Vorsprung durch Technik: Evolution, implementation, QA and safety of new technology in radiotherapy

These are exciting times in radiotherapy. The challenge repeatedly presented to the radiotherapy team by each new patient is one of treatment optimisation i.e., of delivering high and effective doses to the required targets but minimising unwanted side-effects, and this has continued to drive research and the development of technology and techniques. This issue of Radiotherapy and Oncology contains mainly papers from presentations at the recent ESTRO 10th Biennial Conference on Physics and Radiation Technology for Clinical Radiotherapy (Maastricht, September 2009) [ [1] 10th Biennial ESTRO conference on physics and technology for clinical radiotherapy, Aug 30–Sep 3, 2009. Radiother Oncol 2009;92:(Suppl. 1). Google Scholar ]. Each of these meetings presents the current state of the art and draws together developments over the interval since the last [ [2] Nystrom H. Thwaites D.I. Physics and high-technology advances in radiotherapy: are they still worth it?. Radiother Oncol. 2008; 86: 1-3 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar ], as also reflected in publications in the journal over that period. Better insights into radiobiology [ [3] Rodemann H.P. Molecular radiation biology: perspectives for radiation oncology. Radiother Oncol. 2009; 92: 293-298 Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar ] and the increasing application of multi-modality imaging, both morphological and functional [ 4 MacManus M. Nestle U. Rosenzweig K.E. et al. Use of PET and PET/CT for radiation therapy planning: IAEA expert report 2006–2007. Radiother Oncol. 2009; 9: 85-94 Abstract Full Text Full Text PDF Scopus (321) Google Scholar , 5 Lavrenkov K. Singh S. Christian J.A. et al. Effective avoidance of a functional spect-perfused lung using intensity modulated radiotherapy (IMRT) for non-small cell lung cancer (NSCLC): an update of a planning study. Radiother Oncol. 2009; 91: 349-352 Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar , 6 Rosewall T. Kong V. Vesprini D. et al. Prostate delineation using CT and MRI for radiotherapy patients with bilateral hip prostheses. Radiother Oncol. 2009; 90: 325-330 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar ], provide enhanced information on targeting [ 7 Vilarino-Varela M.J. Taylor A. Rockall A.G. et al. A verification study of proposed pelvic lymph node localisation guidelines using nanoparticle-enhanced magnetic resonance imaging. Radiother Oncol. 2008; 89: 92-96 Abstract Full Text Full Text PDF Scopus (32) Google Scholar , 8 van Loon J. Offermann C. Bosmans G. et al. 18FDG-PET based radiation planning of mediastinal lymph nodes in limited disease small cell lung cancer changes radiotherapy fields: a planning study. Radiother Oncol. 2008; 87: 49-54 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar , 9 Schinagl D.A. Hoffmann A.L. Vogel W.V. et al. Can FDG-PET assist in radiotherapy target volume definition of metastatic lymph nodes in head-and-neck cancer?. Radiother Oncol. 2009; 91: 95-100 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar ] and on sub-targets [ 10 van Baardwijk A. Bosmans G. van Suylen R.J. et al. Correlation of intra-tumour heterogeneity on 18F-FDG PET with pathologic features in non-small cell lung cancer: a feasibility study. Radiother Oncol. 2008; 87: 55-58 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar , 11 Aerts H.J. van Baardwijk A.A. Petit S.F. et al. Identification of residual metabolic-active areas within individual NSCLC tumours using a pre-radiotherapy (18)Fluorodeoxyglucose-PET-CT scan. Radiother Oncol. 2009; 91: 386-392 Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar , 12 Abramyuk A. Tokalov S. Zophel K. et al. Is pre-therapeutical FDG-PET/CT capable to detect high risk tumor subvolumes responsible for local failure in non-small cell lung cancer?. Radiother Oncol. 2009; 91: 399-404 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar ]. Intensity-modulated photon radiotherapy (IMRT) [ 13 Fenoglietto P. Laliberte B. Allaw A. et al. Persistently better treatment planning results of intensity-modulated (IMRT) over conformal radiotherapy (3D-CRT) in prostate cancer patients with significant variation of clinical target volume and/or organs-at-risk. Radiother Oncol. 2008; 88: 77-87 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar , 14 Fenkell L. Kaminsky I. Breen S. et al. Dosimetric comparison of IMRT vs. 3D conformal radiotherapy in the treatment of cancer of the cervical esophagus. Radiother Oncol. 2008; 89: 287-291 Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar , 15 St-Hilaire J. Sevigny C. Beaulieu F. et al. Dose escalation in the radiotherapy of non-small-cell lung cancer with aperture-based intensity modulation and photon beam energy optimization for non-preselected patients. Radiother Oncol. 2009; 91: 342-348 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 16 Yaparpalvi R. Hong L. Mah D. et al. ICRU reference dose in an era of intensity-modulated radiation therapy clinical trials: correlation with planning target volume mean dose and suitability for intensity-modulated radiation therapy dose prescription. Radiother Oncol. 2008; 89: 347-352 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 17 Moon S.H. Shin K.H. Kim T.H. et al. Dosimetric comparison of four different external beam partial breast irradiation techniques: three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, helical tomotherapy, and proton beam therapy. Radiother Oncol. 