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Item Artificial Intelligence in magnetic Resonance guided Radiotherapy: Medical and physical considerations on state of art and future perspectives(ELSEVIER SCI LTD, 2021-01-01) Cusumano, Davide; Boldrini, Luca; Dhont, Jennifer; Fiorino, Claudio; Green, Olga; Gungor, Gorkem; Jornet, Nuria; Klueter, Sebastian; Landry, Guillaume; Mattiucci, Gian Carlo; Placidi, Lorenzo; Reynaert, Nick; Ruggieri, Ruggero; Tanadini-Lang, Stephanie; Thorwarth, Daniela; Yadav, Poonam; Yang, Yingli; Valentini, Vincenzo; Verellen, Dirk; Indovina, LucaOver the last years, technological innovation in Radiotherapy (RT) led to the introduction of Magnetic Resonance-guided RT (MRgRT) systems. Due to the higher soft tissue contrast compared to on-board CT-based systems, MRgRT is expected to significantly improve the treatment in many situations. MRgRT systems may extend the management of inter- and intra-fraction anatomical changes, offering the possibility of online adaptation of the dose distribution according to daily patient anatomy and to directly monitor tumor motion during treatment delivery by means of a continuous cine MR acquisition. Online adaptive treatments require a multidisciplinary and well-trained team, able to perform a series of operations in a safe, precise and fast manner while the patient is waiting on the treatment couch. Artificial Intelligence (AI) is expected to rapidly contribute to MRgRT, primarily by safely and efficiently automatising the various manual operations characterizing online adaptive treatments. Furthermore, AI is finding relevant applications in MRgRT in the fields of image segmentation, synthetic CT reconstruction, automatic (on-line) planning and the development of predictive models based on daily MRI. This review provides a comprehensive overview of the current AI integration in MRgRT from a medical physicist's perspective. Medical physicists are expected to be major actors in solving new tasks and in taking new responsibilities: their traditional role of guardians of the new technology implementation will change with increasing emphasis on the managing of AI tools, processes and advanced systems for imaging and data analysis, gradually replacing many repetitive manual tasks.Item Management of symptomatic radiation necrosis after stereotactic radiosurgery and clinical factors for treatment response(KOREAN SOC THERAPEUTIC RADIOLOGY \& ONCOLOGY, 2020-01-01) Sayan, Mutlay; Mustafayev, Teuta Zoto; Balmuk, Aykut; Mamidanna, Swati; Kefelioglu, Erva Seyma Sare; Gungor, Gorkem; Chundury, Anupama; Ohri, Nisha; Karaarslan, Ercan; Ozyar, Enis; Atalar, BanuPurpose: Approximately 10\% of patients who received brain stereotactic radiosurgery (SRS) develop symptomatic radiation necrosis (RN). We sought to determine the effectiveness of treatment options for symptomatic RN, based on patient-reported outcomes. Materials and Methods: We conducted a retrospective review of 217 patients with 414 brain metastases treated with SRS from 2009 to 2018 at our institution. Symptomatic RN was determined by appearance on serial magnetic resonance images (MRIs), MR spectroscopy, requirement of therapy, and development of new neurological complaints without evidence of disease progression. Therapeutic interventions for symptomatic RN included corticosteroids, bevacizumab and/or surgical resection. Patient-reported therapeutic outcomes were graded as complete response (CR), partial response (PR), and no response. Results: Twenty-six patients experienced symptomatic RN after treatment of 50 separate lesions. The mean prescription dose was 22 Gy (range, 15 to 30 Gy) in 1 to 5 fractions (median, 1 fraction). Of the 12 patients managed with corticosteroids, 6 patients (50\%) reported CR and 4 patients (33\%) PR. Of the 6 patients managed with bevacizumab, 3 patients (50\%) reported CR and 1 patient (18\%) PR. Of the 8 patients treated with surgical resection, all reported CR (100\%). Other than surgical resection, age >= 54 years (median, 54 yearsItem Long-term toxicity and