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The first reported case of a patient with pancreatic cancer treated with cone beam computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR)

The first reported case of a patient with pancreatic cancer treated with cone beam computed... Background: Online adaptive stereotactic radiotherapy allows for improved target and organ at risk (OAR) delinea- tion and inter-fraction motion management via daily adaptive planning. The use of adaptive SBRT for the treatment of pancreatic cancer (performed until now using only MRI or CT on rails-guided adaptive radiotherapy), has yielded promising outcomes. Herein we describe the first reported case of cone beam CT-guided stereotactic adaptive radio - therapy (CT-STAR) for the treatment of pancreatic cancer. Case presentation: A 61-year-old female with metastatic pancreatic cancer presented for durable palliation of a symptomatic primary pancreatic mass. She was prescribed 35 Gy/5 fractions utilizing CT-STAR. The patient was simu- lated utilizing an end-exhale CT with intravenous and oral bowel contrast. Both initial as well as daily adapted plans were created adhering to a strict isotoxicity approach in which coverage was sacrificed to meet critical luminal gastro - intestinal OAR hard constraints. Kilovoltage cone beam CTs were acquired on each day of treatment and the radia- tion oncologist edited OAR contours to reflect the patient’s anatomy-of-the-day. The initial and adapted plan were compared using dose volume histogram objectives, and the superior plan was delivered. Use of the initial treatment plan would have resulted in nine critical OAR hard constraint violations. The adapted plans achieved hard constraints in all five fractions for all four critical luminal gastrointestinal structures. Conclusions: We report the successful treatment of a patient with pancreatic cancer treated with CT-STAR. Prior to this treatment, the delivery of ablative adaptive radiotherapy for pancreatic cancer was limited to clinics with MR- guided and CT-on-rails adaptive SBRT technology and workflows. CT-STAR is a promising modality with which to deliver stereotactic adaptive radiotherapy for pancreatic cancer. Keywords: Pancreatic cancer, SBRT, Image guided radiation therapy, CT Background Pancreatic cancer is a lethal malignancy with a five-year Minsol Kim and Joshua P. Schiff should be noted as co-first authors overall survival rate of 2–10% [1–4]. In recent years, there has been an increased focus on the utilization of *Correspondence: j.p.schiff@wustl.edu; henke.lauren@wustl.edu stereotactic body radiotherapy (SBRT) for the definitive Department of Radiation Oncology, Washington University School treatment of pancreatic malignancies [2, 5, 6]. SBRT for of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA pancreatic cancer is also critical in the palliative setting, Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kim et al. Radiation Oncology (2022) 17:157 Page 2 of 8 as SBRT has been demonstrated to elicit durable local (CT-STAR), including a discussion of the workflow and control and long-lasting relief of symptoms of local dosimetric analysis of the treatment. progression such as abdominal pain and gastric outlet obstruction [7–9]. However, the delivery of SBRT for Case presentation pancreatic tumors is challenging given the close proxim- Patient presentation ity of the mobile and radiosensitive luminal gastrointesti- A 61-year-old woman presented following an episode nal tract [10]. Magnetic resonance imaging (MRI) guided of abdominal pain due to acute pancreatitis. During the radiotherapy has been shown to allow precise deline- patient’s work up, a CT chest/abdomen/pelvis demon- ation of daily target and organ at risk (OAR) volumes, strated a mass in the pancreatic body. Biopsy of the mass improving the efficacy of pancreatic SBRT while mini - confirmed pancreatic adenocarcinoma. The patient met mizing toxicity [11–13]. Recently, the implementation of with medical oncology and was recommended neo-adju- daily online adaptive planning via stereotactic magnetic vant systemic therapy but declined and pursued alter- resonance guided adaptive radiotherapy (SMART) has native therapies. The patient returned to clinic several yielded promising progression-free and overall survival months later with abdominal pain and interval imaging rates as well as a favorable toxicity profile in the ablation demonstrating progression of local disease with encase- of pancreatic cancer [4,14–16]. ment of the splenic and superior mesenteric veins (Fig. 1) Recently, a novel ring gantry computed tomography as well as the development of liver metastases. The pri - (CT) based radiotherapy machine has been developed mary mass measured 4.8 × 3.8  cm. The patient was with a high-quality cone-beam CT capable of yielding referred to radiation oncology for consideration of pal- high resolution on-board volumetric images and an arti- liative radiotherapy. On interview, the patient reported ficial intelligence (AI) enhanced treatment planning sys - left upper quadrant and back pain as well as malaise and tem (TPS), which is capable of daily adaptive planning weight loss. Physical exam was otherwise unremarkable. (ETHOS, Varian Medical Systems, Palo Alto, CA) [17– The patient was recommended SBRT to her primary 19]. The use of cone beam CT-guided adaptive radiother - mass for durable palliation, 35 Gy in 5 fractions, 7 Gy per apy for the clinical ablation of pancreatic cancer has not fraction. Given the high dose per fraction and adjacent yet been described. Herein we describe the first reported critical organs at risk, the treating radiation oncologist treatment of a patient with pancreatic cancer using cone elected to use daily online adaptation with cone beam beam CT-guided stereotactic adaptive radiotherapy CT-guidance. Fig. 1 Pancreatic tumor at time of presentation to radiation oncology. Axial, coronal, and sagittal diagnostic (A–C) as well as simulation (D–F) CT images of the patient at time of presentation to radiation oncology. The primary tumor is indicated on the diagnostic images by the red arrow and a liver metastasis is indacted by the yellow arrow. The GTV (red contour) and PTV (cyan contour) are delineated on the CT simulation images K im et al. Radiation Oncology (2022) 17:157 Page 3 of 8 Treatment planning and delivery A PTV optimization (PTV ) structure was generated, opt The patient was simulated utilizing an end-exhale made from the PTV minus any overlap with critical OARs breath-hold CT with intravenous and oral bowel con- plus a 5  mm margin on the OARs. The critical OARs trast and a 4-dimensional CT. Intravenous contrast was were the luminal gastrointestinal structures, namely the administered at the 45-s delay phase per institutional stomach, duodenum, small bowel, and large bowel. This protocol. The primary image used for planning was the PTV was used to drive prescription dose to the tumor opt end-exhale breath-hold CT. The 4D-CT is captured in to drive target coverage, given that areas of direct PTV the case that the patient is non-compliant with breath- and OAR overlap are not prioritized for target coverage hold and requires treatment with