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      Variability of clinical target volume delineation for rectal cancer patients planned for neoadjuvant radiotherapy with the aid of the platform Anatom-e

      research-article
      a , * , b , a , c , a , a , d , e , f , g , h , i , j , a , a , k , a
      Clinical and Translational Radiation Oncology
      Elsevier
      RT, radiotherapy, CHT, chemotherapy, CTV, clinical target volume, OARs, organs at risk, Intra-OV, intra-observer variability, Inter-OV, inter-observer variability, Ros, radiation oncologists, AJCC/UICC, American Joint Committee on Cancer/Union Internationale Contre le Cancer, CT, computed tomography, RTOG, Radiation Therapy Oncology Group, DSC, Dice similarity coefficient, HD, Hausdorff distance, MDA, mean distance to agreement, SD, standard deviation, VMAT, volumetric modulated arc therapy, SWOG, Radiation Committee of the Southwest Oncology Group, GTV, gross tumor volume, MR, magnetic resonance imaging, Rectal cancer, Neoadjuvant radiotherapy, Interobserver variability, Contouring, Target volume delineation

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          Highlights

          • Delineation of treatment volumes is a major source of uncertainties in rectal cancer radiotherapy.

          • Anatom-e is an electronic platform working as an image-based delineation system.

          • The use of Anatom-e was able to decrease the inter-observer variability in the delineation process of clinical target volumes for locally advanced rectal cancer.

          • Anatom-e may be potentially helpful in increasing the compliance to common guidelines and protocols.

          Abstract

          Objective

          Delineation of treatment volumes is a major source of uncertainties in radiotherapy (RT). This is also true for rectal cancer patients undergoing neoadjuvant RT, with a potential impact on treatment quality. We investigated the role of the digital platform Anatom-e (Anatom-e Information Sytems Ltd., Houston, Texas) in increasing the compliance to follow a specific treatment protocol in a multicentric setting.

          Materials and methods

          Two clinical cases of locally advanced rectal cancer were chosen. Participants were instructed to follow the 2009 Radiation Therapy Oncology Group consensus atlas and asked to manually segment clinical target volumes (CTVs), for both patient 1 and 2, on day 1 with and without the use of Anatom-e. After one week (day 2), the same radiation oncologist contoured again, with and without Anatom-e, the same CT series. Intraobserver (Intra-OV) and interobserver (Inter-OV) variability were evaluated with the Dice similarity coefficient (DSC), the Hausdorff distance (HD) and mean distance to agreement (MDA).

          Results

          For clinical case 1, no significant difference was found for Intra-OV and Inter-OV. For clinical case 2, no significant difference was found for Intra-OV but a statistically significant difference was found for Inter-OV in DSC when using or not the platform. Mean DCS was 0.65 (SD: ±0.64; range: 0.58–0.79) for day 1 vs reference volume without Anatom-e and 0.72 (SD: ±0.39; range: 0.67–0.77) (p = 0.03) with it. Mean MDA was lower with Anatom-e (3.61; SD: ±1.33; range: 2.85–4.78) than without (4.14; SD: ±2.97; range: 2.18–5.21), with no statistical significance (p = 0.21) The use of Anatom-e decreased the SD from 2.97 to 1.33. Mean HD was lower with Anatom-e (26.06; SD: ±2.05; range: 24.08–32.62), with no statistical significance (p = 0.14) compared to that without (31.39; SD: ±1.31; range: 26.14–48.72).

          Conclusions

          The use of Anatom-e decreased the Inter-OV in the CTV delineation process for locally advanced rectal cancer with complex disease presentation planned for neoadjuvant RT. This system may be potentially helpful in increasing the compliance to follow shared guidelines and protocols.

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          Most cited references24

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          • Abstract: found
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          Critical impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: results from TROG 02.02.

          To report the impact of radiotherapy quality on outcome in a large international phase III trial evaluating radiotherapy with concurrent cisplatin plus tirapazamine for advanced head and neck cancer. The protocol required interventional review of radiotherapy plans by the Quality Assurance Review Center (QARC). All plans and radiotherapy documentation underwent post-treatment review by the Trial Management Committee (TMC) for protocol compliance. Secondary review of noncompliant plans for predicted impact on tumor control was performed. Factors associated with poor protocol compliance were studied, and outcome data were analyzed in relation to protocol compliance and radiotherapy quality. At TMC review, 25.4% of the patients had noncompliant plans but none in which QARC-recommended changes had been made. At secondary review, 47% of noncompliant plans (12% overall) had deficiencies with a predicted major adverse impact on tumor control. Major deficiencies were unrelated to tumor subsite or to T or N stage (if N+), but were highly correlated with number of patients enrolled at the treatment center ( or = 20 patients, 5.4%; P < .001). In patients who received at least 60 Gy, those with major deficiencies in their treatment plans (n = 87) had a markedly inferior outcome compared with those whose treatment was initially protocol compliant (n = 502): -2 years overall survival, 50% v 70%; hazard ratio (HR), 1.99; P < .001; and 2 years freedom from locoregional failure, 54% v 78%; HR, 2.37; P < .001, respectively. These results demonstrate the critical importance of radiotherapy quality on outcome of chemoradiotherapy in head and neck cancer. Centers treating only a few patients are the major source of quality problems.
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            Tumor delineation: The weakest link in the search for accuracy in radiotherapy

