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      Optimal fractionation and timing of weekly cone-beam CT in daily surface-guided radiotherapy for breast cancer

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          Abstract

          Purpose

          Surface-guided radiotherapy (SGRT) has been demonstrated to be a promising supplement to cone-beam computed tomography (CBCT) in adjuvant breast cancer radiotherapy, but a rational combination mode is lacking in clinical practice. The aim of this study was to explore this mode and investigate its impact on the setup and dose accuracy.

          Methods and materials

          Daily SGRT and weekly CBCT images were acquired for 23 patients with breast cancer who received conventional fractionated radiotherapy after lumpectomy. Sixteen modes were acquired by randomly selecting one (CBCT 1), two (CBCT ij), three (CBCT ijk), four (CBCT ijkl), and five (CBCT 12345) images from the CBCT images for fusion with the SGRT. The CTV-PTV margins, OAR doses, and dose coverage (V95%) of PTV and CTV was calculated based on SGRT setup errors with different regions of interest (ROIs). Dose correlations between these modalities were investigated using Pearson and Spearman’s methods. Patient-specific parameters were recorded to assess their impact on dose.

          Results

          The CTV-PTV margins decreased with increasing CBCT frequencies and were close to 5 mm for CBCT ijkl and CBCT 12345. For the ipsilateral breast ROI, SGRT errors were larger in the AP direction, and target doses were higher in all modes than in the whole breast ROI (P < 0.05). In the ipsilateral ROI, the target dose correlations between all modes increased with increasing CBCT time intervals, decreased, and then increased with increasing CBCT frequencies, with the inflection point being CBCT participation at week 5. The dose deviations in CBCT 123, CBCT 124, CBCT 125, CBCT ijkl, and CBCT 12345 were minimal and did not differ significantly (P > 0.05). There was excellent agreement between CBCT 124 and CBCT 1234, and between (CBCT ijkl, CBCT 12345) and CBCT 125 in determining the classification for the percentage of PTV deviation (Kappa = 0.704–0.901). In addition, there were weak correlations between the patient’s D ips_b (ipsilateral breast diameter with bolus) and CTV doses in modes with CBCT participation at week 4 (R = 0.270 to 0.480).

          Conclusions

          Based on weekly CBCT, these modes with ipsilateral ROI and a combination of daily SGRT and a CBCT frequency of ≥ 3 were recommended, and CBCT was required at weeks 1 and 2 for CBCT ijk.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s13014-023-02279-4.

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          Most cited references29

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          Recent advanced in Surface Guided Radiation Therapy

          The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques. SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments. The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations. Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests. Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition). This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.
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            The Role of Optical Surface Imaging Systems in Radiation Therapy

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              Comparison of initial patient setup accuracy between surface imaging and three point localization: A retrospective analysis

              Abstract Purpose Historically, the process of positioning a patient prior to imaging verification used a set of permanent patient marks, or tattoos, placed subcutaneously. After aligning to these tattoos, plan specific shifts are applied and the position is verified with imaging, such as cone‐beam computed tomography (CBCT). Due to a variety of factors, these marks may deviate from the desired position or it may be hard to align the patient to these marks. Surface‐based imaging systems are an alternative method of verifying initial positioning with the entire skin surface instead of tattoos. The aim of this study was to retrospectively compare the CBCT‐based 3D corrections of patients initially positioned with tattoos against those positioned with the C‐RAD CatalystHD surface imager system. Methods A total of 6000 individual fractions (600–900 per site per method) were randomly selected and the post‐CBCT 3D corrections were calculated and recorded. For both positioning methods, four common treatment site combinations were evaluated: pelvis/lower extremities, abdomen, chest/upper extremities, and breast. Statistical differences were evaluated using a paired sample Wilcoxon signed‐rank test with significance level of <0.01. Results The average magnitudes of the 3D shift vectors for tattoos were 0.9 ± 0.4 cm, 1.0 ± 0.5 cm, 0.9 ± 0.6 cm and 1.4 ± 0.7 cm for the pelvis/lower extremities, abdomen, chest/upper extremities and breast, respectively. For the CatalystHD, the average magnitude of the 3D shifts for the pelvis/lower extremities, abdomen, chest/upper extremities and breast were 0.6 ± 0.3 cm, 0.5 ± 0.3 cm, 0.5 ± 0.3 cm and 0.6 ± 0.2 cm, respectively. Statistically significant differences (P < 0.01) in the 3D shift vectors were found for all four sites. Conclusion This study shows that the overall 3D shift corrections for patients initially aligned with the C‐RAD CatalystHD were significantly smaller than those aligned with subcutaneous tattoos. Surface imaging systems can be considered a viable option for initial patient setup and may be preferable to permanent marks for specific clinics and patients.
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                Author and article information

                Contributors
                jfazj@126.com
                guyexianxue@126.com
                Journal
                Radiat Oncol
                Radiat Oncol
                Radiation Oncology (London, England)
                BioMed Central (London )
                1748-717X
                5 July 2023
                5 July 2023
                2023
                : 18
                : 112
                Affiliations
                GRID grid.190737.b, ISNI 0000 0001 0154 0904, Departments of Radiation Oncology, , Chongqing University Cancer Hospital, ; Chongqing, People’s Republic of China
                Article
                2279
                10.1186/s13014-023-02279-4
                10320897
                37408037
                e6521ef2-5088-4b35-bb6f-2364f28f2817
                © The Author(s) 2023

                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://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 9 March 2023
                : 8 May 2023
                Funding
                Funded by: Chongqing medical scientific research project (Joint project of Chongqing Health Commision and Science and Technology Bureau)
                Award ID: 2022DBXM005
                Funded by: Chongqing Technology Innovation and application demonstration project
                Award ID: cstc2018jscx msybX0115
                Funded by: National Natural Science Foundation of China
                Award ID: 11805025
                Categories
                Research
                Custom metadata
                © BioMed Central Ltd., part of Springer Nature 2023

                Oncology & Radiotherapy
                postmastectomy radiotherapy,multiple “sgrt + cbct” modes,patient-specific parameters,setup error,dose distribution

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