Simulation-free cone beam CT-based online adaptive radiotherapy for metastatic spinal cord compression
DOI:
https://doi.org/10.2340/1651-226X.2025.44040Keywords:
Online adaptive radiotherapy, Cone-beam computed tomography, Simulation-free, Ethos, Metastatic spinal cord compressionAbstract
Background and purpose: A simulation-free approach, using the patient’s diagnostic computed tomography (CT) for treatment planning, eliminates the need for a separate planning CT. Combined with conebeam computed tomography (CBCT)-guided online adaptive radiotherapy (oART), this strategy has the potential to create a more efficient treatment workflow and reduce the burden for the patients.
The study aimed to evaluate the feasibility and time consumption of different simulation-free oART workflows for patients with metastatic spinal cord compression (MSCC) to identify the most suitable option for clinical implementation.
Patient/material and methods: Diagnostic CT scans from patients diagnosed with MSCC were used for treatment planning, while CBCT scans from their first treatment session were retrospectively used to emulate the treatments. Four adaptive workflows were defined and assessed: Deformable Supervised (DefSup), Deformable Unsupervised (DefUn), Rigid Supervised (RigSup), and Rigid Unsupervised (RigUn). The supervised workflows involved manual corrections to the target structures, whereas the unsupervised workflows did not include any manual adjustments. Time stamps, segmentation quality, and dose plans were used to evaluate the feasibility of each workflow.
Results: A total of 120 simulation-free emulations were performed (based on 27 patients with 30 target sites). The DefSup workflow yielded the highest accuracy in both segmentation and dose distribution. Additionally, with a median time consumption of 6.57 min, this workflow demonstrates a level of reliability and quality suitable for clinical application.
Interpretation: The DefSup workflow was found to be the most optimal and safe for clinical implementation, as demonstrated by the successful treatment of the first patient with MSCC using this approach.
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References
Robson P. Metastatic spinal cord compression: a rare but important complication of cancer. Clin Med. 2014;14(5):542.
https://doi.org/10.7861/clinmedicine.14-5-542 DOI: https://doi.org/10.7861/clinmedicine.14-5-542
Ganesh V, Chan S, Raman S, Chow R, Hoskin P, Lam H, et al. A review of patterns of practice and clinical guidelines in the palliative radiation treatment of uncomplicated bone metastases. Radiother Oncol. 2017;124(1):38–44.
https://doi.org/10.1016/j.radonc.2017.06.002 DOI: https://doi.org/10.1016/j.radonc.2017.06.002
Cañón V, Gomez-Iturriaga A, Casquero F, Rades D, Navarro A, del Hoyo O, et al. Quality of life improvement in patients with bone metastases undergoing palliative radiotherapy. Rep Pract Oncol Radiother. 2022;27(3):428–39.
https://doi.org/10.5603/RPOR.a2022.0048 DOI: https://doi.org/10.5603/RPOR.a2022.0048
Gutt R, Malhotra S, Hagan MP, Lee SP, Faricy-Anderson K, Kelly MD, et al. Palliative radiotherapy within the Veterans Health Administration: barriers to referral and timeliness of treatment. JCO Oncol Pract. 2021;17(12):e1913–22.
https://doi.org/10.1200/OP.20.00981 DOI: https://doi.org/10.1200/OP.20.00981
Moazzezi M, Rose B, Kisling K, Moore KL, Ray X. Prospects for daily online adaptive radiotherapy via ethos for prostate cancer patients without nodal involvement using unedited CBCT auto-segmentation. J Appl Clin Med Phys. 2021;22(10):82–93.
https://doi.org/10.1002/acm2.13399 DOI: https://doi.org/10.1002/acm2.13399
Branco D, Mayadev J, Moore KL, Ray X. Dosimetric and feasibility evaluation of a CBCT-based daily adaptive radiotherapy protocol for locally advanced cervical cancer. J Appl Clin Med Phys. 2023;24(1):e13783.
https://doi.org/10.1002/acm2.13783 DOI: https://doi.org/10.1002/acm2.13783
Håkansson K, Giannoulis E, Lindegaard A, Friborg J, Vogelius I. CBCT-based online adaptive radiotherapy for head and neck cancer – dosimetric evaluation of first clinical experience. Acta Oncol. 2023;62(11):1369–74.
https://doi.org/10.1080/0284186X.2023.2256966 DOI: https://doi.org/10.1080/0284186X.2023.2256966
Sibolt P, Andersson LM, Calmels L, Sjöström D, Bjelkengren U, Geertsen P, et. al. Clinical implementation of artificial intelligence-driven cone-beam computed tomography-guided online adaptive radiotherapy in the pelvic region. Phys Imaging Radiat Oncol. 2021;17:1–7.
https://doi.org/10.1016/j.phro.2020.12.004 DOI: https://doi.org/10.1016/j.phro.2020.12.004
Nelissen KJ, Versteijne E, Senan S, Rijksen B, Admiraal M, Visser J, et al. Same-day adaptive palliative radiotherapy without prior CT simulation: early outcomes in the FAST-METS study. Radiother Oncol. 2023;182;109538.
