Radiotherapy quality assurance for mesorectum treatment planning within the multi-center phase II STAR-TReC trial: Dutch results

Roy P J van den Ende, Femke P Peters, Ernst Harderwijk, Heidi Rütten, Liza Bouwmans, Maaike Berbee, Richard A M Canters, Georgiana Stoian, Kim Compagner, Tom Rozema, Mariska de Smet, Martijn P W Intven, Rob H N Tijssen, Jacqueline Theuws, Paul van Haaren, Baukelien van Triest, Dave Eekhout, Corrie A M Marijnen, Uulke A van der Heide, Ellen M Kerkhof, Roy P J van den Ende, Femke P Peters, Ernst Harderwijk, Heidi Rütten, Liza Bouwmans, Maaike Berbee, Richard A M Canters, Georgiana Stoian, Kim Compagner, Tom Rozema, Mariska de Smet, Martijn P W Intven, Rob H N Tijssen, Jacqueline Theuws, Paul van Haaren, Baukelien van Triest, Dave Eekhout, Corrie A M Marijnen, Uulke A van der Heide, Ellen M Kerkhof

Abstract

Background: The STAR-TReC trial is an international multi-center, randomized, phase II study assessing the feasibility of short-course radiotherapy or long-course chemoradiotherapy as an alternative to total mesorectal excision surgery. A new target volume is used for both (chemo)radiotherapy arms which includes only the mesorectum. The treatment planning QA revealed substantial variation in dose to organs at risk (OAR) between centers. Therefore, the aim of this study was to determine the treatment plan variability in terms of dose to OAR and assess the effect of a national study group meeting on the quality and variability of treatment plans for mesorectum-only planning for rectal cancer.

Methods: Eight centers produced 25 × 2 Gy treatment plans for five cases. The OAR were the bowel cavity, bladder and femoral heads. A study group meeting for the participating centers was organized to discuss the planning results. At the meeting, the values of the treatment plan DVH parameters were distributed among centers so that results could be compared. Subsequently, the centers were invited to perform replanning if they considered this to be necessary.

Results: All treatment plans, both initial planning and replanning, fulfilled the target constraints. Dose to OAR varied considerably for the initial planning, especially for dose levels below 20 Gy, indicating that there was room for trade-offs between the defined OAR. Five centers performed replanning for all cases. One center did not perform replanning at all and two centers performed replanning on two and three cases, respectively. On average, replanning reduced the bowel cavity V20Gy by 12.6%, bowel cavity V10Gy by 22.0%, bladder V35Gy by 14.7% and bladder V10Gy by 10.8%. In 26/30 replanned cases the V10Gy of both the bowel cavity and bladder was lower, indicating an overall lower dose to these OAR instead of a different trade-off. In addition, the bowel cavity V10Gy and V20Gy showed more similarity between centers.

Conclusions: Dose to OAR varied considerably between centers, especially for dose levels below 20 Gy. The study group meeting and the distribution of the initial planning results among centers resulted in lower dose to the defined OAR and reduced variability between centers after replanning.

Trial registration: The STAR-TReC trial, ClinicalTrials.gov Identifier: NCT02945566. Registered 26 October 2016, https://ichgcp.net/clinical-trials-registry/NCT02945566).

Keywords: Quality assurance; Radiotherapy; Rectal neoplasms; Treatment planning.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Planning results for the initial planning (blue) and replanning (orange) for each case. The red lines indicate the OAR optimization objective
Fig. 2
Fig. 2
Vector representation for the initial planning and replanning for the bowel cavity V10Gy and the bladder V10Gy for all cases. A vector originates in the values of the DVH parameters of the initial planning and ends in the values of the replanning. The numbers 1 through 8 in the figure legends represent the centers. A plotted point indicates that the corresponding center did not perform replanning
Fig. 3
Fig. 3
Planning results for the initial planning (blue) and replanning (orange) of case 1. The red lines indicate the OAR optimization objective
Fig. 4
Fig. 4
Dose distributions for the initial planning and replanning of case 1 for center 4 and center 6

