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Shimomura A, Wu T, Rusu I, Kishan AU, Tree AC, Solanki AA, Liauw SL. Monitoring Intrafraction Motion of the Prostate During Radiation Therapy: Suggested Practice Points From a Focused Review. Pract Radiat Oncol 2024; 14:146-153. [PMID: 37875222 DOI: 10.1016/j.prro.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE External beam radiation therapy to the prostate is typically delivered after verification of prostatic position with image guidance. Prostate motion can occur during the delivery of each radiation treatment between the time of localization imaging and completion of treatment. The objective of this work is to review the literature on intrafraction motion (IFM) of the prostate during radiation therapy and offer clinical recommendations on management. METHODS AND MATERIALS A comprehensive literature review was conducted on prostate motion during prostate cancer radiation therapy. Information was organized around 3 key clinical questions, followed by an evidence-based recommendation. RESULTS IFM of the prostate during radiation therapy is typically ≤3 mm and is unlikely to compromise prostate dosimetry to a clinically meaningful degree for men treated in a relatively short treatment duration with planning target volume (PTV) margins of ≥3 to 5 mm. IFM of 5 mm or more has been observed in up to ∼10% of treatment fractions, with limited dosimetric effect related to the infrequency of occurrence and longer fractionation of therapy. IFM can be monitored in continuous or discontinuous fashion with a variety of imaging platforms. Correction of IFM may have the greatest value when tighter PTV margins are desired (such as with stereotactic body radiation therapy or intraprostatic nodule boosting), ultrahypofractionated courses, or when treatment time exceeds several minutes. CONCLUSIONS This focused review summarizes literature and provides practical recommendations regarding IFM in the treatment of prostate cancer with external beam radiation therapy.
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Affiliation(s)
- Aoi Shimomura
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Tianming Wu
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Iris Rusu
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois.
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Rao X, Liu H, Zhang Y, Xie Y, Wang G, Zhang S, Wu G, Wang Y, Zhou R. The relationship of body mass index to setup errors, dosimetric parameters and incidence of radiation pneumonitis in non-small cell lung cancer patients undergoing intensity-modulated radiation therapy: a single-center observational study. Int J Radiat Biol 2024; 100:248-255. [PMID: 37747796 DOI: 10.1080/09553002.2023.2261549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The relationship among body mass index (BMI), setup error and radiation pneumonitis is not clearly illustrated. OBJECTIVE The present study aimed to investigate the role of BMI in non-small cell lung cancer (NSCLC) patients' radiation treatment, focusing on its relationship with setup error of patient positioning, the dosimetric parameters of intensity-modulated radiation therapy (IMRT) and the incidence of radiation pneumonitis. METHODS This prospective observational study included 523 cases of NSCLC patients during 2020-2022. Patients were divided into different groups by different BMI. The setup error was obtained by cone beam CT (CBCT) at three positions, lateral (LAT), longitudinal (LNG) and vertical (VRT). IMRT dosimetric parameters of V5, V20, and mean dose were collected. RESULTS Patients with BMI ≥28 kg/m2 showed significantly higher absolute values of LAT, LNG and VRT, higher V5, V20, mean dose, as well as higher total incidence of radiation pneumonitis and grade III radiation pneumonitis compared with patients with BMI <24 kg/m2 or 24-28 kg/m2. Spearman's analysis demonstrated that the absolute values of LAT, LNG and VRT were positively correlated with BMI, and positive correlation existed among BMI, dosimetric parameters and setup errors. ROC curves showed that LAT in setup errors and V5 in dosimetric parameters had the best diagnostic value for prediction of radiation pneumonitis. Only BMI, LAT, V5 and V20 were the independent risk factors for radiation pneumonitis. CONCLUSIONS Setup error caused by higher BMI might be associated with the dosimetric parameters, as well as the incidence of radiation pneumonitis in NSCLC patients.
