Practical applications of Beam's Eye View-based treatment planning to head and neck sites

Intensity modulation technique using the complementary boost-fields for ethmoid sinus cancer

PURPOSE

To explore a static intensity-modulated radiation therapy (IMRT) technique of a more homogeneous isodose distribution to an irregular-shaped tumour of the ethmoid sinus, with concomitantly sparing the adjacent critical normal organs including the orbit.

METHODS AND MATERIALS

We conducted a static IMRT technique adding 2 or smaller complementary boost-fields to the underdosed volume in the PTV, which resulted from complete blocking of the orbits in all coplanar or non-coplanar main ports of the standard 3-D CRT. The standard 3-D CRT plans (Plan A) and IMRT plans adding complementary boost fields (Plan B) were established for 10 patients with ethmoid sinus cancer. Two sets of different plans for each patient were compared using isodose distribution, dose statistics, and dose volume histogram (DVH) of the planning target volume (PTV) and also using dose statistics and DVH of the adjacent critical structures.

RESULTS

The IMRT plans adding 2 or more complementary boost-fields (Plan B) for each patient demonstrated better coverage and improved dose homogeneity of the PTV compared to the standard 3-D CRT plan (Plan A). Moreover, the radiation doses to adjacent normal tissue organs, such as the orbits, optic nerves, brain stem and optic chiasm were similarly spared in both plans.

CONCLUSION

With concomitantly sparing the surrounding visual pathway structures, our IMRT technique using the complementary boost-fields was quantitatively better than current standard 3-D CRT technique with respect to the dose homogeneity within the PTV. Therefore, we believe that our technique, though still not ideal, is thorough enough to be used routinely in treatment of ethmoid sinus tumour.

A structure map as a visualization aid in three-dimensional treatment planning

Conventional 2-dimensional (2D) radiotherapy planning is performed with sets of beams oriented with respect to axial computed tomography (CT) slices containing relevant anatomical information. In general, the central axis of each beam will be constrained to lie in the plane of a particular CT slice. Further constraining the set of beams to coplanar geometry coincident with a single CT slice (the central slice) allows simultaneous visualization of all possible beam orientations with respect to both the target volume and critical structures as represented on the central CT slice. This is possible due to the existence of noncoplanar viewing orientations. In general, a viewing orientation orthogonal to the plane of the CT slices is chosen. Three-dimensional (3D) modeling removes the beam orientation constraints associated with 2D planning, thus allowing greater flexibility in treatment design. It is, in general, no longer possible to identify a single physical plane upon which one may simultaneously view all possible beam orientations. Construction of a virtual orthogonal hyperplane provides a flat surface upon which critical structures may be mapped with respect to all possible beam orientations, thus creating a medium for simultaneous viewing as an aid to 3D treatment plan design.

The development of target-eye-view maps for selection of coplanar or noncoplanar beams in conformal radiotherapy treatment planning

Three-dimensional conformal radiotherapy allows the use of tightly conformed, multiple coplanar or noncoplanar beams. However, visualizing the spatial relationships between the target volume and adjacent critical structures is not always obvious or intuitive. Tools such as beam's eye view (BEV) have aided in this process and been very useful. In this study, a target-eye-view (TEV) map is developed as a functional extension of BEVs. The TEV map for a critical structure is created by checking the BEVs for all gantries and table rotations. For each possible BEV, the amount of overlap between the planning target volume (PTV) and the organ at risk (OAR) is determined. This information is presented in a Mercator spherical map, where the color tone indicates the amount of overlap between the PTV and the OAR. A composite TEV map is then created by summing the TEV grading scores for all OARs. The composite map shows beam orientations with the most overlap being light and the least overlap being dark, thus simplifying the selection of appropriate beam angles. The accuracy of the TEV maps has been confirmed separately with corresponding BEVs generated by a three-dimensional treatment planning system.

[Practice of virtual simulation at the Saint-André hospital]

PURPOSE

Prospective evaluation of a virtual simulation technique.

PATIENTS AND METHODS

From September 1993 to February 1997, 343 patients underwent radiation therapy using this technique. Treated sites were mostly: brain (132), rectum (59), lung (43), and prostate (28). A CT-scan was performed on a patient in treatment position. Twenty-five to 70 jointive slices widely encompassed the treated volume. The target volume (CTV according to ICRU 50) and often critical organs were controured, slice by slice, by the radiation oncologist. Beams covering the CTV plus a security margin (PTV) were placed on the "virtual patient". Digital radiographs were reconstructed (DRR) as simulator radiographs for each field. Thus, the good coverage of PTV was assessed. Fields and beam arrangements were further optimized. Definitive isocenter was then placed using a classical simulator. Perfect matching of DRR and actual simulator radiographs had to be obtained.

RESULTS

Nineteen patients presented grade 3, and 1 grade 4 acute radiation effects. With a median follow-up of 18 months, five patients suffered from grade 3, and one from grade 4 complications. Fifty-five patients had tumor recurrence in the treated volume, and 19 had marginal relapse.

CONCLUSION

In our department, virtual simulation has become a routine technique of treatment planning for deep-seated tumors. This technique remains time-consuming for radiation oncologists: about 2 hours. But it stimulates reflexion on anatomy, tumor extension pathways, target volumes; and is becoming an excellent pedagogical tool.

An analysis of image segmentation time in beam's-eye-view treatment planning

In this work we tabulate and histogram the image segmentation time for beam's eye view (BEV) treatment planning in our center. The average time needed to generate contours on CT images delineating normal structures and treatment target volumes is calculated using a data base containing over 500 patients' BEV plans. The average number of contours and total image segmentation time needed for BEV plans in three common treatment sites, namely, head/neck, lung/chest, and prostate, were estimated.

Beam's eye view volumetrics: an aid in rapid treatment plan development and evaluation

A well-designed treatment plan fully irradiates the target to the prescribed dose while minimizing radiation to adjacent critical structures. Beam's eye view is an important component of treatment planning systems because it provides the operator with tools needed to achieve this goal. Through interactive manipulation of displays, the planner uses beam's eye view to adequately cover the target volume while geometrically avoiding certain critical, normal structures. A factor not considered in current beam's eye view programs is the fractional volume of each structure irradiated given a specified beam direction. We have incorporated a rapid volume calculation capability in our beam's eye view program, and have applied it to provide a quantitative aid to treatment planning development and evaluation. Treatment planning of lung tumors has been studied using this tool. Volumes of lung and spinal cord treated as a function of portal angle may be calculated much more rapidly than dose volume histograms and yet provide quantitative indices which follow the trends of dose volume histograms as a function of field angle. Plots of normal tissue volume irradiated as a function of field angle identify the optimal angle to minimize irradiated volume of a structure at a glance. For multiple field plans, a bitmap approach identifies areas treated by various combinations of beams. Volumetrics combined with beam's eye view are useful in treatment planning because they (a) provide quantitative information needed in choosing and optimizing portal entry angle (b) provide an interactive approach to understanding the relative merits of different multiple field plans and (c) complement the information provided by the more time consuming generation of dose volume histograms. The clinical application of this tool in treatment planning is presented.