Integrated Boost Research Articles

Prostate Stereotactic Body Radiation Therapy With a Focal Simultaneous Integrated Boost: Acute Toxicity and Dosimetry Results From a Prospective Trial

PurposeThis study aimed to report the early toxicity results of a prospective clinical trial of prostate stereotactic body radiation therapy (SBRT) to the entire prostate with a simultaneous integrated boost (SIB) to magnetic resonance imaging (MRI)-defined focal lesions. Methods and materialsEligible patients included men with biopsy-proven prostate stage T1c to T2c adenocarcinoma, a Gleason score ≤7, and prostate-specific antigen values of ≤20 ng/mL, who had at least 1 focal lesion visible on MRI and a total prostate volume no greater than 120 cm3. SBRT consisted of a dose of 36.25 Gy to the entire prostate with an SIB of 40 Gy to the MRI-defined lesions, delivered in 5 fractions. The primary purpose of the study was to confirm the feasibility of treatment planning/delivery and to estimate the rate of urinary retention requiring placement of a Foley catheter within 90 days of treatment. This study was to be considered successful if urinary retention occurred in no more than 15% of cases, with a planned enrollment of at least 25 patients. ResultsA total of 26 men were enrolled, and all underwent SBRT as planned. Twenty patients (77%) had intermediate-risk features, and the remainder were low risk. A treatment plan that met the protocol-defined goals for all cases was developed. Two patients (7.7%) developed acute urinary symptoms that required the temporary placement of a Foley catheter. No grade 3+ toxicity events were observed. ConclusionsPlanning and delivery of prostate SBRT with a whole prostate dose of 36.25 Gy and a focal 40 Gy SIB is feasible. Early follow-up suggests that this treatment is not associated with undue morbidity.

Whole Brain Radiotherapy Combined with Simultaneous Integrated Boost for Brain Metastases of Lung Cancer: Its Clinical Effectiveness and Prognosis

Whole Brain Radiotherapy Combined with Simultaneous Integrated Boost for Brain Metastases of Lung Cancer: Its Clinical Effectiveness and Prognosis

Dose Escalation with Simultaneous Integrated Boost (SIB) Using Volumetric Modulated Arc Therapy (VMAT) in Rectal Cancer.

Assess feasibility-rate of PCR, short-term toxicity after neoadjuvant concurrent chemoradiation (NACRT) delivered via simultaneous integrated boost (SIB) using volumetric modulated arc therapy (VMAT) technique for locally advanced rectal cancer. Retrospective evaluation of patients with locally advanced rectal cancer treated with VMAT-SIB technique preoperatively at an academic tertiary care center in Riyadh, Saudi Arabia between February 2013 and March 2017. One hundred patients with depth of invasion staged as T3/T4 or T2 in 93 and seven patients, respectively. Lymph node metastasis was staged as N1/N2 or N0 in 87 and 13 patients, respectively. Circumferential radial margin (CRM) was involved radiologically prior to treatment in 50 patients. A dose of 55 or 50Gy was given to 71 and 29 patients, respectively. All treatments were completed without interruption. Grade 3/4 toxicity was not observed. Low anterior resection and abdominoperineal resection were performed with negative proximal, distal, and radial margins in 72 and 28 patients, respectively. There were no immediate significant postoperative complications. Histologically, no residual tumor (grade 0) was noted in 20 patients (pCR). Regression grade 1, 2, and 3 were noted in 31, 34, and 15 patients. Average number of lymph nodes retrieved in the surgical specimen was 12 (range 6-22). Lymph nodes were negative for cancer in 80 patients. Dose escalation with SIB-VMAT as NACRT for rectal cancer is feasible. Moreover, it can increase the rate of pathological complete response with a favorable toxicity profile. Clinical benefit of this approach needs to be validated in a larger cohort of patients with longer follow-up.

Feasibility and Efficacy of Simultaneous Integrated Boost Intensity-modulated Radiation Therapy based on MRI-CT fusion in Patients with Brain Metastases of Non-small Cell Lung Cancer.