a different modality per our standard adaptive radiotherapy practices [4, 20– and/or dose and fractionation. Of note, as contrast is not 22]. Both the P and adaptive plans (P ) were generated I A delivered with each subsequent daily cone beam CT, the using a strict isotoxicity approach, in which maximum density of the contrast is overrided on the simulation CT OAR constraints are prioritized over target coverage [21, to the density of water so that the contrast has no dosi- 23]. However, a minimum dose of 25 Gy was maintained metric impact on the initial plan (P ). The patient was to the PTV to ensure some uncertainty margin coverage. positioned in a custom immobilization device with left Dose constraints and objectives are in Table 1. Conserva- arm down and right arm up, per institutional pancreatic tive luminal gastrointestinal OAR constraints were used SBRT practice. An MRI was obtained at time of simula- given the palliative nature of the case. We have provided tion and fused to the simulation images for assistance in our standard departmental pancreatic adaptive SBRT target delineation. All treatment planning was performed dose constraints in Additional file  1: Table  S1. A beam in the ETHOS (v.02.01.00) TPS. The gross tumor vol - arrangement of two ¾ co-planar arcs was used, with 30 ume (GTV) comprised the gross tumor demonstrated and 330 degree collimator angles. on simulation imaging. As the patient was simulated and Daily P were created based on the patient’s anatomy- intended to be treated at end-exhale breath-hold, a inter- of-the-day. The TPS automatically deformed the OAR nal GTV or internal target volume was not created. No and target contours from the P onto the daily cone clinical target volume (CTV) was utilized per standard beam  CT using a vendor supplied elastic deformation institutional pancreatic SBRT practice. A 0.5 cm uniform algorithm, and the TPS AI auto-adjusted the stomach, volumetric expansion was applied to form a planning tar- duodenum, and liver according to the anatomy-of-the- get volume (PTV). The relevant organs-at-risk (OARs) day. The deformed GTV was then overwritten and the were contoured at the axial slices from 3 cm below to 3 simulation GTV was ridigly copied onto the patient’s cm above the PTV. anatomy-of-the-day. OARs within a 3-cm contour ring Table 1 OAR constraint and target volume metrics are presented for the initial non adaptive (P ) and adapted (P ) plans I A Organ-at-risk Strict constraint P mean (std dev) P median (range) P mean (std dev) P median (range) I I A A Stomach V25 Gy < 0.5 cc (cc) 10.2 (3.6) 9.7 (5.6–14.8) 0.0 (0.1) 0.0 (0.0–0.1) Duodenum V25 Gy < 0.5 cc (cc) 0.1 (0.1) 0.1 (0.0–0.2) 0.0 (0.0) 0.0 (0.0–0.0) Small bowel V25 Gy < 0.5 cc (cc) 3.8 (5.1) 1.2 (0.3–13.8) 0.0 (0.0) 0.0 (0.0–0.1) Large bowel V25 Gy < 0.5 cc (cc) 0.0 (0.0) 0.0 (0.0–0.1) 0.1 (0.1) 0.0 (0.0–0.2) Liver V25 Gy < 33% (%) 9.5 (1.6) 10.1 (6.8–11.4) 12.1 (1.8) 11.0 (10.3–14.7) 700 cc < 20 Gy (Gy) 0.4 (.1) 0.3 (0.2–0.6) 0.4 (0.1) 0.4 (0.3–0.5) Mean < 20 Gy (Gy) 1.0 (0.2) 1.0 (0.8–1.2) 1.2 (0.1) 1.2 (1.0–1.3) Spinal cord V25 Gy < 0.5 cc (cc) 0.0 (0.0) 0.0 (0.0–0.0) 0.0 (0.0) 0.0 (0.0–0.0) Kidneys (both) Mean < 18 Gy (Gy) 0.8 (0.7) 0.8 (0.7–0.9) 0.8 (0.1) 0.8 (0.7–0.9) Target volume Coverage goal P mean (std dev) P median (range) P mean (std dev) P median (range) I I A A PT V V100 N/A (%) 77.1 (2.1) 76.0 (74.5–80.0) 77.8 (5.1) 80.8 (67.9–81.3) PTV D95 N/A (Gy) 4.7 (0.1) 4.6 (4.6–4.9) 4.8 (0.1) 4.8 (4.6–5.0) PTV 95% (%) 83.5 (3.8) 83.5 (78.8–91.4) 99.6 (0.3) 99.5 (99.2–100.1) opt GT V V100 N/A (%) 89.9 (1.1) 90.0 (88.5–91.4) 90.0 (4.0) 91.8 (82.2–93) GTV D95 N/A (Gy) 6.0 (0.2) 6.1 (5.6–6.3) 6.4 (0.3) 6.5 (5.7–6.7) Mean and median constraint and target metrics for the P represent the hypothetical use of the P applied to all five fractions I I N/A not applicable, Std Dev standard deviation Kim et al. Radiation Oncology (2022) 17:157 Page 4 of 8 (per standard adaptive protocol [22]) were adjusted by luminal gastrointestinal structures, are demonstrated the radiation oncologist in order to confirm accuracy. in Figs.  2 and 3. The use of the P would have resulted The initial simulation based treatment plan (P ) was pro- in violation of the stomach hard constaint in all five jected on the patient anatomy-of-the-day at the same fractions, and violation of the small bowel constraint time that the re-optimized daily adapted plan (P ) was in four of five fractions (Fig.  2). The P achieved hard A A generated. The P and P were compared using dose vol- constraints in all five fractions for all four critical lumi - I A ume histogram (DVH) objectives, and the superior plan nal gastrointestinal structures. Figure  4 illustrates how that met all dosimetric goals was delivered. Of note, all the use of daily adaptive planning allowed for a specific acquired kV cone beam CTs were considered of sufficient radiotherapy fraction to achieve the small bowel hard quality for target and OAR delineation as well as daily constraint, where as delivery of the P would have vio- adaptation per the treating radiation oncologist and med- lated that constraint. ical physicist. Treatment component times were recorded and are demonstrated in Table  2. Mean (standard deviation) Dosimetric and clinical results total treatment time was 70  min (68.3–81.7) and treat- Constraint and coverage metrics for the P and P are ment time decreased each consecutive fraction. The I A demonstrated in Table  1. Mean PTV and GTV D95 for patient completed all five fractions of CT-STAR with - all five fractions was 23.25  Gy and 30.20  Gy in the P out issue. The patient ultimately progressed locally and 24.11 Gy and 31.85 Gy in the P , respectively. Dosi- and distantly, and passed away several months after metric parameters, specifically the volume received treatment. 25  Gy (V25) and maximum dose (D ) for critical max Fig. 2 V25 (cc) of initial and adaptive plans of critical organs at risk. The V25 of the initial (P ) and adaptive (P ) plans for the critical luminal I A gastrointestinal OARs. Y-axis is in cc. Delivery of the initial plan would have yielded nine OAR hard constraint violations. Adaptive planning was able to meet hard constraints for all OARs in all five fractions. Fx = fraction K im et al. Radiation Oncology (2022) 17:157 Page 5 of 8 Fig. 3 Maximum doses of critical OARs. The D values of the initial (P ) and adaptive (P ) plans for critical luminal gastrointestinal OARs. Y-axis is in max I A Gy. Adaptive planning yielding substantial D reductions for the stomach and small bowel. Fx = fraction max is adjacent to several mobile and radiosensitive OARs. Discussion and conclusions Initial studies evaluating the use of ablative doses of Discussion standard CT-guided stereotactic radiotherapy for the Herein we describe the first reported use of CT-STAR for treatment of pancreatic cancer proved efficacious with the treatment of a patient with pancreatic cancer using regards to local control, but also displayed high rates of a novel ring gantry device. These data demonstrate that luminal gastrointestinal organ toxicity [25–27]. Adaptive the delivery of the P would have led to nine critical OAR radiotherapy can improve the therapeutic index of SBRT hard constraint violations across all five fractions, and for pancreatic cancer. Recently, our institution published that the daily P met all critical OAR hard constraints in outcomes for patients with inoperable pancreatic cancer all five fractions. Furthermore, the use of daily adaptation treated with SMART and demonstrated durable progres- improved PTV , GTV V100, and GTV D95 coverage opt sion-free and overall survival rates as well as a favorable (Table  1) while alleviating the hard constraint violations. toxicity profile [4]. While these data are promising, it’s With regards to workflow, the overall treatment times notable that their application is limited to MR-guided were within the range of previously described treatment workflows. Prior to the advent of the ETHOS platform, times for daily adaptation, and the decreased time per adaptive SBRT for pancreatic cancer was limited to clin- each consecutive fraction suggests that treatment times ics with MR-guided or CT-on-rails workflows [4, 16, 28, decrease with increased patient/staff familiarity [22, 24]. 