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Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction.

ABSTRACT: Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.

SUBMITTER: Liu H

PROVIDER: S-EPMC10475190 | biostudies-literature | 2023 Sep

REPOSITORIES: biostudies-literature

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Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction.

Liu Hefei H Schaal David D Curry Heather H Clark Ryan R Magliari Anthony A Kupelian Patrick P Khuntia Deepak D Beriwal Sushil S

Radiation oncology (London, England) 20230902 1

Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy trea ...[more]

PMID: 37660057

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Project description:PurposeIn postoperative breast irradiation, changes in the breast contour and arm positioning can result in patient positioning errors and offline replanning. This can lead to increased treatment burden and strain on departmental logistics because of the need for additional cone beam computed tomography (CBCT) images or even a new radiation therapy treatment plan (TP). Online daily adaptive radiation therapy (oART) could provide a solution to these challenges. We have clinically implemented and evaluated the feasibility of oART for whole breast irradiation.Methods and materialsTwenty patients treated with postoperative whole breast right irradiation (5 × 5.2 Gy) were included in BREAST-ART, a prospective single-arm trial. The dosimetry of the reference TP calculated on the daily anatomy and adaptive TP were compared. Duration of the oART workflow, in-house satisfaction questionnaires, and acute toxicity (National Cancer Institute Common Terminology Criteria for Adverse Event v5.0) were collected. The oART workflow was evaluated by investigating the impact of manual corrections of influencer and target contours on treatment time and quality.ResultsIn the first 17 patients (85 fractions), the on-couch time, ie, the time between the end of CBCT1 and CBCT3, was a median of 13.8 minutes (range, 11-25). Retrospective evaluation of the use of the influencer (ie, breast) in 4 patients (20 fractions) and manual correction of the most cranial and caudal target contours (ie, 4 mm) in 10 patients (36 fractions) was done. This resulted in a reduced on-couch time in the last 3 clinical patients to a median of 13.0 minutes (range, 11-19). No grade 3 or higher toxicity was observed, and 19 of 20 patients indicated that they preferred the same treatment again. Skin marks for patient positioning during treatment were no longer necessary.ConclusionsThis study showed the feasibility, challenges, and practical solutions for the implementation of oART for breast cancer patients. Future work will focus on more complex breast indications, such as whole breast, including axillary nodes, to further investigate the benefits and challenges of oART in breast cancer.

Project description:PurposeOnline adaptive radiation therapy (oART) treatment planning requires evaluating the temporal robustness of reference plans and anticipating the potential changes during treatment courses that may even lead to risks unique to the adaptive workflow. This study conducted a risk analysis of the cone beam computed tomography guided adaptive workflow and is the first to assess an adaptive-specific reference planning review that mitigates risk in the planning process to prevent events and treatment deficiencies during adaptation.Methods and materialsA quality management team of medical physicists, residents, physicians, and radiation therapists performed a fault tree analysis and failure mode and effects analysis. Fault trees were created for under/overdosing targets and treatment deficiencies and assisted in identifying failure modes for the failure mode and effects analysis. Treatment deficiency was defined as a nonideal oART plan resulting in treatment with a lower quality plan (either oART or scheduled plan), treatment delay, or canceling treatment for the day. A reference planning checklist was created to catch failure modes before reaching the patient. Risk priority numbers (RPNs = severity * detectability * occurrence) were scored with and without the reference planning checklist to quantify risk mitigation. A root cause analysis was conducted for an event where an adaptive plan failed to generate.ResultsThe reference planning checklist (with items covering patient background, contouring/planning robustness for anatomy variability, and machine limitations) reduced the RPN for all failure modes. Only 1 failure mode with an RPN > 150 occurred with the reference planning checklist compared with 29 failure modes without, including 14 adaptive-specific failure modes. Contouring, planning, setup, scheduling, and documentation errors were identified during the fault tree analysis. Twenty-nine of 70 errors were adaptive-specific. The reference planning checklist could address 23 of 33 errors for over- or underdosing and 28 of 37 errors for treatment deficiency. The root cause analysis highlighted the need to check the setup prior to adaptive plan delivery and the time-out checklist.ConclusionsThe reference planning checklist improved the detection of the failure modes and improved the quality and robustness of the plans produced for oART. It is ideally performed before the physician plan review to prevent last-minute replan (before or after first adaptive treatment) and delay of patient start. The checklist presented can be modified based on failures specific to individual clinics and used at various planning steps based on available resources.

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Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction.

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Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction.

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