Abstract Background and purpose To assess whether the pretreatment FDG-PET-defined biologic target volume (PET-BTV) correlates with the anatomical sites of loco-regional failure (LRF) after RT for ...head and neck cancer (HNC). Materials and methods We retrospectively identified 61 HNC patients treated definitively with either 3-D CRT or IMRT who had a pre-therapy PET/CT. The GTV and high-risk CTV1 definitions included composite data obtained from diagnostic CT, PET/CT, physical examination, and MRI when available. The median CTV1 dose was 70 Gy. 95% received chemotherapy. For patients with LRF, a recurrence volume ( Vr ) was identified and was mapped to the pretreatment planning CT and pretreatment PET scan. Results At a median follow-up of 22 months, 15% (9/61) patients had LRF. For patients with a LRF, 100% (9/9) of failures were inside the GTV. One of nine 11% (95% CI: 3–45%) had Vr which mapped outside of the pretreatment PET-BTV, while 8/9 patients had Vr within the PET-BTV. Predictors of LRF in our series included GTV volume ( p = 0.003), but not mean SUV ( p = 0.13) or max SUV ( p = 0.25). Conclusions Following treatment in which the GTV was defined based on the composite of imaging and physical examination, the majority, but not all, LRF occurred within the PET-BTV. These results support an important, but not exclusive, role of FDG-PET in defining the GTV.
To quantify cardiac radiation therapy (RT) exposure using sensitive measures of cardiac dysfunction; and to correlate dysfunction with heart doses, in the setting of adjuvant RT for left-sided breast ...cancer.
On a randomized trial, 32 women with node-positive left-sided breast cancer underwent pre-RT stress single photon emission computed tomography (SPECT-CT) myocardial perfusion scans. Patients received RT to the breast/chest wall and regional lymph nodes to doses of 50 to 52.2 Gy. Repeat SPECT-CT scans were performed 1 year after RT. Perfusion defects (PD), summed stress defects scores (SSS), and ejection fractions (EF) were evaluated. Doses to the heart and coronary arteries were quantified.
The mean difference in pre- and post-RT PD was -0.38% ± 3.20% (P=.68), with no clinically significant defects. To assess for subclinical effects, PD were also examined using a 1.5-SD below the normal mean threshold, with a mean difference of 2.53% ± 12.57% (P=.38). The mean differences in SSS and EF before and after RT were 0.78% ± 2.50% (P=.08) and 1.75% ± 7.29% (P=.39), respectively. The average heart Dmean and D95 were 2.82 Gy (range, 1.11-6.06 Gy) and 0.90 Gy (range, 0.13-2.17 Gy), respectively. The average Dmean and D95 to the left anterior descending artery were 7.22 Gy (range, 2.58-18.05 Gy) and 3.22 Gy (range, 1.23-6.86 Gy), respectively. No correlations were found between cardiac doses and changes in PD, SSS, and EF.
Using sensitive measures of cardiac function, no clinically significant defects were found after RT, with the average heart Dmean <5 Gy. Although a dose response may exist for measures of cardiac dysfunction at higher doses, no correlation was found in the present study for low doses delivered to cardiac structures and perfusion, SSS, or EF.
Abstract Although large volumes of information are entered into our electronic health care records, radiation oncology information systems and treatment planning systems on a daily basis, the goal of ...extracting and using this big data has been slow to emerge. Development of strategies to meet this goal is aided by examining issues with a data farming instead of a data mining conceptualization. Using this model, a vision of key data elements, clinical process changes, technology issues and solutions, and role for professional societies is presented. With a better view of technology, process and standardization factors, definition and prioritization of efforts can be more effectively directed.
The looming potential of deformable alignment tools to play an integral role in adaptive radiotherapy suggests a need for objective assessment of these complex algorithms. Previous studies in this ...area are based on the ability of alignment to reproduce analytically generated deformations applied to sample image data, or use of contours or bifurcations as ground truth for evaluation of alignment accuracy. In this study, a deformable phantom was embedded with 48 small plastic markers, placed in regions varying from high contrast to roughly uniform regional intensity, and small to large regional discontinuities in movement. CT volumes of this phantom were acquired at different deformation states. After manual localization of marker coordinates, images were edited to remove the markers. The resulting image volumes were sent to five collaborating institutions, each of which has developed previously published deformable alignment tools routinely in use. Alignments were done, and applied to the list of reference coordinates at the inhale state. The transformed coordinates were compared to the actual marker locations at exhale. A total of eight alignment techniques were tested from the six institutions. All algorithms performed generally well, as compared to previous publications. Average errors in predicted location ranged from
1.5
to
3.9
mm
, depending on technique. No algorithm was uniformly accurate across all regions of the phantom, with maximum errors ranging from
5.1
to
15.4
mm
. Larger errors were seen in regions near significant shape changes, as well as areas with uniform contrast but large local motion discontinuity. Although reasonable accuracy was achieved overall, the variation of error in different regions suggests caution in globally accepting the results from deformable alignment.