29]. The utility of adaptive stereotactic radiotherapy for the While CT-STAR has the capacity to expand access treatment of pancreatic cancer can not be understated. to adaptive pancreatic SBRT, there are potential limi- The effective ablation of pancreatic cancers requires tations of using a CBCT-guided platform instead of a the delivery of biologic effective dose of at least 100  Gy MR-guided platform. The improved soft tissue contrast [10]. However, this is difficult to achieve as the pancreas Kim et al. Radiation Oncology (2022) 17:157 Page 6 of 8 Fig. 4 Initial and adaptive plan comparison. An initial (A) and adaptive plan (B) for a single fraction of radiotherapy. In the initial plan, the high dose color wash (> 25 Gy) is in the small bowel (light green), whereas in the adapted plan, the high dose color wash does not enter the small bowel. The DVH demonstrates the dose delivered to the small bowel as well as the PTV (cyan) in the initial (triangle) and adaptive plans (square) Table 2 Treatment component times are presented for each fraction Treatment component Fraction 1 Fraction 2 Fraction 3 Fraction 4 Fraction 5 Mean Standard deviation Patient setup 18 9 17 10 N/R 13.5 4.7 CBCT time 1 5 1 2 1 2 1.7 Contouring 39 28 17 19 27 26 8.7 Plan re-optimization 3 7 6 7 6 5.8 1.6 Plan review < 1 < 1 < 1 1 1 0.4 0.5 Quality assurance 8 3 6 2 2 4.2 2.7 Pre-treatment CBCT 1 2 5 3 4 3 1.6 Beam delivery 26 21 8 9 14 15.6 7.8 Patient exit 1 4 1 7 5 3.6 2.6 Total 86 79 63 62 60 70 11.7 Times are in minutes N/R not recorded of MRI can be useful in pancreatic and abdominal con- limited in that subset of patients. This may be of con - touring, which can be of particular importance when sideration when planning to install either a MR- or delineating gross organ invasion. In contrast with cone beam CT-guided adaptive platform. MR-guidance, gross organ invasion is challenging Herein we demonstrate that stereotactic adaptive to delineate on cone beam  CT. In our experience [4], radiotherapy is able to be delivered on a cone beam CT- approximately 10% of patients with locally advanced guided modality, which promises to increase access to pancreatic cancer present with evidence of gross organ, adaptive pancreatic SBRT world wide. This case pres - and the use of CBCT-guided adaptive SBRT may be entation demonstrates the potential for CT-STAR to K im et al. Radiation Oncology (2022) 17:157 Page 7 of 8 Systems, Radialogica; honoraria: ViewRay Inc., Varian Medical Systems; Advisory provide a additional avenue for radiation oncologists to Board: ViewRay Inc. ablate pancreatic cancer. Author details Department of Electrical and Computer Engineering, School of Engineering Conclusions and Applied Science, University of Virginia, 351 McCormick Rd, Charlottsville, VA 22904, USA. Department of Radiation Oncology, Washington University CT-STAR is a viable modality for the delivery of adap- School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. tive stereotactic radiotherapy for the ablation of pancre- Louis, MO 63110, USA. atic cancer. Clinical trials are warranted to investigate the Received: 28 June 2022 Accepted: 26 August 2022 impact of this modality on overall and progression-free survival as well as toxicity. Abbreviations References AI: Artificial intelligence; CBCT: Cone beam computed tomography.; CT: Com- 1. Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: global puted tomography; CT-STAR : CT-guided stereotactic adaptive radiotherapy; trends, etiology and risk factors. World J Oncol. 2019;10(1):10–27. https:// CTV: Clinical target volume; D : Maximum dose recieved; DVH: Dose volume doi. org/ 10. 14740/ wjon1 166. max histogram; GTV: Gross tumor volume; MRI: Magnetic resonance imaging; OAR: 2. Abi Jaoude J, Thunshelle CP, Kouzy R, et al. Stereotactic versus conven- Organ at risk; P : Adapted plan; P : Initial plan; PTV: Planning target volume; tional radiation therapy for patients with pancreatic cancer in the mod- A I PTV : PTV optimization structure; SBRT: Stereotactic body radiation therapy; ern era. Adv Radiat Oncol. 2021;6(6): 100763. https:// doi. org/ 10. 1016/j. opt SMART : Stereotactic magnetic resonance guided adaptive radiotherapy; TPS: adro. 2021. 100763. Treatment planning system; V25: Volume receiving 25 Gy. 3. McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018;24(43):4846–61. https:// doi. Supplementary Information org/ 10. 3748/ wjg. v24. i43. 4846. The online version contains supplementary material available at https:// doi. 4. Hassanzadeh C, Rudra S, Bommireddy A, et al. Ablative five-fraction org/ 10. 1186/ s13014- 022- 02125-z. stereotactic body radiation therapy for inoperable pancreatic cancer using online MR-guided adaptation. Adv Radiat Oncol. 2021;6(1):100506. https:// doi. org/ 10. 1016/j. adro. 2020. 06. 010. Additional file 1: Table S1. Case report and standard OAR constraints. 5. Bourhis J, Sire C, Graff P, et al. Concomitant chemoradiotherapy versus The constraints used for the patient in this case report and our standard acceleration of radiotherapy with or without concomitant chemotherapy departmental pancreatic adaptive SBRT dose constraints are demon- in locally advanced head and neck carcinoma (GORTEC 99–02): an open- strated. The standard luminal gastrointestinal OAR constraints are in bold. label phase 3 randomised trial. Lancet Oncol. 2012;13(2):145–53. https:// doi. org/ 10. 1016/ S1470- 2045(11) 70346-1. 6. Kishan A, Lee P. Having your cake and eating it too: combining SBRT and Acknowledgements multi-agent chemotherapy in locally advanced pancreatic cancer. Cureus. None. 2016;8(7):e686. https:// doi. org/ 10. 7759/ cureus. 686. 7. Vornhülz M, Anton S, Eross B, et al. Role of stereotactic body radiation Author contributions in the enhancement of the quality of life in locally advanced pancreatic MK and JPS—the literature researching, writing the manuscript. SNB—prepar- adenocarcinoma: a systematic review. Radiat Oncol. 2022;17(1):108. ing the radiotherapy plan. LEH—Conception, realization of the treatment. All https:// doi. org/ 10. 1186/ s13014- 022- 02076-5. authors read and approved the final manuscript. 