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Affiliation(s)
- Xinrui Rao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Hongyuan Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Yuewen Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Yaqiong Xie
- Oncology Department, Jianli People's Hospital, Jingzhou, PR China
| | - Geng Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Gang Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Ye Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Rui Zhou
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
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Sakurai T, Takamatsu S, Shibata S, Minamikawa R, Yamazaki M, Kojima H, Noto K, Makino T, Kawaguchi S, Nohara T, Mizokami A, Gabata T. Factors Affecting Prostate Displacement During Volumetric Modulated Arc Therapy in Prone Position After High-Dose-Rate Brachytherapy for Prostate Cancer. Adv Radiat Oncol 2023; 8:101277. [PMID: 38047223 PMCID: PMC10692303 DOI: 10.1016/j.adro.2023.101277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/17/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose In irradiating the prostate and pelvic lymph node regions, registration based on bony structures matches the pelvic lymph node regions but not necessarily the prostate position, and it is important to identify factors that influence prostate displacement. Therefore, we investigated factors influencing prostate displacement during volumetric modulated arc therapy after single-fraction high-dose-rate brachytherapy (HDR-BT) for prostate cancer and the trends in displacement for each fraction. Methods and Materials Seventy patients who underwent pelvic volumetric modulated arc therapy of 46 Gy in the prone position 15 days after 13 Gy HDR-BT were included. Prostate displacement relative to bony structures was calculated using cone beam computed tomography. Systematic error (SE) and random error (RE) were evaluated in the right-left (RL), craniocaudal (CC), and anteroposterior (AP) directions. The association with clinical and anatomic factors on the planning computed tomography or magnetic resonance imaging was analyzed. Prostate volume change (PVC) was defined as the volume change at 2 days after HDR-BT. Displacement trends were individually examined from the first to 23rd fractions. Results The mean SE in the RL, CC, and AP directions was -0.01 mm, -2.34 mm, and -0.47 mm, respectively. The root mean square of the RE in the RL, CC, and AP directions was 0.44 mm, 1.14 mm, and 1.10 mm, respectively. SE in the CC direction was independently associated with bladder volume (P = .021, t statistic = 2.352) and PVC (P < .001, t statistic = -8.526). SE in the AP direction was independently associated with bladder volume (P = .013, t statistic = -2.553), PVC (P < .001, t statistic = 5.477), and rectal mean area (P = .008, t statistic = 2.743). RE in the CC direction was independently associated with smoking (P = .035). RE in the AP direction was associated with PVC (P = .043). Gradual displacement caudally and posteriorly occurred during the irradiation period. Conclusions Anatomic characteristics of the bladder, rectum, and prostate predict SE. Smoking and PVC predict RE. In particular, whether PVC is ≥140% affects setting internal margins.
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Affiliation(s)
- Takayuki Sakurai
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shigeyuki Takamatsu
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Satoshi Shibata
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Risako Minamikawa
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Masahiro Yamazaki
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hironori Kojima
- Department of Radiology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Kimiya Noto
- Department of Radiology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Tomoyuki Makino
- Department of Integrative Cancer Therapy and Urology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shohei Kawaguchi
- Department of Integrative Cancer Therapy and Urology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takahiro Nohara
- Department of Integrative Cancer Therapy and Urology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Atsushi Mizokami
- Department of Integrative Cancer Therapy and Urology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Toshifumi Gabata
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
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Rose C, Ebert MA, Mukwada G, Skorska M, Gill S. Intrafraction motion during CyberKnife® prostate SBRT: impact of imaging frequency and patient factors. Phys Eng Sci Med 2023; 46:669-685. [DOI: 10.1007/s13246-023-01242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
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Ghadjar P, Fiorino C, Munck Af Rosenschöld P, Pinkawa M, Zilli T, van der Heide UA. ESTRO ACROP consensus guideline on the use of image guided radiation therapy for localized prostate cancer. Radiother Oncol 2019; 141:5-13. [PMID: 31668515 DOI: 10.1016/j.radonc.2019.08.027] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022]
Abstract
Use of image-guided radiation therapy (IGRT) helps to account for daily prostate position changes during radiation therapy for prostate cancer. However, guidelines for the use of IGRT are scarce. An ESTRO panel consisting of leading radiation oncologists and medical physicists was assembled to review the literature and formulate a consensus guideline of methods and procedure for IGRT in prostate cases. Advanced methods and procedures are also described which the committee judged relevant to further improve clinical practice. Moreover, ranges for margins for the three most popular IGRT scenarios have been suggested as examples.