            C Njeh (2008)
            Radiotherapy is one of the most effective modalities for the treatment of cancer. However, there is a high degree of uncertainty associated with the target volume of most cancer sites. The sources of these uncertainties include, but are not limited to, the motion of the target, patient setup errors, patient movements, and the delineation of the target volume. Recently, many imaging techniques have been introduced to track the motion of tumors. The treatment delivery using these techniques is collectively called image-guided radiation therapy (IGRT). Ultimately, IGRT is only as good as the accuracy with which the target is known. There are reports of interobserver variability in tumor delineation across anatomical sites, but the widest ranges of variations have been reported for the delineation of head and neck tumors as well as esophageal and lung carcinomas. Significant interobserver variability in target delineation can be attributed to many factors including the impact of imaging and the influence of the observer (specialty, training, and personal bias). The visibility of the target can be greatly improved with the use of multimodality imaging by co-registration of CT with a second modality such as magnetic resonance imaging (MRI) and/or positron emission tomography. Also, continuous education, training, and cross-collaboration of the radiation oncologist with other specialties can reduce the degree of variability in tumor delineation.
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              • Article: not found

              International consensus guidelines on Clinical Target Volume delineation in rectal cancer

              The delineation of Clinical Target Volume (CTV) is a critical step in radiotherapy. Several guidelines suggest different subvolumes and anatomical boundaries in rectal cancer (RC), potentially leading to a misunderstanding in the CTV definition. International consensus guidelines (CG) are needed to improve uniformity in RC CTV delineation.
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                Author and article information

                Contributors
                Journal
                Clin Transl Radiat Oncol
                Clin Transl Radiat Oncol
                Clinical and Translational Radiation Oncology
                Elsevier
                2405-6308
                11 June 2018
                June 2018
                11 June 2018
                : 11
                : 33-39
                Affiliations
                [a ]Department of Oncology, Radiation Oncology, University of Turin, AOU Citta’ della salute e della Scienza, Turin, Italy
                [b ]Department of Oncology, Radiation Oncology, AOU Citta’ della Salute e della Scienza, Turin, Italy
                [c ]Department of Medical Physics, AOU Citta’ della Salute e della Scienza, Turin, Italy
                [d ]Department of Radiation Oncology, Ivrea Community Hospital, Ivrea, Italy
                [e ]Department of Radiation Oncology, ‘Cardinal Massaia’ Community Hospital, Asti, Italy
                [f ]Department of Oncology, Radiation Oncology, University of Turin, AO Ordine Mauriziano, Turin, Italy
                [g ]Department of Radiation Oncology, AOU San Luigi Gonzaga, Orbassano (TO), Italy
                [h ]Department of Oncology, Radiation Oncology, AOU Citta’ della Salute e della Scienza, Presidio San Giovanni Antica Sede, Turin, Italy
                [i ]Department of Radiation Oncology, ASL Verbano Cusio Ossola, Verbania, Italy
                [j ]Department of Radiation Oncology, AO ‘SS Antonio e Biagio e Cesare Arrigo’, Alessandria, Italy
                [k ]Rete Oncologica Piemonte e Valle d’Aosta, Turin, Italy
                Author notes
                [* ]Corresponding author at: Department of Oncology, Radiation Oncology, University of Turin, School of Medicine, Via Genova 3, 10126 Turin, Italy. pierfrancesco.franco@ 123456unito.it
                Article
                S2405-6308(18)30040-5
                10.1016/j.ctro.2018.06.002
                6008279
                29928706
                34c7c684-772c-4ef3-b68b-93c3dc20def6
                © 2018 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 5 May 2018
                : 5 June 2018
                : 8 June 2018
                Categories
                Article

                rt, radiotherapy,cht, chemotherapy,ctv, clinical target volume,oars, organs at risk,intra-ov, intra-observer variability,inter-ov, inter-observer variability,ros, radiation oncologists,ajcc/uicc, american joint committee on cancer/union internationale contre le cancer,ct, computed tomography,rtog, radiation therapy oncology group,dsc, dice similarity coefficient,hd, hausdorff distance,mda, mean distance to agreement,sd, standard deviation,vmat, volumetric modulated arc therapy,swog, radiation committee of the southwest oncology group,gtv, gross tumor volume,mr, magnetic resonance imaging,rectal cancer,neoadjuvant radiotherapy,interobserver variability,contouring,target volume delineation

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