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Article: Adaptive Radiotherapy: Next-Generation Radiotherapy.

Dona Lemus, Olga Maria / Cao, Minsong / Cai, Bin / Cummings, Michael / Zheng, Dandan

2024 Volume 16, Issue 6

Abstract: Radiotherapy, a crucial technique in cancer therapy, has traditionally relied on the premise of largely unchanging patient anatomy during the treatment course and encompassing uncertainties by target margins. This review introduces adaptive radiotherapy ( ...

Abstract	Radiotherapy, a crucial technique in cancer therapy, has traditionally relied on the premise of largely unchanging patient anatomy during the treatment course and encompassing uncertainties by target margins. This review introduces adaptive radiotherapy (ART), a notable innovation that addresses anatomy changes and optimizes the therapeutic ratio. ART utilizes advanced imaging techniques such as CT, MRI, and PET to modify the treatment plan based on observed anatomical changes and even biological changes during the course of treatment. The narrative review provides a comprehensive guide on ART for healthcare professionals and trainees in radiation oncology and anyone else interested in the topic. The incorporation of artificial intelligence in ART has played a crucial role in improving effectiveness, particularly in contour segmentation, treatment planning, and quality assurance. This has expedited the process to render online ART feasible, lowered the burden for radiation oncology practitioners, and enhanced the precision of dynamically personalized treatment. Current technical and clinical progress on ART is discussed in this review, highlighting the ongoing development of imaging technologies and AI and emphasizing their contribution to enhancing the applicability and effectiveness of ART.
Language	English
Publishing date	2024-03-19
Publishing country	Switzerland
Document type	Journal Article ; Review
ZDB-ID	2527080-1
ISSN	2072-6694
ISSN	2072-6694
DOI	10.3390/cancers16061206
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Article ; Online: Intrafraction Motion Management With MR-Guided Radiation Therapy.

Fast, Martin F / Cao, Minsong / Parikh, Parag / Sonke, Jan-Jakob

Seminars in radiation oncology

2023 Volume 34, Issue 1, Page(s) 92–106

Abstract: High quality radiation therapy requires highly accurate and precise dose delivery. MR-guided radiotherapy (MRgRT), integrating an MRI scanner with a linear accelerator, offers excellent quality images in the treatment room without subjecting patient to ... ...

Abstract	High quality radiation therapy requires highly accurate and precise dose delivery. MR-guided radiotherapy (MRgRT), integrating an MRI scanner with a linear accelerator, offers excellent quality images in the treatment room without subjecting patient to ionizing radiation. MRgRT therefore provides a powerful tool for intrafraction motion management. This paper summarizes different sources of intrafraction motion for different disease sites and describes the MR imaging techniques available to visualize and quantify intrafraction motion. It provides an overview of MR guided motion management strategies and of the current technical capabilities of the commercially available MRgRT systems. It describes how these motion management capabilities are currently being used in clinical studies, protocols and provides a future outlook.
MeSH term(s)	Humans ; Radiotherapy Dosage ; Radiotherapy, Image-Guided/methods ; Radiotherapy Planning, Computer-Assisted/methods ; Particle Accelerators ; Magnetic Resonance Imaging/methods
Language	English
Publishing date	2023-12-17
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	1146999-7
ISSN	1532-9461 ; 1053-4296
ISSN (online)	1532-9461
ISSN	1053-4296
DOI	10.1016/j.semradonc.2023.10.008
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Zs.A 3654: Show issues

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Article ; Online: Radiation Therapy for the Treatment of Cardiac Arrhythmias.

Kashani, Rojano / Cao, Minsong / Carlson, David J

International journal of radiation oncology, biology, physics

2022 Volume 112, Issue 3, Page(s) 577–580

MeSH term(s)	Arrhythmias, Cardiac/radiotherapy ; Humans
Language	English
Publishing date	2022-01-31
Publishing country	United States
Document type	Journal Article ; Comment
ZDB-ID	197614-x
ISSN	1879-355X ; 0360-3016
ISSN (online)	1879-355X
ISSN	0360-3016
DOI	10.1016/j.ijrobp.2021.11.002
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Zs.A 1218: Show issues

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Article ; Online: A simulated comparison of lung tumor target verification using stereoscopic tomosynthesis or radiography.