Purpose: To assess the feasibility and therapeutic effects of simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT) based on the fusion imaging of magnetic resonance imaging (MRI) and computed tomography (CT) as a dose-intensive technique in patients with brain metastases (BM) of non-small cell lung cancer (NSCLC).Methods and materials: Forty-six NSCLC patients with 1 to 7 brain metastases were enrolled in this retrospective study between November, 2011 and February, 2017. Thirty-one patients (67.4%) had 1-3 metastases (oligometastases), otherwise, more than 3 metastases were seen in only 15 patients (32.6%). GTV (Gross tumor volume) contouring was based on the fusion imaging of MRI-CT, WBRT was prescribed in 37.5 Gy/15 fractions with a simultaneous boost in the metastatic lesions of 52.5 Gy/15 fractions.Results: The median overall survival (OS) and intracranial progression free survival (PFS) for all the patients were 20.0 months and 11.0 months, respectively. The 6-month and 1-year OS were 87.0% and 69.6% respectively, while the 6-month and 1-year PFS were 78.3% and 43.5% respectively. Until the end of the follow-up, 16 patients (34.8%) were alive. No evidence of intracranial progress or recurrence was found in 6 patients (13.0%) during the follow-up.Conclusion: SIB-IMRT with the dose/fractionation based on the fusion imaging of MRI-CT is feasible and safe. It is beneficial to the NSCLC patients with BM and can reduce the overall costs of treatment.

P1.14-012 Hypofractionated Simultaneous Integrated Boost IMRT Concurrent with Chemotherapy Improved Loco-Regional Control in Locally Advanced NSCLC

This study investigated the loco-regional control (LRC) and toxicity of hypofractionated simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) for locally advanced non-small-cell lung cancer (LANSCLC) in the setting of concurrent chemotherapy. One hundred and ten LANSCLC patients treated with SIB-IMRT and concurrent chemotherapy were retrospectively analyzed. Radical-intent radiotherapy was delivered at a fraction dose of 2.0∼2.2, 2.4∼2.6, and 2.9∼3.1Gy respectively. Factors potentially predictive of LRC (age, sex, tumor stage, tumor volume, biological effective dose (BED), dose per fraction, overall radiation time (ORT) and concurrent chemotherapy) were assessed in the univariate analysis and Cox multivariate model. Toxicity data was collected and analyzed. With a median follow-up of 24.4 months, the median duration of LRC was 21.4 months. LRC was 71.9% at 1 year, 45.9% at 2 years, and 41.8% at 3 years. In univariate analysis, BED (p=0.007), dose per fraction (p=0.002) and ORT (p=0.029) were associated significantly with LRC. In multivariate analysis, RT dose per fraction was independently prognostic of LRC (HR, 0.597; CI, 0.362∼0.986). Grade ≥3 pneumonitis, pulmonary fibrosis and esophagitis were observed in 6 (5.5%), 2 (1.8%) and 19 (17.3%) of patients, respectively. There was no significant difference in toxicity among different doses per fraction. Our study showed that LRC was improved by the dose per fraction escalation in the setting of concurrent chemotherapy. Hypofractionated SIB-IMRT could be a feasible and effective approach for dose intensification, while maintaining tolerable toxicities.

Early Outcomes of a Novel Hypofractionated Dose Escalated Spine Simultaneous Integrated Boost Technique for Treatment of Metastatic Lesions Not Amenable to Spine Stereotactic Radiosurgery

Early Outcomes of a Novel Hypofractionated Dose Escalated Spine Simultaneous Integrated Boost Technique for Treatment of Metastatic Lesions Not Amenable to Spine Stereotactic Radiosurgery

Treatment Results of Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy in 219 patients with Nasopharyngeal Carcinoma

Treatment Results of Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy in 219 patients with Nasopharyngeal Carcinoma

A Comparative Dosimetric Feasibility Study of Robotic Radiosurgery, Volumetric Modulated Arc Therapy, and High Dose–Rate Brachytherapy in the Delivery of a Focal Integrated Boost for Low Risk Prostate Cancer

A Comparative Dosimetric Feasibility Study of Robotic Radiosurgery, Volumetric Modulated Arc Therapy, and High Dose–Rate Brachytherapy in the Delivery of a Focal Integrated Boost for Low Risk Prostate Cancer

Changes in Apparent Diffusion Coefficient of the Dominant Tumor During Dose-Painted Radiation Therapy and High Dose Rate Brachytherapy for Prostate Cancer

