Sander C Kuipers

Margin and robustness settings for a library-of-plans IMPT strategy for locally advanced cervical cancer

Abstract Objective. This study aims to determine a margin and robustness setting for treating locally advanced cervical cancer (LACC) with a library-of-plans (LoP) based online-adaptive intensity-modulated proton therapy (IMPT). Approach. We analyzed 13 LACC patients with delineated planning and weekly repeat CT scans (reCTs). For each patient, 120 IMPT treatments of 25 fractions were simulated with a LoPs approach. Six different robustness settings (2–7 mm set-up robustness (SR) plus 3% range robustness (RR)) were used to create those 120 IMPT plans. Each fraction was simulated with a weekly reCT, combined with the sampling of inter- and intrafraction treatment uncertainties. The fraction doses were accumulated to obtain a treatment dose to the target volumes, distinguishing between the low-risk clinical target volume (CTV-T-LR) and the elective CTV (CTV-E). If one of the two targets obtained an adequate coverage for more than 90% of the treatments, different anisotropic margins were sampled on top of the robustness setting to the other target to obtain the Pareto-optimal margin in terms of adequate coverage versus increase in target volume. Main results. The percentage of treatments that reach the dose criterion V 42.75Gy > 95% for the CTV-T-LR was 22.3%, 28.5%, 51.2%, 73.1%, 85.3%, and 90.0% for 2, 3, 4, 5, 6, and 7 mm SR plus 3% RR and for the CTV-E, this percentage was 60.4%, 73.8%, 86.5%, 92.3%, 96.9%, and 98.5%. The Pareto-optimal margin combined with a 5 mm/3% robustness setting for the CTV-T-LR with an adequate coverage for >90% of the treatments was given by {0, 1, 0, 3, 3, 0} mm in the left, right, anterior, posterior, cranial, caudal direction. Significance. Our study evaluated combinations of robustness and anisotropic margin settings for IMPT for LACC. With 5 mm SR and 3% RR for CTV-E and CTV-T-LR plus a margin to the CTV-T-LR of {0, 1, 0, 3, 3, 0} mm in left, right, anterior, posterior, cranial, and caudal ensured an adequate coverage for >90% of the simulated IMPT treatments.

Predicting lymphocyte dose and surviving fraction for VMAT and IMPT treatments with a dynamic lymphocyte flow model for locally advanced cervical cancer

Abstract Objective. A dynamic model is developed to predict the impact of radiotherapy on circulating lymphocyte counts in women with locally advanced cervical cancer (LACC). This study aims to compare the effects of photon and proton therapy, as well as the influence of bone marrow sparing (BMS) techniques, on relative lymphocyte preservation over time. Approach. A dynamic lymphocyte flow model was developed to simulate the migration of lymphocytes based on seven compartments. Biological cell death and lymphocyte production were integrated across compartments. The lymphocyte flow model was applied to 19 LACC patients. Volumetric modulated arc therapy (VMAT) and intensity modulated proton therapy (IMPT) treatment plans were created for each patient without BMS and with BMS. The model calculated radiation dose to lymphocytes to estimate radiation-induced cell death over time. The output of the model was the relative lymphocyte count relative to baseline (RLC) over time and the RLC nadir in the blood and total body. Main results. According to the model, IMPT resulted in lower doses to lymphocyte and higher RLC nadirs compared to VMAT for all 19 patients. The total RLC nadir (mean ± SD) was 48.4% ± 4.0% for VMAT and 62.5% ± 5.1% for IMPT. In the blood compartment, the RLC nadir was 32.7% ± 3.5% for VMAT and 47.7% ± 5.9% for IMPT. The RLC nadir in the blood compartment improved with 3 Gy BMS from 32.7% ± 3.5% to 33.0% ± 3.5% , while it decreased for IMPT from 47.7% ± 5.9% to 46.6% ± 6.0%. Total RLC nadir decreased with BMS for VMAT from 48.4% ± 4.0% to 48.2% ± 3.9% and for IMPT from 62.5% ± 5.1% to 60.9% ± 5.3%. Significance. By incorporating a dynamic flow model, we predicted the RLC over time. The model predicted a substantial sparing effect IMPT has on the lymphocytes compared to VMAT. This sparing was both present in the blood and the total body. Sparing the bone marrow showed only a minimal effect on the RLC.

