Treatment volume definition for irradiation of primary lymphoma of the orbit: Utility of multimodality imaging

Objective: Irradiation may be utilized for management of orbital lymphomas with successful treatment results. However, adverse radiation effects may be considered as a concern particularly in the setting of higher delivered doses despite the excellent rates of tumor control in majority of irradiated patients. Multimodality imaging may serve as a contemporary approach for precise target definition in management of orbital lymphomas. Within this context, we assessed multimodality imaging based treatment volume definition for irradiation of primary lymphoma of the orbit in this original article.

Materials and methods: Treatment volume definition by multimodality imaging with incorporation of MRI or by computed tomography (CT)-simulation images only was evaluated with comparative analysis in a series of patients receiving irradiation for orbital lymphoma.

Results: Available treatment planning systems at our tertiary referral institution were used for precise radiation treatment planning. Prioritization was given for encompassing of the target volumes with optimal sparing of critical structures in radiation treatment planning. Synergy (Elekta, UK) LINAC was used in RT delivery. Treatment volume determination by CT-only imaging and by CT-MR fusion based imaging was assessed with comparative analysis. As a result, ground truth target volume was found to be identical with treatment volume definition with CT-MR fusion based imaging.

Conclusion: Accurate and precise target and treatment volume determination comprises an indispensable aspect of successful orbital lymphoma irradiation. Within this context, incorporation of MRI in target and treatment volume definition process may be strongly considered for improving the optimization of target and treatment volume determination for optimal irradiation. Clearly future studies are required to shed light on this issue.

Introduction

Although orbital lymphomas comprise a small proportion of of all lymphomas, primary lymphoma of the orbit occurring in the conjunctiva, lacrimal gland, eyelid and ocular musculature is a frequent orbital tumor accounting for approximately one half of all orbital malignancies [1]. Histology may mostly consist of mucosa associated lymphoid tissue (MALT) or diffuse large B cell non Hodgkin lymphoma. Vitrectomy, vitreal biopsy, or choroidal sampling may be utilized for establishing the diagnosis. Affected patients usually present with a painless orbital mass which is mostly located at the superior lateral quadrant in close vicinity of lacrimal gland. Pain, erythema, and swelling are relatively rare symptoms, however, exophthalmos, ptosis, diplopia, and ocular movement disturbances may occur. Impaired vision can also be a symptom despite relatively rare direct infiltration of optic apparatus.

Irradiation may be utilized for management of orbital lymphomas with successful treatment results [2-7]. However, adverse radiation effects may be considered as a concern particularly in the setting of higher delivered doses despite the excellent rates of tumor control in majority of irradiated patients [5-7]. Multimodality imaging may serve as a contemporary approach for precise target definition in management of orbital lymphomas. Within this context, we assessed multimodality imaging based treatment volume definition for irradiation of primary lymphoma of the orbit in this original article.

Materials and methods

Treatment volume definition by multimodality imaging with incorporation of MRI or by Computed Tomography (CT)-simulation images only was evaluated with comparative analysis in a series of patients receiving irradiation for orbital lymphoma. Ground truth target volume to serve as reference for actual treatment and comparison purposes was meticulously defined by board certified radiation oncologists after thorough assessment, collaboration, colleague peer review, and ultimate consensus. Thorough evaluation was performed for each individual patient taking into account lesion sizes, localization, symptoms, patient preferences, and contemplated outcomes of irradiation treatment. CT-simulator (GE Lightspeed RT, GE Healthcare, Chalfont St. Giles, UK) was used in radiation treatment simulation for treatment planning at our institution. Planning CT images were acquired and sent to the delineation workstation (SimMD, GE, UK) for outlining of treatment volumes and nearby critical structures. Either CT-simulation images only or fused CT and MR images were utilized for treatment volume definition for radiation treatment. Treatment volume determination with CT only and with incorporation of CT-MR fusion was evaluated with comparative analysis. Synergy (Elekta, UK) Linear Accelerator (LINAC) was utilized for treatment delivery with routine incorporation of Image Guided Radiation Therapy (IGRT) techniques.

