CBCT-Based Online Adaptive Radiotherapy: A Promising Approach for Gastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma?

Abstract

PurposeDaily online adaptive radiotherapy (oART) opens the opportunity to treat gastric mucosa-associated lymphoid tissue (MALT) lymphoma with a reduced margin. This study reports our early experience of cone-beam computed tomography (CBCT)-based daily oART treating gastric MALT lymphoma with breath-hold (BH) and reduced margins. MethodsTen patients were treated on a CBCT-based oART system. Organs at risk (OARs) and the clinical target volume (CTV) were adjusted based on the daily CBCT. Planning target volume (PTV) was derived from the CTV with a 0.5-0.7 cm margin with BH. Multiple beam arrangements were compared during the preplanning phase to ensure minimal Monitor Unit (MU) for patient comfort and breath-hold reproducibility. For 108 fractions from the ten patients, the PTV, CTV coverage, Paddick Conformity Index (CI) were compared between the adapted and scheduled plans. The MU, Paddick CI, and gradient index (GI) were compared using relative percentage differences between the adapted plans and preplans. The OAR doses from 106 fractions across nine patients were reported for the preplans, adapted plans, and scheduled plans. The time statistics for each step of the clinical workflow were recorded and reported for 93 treatment fractions from nine patients. ResultsThe PTV volume varied from -37.1% to 90.5% (11.7% ± 18.5%) throughout treatments across all patients. The adapted plan was chosen as the treatment plan for each fraction due to superior PTV and CTV coverage while maintaining a similar OAR dose. The PTV and CTV coverage for the adapted and scheduled plans was VRx=95.0 ± 0.3% vs. 64.1 ± 19.6% and VRx=99.9 ± 0.1% vs. 74.0 ± 22.2%, respectively. The adapted plans' MU, Paddick CI, and GI were, on average, 4.1%, 0.4%, and -4.2% of the preplan values, respectively. The console's adaptive workflow and physician time were 25±7 and 19±6 minutes, respectively. ConclusionA CBCT-based oART system with the proposed workflow is feasible for treating gastric MALT lymphoma patients using a reduced PTV margin while maintaining excellent target coverage within a reasonable time, resulting in consistent adapted plan quality. This approach can be expanded to a larger cohort of gastrointestinal patients.