Hsieh, Scott S / Ng, Lydia W / Cao, Minsong / Lee, Percy

Medical physics

2022 Volume 49, Issue 5, Page(s) 3041–3052

Abstract: Purpose: Mobile lung tumors are increasingly being treated with ablative radiotherapy, for which precise motion management is essential. In-room stereoscopic radiography systems are able to guide ablative radiotherapy for stationary cranial lesions but ... ...

Abstract	Purpose: Mobile lung tumors are increasingly being treated with ablative radiotherapy, for which precise motion management is essential. In-room stereoscopic radiography systems are able to guide ablative radiotherapy for stationary cranial lesions but not optimally for lung tumors unless fiducial markers are inserted. We propose augmenting stereoscopic radiographic systems with multiple small x-ray sources to provide the capability of imaging with stereoscopic, single frame tomosynthesis. Methods: In single frame tomosynthesis, nine x-ray sources are placed in a 3 × 3 configuration and energized simultaneously. The beams from these sources are collimated so that they converge on the tumor and then diverge to illuminate nine non-overlapping sectors on the detector. These nine sector images are averaged together and filtered to create the tomosynthesis effect. Single frame tomosynthesis is intended to be an alternative imaging mode for existing stereoscopic systems with a field of view that is three times smaller and a temporal resolution equal to the frame rate of the detector. We simulated stereoscopic tomosynthesis and radiography using Monte Carlo techniques on 60 patients with early-stage lung cancer from the NSCLC-Radiomics dataset. Two board-certified radiation oncologists reviewed these simulated images and rated them on a 4-point scale (1: tumor not visible; 2: tumor visible but inadequate for motion management; 3: tumor visible and adequate for motion management; 4: tumor visibility excellent). Each tumor was independently presented four times (two viewing angles from radiography and two viewing angles from tomosynthesis) in a blinded fashion over two reading sessions. Results: The fraction of tumors that were rated as adequate or excellent for motion management (scores 3 or 4) from at least one viewing angle was 53% using radiography and 90% using tomosynthesis. From both viewing angles, the corresponding fractions were 7% for radiography and 48% for tomosynthesis. Readers agreed exactly on 62% of images and within 1 point on 98% of images. The acquisition technique was estimated to be 75 mAs at 120 kVp per treatment fraction assuming one verification image per breath, approximately one order of magnitude less than a standard dose cone beam CT. Conclusions: Stereoscopic tomosynthesis may provide a noninvasive, low dose, intrafraction motion verification technique for lung tumors treated by ablative radiotherapy. The system architecture is compatible with real-time video capture at 30 frames per second. Simulations suggest that most, but not all, lung tumors can be adequately visualized from at least one viewing angle.
MeSH term(s)	Cone-Beam Computed Tomography/methods ; Fiducial Markers ; Humans ; Lung Neoplasms/diagnostic imaging ; Lung Neoplasms/pathology ; Lung Neoplasms/radiotherapy ; Motion ; Radiography
Language	English
Publishing date	2022-03-30
Publishing country	United States
Document type	Journal Article
ZDB-ID	188780-4
ISSN	2473-4209 ; 0094-2405
ISSN (online)	2473-4209
ISSN	0094-2405
DOI	10.1002/mp.15634
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Article: ASSET: Auto-Segmentation of the Seventeen SEgments for Ventricular Tachycardia Ablation in Radiation Therapy.

Morris, Eric / Chin, Robert / Wu, Trudy / Smith, Clayton / Nejad-Davarani, Siamak / Cao, Minsong

Cancers

2023 Volume 15, Issue 16

Abstract: There has been a recent effort to treat high-risk ventricular tachycardia (VT) patients through radio-ablation. However, manual segmentation of the VT target is complex and time-consuming. This work introduces ASSET, or Auto-segmentation of the Seventeen ...

