Hostname: page-component-cd9895bd7-lnqnp Total loading time: 0 Render date: 2024-12-26T23:04:55.215Z Has data issue: false hasContentIssue false
  • English
  • Français

Prospective observational study to estimate set-up errors and optimise PTV margins in patients undergoing IMRT for head and neck cancers from a Government cancer centre of Eastern India

Published online by Cambridge University Press:  09 July 2019

Priyanka Biswas ,
Debarshi Lahiri Open the ORCID record for Debarshi Lahiri [Opens in a new window] ,
Sanjoy Roy ,
Tapas Maji ,
Kallol Bhadra ,
Dilip Kumar Ray ,
Subhadip Das ,
Palas De  and
Bijan Kumar Mohanta
Priyanka Biswas
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Debarshi Lahiri*
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Sanjoy Roy
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Tapas Maji
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Kallol Bhadra
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Dilip Kumar Ray
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India Department of Medical Physics, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
Bijan Kumar Mohanta
Affiliation:
Department of Radiation Oncology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India Department of Medical Physics, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
*
Author for correspondence: Debarshi Lahiri, Chittaranjan National Cancer Institute, 37, S.P. Mukherjee Road, Kolkata, West Bengal 700026, India. E-mail: debarshil@gmail.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

The head and neck cancers as a whole are the most common cancers among males in India. Technological advancements have led to an improvement in radiation therapy (RT) techniques with subsequent reduction in normal tissue complications. To correct patient set-up errors, an off-line correction method like no action level (NAL) protocol may be used as a preferred protocol particularly for a busy department. The objectives of the study were to measure the translational set-up errors using kV cone-beam computed tomography (CBCT) in patients undergoing intensity modulated radiotherapy (IMRT) in head and neck cancers and also to optimise clinical target volume (CTV) to planning target volume (PTV) margin using NAL protocol.

Material and methods:

On the first 5 days of RT, patient’s position was verified by kV-CBCT and then weekly during the course of treatment. The comparison between the reference and kV-CBCT images was performed, and the shifts measured and recorded. The mean error from the initial five consecutive fractions was corrected on the sixth daily fraction. Displacements in all the directions were measured. The population systematic and random errors were determined and used to estimate PTV margins according to the van Herk formula.

Results:

A total of 322 images were analysed. Before correction, 15, 12 and 9% patients had systematic error ≥3 mm on X, Y and Z axes, but after correction this was reduced to 9, 0 and 0%. The total percentage of patients whose set-up margin was ≥5 mm before correction was 5, 6·25, 3·75%, but after correction it reduced to 1·88, 0, and 0·63%. The margins of total population were reduced to 63, 65 and 56% after correction on X, Y and Z axes, respectively.

Conclusion:

A simple off-line NAL protocol can correct the set-up errors without daily on-line imaging in patients undergoing IMRT and hence acting as a resource sparing alternative. Five millimetre margin to CTVs was adequate and safe to overcome the problem of set-up errors in head and neck IMRT.