Dose escalation has successfully improved cancer outcomes for patients with localized prostate cancer. Targeting subprostatic regions of tumor burden for dose-intensification may further improve tumor control and reduce dose to surrounding normal tissues. Quantitative MRI may provide a clinically useful evaluation of early radiation response to enable the adaptation of dose. Our objective is to determine whether the ADC derived from diffusion-weighted imaging (DWI) of prostate tumors may be used as a biomarker for evaluation of early radiation response and dose adaptation. Patients with biopsy proven prostate adenocarcinoma visualized on MRI prior to radiotherapy were recruited to participate in a prospective trial in which patients received 76 Gy in 38 fractions to the prostate and either an integrated boost (IB) (19 Gy/38#) or an HDR boost (10 Gy/1#) to the dominant tumor. Patients underwent endorectal coil multiparametric MRI (3T Verio, Siemens) at baseline and during week 6 of treatment. ADC was calculated from in-line processing of DWI (b values of 0, 100, 600, and 1000 s/mm2). Dominant tumors, prostate, and common reference points were defined on the baseline T2 weighted (T2w) image (Pinnacle). The prostate and common reference points were again defined on the week 6 T2w image. Deformable registration (Morpheus) was applied to the baseline prostate and reference contours to guide segmentation of the tumor volumes (no longer clearly visible) in the week 6 ADC maps. Volume of interest (VOI) voxel based histogram analysis of mean, skewness, and kurtosis were used to assess ADC response. Of 80 enrolled patients, the first 17 were analyzed. 8 patients received IB and 9 patients received HDR. Tumor volumes were small (baseline mean 2.0 cm3, 95% CI 1.6-2.9 cm3). For all 17 patients, there was a statistically significant increase in tumor ADC from baseline (mean 1.12x10-3 mm2/s, 95% CI 1.04-1.19 x10-3 mm2/s) to week 6 of treatment (mean 1.34x10-3 mm2/s, 95% CI 1.29-1.39 x10-3 mm2/s, p<0.001). Tumor ADC kurtosis increased significantly from 3.1 to 4.0 (95% CI 2.7-3.6 at baseline, 3.3-4.8 at week 6, p=0.04). Mean tumor ADC increased by 24.5% (95% CI 10-39%) in the IB-VMAT arm and 20% (95% CI 6-34%) in the VMAT+HDR arm (p=0.6). Our preliminary data confirm a statistically significant increase in tumor ADC during radiotherapy, worthy of further investigation. Complete analysis of the study cohort will elucidate relationships between early changes in tumor ADC and subsequent response to treatment.

Correction: Evaluation of Acute Toxicity and Early Clinical Outcome in Head and Neck Cancers Treated With Conventional Radiotherapy and Simultaneous Integrated Boost Arc Radiotherapy.

[This corrects the article DOI: 10.14740/wjon1049w.].

Evaluation of Acute Toxicity and Early Clinical Outcome in Head and Neck Cancers Treated With Conventional Radiotherapy and Simultaneous Integrated Boost Arc Radiotherapy.

BackgroundChemoradiotherapy plays an important role in management of locally advanced head and neck cancers. This retrospective analysis was done to evaluate and compare acute toxicity profiles and early clinical outcomes in patients treated with conventional and arc techniques.MethodsFifty-five patients of head and neck cancers were evaluated. Thirty patients received conventional radiotherapy with 6 MV or cobalt 60 and 25 patients were treated with simultaneous integrated boost-volumetric modulated arc radiotherapy (SIB-VMAT) with dose prescription of 66 - 70 Gy. Concurrent chemotherapy was given as cisplatin injection at 40 mg/m2 weekly or 100 mg/m2 thrice weekly.ResultsThe incidence of grade 3-4 mucositis was 56% versus 83.3% with SIB-VMAT and conventional treatments (P = 0.026). The incidence of grade 2-3 xerostomia was 44% versus 80% (P = 0.006) in the two groups. Grade 2 dysphagia was seen in 40% versus 80% (P = 0.008) favoring the arc treatments. Seventeen patients undergoing arc treatment had complete response compared to 14 in the conventional group (P = 0.040). The median disease-free survival (median ± standard error) was 16 months (11 ± 1.987 months) in the conventional and arc groups (P = 0.073).ConclusionSIB-VMAT shows a better toxicity profile and a trend towards better disease-free survival when compared to conventional radiotherapy in head and neck cancers.