8. Ryan JF, Rosati LM, Groot VP, et al. Stereotactic body radiation therapy for palliative management of pancreatic adenocarcinoma in elderly and Funding medically inoperable patients. Oncotarget. 2018;9(23):16427–36. https:// Not applicable. doi. org/ 10. 18632/ oncot arget. 24713. 9. Buwenge M, Macchia G, Arcelli A, et al. Stereotactic radiotherapy Availability of data and materials of pancreatic cancer: a systematic review on pain relief. J Pain Res. Research data are stored in an institutional repository and will be shared upon 2018;11:2169–78. https:// doi. org/ 10. 2147/ JPR. S1679 94. request to the corresponding author. 10. Reyngold M, Parikh P, Crane CH. Ablative radiation therapy for locally advanced pancreatic cancer: techniques and results. Radiat Oncol. Declarations 2019;14:95. https:// doi. org/ 10. 1186/ s13014- 019- 1309-x. 11. Tyagi N, Liang J, Burleson S, Subashi E, Scripes PG, Tringale KR, Romesser Ethics approval and consent to participate PB, Reyngold M, Crane CH. Feasibility of ablative stereotactic body The patient was given ample time to ask questions at time of consultation and radiation therapy of pancreas cancer patients on a 1.5 Tesla magnetic she received answers for all questions raised. Consent for radiotherapy was resonance-linac system using abdominal compression. Phys Imaging obtained from the patient. All authors read and approved the final manuscript. Radiat Oncol. 2021;19:53–9. https:// doi. org/ 10. 1016/j. phro. 2021. 07. 006. 12. Heerkens HD, van Vulpen M, Erickson B, et al. MRI guided stereotac- Consent for publication tic radiotherapy for locally advanced pancreatic cancer. Br J Radiol. The patient had passed away by the time this manuscript was prepared and 2018;91(1091):20170563. https:// doi. org/ 10. 1259/ bjr. 20170 563. therefore consent for publication was unable to be obtained. 13. Tchelebi LT, Zaorsky NG, Rosenberg JC, et al. Reducing the toxicity of radiotherapy for pancreatic cancer with magnetic resonance-guided Competing interests radiotherapy. Toxicol Sci. 2020;175(1):19–23. https:// doi. org/ 10. 1093/ Minsol Kim: none. Joshua P Schiff: none. Alex Price: grants: Varian Medical toxsci/ kfaa0 21. Systems; support for meetings: ViewRay Inc., Sun Nuclear Corporation. Eric 14. Doty DG, Chuong MD, Gomez AG, et al. Stereotactic MR-guided online Laugeman: honoraria: Varian Medical Systems. Pamela P Samson: none. Hyun adaptive radiotherapy reirradiation (SMART reRT ) for locally recurrent Kim: grants: Varian Medical Systems; honoraria: ViewRay Inc., Varian Medi- pancreatic adenocarcinoma: a case report. Med Dosim. 2021;46(4):384–8. cal Systems. Shahed N Badiyan: honoraria: Mevion Medical Systems. Lauren https:// doi. org/ 10. 1016/j. meddos. 2021. 04. 006. E Henke: grants: Varian Medical Systems; consulting fees: Varian Medical 15. Magallon-Baro A, Milder MTW, Granton PV, Nuyttens JJ, Hoogeman MS. Comparison of daily online plan adaptation strategies for a cohort of Kim et al. Radiation Oncology (2022) 17:157 Page 8 of 8 pancreatic cancer patients treated with SBRT. Int J Radiat Oncol Biol Phys. 2021;111(1):208–19. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 03. 050. 16. Chuong MD, Bryant J, Mittauer KE, et al. Ablative 5-fraction stereotactic magnetic resonance-guided radiation therapy with on-table adaptive replanning and elective nodal irradiation for inoperable pancreas cancer. Pract Radiat Oncol. 2021;11(2):134–47. https:// doi. org/ 10. 1016/j. prro. 2020. 09. 005. 17. Pokharel S, Pacheco A, Tanner S. Assessment of efficacy in automated plan generation for Varian Ethos intelligent optimization engine. J Appl Clin Med Phys. 2022. https:// doi. org/ 10. 1002/ acm2. 13539. 18. Moazzezi M, Rose B, Kisling K, Moore KL, Ray X. Prospects for daily online adaptive radiotherapy via ethos for prostate cancer patients without nodal involvement using unedited CBCT auto-segmentation. J Appl Clin Med Phys. 2021;22(10):82–93. https:// doi. org/ 10. 1002/ acm2. 13399. 19. Hao Y, Cai B, Green O, et al. Technical Note: An alternative approach to verify 6FFF beam dosimetry for Ethos and MR Linac without using a 3D water tank. Med Phys. 2021;48(4):1533–9. https:// doi. org/ 10. 1002/ mp. 20. Henke L, Kashani R, Robinson C, et al. Phase I trial of stereotactic MR- guided online adaptive radiation therapy (SMART ) for the treatment of oligometastatic or unresectable primary malignancies of the abdomen. Radiother Oncol. 2018;126(3):519–26. https:// doi. org/ 10. 1016/j. radonc. 2017. 11. 032. 21. Green OL, Henke LE, Hugo GD. Practical clinical workflows for online and offline adaptive radiation therapy. Semin Radiat Oncol. 2019;29(3):219– 27. https:// doi. org/ 10. 1016/j. semra donc. 2019. 02. 004. 22. Bohoudi O, Bruynzeel AME, Senan S, et al. Fast and robust online adaptive planning in stereotactic MR-guided adaptive radiation therapy (SMART ) for pancreatic cancer. Radiother Oncol. 2017;125(3):439–44. https:// doi. org/ 10. 1016/j. radonc. 2017. 07. 028. 23. Henke L, Kashani R, Yang D, et al. Simulated online adaptive magnetic resonance-guided stereotactic body radiation therapy for the treat- ment of oligometastatic disease of the abdomen and central thorax: characterization of potential advantages. Int J Radiat Oncol Biol Phys. 2016;96(5):1078–86. https:// doi. org/ 10. 1016/j. ijrobp. 2016. 08. 036. 24. Henke LE, Stanley JA, Robinson C, et al. Phase I trial of stereotactic MRI-guided online adaptive radiation therapy (SMART ) for the treat- ment of oligometastatic ovarian cancer. Int J Radiat Oncol Biol Phys. 2022;112(2):379–89. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 08. 033. 25. Pollom EL, Alagappan M, von Eyben R, et al. Single- versus multifraction stereotactic body radiation therapy for pancreatic adenocarcinoma: outcomes and toxicity. Int J Radiat Oncol Biol Phys. 2014;90(4):918–25. https:// doi. org/ 10. 1016/j. ijrobp. 2014. 06. 066. 26. Koong AJ, Toesca DAS, Baclay JRM, et al. The utility of stereotactic ablative radiation therapy for palliation of metastatic pancreatic adenocarcinoma. Pract Radiat Oncol. 2020;10(4):274–81. https:// doi. org/ 10. 1016/j. prro. 2020. 02. 010. 27. Schellenberg D, Kim J, Christman-Skieller C, et al. Single-fraction stereo- tactic body radiation therapy and sequential gemcitabine for the treat- ment of locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2011;81(1):181–8. https:// doi. org/ 10. 1016/j. ijrobp. 2010. 05. 006. 28. Niedzielski JS, Liu Y, Ng SSW, et al. Dosimetric uncertainties resulting from interfractional anatomic variations for patients receiving pancreas stereotactic body radiation therapy and cone beam computed tomogra- phy image guidance. Int J Radiat Oncol Biol Phys. 2021;111(5):1298–309. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 08. 002. 29. Magallon-Baro A, Milder MTW, Granton PV, den Toom W, Nuyttens JJ, Re Read ady y to to submit y submit your our re researc search h ? 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The first reported case of a patient with pancreatic cancer treated with cone beam computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR)

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10.1186/s13014-022-02125-z
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Abstract