Abstract	There has been a recent effort to treat high-risk ventricular tachycardia (VT) patients through radio-ablation. However, manual segmentation of the VT target is complex and time-consuming. This work introduces ASSET, or Auto-segmentation of the Seventeen SEgments for Tachycardia ablation, to aid in radiation therapy (RT) planning. ASSET was retrospectively applied to CTs for 26 thoracic RT patients (13 undergoing VT ablation). The physician-defined parasternal long-axis of the left ventricle (LV) and the axes generated from principal component analysis (PCA) were compared using mean distance to agreement (MDA) and angle of separation. The manually selected right ventricle insertion point and LVs were used to apply the ASSET model to automatically generate the 17 segments of the LV myocardium (LVM). Physician-defined parasternal long-axis differed from PCA by 1.2 ± 0.3 mm MDA and 6.9 ± 0.7 degrees. Segments differed by 0.69 ± 0.29 mm MDA and 0.89 ± 0.03 Dice similarity coefficient. Running ASSET takes <5 min where manual segmentation took >2 h/patient. Agreement between ASSET and expert contours was comparable to inter-observer variability. Qualitative scoring conducted by three experts revealed automatically generated segmentations were clinically useable as-is. ASSET offers efficient and reliable automatic segmentations for the 17 segments of the LVM for target generation in RT planning.
Language	English
Publishing date	2023-08-11
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2527080-1
ISSN	2072-6694
ISSN	2072-6694
DOI	10.3390/cancers15164062
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Article ; Online: Identifying predictors of on-table adaptation for pancreas stereotactic body radiotherapy (SBRT).

Wu, Trudy C / Yoon, Stephanie M / Cao, Minsong / Raldow, Ann C / Xiang, Michael

Clinical and translational radiation oncology

2023 Volume 40, Page(s) 100603

Abstract: Purpose: To identify any clinical or dosimetric parameters that predict which individuals may benefit from on-table adaptation during pancreas stereotactic body radiotherapy (SBRT) with MRI-guided radiotherapy.: Methods and materials: This was a ... ...

Abstract	Purpose: To identify any clinical or dosimetric parameters that predict which individuals may benefit from on-table adaptation during pancreas stereotactic body radiotherapy (SBRT) with MRI-guided radiotherapy. Methods and materials: This was a retrospective study of patients undergoing MRI-guided SBRT from 2016 to 2022. Pre-treatment clinical variables and dosimetric parameters on the patient's simulation scan were recorded for each SBRT course, and their ability to predict for on-table adaptation was analyzed using ordinal logistic regression. The outcome measure was number of fractions adapted. Results: Sixty-three SBRT courses consisting of 315 fractions were analyzed. Median prescription dose was 40 Gy in five fractions (range, 33-50 Gy); 52% and 48% of courses were prescribed ≤40 Gy and >40 Gy, respectively. The median minimum dose delivered to 95% (D95) of the gross tumor volume (GTV) and planning target volume (PTV) was 40.1 Gy and 37.0 Gy, respectively. Median number of fractions adapted per course was three, with 58% (183 out of 315) total fractions adapted. On univariable analysis, the prescription dose (>40 Gy vs ≤40 Gy), GTV volume, stomach V20 and V25, duodenum V20 and dose maximum, large bowel V33 and V35, GTV dose minimum, PTV dose minimum, and gradient index were significant determinants for adaptation (all p < 0.05). On multivariable analysis, only the prescription dose was significant (adjusted odds ratio 19.7, p = 0.005), but did not remain significant after multiple test correction (p = 0.08). Conclusions: The likelihood of needing on-table adaptation could not be reliably predicted a priori using pre-treatment clinical characteristics, dosimetry to nearby organs at risk, or other dosimetric parameters based on the patient's anatomy at the time of simulation, suggesting the critical importance of day-to-day variations in anatomy and increasing access to adaptive technology for pancreas SBRT. A higher (ablative) prescription dose was associated with increased use of adaptation.
Language	English
Publishing date	2023-02-22
Publishing country	Ireland
Document type	Journal Article
ISSN	2405-6308
ISSN (online)	2405-6308
DOI	10.1016/j.ctro.2023.100603
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Article ; Online: Target-oriented deep learning-based image registration with individualized test-time adaptation.

Sang, Yudi / McNitt-Gray, Michael / Yang, Yingli / Cao, Minsong / Low, Daniel / Ruan, Dan

Medical physics

2023 Volume 50, Issue 11, Page(s) 7016–7026

Abstract: Background: A classic approach in medical image registration is to formulate an optimization problem based on the image pair of interest, and seek a deformation vector field (DVF) to minimize the corresponding objective, often iteratively. It has a ... ...