2009; 90: 66-73 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar ], including intensity-modulated arc therapy (both fan beam [ 18 Lee T.F. Fang F.M. Chao P.J. et al. Dosimetric comparisons of helical tomotherapy and step-and-shoot intensity-modulated radiotherapy in nasopharyngeal carcinoma. Radiother Oncol. 2008; 89: 89-96 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar , 19 Sterzing F. Sroka-Perez G. Schubert K. et al. Evaluating target coverage and normal tissue sparing in the adjuvant radiotherapy of malignant pleural mesothelioma: helical tomotherapy compared with step-shoot IMRT. Radiother Oncol. 2008; 86: 251-257 Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar , 20 Caudrelier J.M. Morgan S.C. Montgomery L. et al. Helical tomotherapy for locoregional irradiation including the internal mammary chain in left-sided breast cancer: dosimetric evaluation. Radiother Oncol. 2009; 90: 99-105 Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar , 21 Cattaneo G.M. Dell’oca I. Broggi S. et al. Treatment planning comparison between conformal radiotherapy and helical tomotherapy in the case of locally advanced-stage NSCLC. Radiother Oncol. 2008; 88: 310-318 Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar ] and cone beam [ 22 Iori M. Cattaneo G.M. Cagni E. et al. Dose-volume and biological-model based comparison between helical tomotherapy and (inverse-planned) IMAT for prostate tumours. Radiother Oncol. 2008; 88: 34-45 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar , 23 Cozzi L. Dinshaw K.A. Shrivastava S.K. et al. A treatment planning study comparing volumetric arc modulation with RapidArc and fixed field IMRT for cervix uteri radiotherapy. Radiother Oncol. 2008; 89: 180-191 Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar , 24 Fogliata A. Clivio A. Nicolini G. et al. Intensity modulation with photons for benign intracranial tumours: a planning comparison of volumetric single arc, helical arc and fixed gantry techniques. Radiother Oncol. 2008; 89: 254-262 Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar , 25 Verbakel W.F. Senan S. Cuijpers J.P. et al. Rapid delivery of stereotactic radiotherapy for peripheral lung tumors using volumetric intensity-modulated arcs. Radiother Oncol. 2009; 93: 122-124 Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar , 26 Clivio A. Fogliata A. Franzetti-Pellanda A. et al. Volumetric-modulated arc radiotherapy for carcinomas of the anal canal: a treatment planning comparison with fixed field IMRT. Radiother Oncol. 2009; 92: 118-124 Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar , 27 Guckenberger M. Richter A. Krieger T. et al. Is a single arc sufficient in volumetric-modulated arc therapy (VMAT) for complex-shaped target volumes?. Radiother Oncol. 2009; 93: 259-265 Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar , 28 Wolff D. Stieler F. Welzel G. et al. Volumetric modulated arc therapy (VMAT) vs. serial tomotherapy, step-and-shoot IMRT and 3D-conformal RT for treatment of prostate cancer. Radiother Oncol. 2009; 93: 226-233 Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar , 29 Wagner D. Christiansen H. Wolff H. et al. Radiotherapy of malignant gliomas: comparison of volumetric single arc technique (RapidArc), dynamic intensity-modulated technique and 3D conformal technique. Radiother Oncol. 2009; 93: 593-596 Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar ]) can deliver multi-targeted dose-sculpted [ [30] Thorwarth D. Soukup M. Alber M. Dose painting with IMPT helical tomotherapy and IMXT: a dosimetric comparison. Radiother Oncol. 2008; 86: 30-34 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar ] irradiation to these defined volumes, whilst improved dose distributions also drive the growing interest in proton therapy [ 17 Moon S.H. Shin K.H. Kim T.H. et al. Dosimetric comparison of four different external beam partial breast irradiation techniques: three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, helical tomotherapy, and proton beam therapy. Radiother Oncol. 2009; 90: 66-73 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar , 30 Thorwarth D. Soukup M. Alber M. Dose painting with IMPT helical tomotherapy and IMXT: a dosimetric comparison. Radiother Oncol. 2008; 86: 30-34 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar , 31 Georg D. Hillbrand M. Stock M. et al. Can protons improve SBRT for lung lesions? Dosimetric considerations. Radiother Oncol. 2008; 88: 368-375 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar , 32 Widesott L. Amichetti M. Schwarz M. Proton therapy in lung cancer: clinical outcomes and technical issues. A systematic review. Radiother Oncol. 2008; 86: 154-164 Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar , 33 Hillbrand M. Georg D. Gadner H. et al. Abdominal cancer during early childhood: a dosimetric comparison of proton beams to standard and advanced photon radiotherapy. Radiother Oncol. 2008; 89: 141-149 Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar ]. Image-guided radiotherapy (IGRT), using various in-room imaging techniques [ 34 Verellen D. De Ridder M. Storme G.A. (Short) History of image-guided radiotherapy. Radiother Oncol. 