Background: Online adaptive stereotactic radiotherapy allows for improved target and organ at risk (OAR) delinea- tion and inter-fraction motion management via daily adaptive planning. The use of adaptive SBRT for the treatment of pancreatic cancer (performed until now using only MRI or CT on rails-guided adaptive radiotherapy), has yielded promising outcomes. Herein we describe the first reported case of cone beam CT-guided stereotactic adaptive radio - therapy (CT-STAR) for the treatment of pancreatic cancer. Case presentation: A 61-year-old female with metastatic pancreatic cancer presented for durable palliation of a symptomatic primary pancreatic mass. She was prescribed 35 Gy/5 fractions utilizing CT-STAR. The patient was simu- lated utilizing an end-exhale CT with intravenous and oral bowel contrast. Both initial as well as daily adapted plans were created adhering to a strict isotoxicity approach in which coverage was sacrificed to meet critical luminal gastro - intestinal OAR hard constraints. Kilovoltage cone beam CTs were acquired on each day of treatment and the radia- tion oncologist edited OAR contours to reflect the patient’s anatomy-of-the-day. The initial and adapted plan were compared using dose volume histogram objectives, and the superior plan was delivered. Use of the initial treatment plan would have resulted in nine critical OAR hard constraint violations. The adapted plans achieved hard constraints in all five fractions for all four critical luminal gastrointestinal structures. Conclusions: We report the successful treatment of a patient with pancreatic cancer treated with CT-STAR. Prior to this treatment, the delivery of ablative adaptive radiotherapy for pancreatic cancer was limited to clinics with MR- guided and CT-on-rails adaptive SBRT technology and workflows. CT-STAR is a promising modality with which to deliver stereotactic adaptive radiotherapy for pancreatic cancer. Keywords: Pancreatic cancer, SBRT, Image guided radiation therapy, CT Background Pancreatic cancer is a lethal malignancy with a five-year Minsol Kim and Joshua P. Schiff should be noted as co-first authors overall survival rate of 2–10% [1–4]. In recent years, there has been an increased focus on the utilization of *Correspondence: j.p.schiff@wustl.edu; henke.lauren@wustl.edu stereotactic body radiotherapy (SBRT) for the definitive Department of Radiation Oncology, Washington University School treatment of pancreatic malignancies [2, 5, 6]. SBRT for of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA pancreatic cancer is also critical in the palliative setting, Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kim et al. Radiation Oncology (2022) 17:157 Page 2 of 8 as SBRT has been demonstrated to elicit durable local (CT-STAR), including a discussion of the workflow and control and long-lasting relief of symptoms of local dosimetric analysis of the treatment. progression such as abdominal pain and gastric outlet obstruction [7–9]. However, the delivery of SBRT for Case presentation pancreatic tumors is challenging given the close proxim- Patient presentation ity of the mobile and radiosensitive luminal gastrointesti- A 61-year-old woman presented following an episode nal tract [10]. Magnetic resonance imaging (MRI) guided of abdominal pain due to acute pancreatitis. During the radiotherapy has been shown to allow precise deline- patient’s work up, a CT chest/abdomen/pelvis demon- ation of daily target and organ at risk (OAR) volumes, strated a mass in the pancreatic body. Biopsy of the mass improving the efficacy of pancreatic SBRT while mini - confirmed pancreatic adenocarcinoma. The patient met mizing toxicity [11–13]. Recently, the implementation of with medical oncology and was recommended neo-adju- daily online adaptive planning via stereotactic magnetic vant systemic therapy but declined and pursued alter- resonance guided adaptive radiotherapy (SMART) has native therapies. The patient returned to clinic several yielded promising progression-free and overall survival months later with abdominal pain and interval imaging rates as well as a favorable toxicity profile in the ablation demonstrating progression of local disease with encase- of pancreatic cancer [4,14–16]. ment of the splenic and superior mesenteric veins (Fig. 1) Recently, a novel ring gantry computed tomography as well as the development of liver metastases. The pri - (CT) based radiotherapy machine has been developed mary mass measured 4.8 × 3.8  cm. The patient was with a high-quality cone-beam CT capable of yielding referred to radiation oncology for consideration of pal- high resolution on-board volumetric images and an arti- liative radiotherapy. On interview, the patient reported ficial intelligence (AI) enhanced treatment planning sys - left upper quadrant and back pain as well as malaise and tem (TPS), which is capable of daily adaptive planning weight loss. Physical exam was otherwise unremarkable. (ETHOS, Varian Medical Systems, Palo Alto, CA) [17– The patient was recommended SBRT to her primary 19]. The use of cone beam CT-guided adaptive radiother - mass for durable palliation, 35 Gy in 5 fractions, 7 Gy per apy for the clinical ablation of pancreatic cancer has not fraction. Given the high dose per fraction and adjacent yet been described. Herein we describe the first reported critical organs at risk, the treating radiation oncologist treatment of a patient with pancreatic cancer using cone elected to use daily online adaptation with cone beam beam CT-guided stereotactic adaptive radiotherapy CT-guidance. Fig. 1 Pancreatic tumor at time of presentation to radiation oncology. Axial, coronal, and sagittal diagnostic (A–C) as well as simulation (D–F) CT images of the patient at time of presentation to radiation oncology. The primary tumor is indicated on the diagnostic images by the red arrow and a liver metastasis is indacted by the yellow arrow. The GTV (red contour) and PTV (cyan contour) are delineated on the CT simulation images K im et al. Radiation Oncology (2022) 17:157 Page 3 of 8 Treatment planning and delivery A PTV optimization (PTV ) structure was generated, opt The patient was simulated utilizing an end-exhale made from the PTV minus any overlap with critical OARs breath-hold CT with intravenous and oral bowel con- plus a 5  mm margin on the OARs. The critical OARs trast and a 4-dimensional CT. Intravenous contrast was were the luminal gastrointestinal structures, namely the administered at the 45-s delay phase per institutional stomach, duodenum, small bowel, and large bowel. This protocol. The primary image used for planning was the PTV was used to drive prescription dose to the tumor opt end-exhale breath-hold CT. The 4D-CT is captured in to drive target coverage, given that areas of direct PTV the case that the patient is non-compliant with breath- and OAR overlap are not prioritized for target coverage hold and requires treatment with a different modality per our standard adaptive radiotherapy practices [4, 20– and/or dose and fractionation. Of note, as contrast is not 22]. Both the P and adaptive plans (P ) were generated I A delivered with each subsequent daily cone beam CT, the using a strict isotoxicity approach, in which maximum density