Concurrent Weekly Cisplatin and Simultaneous Integrated Boost Intensity Modulated Radiation Therapy (SIB IMRT) of Locally Advanced Squamous Cell Carcinoma of the Head and Neck (LA SCCHN)

We conducted a phase I/II trial to investigate concurrent weekly cisplatin and accelerated SIB IMRT in LA SCCHN. Patients in stage III/IVA were treated with SIB IMRT delivering 67,5/60/54 Gy in 30 fractions over 6 weeks to planning target volumes of gross tumor volume/clinical target volume/prophylactic neck with concurrent 2900weekly cisplatin 40 mg/m2. Dose modification of cisplatin was made if a subject experienced significant toxicity. Common Terminology Criteria of Adverse Events version 4.03 was used for toxicity assessment. We included 41 patients (median age 56 years, range 34 – 64 years) with oral cavity (6), larynx (3), hypopharynx (9) and oropharynx (23) in stage III (16) and IVA (25). HPV status assessed by p16 immunohistochemistry was positive in 27% (11) and negative in 73% (30). Median overall treatment time prolongation was 7 days. Cisplatin cumulative dose of at least 80% of the planned dose, i.e. ≥200 mg/m2, was delivered in 83% (34) and less than 200 mg/m2 in 17% (7). With the median follow-up of 21,4 months (range 5 – 33 months), the 2-years overall survival (OS), cancer specific survival (CSS) and local control rates (LCR) were 80,5%, 85,4% and 68,3% respectively. Most prominent grade 3 acute toxicity was bone marrow in 12% (5), mucositis in 12% (5), gastrointestinal in 10% (4), renal in 2% (1), and dermatitis in 2% (1). Cumulative late dysphagia ≥ grade 2 occurred in 24% (10), grade 2 xerostomia in 20% (8) and grade 2 mandibular osteoradionecrosis in 2% (1). On multivariate analysis, LCR was significantly determined by HPV status (100% vs. 57%, P = 0,001). The cumulative dose of cisplatin proved significant impact on LCR in HPV negative patients (63% vs. 33%, P = 0,041). Site of the primary, stage, age, gender, smoking status and overall treatment time prolongation were not significant in OS, CSS or LCR. High proportion of patients with LA SCCHN received adequate cumulative dose of concurrent cisplatin with SIB IMRT. Weekly cisplatin is effective in HPV positive patients. LCR in HPV negative patients with less than 200 mg/m2 cumulative dose of cisplatin was suboptimal.

The Feasibility and Toxicity Analysis of Simultaneous Integrated Boost of 86 Gy to Intraprostatic Tumor Delivered in 39 Fractions

The Feasibility and Toxicity Analysis of Simultaneous Integrated Boost of 86 Gy to Intraprostatic Tumor Delivered in 39 Fractions

Dose Intensification With Simultaneous Integrated Boost in Preoperative Chemoradiation Therapy in Locally Advanced Rectal Cancer: Preliminary Results of a Prospective Study

Dose Intensification With Simultaneous Integrated Boost in Preoperative Chemoradiation Therapy in Locally Advanced Rectal Cancer: Preliminary Results of a Prospective Study

The Feasibility of Dose Escalation With Simultaneous Integrated Boost (SIB) Technique in Patients With Large Functioning Pituitary Macroadenomas Treated With Robotic Radiosurgery

The Feasibility of Dose Escalation With Simultaneous Integrated Boost (SIB) Technique in Patients With Large Functioning Pituitary Macroadenomas Treated With Robotic Radiosurgery

Feasibility of Simultaneous Integrated Boost (SIB) to Gross Disease in Spine Radiosurgery

Feasibility of Simultaneous Integrated Boost (SIB) to Gross Disease in Spine Radiosurgery

On the Use of Intensity Modulated Arc Therapy for Whole-Brain Radiation Therapy With Hippocampal Avoidance and Simultaneous Integrated Boost for Multiple Brain Metastases

On the Use of Intensity Modulated Arc Therapy for Whole-Brain Radiation Therapy With Hippocampal Avoidance and Simultaneous Integrated Boost for Multiple Brain Metastases

Intensity Modulated Radiation Therapy With Simultaneous Integrated Boost in Patients With Brain Oligometastases: A Phase 1 Study (ISIDE-BM-1)

