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• W2010926773 abstract "To the Editor: We read with interest the article by Register et al. (1Register S.P. Zhang X. Mohan R. et al.Proton stereotactic body radiation therapy for clinically challenging cases of centrally and superiorly located stage I non-small-cell lung cancer.Int J Radiat Oncol Biol Phys. 2011; 80: 1015-1022Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar) suggesting that using protons for stereotactic radiotherapy of central and superiorly located lung tumors can reduce the dose, and therefore the risk of toxicity to critical organs, while simultaneously increasing the likelihood of satisfactory coverage of the planning target volume. We have used photon-based stereotactic body radiotherapy (SBRT) since 2003 in more than 800 patients to treat planning target volume volumes of up to 280 cm3, as well as centrally located tumors, and have frequently encountered the challenges of meeting dose constraints to organs at risk (OARs) that the authors have identified (2Haasbeek CJ, Lagerwaard FJ, Slotman BJ, et al. Outcomes of stereotactic ablative radiotherapy (SABR) for centrally located early stage lung cancer. J Thorac Oncol. In press.Google Scholar, 3Ong C.L. Palma D. Verbakel W.F. et al.Treatment of large stage I-II lung tumors using stereotactic body radiotherapy (SBRT): Planning considerations and early toxicity.Radiother Oncol. 2010; 97: 431-436Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). We would like to take this opportunity to highlight an important point that the authors do not specifically address, namely the need for accurate OAR delineation. This is relevant to clinical treatment and dosimetric comparisons (4Forquer J.A. Fakiris A.J. Timmerman R.D. et al.Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC: Dose-limiting toxicity in apical tumor sites.Radiother Oncol. 2009; 93: 408-413Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar).Several studies have shown significant interobserver variations in OAR contouring, with potential dosimetric consequences (5Collier D.C. Burnett S.S. Amin M. et al.Assessment of consistency in contouring of normal-tissue anatomic structures.J Appl Clin Med Phys. 2003; 4: 17-24Crossref PubMed Google Scholar, 6Yi SK, Hall WH, Mathai M, et al. Validating the RTOG-endorsed brachial plexus contouring atlas: An evaluation of reproducibility among patients treated by intensity-modulated radiotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. In press.Google Scholar). Despite the availability of contouring guidelines and site-specific atlases, findings of our own study of staff and residents conducted in a high-volume SBRT center indicate that such variations remain of concern in SBRT for central and superiorly located lung tumors (7Bongers E.M. Dahele M.R. Kalpathy-Cramer J. et al.Variation in contouring normal organs for stereotactic ablative radiotherapy: Training analysis with an interactive software tool (TaCTICS) (Abstr.).J Thorac Oncol. 2011; 6: S805Google Scholar). All observers were provided with an atlas based on Kong et al. (8Kong FM, Ritter T, Quint DJ, et al. Consideration of dose limits for organs at risk of thoracic radiotherapy: Atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys. In press.Google Scholar), and contouring variation was evaluated using a software tool (9Kalpathy-Cramer J. Fuller C.D. Target Contour Testing/Instructional Computer Software (TaCTICS): A novel training and evaluation platform for radiotherapy target delineation.AMIA Annu Symp Proc. 2010; 2010: 361-365PubMed Google Scholar) that allowed a comparison of individuals against a reference dataset derived from the contours of multiple “experts” (STAPLE algorithm; Simultaneous Truth and Performance Level Estimation [10Warfield S.K. Zou K.H. Wells W.M. Simultaneous truth and performance level estimation (STAPLE): An algorithm for the validation of image segmentation.IEEE Trans Med Imaging. 