survival outcomes after stereotactic ablative radiotherapy for patients with centrally located thoracic tumors(WALTER DE GRUYTER GMBH, 2020-01-01) Atalar, Banu; Mustafayev, Teuta Zoto; Sio, Terence T.; Sahin, Bilgehan; Gungor, Gorkem; Aydin, Gokhan; Yapici, Bulent; Ozyar, EnisBackground. Stereotactic ablative radiotherapy (SABR) is effective for thoracic cancer and metastasesItem Intensity modulated radiotherapy (IMRT) in bilateral retinoblastoma(ASSOC RADIOLOGY \& ONCOLOGY, 2010-01-01) Atalar, Banu; Ozyar, Enis; Gunduz, Kaan; Gungor, GorkemBackground. External beam radiotherapy (EBRT) for retinoblastoma has traditionally been done with conventional radiotherapy techniques which resulted high doses to the surrounding normal tissues. Case report. A 20 month-old girl with group D bilateral retinoblastoma underwent intensity modulated radiotherapy (IMRT) to both eyes after failing chemoreduction and focal therapies including cryotherapy and transpupillary thermotherapy. In this report, we discuss the use of IMRT as a method for reducing doses to adjacent normal tissues while delivering therapeutic doses to the tumour tissues compared with 3-dimensional conformal radiotherapy (3DCRT). At one year follow-up, the patient remained free of any obvious radiation complications. Conclusions. Image guided IMRT provides better dose distribution than 3DCRT in retinoblastoma eyes, delivering the therapeutic dose to the tumours and minimizing adjacent tissue damage.Item Magnetic Resonance Imaging-Guided Online Adaptive Lattice Stereotactic Body Radiotherapy in Voluminous Liver Metastasis: Two Case Reports(CUREUS INC, 2022-01-01) Dincer, Neris; Ugurluer, Gamze; Korkmaz, Latif; Serkizyan, Anatolia; Atalar, Banu; Gungor, Gorkem; Ozyar, EnisLattice Radiotherapy (LRT) is a technique in which heterogeneous doses are delivered to the target so large tumors can have optimal doses of radiation without compromising healthy tissue sparing. lb date, case reports and case series documented its application for bulky tumors mainly in the pelvic region. LRT not only provides dosimetric advantages but also promotes tumor control by triggering some radiobiological and immunological pathways. We report two cases of giant liver metastases for whom other treatment options were not suitable. We treated both patients with Magnetic Resonance Image-Guided Radiotherapy (MRgRT) with online adaptive LRT (OALRT) technique. Adaptive plans were generated before each fraction. Tumors were observed to have regressed interfractionally so the location and number of spheres were adapted to tumor size and daily anatomy of the surrounding organs at risk (OAR). Both patients had good treatment compliance without any Grade 3+ side effects. They are both under follow-up and report improvement. By reporting the first application of OALRT by using MRgRT in liver metastases, we show that MRgRT is a promising modality for LRT technique with better target and OAR visualization as well as online adaptive planning before each fraction according to the daily anatomy of the patient.Item Multichannel Film Dosimetry for Quality Assurance of Intensity Modulated Radiotherapy Treatment Plans Under 0.35 T Magnetic Field(CUREUS INC, 2020-01-01) Gungor, Gorkem; Korkmaz, Latif; Kayalilar, Namik; Aydin, Gokhan; Yapici, Bulent; Mustafayev, Teuta Zoto; Atalar, Banu; Ozyar, EnisPurpose To evaluate the intensity modulated radiotherapy (IMRT) quality assurance (OA) results of the multichannel film dosimetry analysis with single scan method by using Gafchromic (TM) EBT3 (Ashland Inc., Covington, KY, USA) film under 0.35 T magnetic field. Methods Between September 2018 and June 2019, 70 patients were treated with ViewRay MRldian (R) (ViewRay Inc., Mountain View, CA) linear accelerator (Linac). Film dosimetry OA plans were generated for all IMRT treatments. Multichannel film dosimetry for red, green and blue (RGB) channels were compared with treatment planning system (TPS) dose maps by gamma evaluation analysis. Results The mean gamma passing rates of RGB channels are 97.3\% +/- 2.26\%, 96.0\% +/- 