Keywords

head and neck cancersIMRTkV-CBCTNAL protocolset-up errors
Type
Original Article
Information
Journal of Radiotherapy in Practice , Volume 19 , Issue 1 , March 2020 , pp. 52 - 58
Check for updates
Copyright
© Cambridge University Press 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Bray, F, Ferlay, J, Soerjomataram, I, Siegel, R L, Torre, L A, Jemal, A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394–424.CrossRefGoogle ScholarPubMed
Bucci, M K, Bevan, A, Roach, M 3rd. Advances in radiation therapy: conventional to 3D, to IMRT, to 4D, and beyond. CA Cancer J Clin 2005; 55: 117–134.CrossRefGoogle ScholarPubMed
Lee, N, Xia, P, Fischbein, N J, Akazawa, P, Akazawa, C, Quivey, J M. Intensity-modulated radiation therapy for head-and-neck cancer: the UCSF experience focusing on target volume delineation. Int J Radiat Oncol Biol Phys 2003; 57: 49–60.Google ScholarPubMed
Nutting, C M, Morden, J P, Harrington, K J et al. Parotid- sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial. Lancet Oncol 2011; 12: 127–136.CrossRefGoogle ScholarPubMed
Jaffray, D A, Siewerdsen, J H, Wong, J W, Martinez, A A. Flat-panel cone-beam computed tomography for image-guided radiation therapy. Int J Radiat Oncol Biol Phys 2002; 53: 1337–1349.CrossRefGoogle ScholarPubMed
Nielsen, M, Bertelsen, A, Westberg, J, Jensen, H R, Brink, C. Cone beam CT evaluation of patient set-up accuracy as a QA tool. Acta Oncol 2009; 48: 271–276.Google ScholarPubMed
Den, R B, Doemer, A, Kubicek, G et al. Daily image guidance with cone-beam computed tomography for head-and-neck cancer intensity-modulated radiotherapy: a prospective study. Int J Radiat Oncol Biol Phys 2010; 76: 1353–1359.Google ScholarPubMed
van Herk, M. Errors and margins in radiotherapy. Semin Radiat Oncol 2004; 14: 52–64.Google ScholarPubMed
Sterzing, F, Kalz, J, Sroka-Perez, G et al. Megavoltage CT in helical tomotherapy-clinical advantages and limitations of special physical characteristics. Technol Cancer Res Treat 2009; 8: 343–352.CrossRefGoogle ScholarPubMed
Lozano, E, P’erez, L, Torres, J et al. Correction of systematic error in breast and head and neck irradiation through a no- action level (NAL) protocol. Clin Transl Oncol 2011; 13: 34–42.Google ScholarPubMed
de Boer, H C, Heijmen, B J. A protocol for the reduction of systematic patient setup errors with minimal portal imaging workload. Int J Radiat Oncol Biol Phys 2001; 50: 1350–1365.CrossRefGoogle ScholarPubMed
The Royal College of Radiologists SaCoR, Institute of Physics and Engineering in Medicine. On Target: Ensuring Geometric Accuracy in Radiotherapy. London: Royal College of Radiologists, 2008.Google Scholar
Ebookpdf.com. 2019. AJCC 7th Edition 2010.pdf -- Free Download. [online]. https://ebookpdf.com/ajcc-7th-edition-2010.Google Scholar
ECOG-ACRIN. 2019. Spring 2017 Group Meeting -- ECOG-ACRIN. [online]. https://ecog-acrin.org/resources/group-meetings/spring-2017-group-meeting.Google Scholar
Stroom, J C, Heijmen, B J. Geometrical uncertainties, radiotherapy planning margins, and the ICRU-62 report. Radiat Oncol 2002; 64: 75–83.CrossRefGoogle ScholarPubMed
Park, E T, Park, S K. Set-up uncertainities for inter-fractional head and neck cancer in radiotherapy. Oncotarget 2016; 7 (29): 4662–4667.Google Scholar
Kaur, I, Gupta, G, Rawat, S, Ahlawat, P, Kakria, A, Saxena, U. Dosimetric impact of set-up errors in head and neck cancer patients treated by image guided radiotherapy. Int J Med Phys 2016; 41 (2): 144–148.Google Scholar
Ursino, S, Faggioni, L, Guidoccio, F. Role of perfusion CT in the evaluation of functional primary tumour response after radiochemotherapy in head and neck cancer: preliminary findings. Br J Radiol 2016; 89: 20151070.CrossRefGoogle ScholarPubMed