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Affiliation(s)
- Pirus Ghadjar
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Germany
| | - Claudio Fiorino
- Department of Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Per Munck Af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Switzerland
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiation Oncology, Leiden University Medical Center, The Netherlands.
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Brown A, Tan A, Cooper S, Fielding A. Obesity does not influence prostate intrafractional motion. J Med Radiat Sci 2018; 65:31-38. [PMID: 29359862 PMCID: PMC5846017 DOI: 10.1002/jmrs.255] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 11/15/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction Motion of the prostate is problematic in the accurate delivery of external beam radiation therapy (EBRT) for prostate cancer. This study investigated the relationship between body mass index (BMI), an easily measured indicator of obesity, and prostate motion. Methods Prostate motion during EBRT was assessed by measuring the displacement of fiducial markers implanted within the prostate in 130 prostate cancer patients. Interfractional motion was corrected on daily imaging through pre‐treatment cone‐beam‐computed tomography (CBCT) and intrafractional motion measured using movie sequences captured using an electronic portal imaging device (EPID) during treatment delivery. Results There was no statistically significant relationship between the mean intrafractional motion and BMI, except in the left‐right (LR) translation (P = 0.049) over the study population. For each BMI category, there was no statistical significance (P > 0.05) between any of the translations/rotations except LR (P = 0.003). Conclusion While intrafractional motion is an important consideration, prostate motion cannot be reliably predicted through measurement of patient's BMI.
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Affiliation(s)
- Amy Brown
- Townsville Cancer Centre, The Townsville Hospital, Townsville, Queensland, Australia
| | - Alex Tan
- Townsville Cancer Centre, The Townsville Hospital, Townsville, Queensland, Australia.,James Cook University, Townsville, Queensland, Australia
| | - Scott Cooper
- Townsville Cancer Centre, The Townsville Hospital, Townsville, Queensland, Australia
| | - Andrew Fielding
- Queensland University of Technology, Brisbane, Queensland, Australia
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Does body mass index or subcutaneous adipose tissue thickness affect interfraction prostate motion in patients receiving radical prostate radiotherapy? JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396916000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractAimIt is unclear whether body mass index (BMI) is a useful measurement for examining prostate motion. Patient’s subcutaneous adipose tissue thickness (SAT) and weight has been shown to correlate with prostate shifts in the left/right direction. We sought to analyse the relationship between BMI and interfraction prostate movement in order to determine planning target volume (PTV) margins based on patient BMI.Materials and methodsIn all, 38 prostate cancer patients with three implanted gold fiducial markers in their prostate were recruited. Height, mass and SAT were measured, and the extent of interfraction prostate movement in the left/right, superior/inferior and anterior/posterior directions was recorded during each daily fiducial marker-based image-guided radiotherapy treatment. Mean corrective shift in each direction for each patient, along with BMI values, were calculated.ResultsThe median BMI value was 28·4 kg/m2 (range 21·4–44·7). Pearson’s product-moment correlation analysis showed no significant relationship between BMI, mass or SAT and the extent of prostate movement in any direction. Linear regression analysis also showed no relationship between any of the patient variables and the extent of prostate movement in any direction (BMI: R2=0·006 (ρ=0·65), 0·002 (ρ=0·80) and 0·001 (ρ=0·86); mass: R2=0·001 (ρ=0·87), 0·010 (ρ=0·54) and 0·000 (ρ=0·99); SAT: R2=0·012 (ρ=0·51), 0·013 (ρ=0·50) and 0·047 (ρ=0·19) for shifts in the X, Y and Z axis, respectively). Patients were grouped according to BMI, as BMI<30 (n=25, 65·8%) and BMI≥30 (n=13, 34·2%). A two-tailed t-test showed no significant difference between the mean prostate shifts for the two groups in any direction (ρ=0·320, 0·839 and 0·325 for shifts in the X, Y and Z axis, respectively).FindingsBMI is not a useful parameter for determining individualised PTV margins. Gold fiducial marker insertion should be used as standard to improve treatment accuracy.