Results

Available treatment planning systems at our tertiary referral institution were used for precise radiation treatment planning. Prioritization was given for encompassing of the target volumes with optimal sparing of critical structures in radiation treatment planning. Determination of ground truth target volume was performed by board-certified radiation oncologists after meticulous assessment, collaboration, colleague peer review and ultimate consensus to be used for actual treatment and for comparative evaluations. Synergy (Elekta, UK) LINAC was used in RT delivery. Treatment volume determination by CT-only imaging and by CT-MR fusion based imaging was assessed with comparative analysis. As a result, ground truth target volume was found to be identical with treatment volume definition with CT-MR fusion based imaging.

Discussion

Although the delivered irradiation doses for management of orbital lymphomas may be relatively lower, optimal sparing of surrounding normal tissues and critical structures is an indispensable component of contemporary radiotherapy applications in the millennium era. In this context, precise target and treatment volume definition comprises an integral part of current radiotherapy practice. There has been tremendous progress in recent years with substantial improvements radiation oncology discipline thanks to introduction of adaptive irradiation strategies along with modernized treatment delivery techniques such as incorporation of Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy (IMRT), Adaptive Radiation Therapy (ART), Breathing Adapted Radiation Therapy (BART), automatic segmentation techniques, molecular imaging methods and stereotactic irradiation [8-43]. In the context of orbital lymphoma irradiation, several studies have reported encouraging treatment outcomes [1-7]. However, precise target definition is a more critical aspect of successful irradiation with introduction of contemporary treatment techniques and modalities. While sophisticated technologies such as radiosurgery may allow for focused irradiation under robust immobilization and thus offer improved precision and accuracy, target definition gains utmost importantance considering the high doses of irradiation delivered in a single or a few fractions. Optimal target and treatment volume definition is a worthwhile component of irradiation for orbital lymphomas. Determination of larger than actual treatment volumes can substantially increase exposure of surrounding structures leading to untowards toxicity of irradiation. From another standpoint, definition of smaller than actual treatment volumes with inadequate encompassing of treatment volumes may result in consequential treatment failure. Within this context, there remains to be an apparent requirement for optimized treatment volume definition. IGRT techniques typically offer improvements in target localization, and utilization of matched CT and MR images can facilitate optimization of target determination for accurate irradiation. Indeed, several other studies have addressed multimodality imaging based treatment volume definition for a variety of indications [44-74]. This study can add to the growing body of evidence by addressing of multimodality imaging for target definition of orbital lymphomas.

Conclusion

Accurate and precise target and treatment volume determination comprises an indispensable aspect of successful orbital lymphoma irradiation. Within this context, incorporation of MRI in target and treatment volume definition process may be strongly considered for improving the optimization of target and treatment volume determination for optimal irradiation. Clearly future studies are required to shed light on this issue.