of the contrast is overrided on the simulation CT OAR constraints are prioritized over target coverage [21, to the density of water so that the contrast has no dosi- 23]. However, a minimum dose of 25 Gy was maintained metric impact on the initial plan (P ). The patient was to the PTV to ensure some uncertainty margin coverage. positioned in a custom immobilization device with left Dose constraints and objectives are in Table 1. Conserva- arm down and right arm up, per institutional pancreatic tive luminal gastrointestinal OAR constraints were used SBRT practice. An MRI was obtained at time of simula- given the palliative nature of the case. We have provided tion and fused to the simulation images for assistance in our standard departmental pancreatic adaptive SBRT target delineation. All treatment planning was performed dose constraints in Additional file  1: Table  S1. A beam in the ETHOS (v.02.01.00) TPS. The gross tumor vol - arrangement of two ¾ co-planar arcs was used, with 30 ume (GTV) comprised the gross tumor demonstrated and 330 degree collimator angles. on simulation imaging. As the patient was simulated and Daily P were created based on the patient’s anatomy- intended to be treated at end-exhale breath-hold, a inter- of-the-day. The TPS automatically deformed the OAR nal GTV or internal target volume was not created. No and target contours from the P onto the daily cone clinical target volume (CTV) was utilized per standard beam  CT using a vendor supplied elastic deformation institutional pancreatic SBRT practice. A 0.5 cm uniform algorithm, and the TPS AI auto-adjusted the stomach, volumetric expansion was applied to form a planning tar- duodenum, and liver according to the anatomy-of-the- get volume (PTV). The relevant organs-at-risk (OARs) day. The deformed GTV was then overwritten and the were contoured at the axial slices from 3 cm below to 3 simulation GTV was ridigly copied onto the patient’s cm above the PTV. anatomy-of-the-day. OARs within a 3-cm contour ring Table 1 OAR constraint and target volume metrics are presented for the initial non adaptive (P ) and adapted (P ) plans I A Organ-at-risk Strict constraint P mean (std dev) P median (range) P mean (std dev) P median (range) I I A A Stomach V25 Gy < 0.5 cc (cc) 10.2 (3.6) 9.7 (5.6–14.8) 0.0 (0.1) 0.0 (0.0–0.1) Duodenum V25 Gy < 0.5 cc (cc) 0.1 (0.1) 0.1 (0.0–0.2) 0.0 (0.0) 0.0 (0.0–0.0) Small bowel V25 Gy < 0.5 cc (cc) 3.8 (5.1) 1.2 (0.3–13.8) 0.0 (0.0) 0.0 (0.0–0.1) Large bowel V25 Gy < 0.5 cc (cc) 0.0 (0.0) 0.0 (0.0–0.1) 0.1 (0.1) 0.0 (0.0–0.2) Liver V25 Gy < 33% (%) 9.5 (1.6) 10.1 (6.8–11.4) 12.1 (1.8) 11.0 (10.3–14.7) 700 cc < 20 Gy (Gy) 0.4 (.1) 0.3 (0.2–0.6) 0.4 (0.1) 0.4 (0.3–0.5) Mean < 20 Gy (Gy) 1.0 (0.2) 1.0 (0.8–1.2) 1.2 (0.1) 1.2 (1.0–1.3) Spinal cord V25 Gy < 0.5 cc (cc) 0.0 (0.0) 0.0 (0.0–0.0) 0.0 (0.0) 0.0 (0.0–0.0) Kidneys (both) Mean < 18 Gy (Gy) 0.8 (0.7) 0.8 (0.7–0.9) 0.8 (0.1) 0.8 (0.7–0.9) Target volume Coverage goal P mean (std dev) P median (range) P mean (std dev) P median (range) I I A A PT V V100 N/A (%) 77.1 (2.1) 76.0 (74.5–80.0) 77.8 (5.1) 80.8 (67.9–81.3) PTV D95 N/A (Gy) 4.7 (0.1) 4.6 (4.6–4.9) 4.8 (0.1) 4.8 (4.6–5.0) PTV 95% (%) 83.5 (3.8) 83.5 (78.8–91.4) 99.6 (0.3) 99.5 (99.2–100.1) opt GT V V100 N/A (%) 89.9 (1.1) 90.0 (88.5–91.4) 90.0 (4.0) 91.8 (82.2–93) GTV D95 N/A (Gy) 6.0 (0.2) 6.1 (5.6–6.3) 6.4 (0.3) 6.5 (5.7–6.7) Mean and median constraint and target metrics for the P represent the hypothetical use of the P applied to all five fractions I I N/A not applicable, Std Dev standard deviation Kim et al. Radiation Oncology (2022) 17:157 Page 4 of 8 (per standard adaptive protocol [22]) were adjusted by luminal gastrointestinal structures, are demonstrated the radiation oncologist in order to confirm accuracy. in Figs.  2 and 3. The use of the P would have resulted The initial simulation based treatment plan (P ) was pro- in violation of the stomach hard constaint in all five jected on the patient anatomy-of-the-day at the same fractions, and violation of the small bowel constraint time that the re-optimized daily adapted plan (P ) was in four of five fractions (Fig.  2). The P achieved hard A A generated. The P and P were compared using dose vol- constraints in all five fractions for all four critical lumi - I A ume histogram (DVH) objectives, and the superior plan nal gastrointestinal structures. Figure  4 illustrates how that met all dosimetric goals was delivered. Of note, all the use of daily adaptive planning allowed for a specific acquired kV cone beam CTs were considered of sufficient radiotherapy fraction to achieve the small bowel hard quality for target and OAR delineation as well as daily constraint, where as delivery of the P would have vio- adaptation per the treating radiation oncologist and med- lated that constraint. ical physicist. Treatment component times were recorded and are demonstrated in Table  2. Mean (standard deviation) Dosimetric and clinical results total treatment time was 70  min (68.3–81.7) and treat- Constraint and coverage metrics for the P and P are ment time decreased each consecutive fraction. The I A demonstrated in Table  1. Mean PTV and GTV D95 for patient completed all five fractions of CT-STAR with - all five fractions was 23.25  Gy and 30.20  Gy in the P out issue. The patient ultimately progressed locally and 24.11 Gy and 31.85 Gy in the P , respectively. Dosi- and distantly, and passed away several months after metric parameters, specifically the volume received treatment. 25  Gy (V25) and maximum dose (D ) for critical max Fig. 2 V25 (cc) of initial and adaptive plans of critical organs at risk. The V25 of the initial (P ) and adaptive (P ) plans for the critical luminal I A gastrointestinal OARs. Y-axis is in cc. Delivery of the initial plan would have yielded nine OAR hard constraint violations. Adaptive planning was able to meet hard constraints for all OARs in all five fractions. Fx = fraction K im et al. Radiation Oncology (2022) 17:157 Page 5 of 8 Fig. 3 Maximum doses of critical OARs. The D values of the initial (P ) and adaptive (P ) plans for critical luminal gastrointestinal OARs. Y-axis is in max I A Gy. Adaptive planning yielding substantial D reductions for the stomach and small bowel. Fx = fraction max is adjacent to several mobile and radiosensitive OARs. Discussion and conclusions Initial studies evaluating the use of ablative doses of Discussion standard CT-guided stereotactic radiotherapy for the Herein we describe the first reported use of CT-STAR for treatment of pancreatic cancer proved efficacious with the treatment of a patient with pancreatic cancer using regards to local control, but also displayed high rates of a novel ring gantry device. These data demonstrate that luminal gastrointestinal organ toxicity [25–27]. Adaptive the delivery of the P would have led to nine critical OAR radiotherapy can improve the therapeutic index of SBRT hard constraint violations across all five fractions, and for pancreatic cancer. Recently, our institution published that the daily P met all critical OAR hard constraints in outcomes for patients with inoperable pancreatic cancer all five fractions. Furthermore, the use of daily adaptation treated with SMART and demonstrated durable progres- improved PTV , GTV V100, and GTV D95 coverage opt sion-free and overall survival rates as well as a favorable (Table  1) while alleviating the hard constraint violations. toxicity profile [4]. While these data are promising, it’s With regards to workflow, the overall treatment times notable that their application is limited to MR-guided were within the range of previously described treatment workflows. Prior to the advent of the ETHOS platform, times for daily adaptation, and the decreased time per adaptive SBRT for pancreatic cancer was limited to clin- each consecutive fraction suggests that treatment times ics with MR-guided or CT-on-rails workflows [4, 16, 28, decrease with increased patient/staff familiarity [22, 24]. 