For chemotherapy to act synergistically and safely with radiation against high-grade gliomas, drugs must pass the endothelial junctions of the blood-tumor barrier (BTB) to reach all tumor cells, and ...should not pass the blood-brain barrier (BBB) to cause toxicity to normal brain. The objective of this study was to assess BBB/BTB status using magnetic resonance imaging (MRI) during a course of radiotherapy of high-grade gliomas.
Sixteen patients with grade 3 or 4 supratentorial malignant glioma receiving conformal radiotherapy (RT) underwent contrast-enhanced MRI before, during, and after completion of RT. A gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA) uptake index was analyzed with respect to the tumor and RT dose received.
In the nonenhanced tumor region, contrast uptake increased significantly after the receipt of approximately 10 Gy (P < .01), and reached a maximum after the receipt of approximately 30 Gy. In the initially contrast-enhanced tumor region, contrast uptake decreased over the course of RT and became significant after completion of RT in patients without progressive disease. The healthy brain showed only nonsignificant changes during and after irradiation.
Contrast MRI reveals increases in Gd-DTPA uptake in the initially nonenhanced tumor region but not in the remaining brain during the course of RT, suggesting opening of the BTB. This finding suggests that the effect of conformal radiation is more selective on the BTB than the BBB, and there may be a window extending from 1 week after the initiation of radiotherapy to 1 month after the completion of treatment during which a pharmaceutical agent has maximum access to high-grade gliomas.
To reduce cardiotoxicity from breast radiotherapy (RT), innovative techniques are under investigation. Information about cardiac motion with respiration and positional reproducibility under active ...breathing control (ABC) is necessary to evaluate these techniques.
Patients requiring loco-regional RT for breast cancer were scanned by computed tomography using an ABC device at various breath-hold states, before and during treatment. Ten patients were studied. For each patient, 12 datasets were analyzed. Mutual information-based regional rigid alignment was used to determine the magnitude and reproducibility of cardiac motion as a function of breathing state. For each scan session, motion was quantified by evaluating the displacement of a point along the left anterior descending artery (LAD) with respect to its position at end expiration. Long-term positional reproducibility was also assessed.
Displacement of the LAD was greatest in the inferior direction, moderate in the anterior direction, and lowest in the left-right direction. At shallow breathing states, the average displacement of LAD position was up to 6 mm in the inferior direction. The maximum displacement in any patient was 2.8 cm in the inferior direction, between expiration and deep-inspiration breath hold. At end expiration, the long-term reproducibility (SD) of the LAD position was 3 mm in the A-P, 6 mm in the S-I, and 4 mm in the L-R directions. At deep-inspiration breath hold, long-term reproducibility was 3 mm in the A-P, 7 mm in the S-I, and 3 mm in the L-R directions.
These data demonstrate the extent of LAD displacement that occurs with shallow breathing and with deep-inspiration breath hold. This information may guide optimization studies considering the effects of respiratory motion and reproducibility of cardiac position on cardiac dose, both with and without ABC.
Improving treatment plan evaluation with automation Covington, Elizabeth L.; Chen, Xiaoping; Younge, Kelly C. ...
Journal of applied clinical medical physics,
11/2016, Letnik:
17, Številka:
6
Journal Article
Recenzirano
Odprti dostop
The goal of this work is to evaluate the effectiveness of Plan‐Checker Tool (PCT) which was created to improve first‐time plan quality, reduce patient delays, increase the efficiency of our ...electronic workflow, and standardize and automate the physics plan review in the treatment planning system (TPS). PCT uses an application programming interface to check and compare data from the TPS and treatment management system (TMS). PCT includes a comprehensive checklist of automated and manual checks that are documented when performed by the user as part of a plan readiness check for treatment. Prior to and during PCT development, errors identified during the physics review and causes of patient treatment start delays were tracked to prioritize which checks should be automated. Nineteen of 33 checklist items were automated, with data extracted with PCT. There was a 60% reduction in the number of patient delays in the six months after PCT release. PCT was successfully implemented for use on all external beam treatment plans in our clinic. While the number of errors found during the physics check did not decrease, automation of checks increased visibility of errors during the physics check, which led to decreased patient delays. The methods used here can be applied to any TMS and TPS that allows queries of the database.