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20. Sager O, Beyzadeoglu M, Dincoglan F, Oysul K, Kahya YE, et al. (2012) The Role of Active Breathing Control-Moderate Deep Inspiration Breath-Hold (ABC-mDIBH) Usage in non-Mastectomized Left-sided Breast Cancer Radiotherapy: A Dosimetric Evaluation. UHOD - Uluslararasi Hematoloji-Onkoloji Dergisi 22: 147-155. Link: http://bit.ly/3bMn7dF
21. Sager O, Beyzadeoglu M, Dincoglan F, Demiral S, Gamsiz H, et al. (2020) Multimodality management of cavernous sinus meningiomas with less extensive surgery followed by subsequent irradiation: Implications for an improved toxicity profile. J Surg Surgical Res 6: 056-061. Link: https://bit.ly/3toiKvl
22. Beyzadeoglu M, Sager O, Dincoglan F, Demiral S, Uysal B, et al. (2020) Single Fraction Stereotactic Radiosurgery (SRS) versus Fractionated Stereotactic Radiotherapy (FSRT) for Vestibular Schwannoma (VS). J Surg Surgical Res 6: 062-066. Link: https://bit.ly/3qVHOs1
23. Dincoglan F, Beyzadeoglu M, Sager O, Demiral S, Uysal B, et al. (2020) A Concise Review of Irradiation for Temporal Bone Chemodectomas (TBC). Arch Otolaryngol Rhinol 6: 016-020. Link: https://bit.ly/3cymTWr
24. Dincoglan F, Sager O, Uysal B, Demiral S, Gamsiz H, et al. (2019) Evaluation of hypofractionated stereotactic radiotherapy (HFSRT) to the resection cavity after surgical resection of brain metastases: A single center experience. Indian J Cancer 56: 202-206. Link: https://bit.ly/38EOeVM
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27. Dincoglan F, Sager O, Demiral S, Uysal B, Gamsiz H, et al. (2017) Radiosurgery for recurrent glioblastoma: A review article. Neurol Disord Therap 1: 1-5. Link: https://bit.ly/30JZTOQ
28. Demiral S, Dincoglan F, Sager O, Gamsiz H, Uysal B, et al. (2016) Hypofractionated stereotactic radiotherapy (HFSRT) for who grade I anterior clinoid meningiomas (ACM). Jpn J Radiol 34: 730-737. Link: https://bit.ly/30FFBpK
29. Gamsiz H, Beyzadeoglu M, Sager O, Demiral S, Dincoglan F, et al. (2015) Evaluation of stereotactic body radiation therapy in the management of adrenal metastases from non-small cell lung cancer. Tumori 101: 98-103. Link: https://bit.ly/3tkGpNa
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33. Gamsiz H, Beyzadeoglu M, Sager O, Dincoglan F, Demiral S, et al. (2014) Management of pulmonary oligometastases by stereotactic body radiotherapy. Tumori 100: 179-183. Link: https://bit.ly/2Q7uCDH
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38. Sager O, Beyzadeoglu M, Dincoglan F, Demiral S, Uysal B, et al. (2013) Management of vestibular schwannomas with linear accelerator-based stereotactic radiosurgery: a single center experience. Tumori 99: 617-622. Link: https://bit.ly/3bMgoAf
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45. Sager O, Dincoglan F, Demiral S, Gamsiz H, Uysal B, et al. (2019) Utility of Magnetic Resonance Imaging (Imaging) in Target Volume Definition for Radiosurgery of Acoustic Neuromas. Int J Cancer Clin Res 6: 119. Link: https://bit.ly/3bMhr3j
46. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2019) Evaluation of Radiosurgery Target Volume Determination for Meningiomas Based on Computed Tomography (CT) And Magnetic Resonance Imaging (MRI). Cancer Sci Res Open Access 5: 1-4. Link: https://bit.ly/3vp4hkw
47. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2019) Multimodality Imaging for Radiosurgical Management of Arteriovenous Malformations. Asian Journal of Pharmacy, Nursing and Medical Sciences 7: 7-12. Link: https://bit.ly/3cwnFmX
48. Beyzadeoglu M, Sager O, Dincoglan F, Demiral S (2019) Evaluation of Target Definition for Stereotactic Reirradiation of Recurrent Glioblastoma. Arch Can Res 7: 3. Link: https://bit.ly/2OpxR90
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51. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2019) Assessment of Computed Tomography (CT) And Magnetic Resonance Imaging (MRI) Based Radiosurgery Treatment Planning for Pituitary Adenomas. Canc Therapy Oncol Int J 13: 555857. Link: https://bit.ly/3qKvfPR
52. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2019) Incorporation of Multimodality Imaging in Radiosurgery Planning for Craniopharyngiomas: An Original Article. SAJ Cancer Sci 6: 103. Link: https://bit.ly/2NiFkpL
53. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Evaluation of Target Volume Determination for Irradiatıon of Pilocytic Astrocytomas: An Original Article. ARC Journal of Cancer Science 6: 1-5. Link: https://bit.ly/3rRdSyc
54. Demiral S, Beyzadeoglu M, Dincoglan F, Sager O (2020) Evaluation of Radiosurgery Target Volume Definition for Tectal Gliomas with Incorporation of Magnetic Resonance Imaging (MRI): An Original Article. Biomedical Journal of Scientific & Technical Research (BJSTR) 27: 20543-20547. Link: https://bit.ly/3bNk0lO