3.27\% and 96.2\% +/- 3.14\% for gamma evaluation with 2\% DD/2 mm distance to agreement (DTA), respectively. Moreover, the mean gamma passing rates of RGB channels are 99.7\% +/- 0.41\%, 99.6\% +/- 0.59\% and 99.5\% +/- 0.67\% for gamma evaluation with 3\% DD/3 mm DTA, respectively. Conclusion The patient specific QA using Gafchromic (TM) EBT3 film with multichannel film dosimetry seems to he a suitable tool to implement for MR-guided IMRT treatments under 0.35 T magnetic field. Multichannel film dosimetry with Gafchromic (TM) EBT3 is a consistent QA tool for gamma evaluation of the treatment plans even with 2\% DD/2 mm DTA under 0.35 T magnetic field presence.Item Evaluation of response to stereotactic radiosurgery in patients with radioresistant brain metastases(KOREAN SOC THERAPEUTIC RADIOLOGY \& ONCOLOGY, 2019-01-01) Sayan, Mutlay; Mustafayev, Teuta Zoto; Sahin, Bilgehan; Kefelioglu, Erva Seyma Sare; Wang, Shang-Jui; Kurup, Varsha; Balmuk, Aykut; Gungor, Gorkem; Ohri, Nisha; Weiner, Joseph; Ozyar, Enis; Atalar, BanuPurpose: Renal cell carcinoma (RCC) and melanoma have been considered `radioresistant' due to the fact that they do not respond to conventionally fractionated radiation therapy. Stereotactic radiosurgery (SRS) provides high-dose radiation to a defined target volume and a limited number of studies have suggested the potential effectiveness of SRS in radioresistant histologies. We sought to determine the effectiveness of SRS for the treatment of patients with radioresistant brain metastases. Materials and Methods: We performed a retrospective review of our institutional database to identify patients with RCC or melanoma brain metastases treated with SRS. Treatment response were determined in accordance with the Response Evaluation Criteria in Solid Tumors. Results: We identified 53 radioresistant brain metastases (28\% RCC and 72\% melanoma) treated in 18 patients. The mean target volume and coverage was 6.2 +/- 9.5 mL and 95.5\% +/- 2.9\%, respectively. The mean prescription dose was 20 +/- 4.9 Gy. Forty lesions (75\%) demonstrated a complete/partial response and 13 lesions (24\%) with progressive/stable disease. Smaller target volume (p < 0.001), larger SRS dose (p < 0.001), and coverage (p = 0.008) were found to be positive predictors of complete response to SRS. Conclusion: SRS is an effective management option with up to 75\% response rate for radioresistant brain metastases. Tumor volume and radiation dose are predictors of response and can be used to guide the decision-making for patients with radioresistant brain metastases.Item Magnetic Resonance Image-Guided Hypofractionated Ablative Radiation Therapy for Hepatocellular Carcinoma With Tumor Thrombus Extending to the Right Atrium(CUREUS INC, 2022-01-01) Dincer, Neris; Ugurluer, Gamze; Mustafayev, Teuta Zoto; Gungor, Gorkem; Atalar, Banu; Guven, Koray; Ozyar, EnisHepatocellular carcinoma (HCC) presenting with tumor thrombus and inferior vena cave (IVC)/right atrium (RA) infringement point to an advanced-stage disease that is deemed inoperable. Stereotactic body radiotherapy is an emerging treatment option for this group of patients with promising outcomes in recent studies that are comparable to conventional treatment methods, namely, transarterial chemoembolization and transarterial radioembolization. Here, we report a case of HCC with RA extension through the IVC. The patient was referred to our clinic for treatment options, and he was found suitable for magnetic resonance imaging-guided radiotherapy (MRgRT). We treated the patient with MRgRT in five fractions to a total dose of 40 Gray. The tumor was tracked during the treatment sessions, and adaptive treatment planning was performed before each fraction. The patient tolerated the treatment well with no acute grade 3-4 toxicities. The last follow-up showed that the patient had a complete biochemical response and is now a candidate for an orthotopic liver transplant. To our knowledge, this report is the first to document the MRgRT treatment of an HCC with TT and RA extension. MRgRT