https://doi.org/10.1016/j.radonc.2023.109538 DOI: https://doi.org/10.1016/j.radonc.2023.109538
MacDonald RL, Fallone C, Chytyk-Praznik K, Robar J, Cherpak A. The feasibility of CT simulation-free adaptive radiation therapy. J Appl Clin Med Phys. 2024;25(9):e14438.
https://doi.org/10.1002/acm2.14438 DOI: https://doi.org/10.1002/acm2.14438
Kejda A, Quinn A, Wong S, Lowe T, Fent I, Gargett M, et al. Evaluation of the clinical feasibility of cone-beam computed tomography guided online adaption for simulation-free palliative radiotherapy. Phys Imaging Radiat Oncol. 2023;28:100490.
https://doi.org/10.1016/j.phro.2023.100490 DOI: https://doi.org/10.1016/j.phro.2023.100490
O’Neil M, Nguyen TK, Laba J, Dinniwell R, Warner A, Palma DA. DART: diagnostic-CT-enabled planning: a randomized trial in palliative radiation therapy (study protocol). BMC Palliat Care. 2022;21(1):220.
https://doi.org/10.1186/s12904-022-01115-y DOI: https://doi.org/10.1186/s12904-022-01115-y
Fallone C, MacDonald L, Cherpak A, Chytyk-Praznik K, Robar J. PD-0662 Evaluation of Ethos HyperSight imaging performance compared to standard CBCT and FBCT. In: European Society of Radiotherapy and Oncology 2023. [cited 2024 dec 13] Available from: https://www.estro.org/Congresses/ESTRO-2023/1389/imaging/12842/evaluationofethoshypersightimagingperformancecompa DOI: https://doi.org/10.1016/S0167-8140(23)08956-9
Robar LJ, Cherpak A, MacDonald RL, Yashayaeva A, McAloney D, McMaster N, et al. Novel technology allowing cone beam computed tomography in 6 seconds: a patient study of comparative image quality. Pract Radiat Oncol 2024;14(3):277–86.
https://doi.org/10.1016/j.prro.2023.10.014 DOI: https://doi.org/10.1016/j.prro.2023.10.014
Nelissen KJ, Versteijne E, Senan S, Hoffmans D, Slotman BJ, Verbakel WFAR. Evaluation of a workflow for cone-beam CT-guided online adaptive palliative radiotherapy planned using diagnostic CT scans. J Appl Clin Med Phys 2023;24(3):e13841.
https://doi.org/10.1002/acm2.13841 DOI: https://doi.org/10.1002/acm2.13841
Oldenburger E, De Roover R, Poels K, Depuydt T, Isebaert S, Haustermans K. ‘Scan-(pre)plan-treat’ workflow for bone metastases using the ethos therapy system: a single-center, in silico experience. Adv Radiat Oncol. 2023;8(6):101258.
https://doi.org/10.1016/j.adro.2023.101258 DOI: https://doi.org/10.1016/j.adro.2023.101258
R Core Team (2024). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria [cited 2025 mar 3] Available from: https://www.R-project.org/.
Schuler T, Back M, Hruby G, Carroll S, Jayamanne D, Kneebone A, et al. Introducing computed tomography simulation-free and electronic patient-reported outcomes-monitored palliative radiation therapy into routine care: clinical outcomes and implementation experience. Adv Radiat Oncol. 2020;6(2):100632.
https://doi.org/10.1016/j.adro.2020.100632 DOI: https://doi.org/10.1016/j.adro.2020.100632
Parsons D, Domal S, Chambers E, Salazar D, Visak J, Arbab M, et al. Feasibility and impact of a radiation therapy technologist-driven workflow for cone beam computed tomography guided partial breast adaptive radiation therapy. Int J Radiat Oncol Biol Phys. 2025;122(4):893–901.
https://doi.org/10.1016/j.ijrobp.2025.03.055 DOI: https://doi.org/10.1016/j.ijrobp.2025.03.055
Goudschaal K, Azzarouali S, Visser J, Admiraal M, Wiersma J, van Wieringen N, et al. Clinical implementation of RTT-only CBCT-guided online adaptive focal radiotherapy for bladder cancer. Clin Transl Radiat Oncol. 2024;50:100884.
https://doi.org/10.1016/j.ctro.2024.100884 DOI: https://doi.org/10.1016/j.ctro.2024.100884
Nelissen KJ, Verbakel WFAR, Slotman BJ, Visser J, Versteijne E. Routine use of single visit online adaptive cone beam computed tomography guided sim-free palliative radiation therapy. Int J Radiat Oncol Biol Phys. 2025;122(4):1035–44.
https://doi.org/10.1016/j.ijrobp.2025.03.040 DOI: https://doi.org/10.1016/j.ijrobp.2025.03.040
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Copyright (c) 2025 Lisette Sandt, Evangelos Giannoulis, Laura Ann Rechner, Lina Åström, Anna Mann Nielsen, Jens Morgenthaler Edmund, Gitte Fredberg Persson
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