2004; 23: 903-921Crossref PubMed Scopus (1387) Google Scholar]) using metrics such as the Dice similarity coefficient (DSC). We found least variations for contouring the heart (DSC 0.87–0.92), moderate consistency in contours of the esophagus and distal bronchial airways (DSC 0.51–0.72 and 0.58–0.66, respectively), and large differences in contouring the brachial plexus, even among experienced clinicians (DSC 0.28–0.32).Our findings suggest opportunities to improve the training of lung SBRT practitioners, regardless of their prior experience with thoracic radiotherapy. One training strategy is the use of consensus delineation guidelines in conjunction with software-based tools that allow an individual user to benchmark his/her performance (6Yi SK, Hall WH, Mathai M, et al. Validating the RTOG-endorsed brachial plexus contouring atlas: An evaluation of reproducibility among patients treated by intensity-modulated radiotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. In press.Google Scholar, 7Bongers E.M. Dahele M.R. Kalpathy-Cramer J. et al.Variation in contouring normal organs for stereotactic ablative radiotherapy: Training analysis with an interactive software tool (TaCTICS) (Abstr.).J Thorac Oncol. 2011; 6: S805Google Scholar, 8Kong FM, Ritter T, Quint DJ, et al. Consideration of dose limits for organs at risk of thoracic radiotherapy: Atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys. In press.Google Scholar, 9Kalpathy-Cramer J. Fuller C.D. Target Contour Testing/Instructional Computer Software (TaCTICS): A novel training and evaluation platform for radiotherapy target delineation.AMIA Annu Symp Proc. 2010; 2010: 361-365PubMed Google Scholar). The latter would ideally provide real-time three-dimensional visual feedback. In individual clinical cases, review of critical OAR delineation by more than one observer may be helpful. More attention to strategies for reducing interobserver variations in OAR delineation, both within and between institutes, should be recognized as an important component of knowledge transfer and the implementation and evaluation of advanced treatment techniques such as SBRT. To the Editor: We read with interest the article by Register et al. (1Register S.P. Zhang X. Mohan R. et al.Proton stereotactic body radiation therapy for clinically challenging cases of centrally and superiorly located stage I non-small-cell lung cancer.Int J Radiat Oncol Biol Phys. 2011; 80: 1015-1022Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar) suggesting that using protons for stereotactic radiotherapy of central and superiorly located lung tumors can reduce the dose, and therefore the risk of toxicity to critical organs, while simultaneously increasing the likelihood of satisfactory coverage of the planning target volume. We have used photon-based stereotactic body radiotherapy (SBRT) since 2003 in more than 800 patients to treat planning target volume volumes of up to 280 cm3, as well as centrally located tumors, and have frequently encountered the challenges of meeting dose constraints to organs at risk (OARs) that the authors have identified (2Haasbeek CJ, Lagerwaard FJ, Slotman BJ, et al. Outcomes of stereotactic ablative radiotherapy (SABR) for centrally located early stage lung cancer. J Thorac Oncol. In press.Google Scholar, 3Ong C.L. Palma D. Verbakel W.F. et al.Treatment of large stage I-II lung tumors using stereotactic body radiotherapy (SBRT): Planning considerations and early toxicity.Radiother Oncol. 2010; 97: 431-436Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). We would like to take this opportunity to highlight an important point that the authors do not specifically address, namely the need for accurate OAR delineation. This is relevant to clinical treatment and dosimetric comparisons (4Forquer J.A. Fakiris A.J. Timmerman R.D. et al.Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC: Dose-limiting toxicity in apical tumor sites.Radiother Oncol. 2009; 93: 408-413Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar). Several studies have shown significant interobserver variations in OAR contouring, with potential dosimetric consequences (5Collier D.C. Burnett S.S. Amin M. et al.Assessment of consistency in contouring of normal-tissue anatomic structures.J Appl Clin Med Phys. 2003; 4: 17-24Crossref PubMed Google Scholar, 6Yi SK, Hall WH, Mathai M, et al. Validating the RTOG-endorsed brachial plexus contouring atlas: An evaluation of reproducibility among patients treated by intensity-modulated radiotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. In press.Google Scholar). Despite the availability of contouring guidelines and site-specific atlases, findings of our own study of staff and residents conducted in a high-volume SBRT center indicate that such variations remain of concern in SBRT for central and superiorly located lung tumors (7Bongers E.M. Dahele M.R. Kalpathy-Cramer J. et al.Variation in contouring normal organs for stereotactic ablative radiotherapy: Training analysis with an interactive software tool (TaCTICS) (Abstr.).J Thorac Oncol. 