Correlations between bone marrow radiation dose and hematologic toxicity in locally advanced cervical cancer patients receiving chemoradiation with cisplatin: a systematic review

Patients with locally advanced cervical cancer (LACC) treated with chemoradiation often experience hematologic toxicity (HT), as chemoradiation can induce bone marrow (BM) suppression. Studies on the relationship between BM dosimetric parameters and clinically significant HT might provide relevant indices for developing BM sparing (BMS) radiotherapy techniques. This systematic review studied the relationship between BM dose and HT in patients with LACC treated with primary cisplatin-based chemoradiation. A systematic search was conducted in Embase, Medline, and Web of Science. Eligibility criteria were treatment of LACC-patients with cisplatin-based chemoradiation and report of HT or complete blood cell count (CBC). The search identified 1346 papers, which were screened on title and abstract before two reviewers independently evaluated the full-text. 17 articles were included and scored according to a selection of the TRIPOD criteria. The mean TRIPOD score was 12.1 out of 29. Fourteen studies defining BM as the whole pelvic bone contour (PB) detected significant associations with V10 (3/14), V20 (6/14), and V40 (4/11). Recommended cut-off values were V10 > 95-75%, V20 > 80-65%, and V40 > 37-28%. The studies using lower density marrow spaces (PBM) or active bone marrow (ABM) as a proxy for BM only found limited associations with HT. Our study was the first literature review providing an overview of articles evaluating the correlation between BM and HT for patients with LACC undergoing cisplatin-based chemoradiation. There is a scarcity of studies independently validating developed prediction models between BM dose and HT. Future studies may use PB contouring to develop normal tissue complication probability models.

Changes in bone marrow fat fraction and immune cell counts in women with cervical cancer treated with primary chemoradiotherapy

Hematologic toxicity (HT) is a common effect of chemoradiotherapy in primary locally advanced cervical cancer (LACC) and related to bone marrow (BM) fat increase. However, longitudinal effects and dose-relationships are unknown. In this study, pre- and post-treatment BM fat fraction and blood immune cell counts were evaluated in women with primary LACC undergoing BM sparing chemoradiotherapy. Water-fat MRI scans and blood samples were obtained at baseline, during, and at 3 and 12 months (post-)treatment. The mean proton density fat fraction (PDFF) [%] was calculated for each vertebra, categorized into a no (5 Gy) dose group, and the pelvic bones. Associations between PDFF and dose, immune cells, and patient characteristics were assessed with linear mixed models. Eighteen women were included. Vertebral PDFF in the no dose group remained unchanged, whereas the low and high dose group showed an increase of 24-35 PDFF% during treatment. PDFF in the low dose group recovered slightly but remained elevated up to 12 months post-treatment. Mean dose to pelvic subregions was ≥ 18.8 Gy and PDFF increase was 12-29 PDFF%. Only the lower pelvic PDFF recovered to baseline. Blood immune cell decline lasted up to 12 months post-treatment and was correlated with higher mean vertebral PDFF. Vertebral fat fraction increased during treatment for dose > 1 Gy, without post-treatment recovery for dose > 5 Gy. Immunosuppression persisted up to 12 months post-treatment and was related to a higher mean vertebral PDFF. 5 Gy might be relevant for BM damage, but this threshold should be validated.

Hematopoietic Stem Cell-containing Autologous Blood Transfusion for Bone Marrow Protection in Patients With Cervical Cancer

The aim of this project is to promote the reconstruction of haematopoietic function after chemoradiotherapy for cervical cancer with the innovative use of autologous haematopoietic containing stem cell blood transfusion support.To explore the effect of stored hemopoietic stem cell support therapy on bone marrow protection after concurrent chemoradiotherapy, in order to promote its clinical application.