is safe and feasible for this patient group and can be an effective bridging therapy for liver transplants.Item Magnetic Resonance Imaging-Guided Radiation Therapy for Early-Stage Gastric Mucosa-Associated Lymphoid Tissue Lymphoma(CUREUS INC, 2022-01-01) Dincer, Neris; Ugurluer, Gamze; Gungor, Gorkem; Mustafayev, Teuta Zoto; Atalar, Banu; Ozyar, EnisLymphoid neoplasia derived from mucosa-associated lymphoid tissue (MALTItem First 500 Fractions Delivered with a Magnetic Resonance-guided Radiotherapy System: Initial Experience(CUREUS INC, 2019-01-01) Sahin, Bilgehan; Mustafayev, Teuta Zoto; Gungor, Gorkem; Aydin, Gokhan; Yapici, Bulent; Atalar, Banu; Ozyar, EnisObjectives Improved soft-tissue visualization, afforded by magnetic resonance imaging integrated into a radiation therapy linear accelerator-based radiation delivery system (MR-linac) promises improved image-guidance. The availability of MR-imaging can facilitate on-table adaptive radiation planning and enable real-time intra-fraction imaging with beam gating without additional exposure to radiation. However, the novel use of magnetic resonance-guided radiation therapy (MRgRT) in the field of radiation oncology also potentially poses challenges for routine clinical implementation. Herein the early experience of a single institution, implementing the first MRgRT system in the country is reported. We aim to describe the workflow and to characterize the clinical utility and feasibility of routine use of an MR-linac system. Methods The ViewRay MRIdian MR-linac system consists of a split-magnet 0.35 T MR-imaging scanner with a double focused multi-leaf collimator (MLC) equipped 6MV linear accelerator. Unique to the system are the control console integrated on-table adaptive radiation therapy (oART) planning capabilities as well as automated beam gating based on real-time intra-fraction MR imaging. From the first day of clinical implementation, oART was performed according to physicians' discretion when medically indicated. All fractions were delivered under real-time imaging with soft tissue-based automated beam gating with individualized gating boundary settings. Patients actively assisted in breath-hold beam gating with the help of custom designed prismatic glasses allowing sight of a computer monitor mounted on the back wall just behind the MRI system bore. Patient demographics and treatment experience, indications for MRgRT including diagnosis and disease site, radiation dose prescribed and fractionation scheme, utilization of oART, respiratory gating settings, as well as duration of each treatment phase were analyzed. Results Between September 2018 and May 2019, 72 patients with 84 tumor sites were treated with MRgRT in 500 total fractions. Median patient age was 66 years (range: 28-83 years). Among 84 tumor sites, the most frequently treated regions were upper abdominal and pelvic (n = 36, 43\% and n = 29, 34\%, respectively). The most common diagnosis was prostate cancer, with 14 patients treated. In 69 patients (93.2\%) oART was used at least once during a treatment course. Twenty-nine targets (43.1\%) with significant breathing-related motion were treated in breath-hold with patient visual feedback. Median prescribed dose was 36.25 Gy (range: 24-70 Gy) in median five fractions (range: 3-28 fractions). A gating boundary of 3 mm around a gating region of interest (gROI) was most commonly used (range: 3-5 mm) with 95\% of the gROI (range: 93-97\%) required to be within the gating boundary for the beam to automatically engage. Mean total treatment time was 47 min (range: 21-125 min) and mean beam-on time was 16.7 min (range: 6-62 min). Conclusions MRgRT afforded by an MR-linac system has been successfully implemented into routine clinical use at our institution as the first system of its kind in Turkey. While the overall number of patients treated and fractions delivered is still limited, we have demonstrated the feasibility of both on-table adaptive radiation therapy as well as automated real-time beam gating on a daily basis in acceptable time schedules.