2011; 6: S805Google Scholar). All observers were provided with an atlas based on Kong et al. (8Kong FM, Ritter T, Quint DJ, et al. Consideration of dose limits for organs at risk of thoracic radiotherapy: Atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys. In press.Google Scholar), and contouring variation was evaluated using a software tool (9Kalpathy-Cramer J. Fuller C.D. Target Contour Testing/Instructional Computer Software (TaCTICS): A novel training and evaluation platform for radiotherapy target delineation.AMIA Annu Symp Proc. 2010; 2010: 361-365PubMed Google Scholar) that allowed a comparison of individuals against a reference dataset derived from the contours of multiple “experts” (STAPLE algorithm; Simultaneous Truth and Performance Level Estimation [10Warfield S.K. Zou K.H. Wells W.M. Simultaneous truth and performance level estimation (STAPLE): An algorithm for the validation of image segmentation.IEEE Trans Med Imaging. 2004; 23: 903-921Crossref PubMed Scopus (1387) Google Scholar]) using metrics such as the Dice similarity coefficient (DSC). We found least variations for contouring the heart (DSC 0.87–0.92), moderate consistency in contours of the esophagus and distal bronchial airways (DSC 0.51–0.72 and 0.58–0.66, respectively), and large differences in contouring the brachial plexus, even among experienced clinicians (DSC 0.28–0.32). Our findings suggest opportunities to improve the training of lung SBRT practitioners, regardless of their prior experience with thoracic radiotherapy. One training strategy is the use of consensus delineation guidelines in conjunction with software-based tools that allow an individual user to benchmark his/her performance (6Yi SK, Hall WH, Mathai M, et al. Validating the RTOG-endorsed brachial plexus contouring atlas: An evaluation of reproducibility among patients treated by intensity-modulated radiotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. In press.Google Scholar, 7Bongers E.M. Dahele M.R. Kalpathy-Cramer J. et al.Variation in contouring normal organs for stereotactic ablative radiotherapy: Training analysis with an interactive software tool (TaCTICS) (Abstr.).J Thorac Oncol. 2011; 6: S805Google Scholar, 8Kong FM, Ritter T, Quint DJ, et al. Consideration of dose limits for organs at risk of thoracic radiotherapy: Atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys. In press.Google Scholar, 9Kalpathy-Cramer J. Fuller C.D. Target Contour Testing/Instructional Computer Software (TaCTICS): A novel training and evaluation platform for radiotherapy target delineation.AMIA Annu Symp Proc. 2010; 2010: 361-365PubMed Google Scholar). The latter would ideally provide real-time three-dimensional visual feedback. In individual clinical cases, review of critical OAR delineation by more than one observer may be helpful. More attention to strategies for reducing interobserver variations in OAR delineation, both within and between institutes, should be recognized as an important component of knowledge transfer and the implementation and evaluation of advanced treatment techniques such as SBRT. Proton Stereotactic Body Radiation Therapy for Clinically Challenging Cases of Centrally and Superiorly Located Stage I Non-Small-Cell Lung CancerInternational Journal of Radiation Oncology, Biology, PhysicsVol. 80Issue 4PreviewTo minimize toxicity while maintaining tumor coverage with stereotactic body radiation therapy (SBRT) for centrally or superiorly located stage I non-small-cell lung cancer (NSCLC), we investigated passive-scattering proton therapy (PSPT) and intensity-modulated proton therapy (IMPT). Full-Text PDF In Reply to Dr. Bonger et al.International Journal of Radiation Oncology, Biology, PhysicsVol. 82Issue 1PreviewTo the Editor: We welcome Dr. Bonger and colleagues’ comments about our recently published work (1). Our data show that proton-based stereotactic ablative radiotherapy (SABR) spares more critical structures in centrally or superiorly located Stage I non–small cell lung cancer compared with photon-based SABR, which could translate to improved toxicity. Dr. Bonger et al. pointed out the issues of contouring variation of critical normal tissues and its impact in radiotherapy of lung cancer, particularly for SABR. Full-Text PDF" @default.
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• W2010926773 title "Proton Stereotactic Body Radiation Therapy for Clinically Challenging Cases of Centrally and Superiorly Located Stage I Non-Small-Cell Lung Cancer: In Regards to Register et al. Int J Radiat Oncol Biol Phys 2011;80:1015–1022." @default.
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