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Maruoka S, Yoshioka Y, Isohashi F, Suzuki O, Seo Y, Otani Y, Akino Y, Takahashi Y, Sumida I, Ogawa K. Correlation between patients' anatomical characteristics and interfractional internal prostate motion during intensity modulated radiation therapy for prostate cancer. SPRINGERPLUS 2015; 4:579. [PMID: 26543714 PMCID: PMC4628000 DOI: 10.1186/s40064-015-1382-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/27/2015] [Indexed: 11/23/2022]
Abstract
Intensity modulated radiation therapy (IMRT) is one of a standard treatment for localized prostate cancer. Although lower complication is expected for smaller target margin, determination of optimal margin is important. For bony-structure based registration, internal prostate motion is the main factor determining the margin from clinical target volume to planning target volume. The purpose of this study was to measure interfractional internal motion of the prostate and to identity the factors which enlarge or reduce the margin, with special focus on patients’ anatomical characteristics. The 586 image sets of 16 patients acquired with megavoltage cone beam computed tomography were analyzed. For each patient, prostate shift in three directions was recorded for each fraction to calculate the required margin. Correlations between these values and patients’ anatomical characteristics were evaluated. The posteriorly required margin correlated positively with rectal volume and rectal mean area (p = 0.015 and p = 0.008), while random error in lateral, craniocaudal and anteroposterior direction correlated negatively (p = 0.014, 0.04 and 0.0026, respectively) with body mass index (BMI). In addition to the previously identified factor of distended rectum, BMI was newly identified as another significant factor influencing interfractional internal prostate motion.
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Affiliation(s)
- Shintaroh Maruoka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yuki Otani
- Kaizuka City Hospital, 3-10-20 Hori, Kaizuka, Osaka, 597-0015 Japan
| | - Yuichi Akino
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yutaka Takahashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
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Image guidance procedures in radiotherapy for prostate cancer and the influence of body mass index. JOURNAL OF RADIOTHERAPY IN PRACTICE 2014. [DOI: 10.1017/s1460396914000193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractPurposeTo investigate possible optimisation of the image guidance procedure for the prostate cancer patients with respect to imaging frequency and patient body mass index (BMI).MethodsThe 6,085 setup correction shifts and BMI for 216 prostate cancer patients treated on tomotherapy units in two centres were analysed. Margins needed to account for inter-fraction target motion with daily only automatic correction and with automatic and manual corrections during one, three or five first fractions as a reference for further treatment without imaging were calculated.ResultsThe planning target volume margin calculated for the daily automatic correction only scheme was significantly lower than the margins calculated for the image guidance limited to a few initial fractions. Manual corrections after automatic fusion were more important for patients with higher BMI. On average, the patients with normal BMI had manual correction shift of 0·7 mm in anterioposterior direction, while overweight and obese patients required, correspondingly, the shifts of 1·3 and 1·4 mm.ConclusionOverweight and obese patients require daily imaging with time saving available by performing automatic kV/MV computed tomography registration only. The patients with normal BMI may be treated with imaging guidance during a few initial treatment fractions.
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Pichon B, Thureau S, Delpon G, Barillot I, Mahé MA. [Obesity and radiation: technical difficulties, toxicity and efficacy]. Cancer Radiother 2013; 17:543-8. [PMID: 23969243 DOI: 10.1016/j.canrad.2013.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/18/2013] [Indexed: 01/10/2023]
Abstract
The number of obese patients has increased in France over the last two decades, which has had an impact on the incidence of numerous types of cancer. The treatment of cancer by radiotherapy is impacted by obesity as a result of the physical, technical and dosimetric constraints, the acute and late toxicity, local control and the survival of patients.
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Affiliation(s)
- B Pichon
- Service de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Jacques-Monod, 44805 Saint-Herblain, France.
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