Abstract	Background: A classic approach in medical image registration is to formulate an optimization problem based on the image pair of interest, and seek a deformation vector field (DVF) to minimize the corresponding objective, often iteratively. It has a clear focus on the targeted pair, but is typically slow. In contrast, more recent deep-learning-based registration offers a much faster alternative and can benefit from data-driven regularization. However, learning is a process to "fit" the training cohort, whose image or motion characteristics or both may differ from the pair of images to be tested, which is the ultimate goal of registration. Therefore, generalization gap poses a high risk with direct inference alone. Purpose: In this study, we propose an individualized adaptation to improve test sample targeting, to achieve a synergy of efficiency and performance in registration. Methods: Using a previously developed network with an integrated motion representation prior module as the implementation backbone, we propose to adapt the trained registration network further for image pairs at test time to optimize the individualized performance. The adaptation method was tested against various characteristics shifts caused by cross-protocol, cross-platform, and cross-modality, with test evaluation performed on lung CBCT, cardiac MRI, and lung MRI, respectively. Results: Landmark-based registration errors and motion-compensated image enhancement results demonstrated significantly improved test registration performance from our method, compared to tuned classic B-spline registration and network solutions without adaptation. Conclusions: We have developed a method to synergistically combine the effectiveness of pre-trained deep network and the target-centric perspective of optimization-based registration to improve performance on individual test data.
MeSH term(s)	Humans ; Deep Learning ; Image Processing, Computer-Assisted/methods ; Lung ; Algorithms
Language	English
Publishing date	2023-05-24
Publishing country	United States
Document type	Journal Article
ZDB-ID	188780-4
ISSN	2473-4209 ; 0094-2405
ISSN (online)	2473-4209
ISSN	0094-2405
DOI	10.1002/mp.16477
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Article ; Online: Early Safety and Efficacy Profile of Homogeneously Dosed Salvage Stereotactic Body Radiotherapy (SBRT) for Intraprostatic Recurrences After Low Dose Rate (LDR) Brachytherapy.

Nikitas, John / Cao, Minsong / Nickols, Nicholas G / Valle, Luca / Steinberg, Michael L / Kishan, Amar U

Clinical genitourinary cancer

2023 Volume 21, Issue 2, Page(s) 208–212

Abstract: Introduction: We set out to evaluate the safety and efficacy of homogeneously dosed salvage stereotactic body radiation therapy (SBRT) for intraprostatic recurrences following low dose rate (LDR) brachytherapy.: Patients and methods: An institutional ...

Abstract	Introduction: We set out to evaluate the safety and efficacy of homogeneously dosed salvage stereotactic body radiation therapy (SBRT) for intraprostatic recurrences following low dose rate (LDR) brachytherapy. Patients and methods: An institutional prostate SBRT database was interrogated for patients treated between January 2018 and December 2021 with salvage SBRT for intraprostatic recurrences who were previously treated with LDR brachytherapy. Patients received 30 to 34 Gy in 5 fractions to the prostate with a simultaneous integrated boost of 34 to 37.5 Gy to gross disease. The maximum urethral dose allowed was 34 Gy. Toxicities were graded using Common Terminology Criteria for Adverse Events, version 5.0. Results: Eleven patients met our study's inclusion criteria with a median follow-up time of 37.9 months (range, 24.3-51.8 months). Median time between LDR brachytherapy and salvage SBRT was 7 years (range, 2-11 years) with a median PSA of 3.15 ng/mL (range, 0.90-9.83) at the time of salvage radiation. All 11 patients were alive at the time of last follow-up. Our 3-year Kaplan-Meier progression-free survival rate was 70.1%. Median time to recurrence was 24.1 months (range, 18.7-29.7 months). Late (≥3 months) grade 1, 2, and 3 urinary toxicity rates were 27.3%, 36.4%, and 9.1%, respectively. Late (≥3 months) grade 1, 2, and 3 gastrointestinal toxicity rates were 18.2%, 0%, and 9.1%, respectively. Conclusion: Homogeneous salvage SBRT to the prostate with urethral dose minimization has a favorable safety and efficacy profile for treating intra-prostatic recurrences following LDR brachytherapy. This may represent an ideal form of salvage SBRT for re-irradiation.
MeSH term(s)	Male ; Humans ; Brachytherapy/adverse effects ; Radiosurgery/adverse effects ; Prostatic Neoplasms/surgery ; Salvage Therapy/adverse effects ; Prostate-Specific Antigen
Chemical Substances	Prostate-Specific Antigen (EC 3.4.21.77)
Language	English
Publishing date	2023-01-18
Publishing country	United States
Document type	Journal Article
ZDB-ID	2225121-2
ISSN	1938-0682 ; 1558-7673
ISSN (online)	1938-0682
ISSN	1558-7673
DOI	10.1016/j.clgc.2023.01.007
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Zs.A 6168: Show issues

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Article: Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown.

