Research ArticleAbstract
Objective: Radiation therapy (RT) typically plays a major role in the management of soft tissue sarcomas. In the context of myxoid liposarcoma (MLS) management, several studies have addressed the utility of neoadjuvant RT. Longer life expectancy of patients with MLS with more efficacious treatments rendered quality of life a critical aspect of management. From this standpoint, improving the toxicity profile of radiation delivery has gained utmost priority in the millennium era. Accurate RT target definition comprises an indispensable and critical component of successful MLS management. Within this context, we assessed target definition for neoadjuvant RT of MLS in this original article.
Materials and Methods: A comparative evaluation was performed regarding target definition with multimodality imaging by incorporation of magnetic resonance imaging (MRI) or by computed tomography (CT)-simulation images only for patients receiving neoadjuvant RT for MLS.
Results: Priorities in RT planning included encompassing of target volumes adequately with optimal sparing of critical structures. Determination of ground truth target volume was performed by the board-certified radiation oncologists after meticulous assessment, collaboration, colleague peer review, and ultimate consensus. Target definition by CT-only imaging and by CT-MR fusion based imaging was assessed with comparative analysis. Ground truth target volume was found to be identical with target volume determination by CT-MR fusion based imaging as the primary endpoint result of the study.
Conclusion: Multimodality imaging should be considered for target definition of MLS for neoadjuvant radiotherapeutic management. Clearly, further studies are warranted to address this issue.
Keywords: Myxoid Liposarcoma (MLS); Neoadjuvant Radiation Therapy (RT); Magnetic Resonance Imaging (MRI)
Abbreviations: MLS: Myxoid Liposarcoma; RT: Radiation Therapy; MRI: Magnetic Resonance Imaging; CT: computed tomography; LINAC: linear accelerator; IGRT: Image Guided Radiation Therapy; ART: Adaptive Radiation Therapy; BART: Breathing Adapted Radiation Therapy; IMRT: Intensity Modulated Radiation Therapy
Introduction
Liposarcomas constitute a considerable proportion of soft tissue sarcomas [1]. Among the various subtypes of liposarcoma, myxoid liposarcoma (MLS) represents a distinct pathological entity which is characterized by tumor cells within a myxoid stroma with rich, branching thin-walled vasculature, and focal lipomatous differentiation [2-4]. This distinctive subtype of liposarcomas may have a hypercellular round cell component, and a propensity for metastasis to fat bearing areas including the bone marrow, mediastinum, and retroperitoneum may be observed [2-4]. Patients suffering from liposarcomas may present with various symptoms depending on disease location and association with critical neurovascular structures. Surgery, chemotherapy, and radiation therapy (RT) are among the therapeutic options. RT typically plays a major role in the management of soft tissue sarcomas [5]. In the context of MLS management, several studies have addressed the utility of neoadjuvant RT [4,6,7]. Longer life expectancy of patients with MLS with more efficacious treatments rendered quality of life a critical aspect of management. From this standpoint, improving the toxicity profile of radiation delivery has gained utmost priority in the millennium era. Accurate RT target definition comprises an indispensable and critical component of successful MLS management. Within this context, we assessed target definition for neoadjuvant RT of MLS in this original article.
Materials and Methods
A comparative evaluation was performed regarding target definition with multimodality imaging by incorporation of magnetic resonance imaging (MRI) or by computed tomography (CT)-simulation images only for patients receiving neoadjuvant RT for MLS. Ground truth target volume which served as the reference for actual treatment and comparison purposes was meticulously outlined by board certified radiation oncologists after comprehensive assessment, colleague peer review, collaboration, and ultimate consensus. Thorough patient evaluation was performed considering the lesion size, localization, symptomatology, patient preferences, and projected outcomes of management. CT-simulator (GE Lightspeed RT, GE Healthcare, Chalfont St. Giles, UK) was used in RT simulation. Planning CT images were acquired and sent to the contouring workstation (SimMD, GE, UK) via the network for delineation of treatment volumes and critical structures. Either CTsimulation images only or fused CT and MR images were utilized for target volume definition for neoadjuvant RT. Target determination with CT only and with incorporation of CT-MR fusion was evaluated with comparative analysis. Treatment was delivered by use of Synergy (Elekta, UK) linear accelerator (LINAC) with the capability of Image Guided Radiation Therapy (IGRT).
Results
Treatment planning procedure for neoadjuvant radiotherapeutic management of MLS patients was accomplished by the available RT planning systems at our tertiary referral institution. Priorities in RT planning included encompassing of target volumes adequately with optimal sparing of critical structures. Determination of ground truth target volume was performed by the board certified radiation oncologists after meticulous assessment, collaboration, colleague peer review, and ultimate consensus. Synergy (Elekta, UK) LINAC was used for RT administration. Target definition by CT-only imaging and by CT-MR fusion based imaging was assessed with comparative analysis. Ground truth target volume was found to be identical with target volume determination by CT-MR fusion based imaging as the primary endpoint result of the study.
Discussion
Soft tissue sarcomas may be observed at several locations throughout the human body. MLS is a distinct subtype of soft tissue sarcoma with specific features. RT has been utilized for management of MLS with encouraging treatment outcomes [4-7]. Nevertheless, there is room for further progress in management to achieve improved therapeutic ratio. RT planning for MLS is typically based on CT-simulation. CT is a viable imaging modality for initial assessment of disease extent and may provide valuable information for staging. Mineralization and osseous changes along with presence or absence of distant metastases may also be assessed by use of CT. However, initial evaluation of extremity and other superficial soft tissue sarcomas may be superiorly performed by use of MRI. Incorporation of MRI in target definition for neoadjuvant RT of MLS may offer several advantages including improved soft tissue contrast and capability of multiplanar assessment. Artificial intelligence-based applications have facilitated several steps of the RT workflow with excellent image registration, reconstruction, segmentation, and automated planning tools.
Within this context, it has now been easier to exploit the advantages of multimodality imaging in radiotherapeutic management of MLS. Indeed, many studies have investigated incorporation of multimodality imaging in target definition for RT [8-27]. Recently, substantial advances have taken place in the discipline of radiation oncology with introduction of adaptive irradiation strategies and modernized treatment delivery techniques and equipment with incorporation of Adaptive Radiation Therapy (ART), Breathing Adapted Radiation Therapy (BART), Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), automatic segmentation methods, molecular imaging techniques, and stereotactic irradiation approaches [28-63]. With respect to MLS management, studies have addressed the utility of neoadjuvant RT [4-7]. Quality of life a has been a more important endpoint of contemporary management approaches with longer life expectancy of patients by effective therapies. Within this context, improving the toxicity profile of radiation delivery has gained increasing priority in the era of artificial intelligence and state of the art treatment strategies. In conclusion, multimodality imaging should be considered for target definition of MLS for neoadjuvant radiotherapeutic management. Clearly, further studies are warranted to address this issue. There are no conflicts of interest and no acknowledgements.
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