PACS number(s): 87.55.‐x, 87.55.N‐, 87.55.Qr, 87.55.tm, 89.20.Bb
The purpose of this study was to investigate the feasibility of a simple deformable phantom as a QA tool for testing and validation of deformable image registration algorithms. A diagnostic thoracic ...imaging phantom with a deformable foam insert was used in this study. Small plastic markers were distributed through the foam to create a lattice with a measurable deformation as the ground truth data for all comparisons. The foam was compressed in the superior-inferior direction using a one-dimensional drive stage pushing a flat “diaphragm” to create deformations similar to those from inhale and exhale states. Images were acquired at different compressions of the foam and the location of every marker was manually identified on each image volume to establish a known deformation field with a known accuracy. The markers were removed digitally from corresponding images prior to registration. Different image registration algorithms were tested using this method. Repeat measurement of marker positions showed an accuracy of better than
1
mm
in identification of the reference marks. Testing the method on several image registration algorithms showed that the system is capable of evaluating errors quantitatively. This phantom is able to quantitatively assess the accuracy of deformable image registration, using a measure of accuracy that is independent of the signals that drive the deformation parameters.
The advent of dynamic radiotherapy modeling and treatment techniques requires an infrastructure to weigh the merits of various interventions (breath holding, gating, tracking). The creation of ...treatment planning models that account for motion and deformation can allow the relative worth of such techniques to be evaluated. In order to develop a treatment planning model of a moving and deforming organ such as the lung, registration tools that account for deformation are required. We tested the accuracy of a mutual information based image registration tool using thin-plate splines driven by the selection of control points and iterative alignment according to a simplex algorithm. Eleven patients each had sequential CT scans at breath-held normal inhale and exhale states. The exhale right lung was segmented from CT and served as the reference model. For each patient, thirty control points were used to align the inhale CT right lung to the exhale CT right lung. Alignment accuracy (the standard deviation of the difference in the actual and predicted inhale position) was determined from locations of vascular and bronchial bifurcations, and found to be 1.7, 3.1, and
3.6
mm
about the RL, AP, and IS directions. The alignment accuracy was significantly different from the amount of measured movement during breathing only in the AP and IS directions. The accuracy of alignment including thin-plate splines was more accurate than using affine transformations and the same iteration and scoring methodology. This technique shows promise for the future development of dynamic models of the lung for use in four-dimensional (4-D) treatment planning.
In this study we investigated the accumulation of dose to a deforming anatomy (such as lung) based on voxel tracking and by using time weighting factors derived from a breathing probability ...distribution function (p.d.f.). A mutual information registration scheme (using thin-plate spline warping) provided a transformation that allows the tracking of points between exhale and inhale treatment planning datasets (and/or intermediate state scans). The dose distributions were computed at the same resolution on each dataset using the Dose Planning Method (DPM) Monte Carlo code. Two accumulation/interpolation approaches were assessed. The first maps exhale dose grid points onto the inhale scan, estimates the doses at the “tracked” locations by trilinear interpolation and scores the accumulated doses (via the p.d.f.) on the original exhale data set. In the second approach, the “volume” associated with each exhale dose grid point (exhale dose voxel) is first subdivided into octants, the center of each octant is mapped to locations on the inhale dose grid and doses are estimated by trilinear interpolation. The octant doses are then averaged to form the inhale voxel dose and scored at the original exhale dose grid point location. Differences between the interpolation schemes are voxel size and tissue density dependent, but in general appear primarily only in regions with steep dose gradients (e.g., penumbra). Their magnitude (small regions of few percent differences) is less than the alterations in dose due to positional and shape changes from breathing in the first place. Thus, for sufficiently small dose grid point spacing, and relative to organ motion and deformation, differences due solely to the interpolation are unlikely to result in clinically significant differences to volume-based evaluation metrics such as mean lung dose (MLD) and tumor equivalent uniform dose (gEUD). The overall effects of deformation vary among patients. They depend on the tumor location, field size, volume expansion, tissue heterogeneity, and direction of tumor displacement with respect to the beam, and are more likely to have an impact on serial organs (such as esophagus), rather than on large parallel organs (such as lung).
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