reports grants and personal fees from Varian, grants from Elekta, personal fees from Radialogica, and personal fees from ViewRay, outside the submitted work;.

Dr. Wooten reports personal fees from ViewRay, Inc, outside the submitted work.

Dr. Yang reports grants from ViewRay and one software license agreement with ViewRay Inc, outside the submitted work.

Figures

Figure 1
Figure 1
Patient anatomy at simulation (1a, 1d) compared with “anatomy-of-the-day” revealed by the MR-image set at fraction one (1b, 1e) versus “anatomy-of-the-day” revealed by MR imaging at fraction two (1c, 1f). In frames 1a–1c, large interfractional shifts occur in the position of the stomach (S) relative to the adrenal tumor (T). Similarly, in a separate patient (frames 1d to 1f), interfractional variability in esophageal position (E) relative to a paraaortic lymph node tumor (T) was observed.
Figure 2
Figure 2
Computed tomography (CT)-based, non-adaptive PI met all organ-at-risk (OAR) constraints based on anatomy from initial CT simulation (2a). Application of PI to the daily MR-image set of a patient with a pancreatic tumor (blue colorwash) resulted in violation of hard duodenal constraints (2b). Daily adaptive planning achieved resolution of the OAR constraint violation to the duodenum (marked with arrows) while preserving target volume coverage (2c).
Figure 3
Figure 3
Maximum point dose delivered to constraint volumes of organs-at risk (OARs) when initial non-adaptive plans were applied to daily anatomy.
Figure 4
Figure 4
Dose-volume histograms (DVH) comparing esophageal (4a), stomach (4b), and planning target volume (PTV, 4a and 4b) dose for initial simulation plans based on simulation anatomy, non-adaptive plans applied to daily anatomy, and daily adaptive plans. In 4a, esophageal protection occurred concurrently with PTV dose escalation. In 4b, dose de-escalation to the PTV was required to meet hard stomach constraints.
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