Chao, K S, Ozyigit, G, Tran, B N, Cengiz, M, Dempsey, J F, Low, D A. Patterns of failure in patients receiving definitive and postoperative IMRT for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2003; 55: 312–321.CrossRefGoogle ScholarPubMed
Ursino, S, D’Angelo, E, Mazzola, R et al. A comparison of swallowing dysfunction after three-dimensional conformal and intensity-modulated radiotherapy: a systematic review by the Italian Head and Neck Radiotherapy Study Group. Strahlenther Onkol 2017; 193: 877–889.CrossRefGoogle ScholarPubMed
Eisbruch, A, Kim, H M, Terrell, J E, Marsh, L H, Dawson, L A, Ship, J A. Xerostomia and its predictors following parotid-sparing irradiation of head-and-neck cancer. Int J Radiat Oncol Biol Phys 2001; 50: 695–704.CrossRefGoogle ScholarPubMed
Chao, K S, Deasy, J O, Markman, J et al. A prospective study of salivary function sparing in patients with head-and-neck cancers receiving intensity-modulated or three-dimensional radiation therapy: initial results. Int J Radiat Oncol Biol Phys 2001; 49: 907–916.CrossRefGoogle ScholarPubMed
Delishaj, D, Ursino, S, Lombardo, E et al. Impact of treatment volumes in loco-regional failure of oral cancer in patients treated with IMRT. Radiat Oncol 2016; 119: 985.CrossRefGoogle Scholar
Parliament, M B, Scrimger, R A, Anderson, S G et al. Preservation of oral health-related quality of life and salivary flow rates after inverse- planned intensity- modulated radiotherapy (IMRT) for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2004; 58: 663–673.CrossRefGoogle ScholarPubMed
Amer, A M, Mackay, R I, Roberts, S A, Hendry, J H, Williams, P C. The required number of treatment imaging days for an effective off-line correction of systematic errors in conformal radiotherapy of prostate cancer: a radiobiological analysis. Radiother Oncol 2001; 61: 143–150.CrossRefGoogle ScholarPubMed
Delishaj, D, Ursino, S, Lombardo, E et al. OC-0274: analysis of set-up errors in head and neck cancer treated with IMRT technique assessed by CBCT. Radiother Oncol 2016; 119 (Suppl1): 127–128.CrossRefGoogle Scholar
Bortfeld, T, van Herk, M, Jiang, S B. When should systematic patient positioning errors in radiotherapy be corrected?. Phys Med Biol 2002; 47: 297–302.CrossRefGoogle ScholarPubMed
Suzuki, M, Nishimura, Y, Nakamatsu, K et al. Analysis of interfractional set-up errors and intrafractional organ motions during IMRT for head and neck tumors to define an appropriate planning target volume (PTV)- and planning organs at risk volume (PRV)-margins. Radiother Oncol 2006; 78: 283–290.CrossRefGoogle ScholarPubMed
Su, J, Chen, W, Yang, H et al. Different setup errors assessed by weekly cone-beam computed tomography on different registration in nasopharyngeal carcinoma treated with intensity-modulated radiation therapy. Onco Targets Ther 2015; 8: 2545–2553.Google ScholarPubMed
Houghton, F, Benson, R J, Tudor, G S et al. An assessment of action levels in imaging strategies in head and neck cancer using TomoTherapy. Are our margins adequate in the absence of image guidance?. Clin Oncol (R Coll Radiol) 2009; 21: 720–727.CrossRefGoogle ScholarPubMed
Bissonnette, J P, Moseley, D, White, E, Sharpe, M, Purdie, T, Jaffray, D A. Quality assurance for the geometric accuracy of conebeam CT guidance in radiation therapy. Int J Radiat Oncol Biol Phys 2008; 71 (suppl 1), 57–61.CrossRefGoogle Scholar
McKenzie, A, van Herk, M, Mijnheer, B. Margins for geometric uncertainty around organs at risk in radiotherapy. Radiother Oncol 2002; 62: 299–307.CrossRefGoogle ScholarPubMed
Pisani, L, Lockman, D, Jaffray, D, Yan, D, Martinez, A, Wong, J. Setup error in radiotherapy: on- line correction using electronic kilovoltage and megavoltage radiographs. Int J Radiat Oncol Biol Phys 2000; 47: 825–839.Google ScholarPubMed
Wang, J, Bai, S, Chen, N et al. The clinical feasibility and effect of online cone beam computer tomography-guided intensity modulated radiotherapy for nasopharyngeal cancer. Radiother Oncol 2009; 90: 221–227.CrossRefGoogle ScholarPubMed