To investigate the maximum tolerated dose of intensity modulated radiationtherapy simultaneous integrated boost whole-brain radiation therapy for palliative treatment of patients with <5 brain metastases using a standard linear accelerator. The whole brain plus 3-mm margin was defined as the planning target volume (PTVwb), whereas each brain metastasis, defined as the contrast-enhancing tumor on MRI T1 scans, plus a 3-mm isotropic margin, was defined as metastases PTV (PTVm). Radiation therapy was delivered in 10 daily fractions (2weeks). Only the dose to PTVm was progressively increased in the patient cohorts (35Gy, 40Gy, 45Gy, 50Gy), whereas the PTVwb was always treated with 30Gy (3Gy per fraction) in all patients. The dose-limiting toxicity was evaluated providing that 3months of follow-up had occurred after the treatment of a 6-patient cohort. Thirty patients were enrolled in the study (dose PTVm: 35Gy, 8 patients; 40Gy, 6 patients; 45Gy, 6 patients; 50Gy, 10 patients). The number of treated brain metastases was 1 in 18 patients, 2 in 5 patients, 3 in 6 patients, and 4 in 1 patient. Three patients experienced dose-limiting toxicity: 1 patient at dose level 2 presented grade 3 (G3) skin toxicity; 1 patient at dose level 4 presented G3 neurologic toxicity; and 1 patient at the same level showed brain hemorrhage. Most patients showed G1 to 2 acute toxicity, in most cases skin (n=19) or neurologic (n=10). Twenty-seven were evaluable for response: 6 (22%) stable disease, 18 (67%) partial response, and 3 (11%) complete response. Median survival and 1-year overall survival were 12months and 53%, respectively. No patient showed late toxicity. In this first prospective trial on the use of intensity modulated radiation therapy simultaneous integrated boost delivered with a standard linear accelerator in patients with brain oligometastases, a boost dose up to 50Gy in 10 fractions was tolerable according to the study design.

Acute Toxicity and Tumor Response in Locally Advanced Rectal Cancer After Preoperative Chemoradiation Therapy With Shortening of the Overall Treatment Time Using Intensity-Modulated Radiation Therapy With Simultaneous Integrated Boost: A Phase 2 Trial

This phase 2 study investigated the efficacy and safety of preoperative intensity modulated radiation therapy with a simultaneous integrated boost (IMRT-SIB) without dose escalation, concomitant with standard capecitabine chemotherapy in locally advanced rectal cancer. Between January 2014 and March 2015, 51 patients with operable stage II-III rectal adenocarcinoma received preoperative IMRT with pelvic dose of 41.8Gy and simultaneously delivered 46.2Gy to T2/3 and 48.4Gy to T4 tumor in 22 fractions, concomitant with capecitabine, 825mg/m2/12hours, including weekends. The primary endpoint was pathologic complete response (pCR). Fifty patients completed preoperative treatment according to the protocol, and 47 underwent surgical resection. The sphincter preservation rate for the low rectal tumors was 62%, and the resection margins were free in all but 1 patient. Decrease in tumor and nodal stage was observed in 32 (68%) and 39 (83%) patients, respectively, with pCR achieved in 12 (25.5%) patients. There were only 2G≥ 3 acute toxicities, with infectious enterocolitis in 1 patient and dermatitis over the sacral area caused by the bolus effect of the treatment table in the second patient. Preoperative IMRT-SIB without dose escalation is well tolerated, with alow acute toxicity profile, and can achieve a high rate of pCR and downstaging.

SU-F-T-597: Modeling and Evaluation of RapidPlan for Simultaneous Integrated Boost NPC Cases

Purpose: The evaluation of using RapidPlan to generate the model of simultaneous integrated boost (SIB) VMAT plans for nasopharyngeal carcinoma (NPC). Methods: In this study, the training models were established for SIB NPC cases in RadpidPlan system. The knowledge database was created from 46 VMAT plans for NPC with two dose level targets. CTV212 received 69.96 Gy in 33 fractions at 2.12 Gy per fraction. PTV164 received 54.12 Gy at 1.64 Gy per fraction. To validate the models, we generated plans with model-estimated objectives on four new NPC cases that were not included in the model-training database. Among these four cases, there were two cases with advanced stage NPC, which the targets invaded into eye level region. A comparison of results between the models and the clinical treatment plans were analyzed. Results: For typical cases, the model plans resulted in slightly superior V95% of targets than the clinical treatment plans by up to 2%. Conformity indices for targets were 1.05 and 1.22 for clinical and model plans, respectively. Homogeneity indices for targets were 1.25 and 1.21 for clinical and model plans, respectively. For advanced stage cases, the results of clinical treatment plans had better V95% coverage of targets than that of model plans by approximately 3%. Conformity indices for targets were 1.19 and 1.21, for clinical and model plans, respectively. Homogeneity indices for targets were 1.36 and 1.15 for clinical plans and model plans, respectively. In general, there was no significant difference between model and clinical plans observed. Conclusion: RapidPlan models are powerful dynamic tools to meet the clinical needs. It is user-friendly and allows for standardization of planning process. This approach has the potential to improve the efficiency of the treatment planning process while ensuring that good quality plans are developed.