Thomas Berger1, Yvette Seppenwoolde2, Richard Pötter2, Marianne Sanggaard Assenholt3, Jacob C Lindegaard3, Remi A Nout4, Astrid de Leeuw5, Ina Jürgenliemk-Schulz5, Li Tee Tan6, Dietmar Georg2, Christian Kirisits2, Isabelle Dumas7, Nicole Nesvacil2, Jamema Swamidas8, Robert Hudej9, Gerry Lowe10, Taran Paulsen Hellebust11, Geetha Menon12, Lars Fokdal3, Kari Tanderup3. 1. Department of Oncology, Aarhus University Hospital, Denmark. Electronic address: tomber@rm.dk. 2. Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria. 3. Department of Oncology, Aarhus University Hospital, Denmark. 4. Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands. 5. Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands. 6. Departments of Oncology, Radiology and Gynae-oncology, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Trust, United Kingdom. 7. Department of Radiotherapy, Gustave-Roussy, Villejuif, France. 8. Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Navi Mumbai, India. 9. Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia. 10. Cancer Centre, Mount Vernon Hospital, London, United Kingdom. 11. Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway. 12. Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada.
Abstract
PURPOSE: To describe the evolution of external beam radiation therapy (EBRT) from EMBRACE-I (general guidelines for EBRT) to the initial phase of the EMBRACE-II study (detailed protocol for EBRT). METHODS AND MATERIALS: EMBRACE-I enrolled 1416 locally advanced cervical cancer patients treated with chemoradiation including image-guided adaptive brachytherapy during 2008 to 2015. From March 2016 until March 2018, 153 patients were enrolled in the ongoing EMBRACE-II study, which involves a comprehensive detailed strategy and accreditation procedure for EBRT target contouring, treatment planning, and image guidance. EBRT planning target volumes (PTVs), treated volumes (V43 Gy), and conformity index (CI; V43 Gy/PTV) were evaluated in both studies and compared. RESULTS: For EMBRACE-I, conformal radiation therapy (60% of patients) or intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT; 40%) was applied with 45 to 50 Gy over 25 to 30 fractions to the elective clinical target volume (CTV). For pelvic CTVs (82%), median PTV and V43 Gy volumes were 1549 and 2390 mL, respectively, and CI was 1.54. For pelvic plus paraortic nodal (PAN) CTVs (15%), median PTV and V43 Gy volumes were 1921 and 2895 mL, and CI was 1.51. For pelvic CTVs treated with 45 to 46 Gy, the use of conformal radiation therapy was associated with a median V43 Gy volume that was 546 mL larger than with IMRT/VMAT. For pelvic CTVs treated with IMRT, the use of a dose prescription ≥48 Gy was associated with a median V43 Gy volumes that was 428 mL larger than with a dose prescription of 45 to 46 Gy. For EMBRACE-II, all patients were treated with: IMRT/VMAT, daily IGRT, 45 Gy over 25 fractions for the elective CTV, and simultaneously integrated boost for pathologic lymph nodes. For pelvic CTVs (61%), median PTV and V43 Gy volumes were 1388 and 1418 mL, and CI was 1.02. For pelvic plus PAN CTVs (32%), median PTV and V43 Gy volumes were 1720 and 1765 mL, and CI was 1.03. From EMBRACE-I to initial II, median V43 Gy was decreased by 972 mL (41%) and 1130 mL (39%), and median CI decreased from 1.54 to 1.02 and 1.51 to 1.03 for pelvic and pelvic plus PAN irradiation, respectively. CONCLUSIONS: Application of IMRT/VMAT, IGRT, and a 45-Gy dose provides the potential of higher conformality inducing significant reduction of treated volume. Adherence to a detailed protocol including comprehensive accreditation, as in EMBRACE-II, reduces considerably V43 Gy and V50 Gy and improves conformality and interinstitutional consistency.
PURPOSE: To describe the evolution of external beam radiation therapy (EBRT) from EMBRACE-I (general guidelines for EBRT) to the initial phase of the EMBRACE-II study (detailed protocol for EBRT). METHODS AND MATERIALS: EMBRACE-I enrolled 1416 locally advanced cervical cancerpatients treated with chemoradiation including image-guided adaptive brachytherapy during 2008 to 2015. From March 2016 until March 2018, 153 patients were enrolled in the ongoing EMBRACE-II study, which involves a comprehensive detailed strategy and accreditation procedure for EBRT target contouring, treatment planning, and image guidance. EBRT planning target volumes (PTVs), treated volumes (V43 Gy), and conformity index (CI; V43 Gy/PTV) were evaluated in both studies and compared. RESULTS: For EMBRACE-I, conformal radiation therapy (60% of patients) or intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT; 40%) was applied with 45 to 50 Gy over 25 to 30 fractions to the elective clinical target volume (CTV). For pelvic CTVs (82%), median PTV and V43 Gy volumes were 1549 and 2390 mL, respectively, and CI was 1.54. For pelvic plus paraortic nodal (PAN) CTVs (15%), median PTV and V43 Gy volumes were 1921 and 2895 mL, and CI was 1.51. For pelvic CTVs treated with 45 to 46 Gy, the use of conformal radiation therapy was associated with a median V43 Gy volume that was 546 mL larger than with IMRT/VMAT. For pelvic CTVs treated with IMRT, the use of a dose prescription ≥48 Gy was associated with a median V43 Gy volumes that was 428 mL larger than with a dose prescription of 45 to 46 Gy. For EMBRACE-II, all patients were treated with: IMRT/VMAT, daily IGRT, 45 Gy over 25 fractions for the elective CTV, and simultaneously integrated boost for pathologic lymph nodes. For pelvic CTVs (61%), median PTV and V43 Gy volumes were 1388 and 1418 mL, and CI was 1.02. For pelvic plus PAN CTVs (32%), median PTV and V43 Gy volumes were 1720 and 1765 mL, and CI was 1.03. From EMBRACE-I to initial II, median V43 Gy was decreased by 972 mL (41%) and 1130 mL (39%), and median CI decreased from 1.54 to 1.02 and 1.51 to 1.03 for pelvic and pelvic plus PAN irradiation, respectively. CONCLUSIONS: Application of IMRT/VMAT, IGRT, and a 45-Gy dose provides the potential of higher conformality inducing significant reduction of treated volume. Adherence to a detailed protocol including comprehensive accreditation, as in EMBRACE-II, reduces considerably V43 Gy and V50 Gy and improves conformality and interinstitutional consistency.
Authors: Yvette Seppenwoolde; Katarina Majercakova; Martin Buschmann; Elke Dörr; Alina E Sturdza; Maximilian P Schmid; Richard Pötter; Dietmar Georg Journal: Strahlenther Onkol Date: 2021-04-30 Impact factor: 3.621
Authors: Thomas Berger; Lars U Fokdal; Marianne S Assenholt; Nina B K Jensen; Jørgen B B Petersen; Lars Nyvang; Stine Korreman; Jacob C Lindegaard; Kari Tanderup Journal: Phys Imaging Radiat Oncol Date: 2019-06-26
Authors: Martin P Nilsson; Erik D Nilsson; Anders Johnsson; Otilia Leon; Adalsteinn Gunnlaugsson; Jonas Scherman Journal: Radiat Oncol Date: 2020-05-27 Impact factor: 3.481