29]. The utility of adaptive stereotactic radiotherapy for the While CT-STAR has the capacity to expand access treatment of pancreatic cancer can not be understated. to adaptive pancreatic SBRT, there are potential limi- The effective ablation of pancreatic cancers requires tations of using a CBCT-guided platform instead of a the delivery of biologic effective dose of at least 100  Gy MR-guided platform. The improved soft tissue contrast [10]. However, this is difficult to achieve as the pancreas Kim et al. Radiation Oncology (2022) 17:157 Page 6 of 8 Fig. 4 Initial and adaptive plan comparison. An initial (A) and adaptive plan (B) for a single fraction of radiotherapy. In the initial plan, the high dose color wash (> 25 Gy) is in the small bowel (light green), whereas in the adapted plan, the high dose color wash does not enter the small bowel. The DVH demonstrates the dose delivered to the small bowel as well as the PTV (cyan) in the initial (triangle) and adaptive plans (square) Table 2 Treatment component times are presented for each fraction Treatment component Fraction 1 Fraction 2 Fraction 3 Fraction 4 Fraction 5 Mean Standard deviation Patient setup 18 9 17 10 N/R 13.5 4.7 CBCT time 1 5 1 2 1 2 1.7 Contouring 39 28 17 19 27 26 8.7 Plan re-optimization 3 7 6 7 6 5.8 1.6 Plan review < 1 < 1 < 1 1 1 0.4 0.5 Quality assurance 8 3 6 2 2 4.2 2.7 Pre-treatment CBCT 1 2 5 3 4 3 1.6 Beam delivery 26 21 8 9 14 15.6 7.8 Patient exit 1 4 1 7 5 3.6 2.6 Total 86 79 63 62 60 70 11.7 Times are in minutes N/R not recorded of MRI can be useful in pancreatic and abdominal con- limited in that subset of patients. This may be of con - touring, which can be of particular importance when sideration when planning to install either a MR- or delineating gross organ invasion. In contrast with cone beam CT-guided adaptive platform. MR-guidance, gross organ invasion is challenging Herein we demonstrate that stereotactic adaptive to delineate on cone beam  CT. In our experience [4], radiotherapy is able to be delivered on a cone beam CT- approximately 10% of patients with locally advanced guided modality, which promises to increase access to pancreatic cancer present with evidence of gross organ, adaptive pancreatic SBRT world wide. This case pres - and the use of CBCT-guided adaptive SBRT may be entation demonstrates the potential for CT-STAR to K im et al. Radiation Oncology (2022) 17:157 Page 7 of 8 Systems, Radialogica; honoraria: ViewRay Inc., Varian Medical Systems; Advisory provide a additional avenue for radiation oncologists to Board: ViewRay Inc. ablate pancreatic cancer. Author details Department of Electrical and Computer Engineering, School of Engineering Conclusions and Applied Science, University of Virginia, 351 McCormick Rd, Charlottsville, VA 22904, USA. Department of Radiation Oncology, Washington University CT-STAR is a viable modality for the delivery of adap- School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. tive stereotactic radiotherapy for the ablation of pancre- Louis, MO 63110, USA. atic cancer. Clinical trials are warranted to investigate the Received: 28 June 2022 Accepted: 26 August 2022 impact of this modality on overall and progression-free survival as well as toxicity. Abbreviations References AI: Artificial intelligence; CBCT: Cone beam computed tomography.; CT: Com- 1. Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: global puted tomography; CT-STAR : CT-guided stereotactic adaptive radiotherapy; trends, etiology and risk factors. World J Oncol. 2019;10(1):10–27. https:// CTV: Clinical target volume; D : Maximum dose recieved; DVH: Dose volume doi. org/ 10. 14740/ wjon1 166. max histogram; GTV: Gross tumor volume; MRI: Magnetic resonance imaging; OAR: 2. Abi Jaoude J, Thunshelle CP, Kouzy R, et al. Stereotactic versus conven- Organ at risk; P : Adapted plan; P : Initial plan; PTV: Planning target volume; tional radiation therapy for patients with pancreatic cancer in the mod- A I PTV : PTV optimization structure; SBRT: Stereotactic body radiation therapy; ern era. Adv Radiat Oncol. 2021;6(6): 100763. https:// doi. org/ 10. 1016/j. opt SMART : Stereotactic magnetic resonance guided adaptive radiotherapy; TPS: adro. 2021. 100763. Treatment planning system; V25: Volume receiving 25 Gy. 3. McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018;24(43):4846–61. https:// doi. Supplementary Information org/ 10. 3748/ wjg. v24. i43. 4846. The online version contains supplementary material available at https:// doi. 4. Hassanzadeh C, Rudra S, Bommireddy A, et al. Ablative five-fraction org/ 10. 1186/ s13014- 022- 02125-z. stereotactic body radiation therapy for inoperable pancreatic cancer using online MR-guided adaptation. Adv Radiat Oncol. 2021;6(1):100506. https:// doi. org/ 10. 1016/j. adro. 2020. 06. 010. Additional file 1: Table S1. Case report and standard OAR constraints. 5. Bourhis J, Sire C, Graff P, et al. Concomitant chemoradiotherapy versus The constraints used for the patient in this case report and our standard acceleration of radiotherapy with or without concomitant chemotherapy departmental pancreatic adaptive SBRT dose constraints are demon- in locally advanced head and neck carcinoma (GORTEC 99–02): an open- strated. The standard luminal gastrointestinal OAR constraints are in bold. label phase 3 randomised trial. Lancet Oncol. 2012;13(2):145–53. https:// doi. org/ 10. 1016/ S1470- 2045(11) 70346-1. 6. Kishan A, Lee P. Having your cake and eating it too: combining SBRT and Acknowledgements multi-agent chemotherapy in locally advanced pancreatic cancer. Cureus. None. 2016;8(7):e686. https:// doi. org/ 10. 7759/ cureus. 686. 7. Vornhülz M, Anton S, Eross B, et al. Role of stereotactic body radiation Author contributions in the enhancement of the quality of life in locally advanced pancreatic MK and JPS—the literature researching, writing the manuscript. SNB—prepar- adenocarcinoma: a systematic review. Radiat Oncol. 2022;17(1):108. ing the radiotherapy plan. LEH—Conception, realization of the treatment. All https:// doi. org/ 10. 1186/ s13014- 022- 02076-5. authors read and approved the final manuscript. 8. Ryan JF, Rosati LM, Groot VP, et al. Stereotactic body radiation therapy for palliative management of pancreatic adenocarcinoma in elderly and Funding medically inoperable patients. Oncotarget. 2018;9(23):16427–36. https:// Not applicable. doi. org/ 10. 18632/ oncot arget. 24713. 