55. Beyzadeoglu M, Dincoglan F, Demiral S, Sager O (2020) Target Volume Determination for Precise Radiation Therapy (RT) of Central Neurocytoma: An Original Article. International Journal of Research Studies in Medical and Health Sciences 5: 29-34.
56. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Radiosurgery Treatment Volume Determination for Brain Lymphomas with and without Incorporation of Multimodality Imaging. Journal of Medical Pharmaceutical and Allied Sciences 9: 2398-2404. Link: https://bit.ly/3eyrkn0
57. Demiral S, Beyzadeoglu M, Dincoglan F, Sager O (2020) Assessment of Target Volume Definition for Radiosurgery of Atypical Meningiomas with Multimodality Imaging. Journal of Hematology and Oncology Research 3: 14-21. Link: https://bit.ly/3eFbEy7
58. Beyzadeoglu M, Dincoglan F, Sager O, Demiral S (2020) Determination of Radiosurgery Treatment Volume for Intracranial Germ Cell Tumors (GCTS). Asian Journal of Pharmacy, Nursing and Medical Sciences 8: 18-23. Link: https://bit.ly/3toPNzn
59. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2020) Target Volume Definition for Stereotactic Radiosurgery (SRS) Of Cerebral Cavernous Malformations (CCMs). Canc Therapy Oncol Int J 15: 555917. Link: https://bit.ly/3ldxev6
60. Dincoglan F, Demiral S, Sager O, Beyzadeoglu M (2020) Utility of Multimodality Imaging Based Target Volume Definition for Radiosurgery of Trigeminal Neuralgia: An Original Article. Biomed J Sci Tech Res 26: 19728-19732. Link: https://bit.ly/2OXKAja
61. Dincoglan F, Beyzadeoglu M, Demiral S, Sager O (2020) Assessment of Treatment Volume Definition for Irradiation of Spinal Ependymomas: an Original Article. ARC Journal of Cancer Science 6: 1-6. Link: https://bit.ly/2Q387zE
62. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Evaluation of Treatment Volume Determination for Irradiation of chordoma: an Original Article. International Journal of Research Studies in Medical and Health Sciences 5: 3-8. Link: https://bit.ly/3rSbLKE
63. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Assessment of Target Volume Definition for Irradiation of Hemangiopericytomas: An Original Article. Canc Ther Oncol Int J 17. Link: https://bit.ly/3bMfQub
64. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2021) Treatment Volume Determination for Irradiation of Recurrent Nasopharyngeal Carcinoma with Multimodality Imaging: An Original Article. ARC Journal of Cancer Science 6: 18-23.
65. Demiral S, Dincoglan F, Sager O, Beyzadeoglu M (2021) Multimodality Imaging Based Target Definition of Cervical Lymph Nodes in Precise Limited Field Radiation Therapy (Lfrt) for Nodular Lymphocyte Predominant Hodgkin Lymphoma (Nlphl). ARC Journal of Cancer Science 6: 06-11.
66. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2021) Target Definition of orbital Embryonal Rhabdomyosarcoma (Rms) by Multimodality Imaging: An Original Article. ARC Journal of Cancer Science 6: 12-17.
67. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2021) Radiation Therapy (RT) Target Volume Definition for Peripheral Primitive Neuroectodermal Tumor (PPNET) by Use of Multimodality Imaging: An Original Article. Biomed J Sci Tech Res 34: 26970-26974.
68. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2021) Multimodality Imaging Based Treatment Volume Definition for Reirradiation of Recurrent Small Cell Lung Cancer (SCLC). Arch Can Res 9: 1-5. Link: https://bit.ly/3avNtzs
69. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2021) Assessment of posterior fossa target definition by multimodality imaging for patients with medulloblastoma. J Surg Surgical Res 7: 032-035. Link: https://bit.ly/3auMeAK
70. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2021) Evaluation of Changes in Tumor Volume Following Upfront Chemotherapy for Locally Advanced Non Small Cell Lung Cancer (NSCLC). Glob J Cancer Ther 7: 31-34. Link: https://bit.ly/3elzsFD
71. Dincoglan F, Demiral S, Sager O, Beyzadeoglu M (2021) Evaluation of Target Definition for Management of Myxoid Liposarcoma (MLS) with Neoadjuvant Radiation Therapy (RT). Biomed J Sci Tech Res 33: 26171-26174. Link: https://bit.ly/3n8ZqjH
72. Demiral S, Dincoglan F, Sager O, Beyzadeoglu M (2021) Assessment of Multimodality Imaging for Target Definition of Intracranial Chondrosarcomas. Canc Therapy Oncol Int J 18: 555981. Link: https://bit.ly/3grb6gp
73. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2021) Impact of Multimodality Imaging to Improve Radiation Therapy (RT) Target Volume Definition for Malignant Peripheral Nerve Sheath Tumor (MPNST). Biomed J Sci Tech Res 34: 26734-26738.
74. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2021) Radiation Therapy (RT) target determination for irradiation of bone metastases with soft tissue component: Impact of multimodality imaging. J Surg Surgical Res 7: 042-046. Link: https://bit.ly/2QK17rQ