Abstract
Radiation therapy (RT) is increasingly being used in gynecological cancer management. RT delivered with curative or palliative intent can be administered alone or combined with chemotherapy or surgery. Advanced treatment planning and delivery techniques such as intensity-modulated radiation therapy, including volumetric modulated arc therapy, and image-guided adaptive brachytherapy allow for highly conformal radiation dose delivery leading to improved tumor control rates and less treatment toxicity. Quality on-board imaging that provides accurate visualization of target and surrounding organs at risk is a critical feature of these advanced techniques. As soft tissue contrast resolution is superior with magnetic resonance imaging (MRI) compared to other imaging modalities, MRI has been used increasingly to delineate tumor from adjacent soft tissues and organs at risk from initial diagnosis to tumor response evaluation. Gynecological cancers often have poor contrast resolution compared to the surrounding tissues on computed tomography scan, and consequently the benefit of MRI is high. One example is in management of locally advanced cervix cancer where adaptive MRI guidance has been broadly implemented for adaptive brachytherapy. The role of MRI for external beam RT is also steadily increasing. MRI information is being used for treatment planning, predicting, and monitoring position shifts and accounting for tissue deformation and target regression during treatment. The recent clinical introduction of online MRI-guided radiation therapy (oMRgRT) could be the next step in high-precision RT. This technology provides a tool to take full advantage of MRI not only at the time of initial treatment planning but as well as for daily position verification and online plan adaptation. Cervical, endometrial, vaginal, and oligometastatic ovarian cancers are being treated on MRI linear accelerator systems throughout the world. This review summarizes the current state, early experience, ongoing trials, and future directions of oMRgRT in the management of gynecological cancers.
Highlights
As early as 1990, magnetic resonance imaging (MRI) was described as a promising tool in management of gynecological cancers providing superior visualization of tumor and adjacent pelvic anatomy compared to other imaging modalities [1]
MRI-guided (MRg) BT is based on an adaptive target concept that accounts for the topography of the primary tumor at diagnosis as well as the regression observed during external beam radiation therapy (EBRT) [4]
In the management of patients diagnosed with locally advanced cervical cancer (LACC), it is well known that the primary tumor exhibits large inter fraction motion due to day-to-day changes in the volume of the surrounding pelvic organs seen during the delivery of pelvic EBRT
Summary
Radiation therapy (RT) is increasingly being used in gynecological cancer management. Quality on-board imaging that provides accurate visualization of target and surrounding organs at risk is a critical feature of these advanced techniques. Gynecological cancers often have poor contrast resolution compared to the surrounding tissues on computed tomography scan, and the benefit of MRI is high. The recent clinical introduction of online MRI-guided radiation therapy (oMRgRT) could be the step in high-precision RT. This technology provides a tool to take full advantage of MRI at the time of initial treatment planning but as well as for daily position verification and online plan adaptation.
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