9. Buwenge M, Macchia G, Arcelli A, et al. Stereotactic radiotherapy Availability of data and materials of pancreatic cancer: a systematic review on pain relief. J Pain Res. Research data are stored in an institutional repository and will be shared upon 2018;11:2169–78. https:// doi. org/ 10. 2147/ JPR. S1679 94. request to the corresponding author. 10. Reyngold M, Parikh P, Crane CH. Ablative radiation therapy for locally advanced pancreatic cancer: techniques and results. Radiat Oncol. Declarations 2019;14:95. https:// doi. org/ 10. 1186/ s13014- 019- 1309-x. 11. Tyagi N, Liang J, Burleson S, Subashi E, Scripes PG, Tringale KR, Romesser Ethics approval and consent to participate PB, Reyngold M, Crane CH. Feasibility of ablative stereotactic body The patient was given ample time to ask questions at time of consultation and radiation therapy of pancreas cancer patients on a 1.5 Tesla magnetic she received answers for all questions raised. Consent for radiotherapy was resonance-linac system using abdominal compression. Phys Imaging obtained from the patient. All authors read and approved the final manuscript. Radiat Oncol. 2021;19:53–9. https:// doi. org/ 10. 1016/j. phro. 2021. 07. 006. 12. Heerkens HD, van Vulpen M, Erickson B, et al. MRI guided stereotac- Consent for publication tic radiotherapy for locally advanced pancreatic cancer. Br J Radiol. The patient had passed away by the time this manuscript was prepared and 2018;91(1091):20170563. https:// doi. org/ 10. 1259/ bjr. 20170 563. therefore consent for publication was unable to be obtained. 13. Tchelebi LT, Zaorsky NG, Rosenberg JC, et al. Reducing the toxicity of radiotherapy for pancreatic cancer with magnetic resonance-guided Competing interests radiotherapy. Toxicol Sci. 2020;175(1):19–23. https:// doi. org/ 10. 1093/ Minsol Kim: none. Joshua P Schiff: none. Alex Price: grants: Varian Medical toxsci/ kfaa0 21. Systems; support for meetings: ViewRay Inc., Sun Nuclear Corporation. Eric 14. Doty DG, Chuong MD, Gomez AG, et al. Stereotactic MR-guided online Laugeman: honoraria: Varian Medical Systems. Pamela P Samson: none. Hyun adaptive radiotherapy reirradiation (SMART reRT ) for locally recurrent Kim: grants: Varian Medical Systems; honoraria: ViewRay Inc., Varian Medi- pancreatic adenocarcinoma: a case report. Med Dosim. 2021;46(4):384–8. cal Systems. Shahed N Badiyan: honoraria: Mevion Medical Systems. Lauren https:// doi. org/ 10. 1016/j. meddos. 2021. 04. 006. E Henke: grants: Varian Medical Systems; consulting fees: Varian Medical 15. Magallon-Baro A, Milder MTW, Granton PV, Nuyttens JJ, Hoogeman MS. Comparison of daily online plan adaptation strategies for a cohort of Kim et al. Radiation Oncology (2022) 17:157 Page 8 of 8 pancreatic cancer patients treated with SBRT. Int J Radiat Oncol Biol Phys. 2021;111(1):208–19. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 03. 050. 16. Chuong MD, Bryant J, Mittauer KE, et al. Ablative 5-fraction stereotactic magnetic resonance-guided radiation therapy with on-table adaptive replanning and elective nodal irradiation for inoperable pancreas cancer. Pract Radiat Oncol. 2021;11(2):134–47. https:// doi. org/ 10. 1016/j. prro. 2020. 09. 005. 17. Pokharel S, Pacheco A, Tanner S. Assessment of efficacy in automated plan generation for Varian Ethos intelligent optimization engine. J Appl Clin Med Phys. 2022. https:// doi. org/ 10. 1002/ acm2. 13539. 18. Moazzezi M, Rose B, Kisling K, Moore KL, Ray X. Prospects for daily online adaptive radiotherapy via ethos for prostate cancer patients without nodal involvement using unedited CBCT auto-segmentation. J Appl Clin Med Phys. 2021;22(10):82–93. https:// doi. org/ 10. 1002/ acm2. 13399. 19. Hao Y, Cai B, Green O, et al. Technical Note: An alternative approach to verify 6FFF beam dosimetry for Ethos and MR Linac without using a 3D water tank. Med Phys. 2021;48(4):1533–9. https:// doi. org/ 10. 1002/ mp. 20. Henke L, Kashani R, Robinson C, et al. Phase I trial of stereotactic MR- guided online adaptive radiation therapy (SMART ) for the treatment of oligometastatic or unresectable primary malignancies of the abdomen. Radiother Oncol. 2018;126(3):519–26. https:// doi. org/ 10. 1016/j. radonc. 2017. 11. 032. 21. Green OL, Henke LE, Hugo GD. Practical clinical workflows for online and offline adaptive radiation therapy. Semin Radiat Oncol. 2019;29(3):219– 27. https:// doi. org/ 10. 1016/j. semra donc. 2019. 02. 004. 22. Bohoudi O, Bruynzeel AME, Senan S, et al. Fast and robust online adaptive planning in stereotactic MR-guided adaptive radiation therapy (SMART ) for pancreatic cancer. Radiother Oncol. 2017;125(3):439–44. https:// doi. org/ 10. 1016/j. radonc. 2017. 07. 028. 23. Henke L, Kashani R, Yang D, et al. Simulated online adaptive magnetic resonance-guided stereotactic body radiation therapy for the treat- ment of oligometastatic disease of the abdomen and central thorax: characterization of potential advantages. Int J Radiat Oncol Biol Phys. 2016;96(5):1078–86. https:// doi. org/ 10. 1016/j. ijrobp. 2016. 08. 036. 24. Henke LE, Stanley JA, Robinson C, et al. Phase I trial of stereotactic MRI-guided online adaptive radiation therapy (SMART ) for the treat- ment of oligometastatic ovarian cancer. Int J Radiat Oncol Biol Phys. 2022;112(2):379–89. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 08. 033. 25. Pollom EL, Alagappan M, von Eyben R, et al. Single- versus multifraction stereotactic body radiation therapy for pancreatic adenocarcinoma: outcomes and toxicity. Int J Radiat Oncol Biol Phys. 2014;90(4):918–25. https:// doi. org/ 10. 1016/j. ijrobp. 2014. 06. 066. 26. Koong AJ, Toesca DAS, Baclay JRM, et al. The utility of stereotactic ablative radiation therapy for palliation of metastatic pancreatic adenocarcinoma. Pract Radiat Oncol. 2020;10(4):274–81. https:// doi. org/ 10. 1016/j. prro. 2020. 02. 010. 27. Schellenberg D, Kim J, Christman-Skieller C, et al. Single-fraction stereo- tactic body radiation therapy and sequential gemcitabine for the treat- ment of locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2011;81(1):181–8. https:// doi. org/ 10. 1016/j. ijrobp. 2010. 05. 006. 28. Niedzielski JS, Liu Y, Ng SSW, et al. Dosimetric uncertainties resulting from interfractional anatomic variations for patients receiving pancreas stereotactic body radiation therapy and cone beam computed tomogra- phy image guidance. Int J Radiat Oncol Biol Phys. 2021;111(5):1298–309. https:// doi. org/ 10. 1016/j. ijrobp. 2021. 08. 002. 29. Magallon-Baro A, Milder MTW, Granton PV, den Toom W, Nuyttens JJ, Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : Hoogeman MS. Impact of using unedited CT-based DIR-propagated autocontours on online ART for pancreatic SBRT. Front Oncol. fast, convenient online submission 2022;12:910792. https:// doi. org/ 10. 3389/ fonc. 2022. 910792. thorough peer review by experienced researchers in your field rapid publication on acceptance Publisher’s Note support for research data, including large and complex data types Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

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Radiation OncologySpringer Journals

Published: Sep 13, 2022

Keywords: Pancreatic cancer; SBRT; Image guided radiation therapy; CT

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