Abstract
To assess practice patterns of pediatric image-guided radiotherapy (IGRT) within Children’s Oncology Group (COG) member institutions. A survey was directed to 347 COG member radiation oncologists and medical physicists between October and December 2017. Eleven vignettes asked clinicians for recommended treatment modalities [intensity modulation (IMRT), volumetric arc (VMAT), 3-dimensional conformal (3DCRT), anterior-posterior fields (AP/PA), proton (PT)], IGRT preferences [kilovoltage planar imaging (kVi), megavoltage portal imaging (MVi), cone beam computed tomography (CBCT)], and frequency. Technical questions queried physicists about imaging protocol, dose reduction, and adaptive therapy. One hundred sixty-eight responses (48%) were received (105 radiation oncologists and 63 physicists). First vs. second choices for treatment and IGRT modality varied by disease site: ependymoma (52% IMRT/VMAT vs. 36% PT guided by 29% kVi vs. 26% CBCT); craniopharyngioma (51% IMRT/VMAT vs. 38% PT guided by 32% combined CBCT/kVi vs. 24% CBCT); germinoma (59% IMRT/VMAT vs. 29% PT guided by 30% CBCT vs. 24% kVi); medulloblastoma (52% PT vs. 20% IMRT/VMAT guided by 33% kVi vs. 24% combined CBCT/kVi); rhabdomyosarcoma (RMS) (63% IMRT/VMAT vs. 44% PT guided by 34% CBCT vs. 31% combined CBCT/kVi); non-RMS soft tissue sarcoma (58% IMRT/VMAT vs. 31% 3DCRT guided by 34% CBCT vs. 27% combined CBCT/kVi); Ewing sarcoma (70% IMRT/VMAT vs. 29% PT guided by 34% CBCT vs. 34% combined CBCT/kVi); Hodgkin lymphoma (32% IMRT/VMAT vs. 28% 3DCRT guided by 33% kVi vs. 24% CBCT); neuroblastoma (61% IMRT/VMAT vs. 20% 3DCRT guided by 30% combined CBCT/kVi vs. 30% CBCT); Wilms tumor (66% AP/PA vs. 22% 3DCRT guided by 55% kVi vs. 26% MVi); and acute lymphocytic leukemia (ALL) (61% opposed laterals vs. 29% 3DCRT guided by 49% kVi vs. 27% MVi). IGRT frequency was primarily daily for all sites except Wilms tumor (45% daily vs. 35% weekly), Hodgkin lymphoma (58% daily vs. 19% weekly), and ALL (32% daily vs. 45% weekly). The use of IGRT images for making decisions on adaptive replanning was confirmed in 79% responses. Methods to reduce IGRT dose included: lower kV/milliampere-seconds (65%), selecting kV over MV (62%), collimation (48%), and reduced imaging (38%). Responses varied or were neutral (38%) on lowering IGRT doses due to second cancer risk. We report pediatric IGRT practice patterns in COG member institutions. Daily image guidance was used approximately 70% of the time across all sites. Although disease specific, kVi was most common for simple, while CBCT was frequent for complex treatments. Expert guidelines provided by COG Radiation Oncology Discipline for the utilization of IGRT methods are based on these results and existing evidence. Improved institutional technical capabilities should cultivate investigators to propose trials requiring highly precise tumor localization, verified by IGRT.
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