Barker, J L Jr, Garden, A S, Ang, K K et al. Quantification of volumetric and geometric changes occurring during fractionated radiotherapy for head-and-neck cancer using an integrated CT/linear accelerator system. Int J Radiat Oncol Biol Phys 2004; 59: 960–970.CrossRefGoogle ScholarPubMed
Zhang, L, Garden, A S, Lo, J et al. Multiple regions-of-interest analysis of setup uncertainties for head-and-neck cancer radiotherapy. Int J Radiat Oncol Biol Phys 2006; 64: 1559–1569.CrossRefGoogle ScholarPubMed
Clarizio, M, Zani, M, Delishaj, D, Fedele, D, Busutti, L, Fabrini, M. EP-1619: comparison between two different commercial thermoplastic mask systems in image-guided radiation therapy. Radiother Oncol 2015; 115: 887–888.CrossRefGoogle Scholar
Osman, S O, de Boer, H C, Astreinidou, E, Gangsaas, A, Heijmen, B J, Levendag, P C. On-line cone beam CT image guidance for vocal cord tumor targeting. Radiother Oncol 2009; 93: 8–13.CrossRefGoogle ScholarPubMed
van Kranen, S, van Beek, S, Rasch, C, van Herk, M, Sonke, J J. Setup uncertainties of anatomical sub-regions in head-and neck cancer patients after offline CBCT guidance. Int J Radiat Oncol Biol Phys 2009; 73: 1566–1573.CrossRefGoogle ScholarPubMed
Shalev, S. Treatment verification using digital imaging. In: Smith, A R (ed). Radiation Therapy Physics. Berlin: Springer, 1995: 155–173.CrossRefGoogle Scholar
van Herk, M, Remeiijer, P, Rasch, C. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int J Radiat Oncol Biol Phys 2000; 47: 1121–1135.CrossRefGoogle ScholarPubMed
Stroom, J C, de Boer, H C, Huizenga, H, Visser, A G. Inclusion of geometrical uncertainties in radiotherapy treatment planning. Int J Radiat Oncol Biol Phys 1999; 43: 905–919.CrossRefGoogle ScholarPubMed
de Boer, H C, van Sörnser de Koste, J R, Creutzberg, C L, Visser, A G, Heijmen, B J, Levendag, P C. Electronic portal image assisted reduction of systematic set-up errors in head and neck irradiation. Radiat Oncol 2001; 61: 299–308.CrossRefGoogle ScholarPubMed
Humphreys, M, Guerrero, M T, Mubata, C et al. Assessment of a customised immobilisation system for head and neck IMRT using electronic portal imaging. Radiat Oncol 2005; 77: 39–44.CrossRefGoogle ScholarPubMed
Dionisi, F, Palazzi, M F, Bracco, F et al. Set-up errors and planning target volume margins in head and neck cancer radiotherapy: a clinical study of image guidance with on-line cone-beam computed tomography. Int J Clin Oncol 2013; 18: 418–427.CrossRefGoogle ScholarPubMed
Xu, F, Wang, J, Bai, S, Xu, Q F, Shen, Y L, Zhong, R M. Detection of intra-fractional tumour position error in radiotherapy utilizing cone beam computed tomography. Radiat Oncol 2008; 89: 311–319.Google Scholar
Velec, M, Waldron, J N, O’Sullivan, B et al. Cone-beam CT assessment of inter-fraction and intrafraction setup error of two head-and-neck cancer thermoplastic masks. Int J Radiat Oncol Biol Phys 2010;76: 949–955.CrossRefGoogle Scholar
Johansen, J, Bertelsen, A, Hansen, C R, Westberg, J, Hansen, O, Brink, C. Set-up errors in patients undergoing image guided radiation treatment. Relationship to body mass index and weight loss. Acta Oncol 2008; 47: 1454–1458.CrossRefGoogle ScholarPubMed
De Bari, B, Ait Erraisse, M, Chekrine, T et al. Does weight loss predict accuracy of setup in head and neck cancer patients treated with intensity-modulated radiation therapy?. Radiol Med 2012; 117: 885–891.CrossRefGoogle ScholarPubMed
Saha, A, Mallick, I, Das, P, Chatterjee, S, Achari, R, Shrimali, R K. Evaluating the need for daily image guidance in head and neck cancers treated with helical tomotherapy: a retrospective analysis of a large number of daily image based corrections. Clin Oncol 2016; 28: 178–184.CrossRefGoogle ScholarPubMed