References

    1. Bentrem DJ, Okabe S, Wong WD, Guillem JG, Weiser MR, Temple LK, et al. T1 adenocarcinoma of the rectum: transanal excision or radical surgery? Ann Surg. 2005;242:472–477. doi: 10.1097/01.sla.0000183355.94322.db.
    1. Van Gijn W, Marijnen CAM, Nagtegaal ID, Kranenbarg EMK, Putter H, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol. 2011;12:575–582. doi: 10.1016/S1470-2045(11)70097-3.
    1. Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A, et al. Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum. 2005;48:1380–1388. doi: 10.1007/s10350-005-0044-6.
    1. Lange MM, Maas CP, Marijnen CAM, Wiggers T, Rutten HJ, Klein Kranenbarg E, et al. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg. 2008;95:1020–1028. doi: 10.1002/bjs.6126.
    1. Hendren SK, O’Connor BI, Liu M, Asano T, Cohen Z, Swallow CJ, et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg. 2005;242:212–223. doi: 10.1097/01.sla.0000171299.43954.ce.
    1. Peeters KCMJ, van de Velde CJH, Leer JWH, Martijn H, Junggeburt JMC, Kranenbarg EK, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients - a Dutch colorectal Cancer group study. J Clin Oncol. 2005;23:6199–6206. doi: 10.1200/JCO.2005.14.779.
    1. Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, et al. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys. 2014;88:822–828. doi: 10.1016/j.ijrobp.2013.12.012.
    1. Glynne-Jones R, Hughes R. Critical appraisal of the “wait and see” approach in rectal cancer for clinical complete responders after chemoradiation. Br J Surg. 2012;99:897–909. doi: 10.1002/bjs.8732.
    1. Marijnen CAM. Organ preservation in rectal cancer: have all questions been answered? Lancet Oncol. 2015;16:e13–e22. doi: 10.1016/S1470-2045(14)70398-5.
    1. Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol. 2018;44:209–219. doi: 10.1016/j.ejso.2017.11.024.
    1. Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, Baatrup G, Bach S, et al. Can we save the rectum by watchful waiting or TransAnal microsurgery following (chemo) radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open. 2017;7:e019474. doi: 10.1136/bmjopen-2017-019474.
    1. Peters Femke P., Teo Mark T.W., Appelt Ane L., Bach Simon, Baatrup Gunnar, de Wilt Johannes H.W., Jensenius Kronborg Camilla, Garm Spindler Karen-Lise, Marijnen Corrie A.M., Sebag-Montefiore David. Mesorectal radiotherapy for early stage rectal cancer: A novel target volume. Clinical and Translational Radiation Oncology. 2020;21:104–111. doi: 10.1016/j.ctro.2020.02.001.
    1. Appelt Ane L., Kerkhof Ellen M., Nyvang Lars, Harderwijk Ernst C., Abbott Natalie L., Teo Mark, Peters Femke P., Kronborg Camilla J.S., Spindler Karen-Lise G., Sebag-Montefiore David, Marijnen Corrie A.M. Robust dose planning objectives for mesorectal radiotherapy of early stage rectal cancer – A multicentre dose planning study. Technical Innovations & Patient Support in Radiation Oncology. 2019;11:14–21. doi: 10.1016/j.tipsro.2019.09.001.
    1. Hussein M, Heijmen BJM, Verellen D, Nisbet A. Automation in intensity modulated radiotherapy treatment planning—a review of recent innovations. Br J Radiol. 2018;91:20180270. doi: 10.1259/bjr.20180270.
    1. Joye I, Lambrecht M, Jegou D, Hortobágyi E, Scalliet P, Haustermans K. Does a central review platform improve the quality of radiotherapy for rectal cancer? Results of a national quality assurance project. Radiother Oncol. 2014;111:400–405. doi: 10.1016/j.radonc.2014.03.003.
    1. Habraken SJM, Sharfo AWM, Buijsen J, Verbakel WFAR, Haasbeek CJA, Öllers MC, et al. The TRENDY multi-center randomized trial on hepatocellular carcinoma – trial QA including automated treatment planning and benchmark-case results. Radiother Oncol. 2017;125:507–513. doi: 10.1016/j.radonc.2017.09.007.
    1. Fenton PA, Hurkmans C, Gulyban A, Van Der Leer J, Matzinger O, Poortmans P, et al. Quality assurance of the EORTC 22043-30041 trial in post-operative radiotherapy in prostate cancer: results of the dummy run procedure. Radiother Oncol. 2013;107:346–351. doi: 10.1016/j.radonc.2013.04.020.

Source: PubMed

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