2008; 86: 4-13 Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar , 35 Korreman S. Rasch C. McNair H. et al. The European Society of Therapeutic Radiology and Oncology-European Institute of Radiotherapy (ESTRO-EIR) report on 3D CT-based in-room image guidance systems: A practical and technical review and guide. Radiother Oncol. 2010; 94: 129-144 Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar , 36 Lagendijk J.J. Raaymakers B.W. Raaijmakers A.J. et al. MRI/linac integration. Radiother Oncol. 2008; 86: 25-29 Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar , 37 Stutzel J. Oelfke U. Nill S. A quantitative image quality comparison of four different image guided radiotherapy devices. Radiother Oncol. 2008; 86: 20-24 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar , 38 Calcerrada Diaz-Santos N. Blasco Amaro J.A. Cardiel G.A. et al. The safety and efficacy of robotic image-guided radiosurgery system treatment for intra- and extracranial lesions: a systematic review of the literature. Radiother Oncol. 2008; 89: 245-253 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar ], provides precise real-time monitoring of target position, enabling treatment verification and correction and also the basis for responsive adaptive techniques [ 39 Guckenberger M. Krieger T. Richter A. et al. Potential of image-guidance, gating and real-time tracking to improve accuracy in pulmonary stereotactic body radiotherapy. Radiother Oncol. 2009; 9: 288-295 Abstract Full Text Full Text PDF Scopus (110) Google Scholar , 40 Castadot P. Lee J.A. Parraga A. et al. Comparison of 12 deformable registration strategies in adaptive radiation therapy for the treatment of head and neck tumors. Radiother Oncol. 2008; 89: 1-12 Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar , 41 Schulze D. Liang J. Yan D. et al. Comparison of various online IGRT strategies: the benefits of online treatment plan re-optimization. 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Radiother Oncol. 2008; 88: 233-240 Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar ]. 4D techniques underpin strategies for dealing with organ motion [ 39 Guckenberger M. Krieger T. Richter A. et al. Potential of image-guidance, gating and real-time tracking to improve accuracy in pulmonary stereotactic body radiotherapy. Radiother Oncol. 2009; 9: 288-295 Abstract Full Text Full Text PDF Scopus (110) Google Scholar , 45 Wang L. Hayes S. Paskalev K. et al. Dosimetric comparison of stereotactic body radiotherapy using 4D CT and multiphase CT images for treatment planning of lung cancer: evaluation of the impact on daily dose coverage. Radiother Oncol. 2009; 91: 314-324 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar , 46 Ehler E.D. Tome W.A. Lung 4D-IMRT treatment planning: an evaluation of three methods applied to four-dimensional data sets. Radiother Oncol. 2008; 88: 319-325 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar , 47 Admiraal M.A. Schuring D. Hurkmans C.W. Dose calculations accounting for breathing motion in stereotactic lung radiotherapy based on 4D-CT and the internal target volume. Radiother Oncol. 2008; 86: 55-60 Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar ]. In vivo, in-phantom and associated dose verification techniques provide assurance for complex treatment delivery [ 48 McDermott L.N. Wendling M. Nijkamp J. et al. 3D in vivo dose verification of entire hypo-fractionated IMRT treatments using an EPID and cone-beam CT. Radiother Oncol. 2008; 86: 35-42 Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar , 49 Pawlicki T. Yoo S. Court L.E. et al. Moving from IMRT QA measurements toward independent computer calculations using control charts. Radiother Oncol. 2008; 89: 330-337 Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar , 50 Wagner D. Anton M. Vorwerk H. et al. In vivo alanine/electron spin resonance (ESR) dosimetry in radiotherapy of prostate cancer: a feasibility study. Radiother Oncol. 2008; 88: 140-147 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar , 51 Reynders T. Tournel K. De Coninck P. et al. Dosimetric assessment of static and helical TomoTherapy in the clinical implementation of breast cancer treatments. Radiother Oncol. 2009; 93: 71-79 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar ]. Image-guided brachytherapy techniques [ [52] Potter R. Image-guided brachytherapy sets benchmarks in advanced radiotherapy. Radiother Oncol. 2009; 91: 141-146 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ] are developing in parallel for specific applications. IT systems for radiotherapy, including Oncology Information Systems (OIS) and treatment planning systems (TPS), continue to expand and develop to handle the very significant amounts of information involved, to better model and optimise treatment, to move increasingly towards integration of all the necessary process functions, and to provide greater workflow efficiency [ 53 Sims R. Isambert A. Gregoire V. et al. A pre-clinical assessment of an atlas-based automatic segmentation tool for the head and neck. Radiother Oncol. 2009; 93: 474-478 Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar , 54 Morgan A.M. Knoos T. McNee S.G. et al. Clinical implications of the implementation of advanced treatment planning algorithms for thoracic treatments. Radiother Oncol. 2008; 86: 48-54 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar , 55 Huyskens D.P. Maingon P. Vanuytsel L. et al. 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