Hayase, Justin / Chin, Robert / Cao, Minsong / Hu, Peng / Shivkumar, Kalyanam / Bradfield, Jason S

The Journal of innovations in cardiac rhythm management

2022 Volume 13, Issue 2, Page(s) 4894–4899

Abstract: Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and ... ...

Abstract	Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
Language	English
Publishing date	2022-02-15
Publishing country	United States
Document type	Journal Article
ISSN	2156-3977
ISSN	2156-3977
DOI	10.19102/icrm.2022.130202
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Article: Dosimetric Effects of Air Cavities for MRI-Guided Online Adaptive Radiation Therapy (MRgART) of Prostate Bed after Radical Prostatectomy.

Pham, Jonathan / Cao, Minsong / Yoon, Stephanie M / Gao, Yu / Kishan, Amar U / Yang, Yingli

Journal of clinical medicine

2022 Volume 11, Issue 2

Abstract: Purpose: To evaluate dosimetric impact of air cavities and their corresponding electron density correction for 0.35 tesla (T) Magnetic Resonance-guided Online Adaptive Radiation Therapy (MRgART) of prostate bed patients.: Methods: Three 0.35 T MRgRT ... ...

Abstract	Purpose: To evaluate dosimetric impact of air cavities and their corresponding electron density correction for 0.35 tesla (T) Magnetic Resonance-guided Online Adaptive Radiation Therapy (MRgART) of prostate bed patients. Methods: Three 0.35 T MRgRT plans (anterior-posterior (AP) beam, AP-PA beams, and clinical intensity modulated radiation therapy (IMRT)) were generated on a prostate bed patient's (Patient A) planning computed tomography (CT) with artificial rectal air cavities of various sizes (0-3 cm, 0.5 cm increments). Furthermore, two 0.35 T MRgART plans ('Deformed' and 'Override') were generated on a prostate bed patient's (Patient B) daily magnetic resonance image (MRI) with artificial rectal air cavities of various sizes (0-3 cm, 0.5 cm increments) and on five prostate bed patient's (Patient 1-5) daily MRIs (2 MRIs: Fraction A and B) with real air cavities. For each MRgART plan, daily MRI electron density map was obtained by deformable registration with simulation CT. In the 'Deformed' plan, a clinical IMRT plan is calculated on the daily MRI with electron density map obtained from deformable registration only. In the 'Override' plan, daily MRI and simulation CT air cavities are manually corrected and bulk assigned air and water density on the registered electron density map, respectively. Afterwards, the clinical IMRT plan is calculated. Results: For the MRgRT plans, AP and AP-PA plans' rectum/rectal wall max dose increased with increasing air cavity size, where the 3 cm air cavity resulted in a 20%/17% and 13%/13% increase, relative to no air cavity, respectively. Clinical IMRT plan was robust to air cavity size, where dose change remained less than 1%. For the MRgART plans, daily MRI electron density maps, obtained from deformable registration with simulation CT, was unable to accurately produce electron densities reflecting the air cavities. However, for the artificial daily MRI air cavities, dosimetric change between 'Deformed' and 'Override' plan was small (<4%). Similarly, for the real daily MRI air cavities, clinical constraint changes between 'Deformed' and 'Override' plan was negligible and did not lead to change in clinical decision for adaptive planning except for two fractions. In these fractions, the 'Override' plan indicated that the bladder max dose and rectum V35.7 exceeded the constraint, while the 'Deformed' plan showed acceptable dose, although the absolute difference was only 0.3 Gy and 0.03 cc, respectively. Conclusion: Clinical 0.35 T IMRT prostate bed plans are dosimetrically robust to air cavities. MRgART air cavity electron density correction shows clinically insignificant change and is not warranted on low-field systems.
Language	English
Publishing date	2022-01-12
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2662592-1
ISSN	2077-0383
ISSN	2077-0383
DOI	10.3390/jcm11020364
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