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Loebner HA, Bertholet J, Mackeprang PH, Volken W, Elicin O, Mueller S, Guyer G, Aebersold DM, Stampanoni MF, Fix MK, Manser P. Robustness analysis of dynamic trajectory radiotherapy and volumetric modulated arc therapy plans for head and neck cancer. Phys Imaging Radiat Oncol 2024; 30:100586. [PMID: 38808098 PMCID: PMC11130727 DOI: 10.1016/j.phro.2024.100586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/30/2024] Open
Abstract
Background and purpose Dynamic trajectory radiotherapy (DTRT) has been shown to improve healthy tissue sparing compared to volumetric arc therapy (VMAT). This study aimed to assess and compare the robustness of DTRT and VMAT treatment-plans for head and neck (H&N) cancer to patient-setup (PS) and machine-positioning uncertainties. Materials and methods The robustness of DTRT and VMAT plans previously created for 46 H&N cases, prescribed 50-70 Gy to 95 % of the planning-target-volume, was assessed. For this purpose, dose distributions were recalculated using Monte Carlo, including uncertainties in PS (translation and rotation) and machine-positioning (gantry-, table-, collimator-rotation and multi-leaf collimator (MLC)). Plan robustness was evaluated by the uncertainties' impact on normal tissue complication probabilities (NTCP) for xerostomia and dysphagia and on dose-volume endpoints. Differences between DTRT and VMAT plan robustness were compared using Wilcoxon matched-pair signed-rank test (α = 5 %). Results Average NTCP for moderate-to-severe xerostomia and grade ≥ II dysphagia was lower for DTRT than VMAT in the nominal scenario (0.5 %, p = 0.01; 2.1 %, p < 0.01) and for all investigated uncertainties, except MLC positioning, where the difference was not significant. Average differences compared to the nominal scenario were ≤ 3.5 Gy for rotational PS (≤ 3°) and machine-positioning (≤ 2°) uncertainties, <7 Gy for translational PS uncertainties (≤ 5 mm) and < 20 Gy for MLC-positioning uncertainties (≤ 5 mm). Conclusions DTRT and VMAT plan robustness to the investigated uncertainties depended on uncertainty direction and location of the structure-of-interest to the target. NTCP remained on average lower for DTRT than VMAT even when considering uncertainties.
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Affiliation(s)
- Hannes A. Loebner
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Paul-Henry Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Werner Volken
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Olgun Elicin
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Silvan Mueller
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Daniel M. Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Michael K. Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Maniscalco A, Liang X, Lin MH, Jiang S, Nguyen D. Single patient learning for adaptive radiotherapy dose prediction. Med Phys 2023; 50:7324-7337. [PMID: 37861055 PMCID: PMC10843391 DOI: 10.1002/mp.16799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/30/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Throughout a patient's course of radiation therapy, maintaining accuracy of their initial treatment plan over time is challenging due to anatomical changes-for example, stemming from patient weight loss or tumor shrinkage. Online adaptation of their RT plan to these changes is crucial, but hindered by manual and time-consuming processes. While deep learning (DL) based solutions have shown promise in streamlining adaptive radiation therapy (ART) workflows, they often require large and extensive datasets to train population-based models. PURPOSE This study extends our prior research by introducing a minimalist approach to patient-specific adaptive dose prediction. In contrast to our prior method, which involved fine-tuning a pre-trained population model, this new method trains a model from scratch using only a patient's initial treatment data. This patient-specific dose predictor aims to enhance clinical accessibility, thereby empowering physicians and treatment planners to make more informed, quantitative decisions in ART. We hypothesize that patient-specific DL models will provide more accurate adaptive dose predictions for their respective patients compared to a population-based DL model. METHODS We selected 33 patients to train an adaptive population-based (AP) model. Ten additional patients were selected, and their respective initial RT data served as single samples for training patient-specific (PS) models. These 10 patients contained an additional 26 ART plans that were withheld as the test dataset to evaluate AP versus PS model dose prediction performance. We assessed model performance using Mean Absolute Percent Error (MAPE) by comparing predicted doses to the originally delivered ground truth doses. We used the Wilcoxon signed-rank test to determine statistically significant differences in terms of MAPE between the AP and PS model results across the test dataset. Furthermore, we calculated differences between predicted and ground truth mean doses for segmented structures and determined statistical significance in the differences for each of them. RESULTS The average MAPE across AP and PS model dose predictions was 5.759% and 4.069%, respectively. The Wilcoxon signed-rank test yielded two-tailed p-value = 2.9802 × 10 - 8 $2.9802\ \times \ {10}^{ - 8}$ , indicating that the MAPE differences between the AP and PS model dose predictions are statistically significant, and 95% confidence interval = [-2.1610, -1.0130], indicating 95% confidence that the MAPE difference between the AP and PS models for a population lies in this range. Out of 24 total segmented structures, the comparison of mean dose differences for 12 structures indicated statistical significance with two-tailed p-values < 0.05. CONCLUSION Our study demonstrates the potential of patient-specific deep learning models in application to ART. Notably, our method streamlines the training process by minimizing the size of the required training dataset, as only a single patient's initial treatment data is required. External institutions considering the implementation of such a technology could package such a model so that it only requires the upload of a reference treatment plan for model training and deployment. Our single patient learning strategy demonstrates promise in ART due to its minimal dataset requirement and its utility in personalization of cancer treatment.
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Affiliation(s)
- Austen Maniscalco
- Medical Artificial Intelligence and Automation Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Xiao Liang
- Medical Artificial Intelligence and Automation Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mu-Han Lin
- Medical Artificial Intelligence and Automation Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steve Jiang
- Medical Artificial Intelligence and Automation Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dan Nguyen
- Medical Artificial Intelligence and Automation Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Niyazi M, Andratschke N, Bendszus M, Chalmers AJ, Erridge SC, Galldiks N, Lagerwaard FJ, Navarria P, Munck Af Rosenschöld P, Ricardi U, van den Bent MJ, Weller M, Belka C, Minniti G. ESTRO-EANO guideline on target delineation and radiotherapy details for glioblastoma. Radiother Oncol 2023; 184:109663. [PMID: 37059335 DOI: 10.1016/j.radonc.2023.109663] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND PURPOSE Target delineation in glioblastoma is still a matter of extensive research and debate. This guideline aims to update the existing joint European consensus on delineation of the clinical target volume (CTV) in adult glioblastoma patients. MATERIAL AND METHODS The ESTRO Guidelines Committee identified 14 European experts in close interaction with the ESTRO clinical committee and EANO who discussed and analysed the body of evidence concerning contemporary glioblastoma target delineation, then took part in a two-step modified Delphi process to address open questions. RESULTS Several key issues were identified and are discussed including i) pre-treatment steps and immobilisation, ii) target delineation and the use of standard and novel imaging techniques, and iii) technical aspects of treatment including planning techniques and fractionation. Based on the EORTC recommendation focusing on the resection cavity and residual enhancing regions on T1-sequences with the addition of a reduced 15 mm margin, special situations are presented with corresponding potential adaptations depending on the specific clinical situation. CONCLUSIONS The EORTC consensus recommends a single clinical target volume definition based on postoperative contrast-enhanced T1 abnormalities, using isotropic margins without the need to cone down. A PTV margin based on the individual mask system and IGRT procedures available is advised; this should usually be no greater than 3 mm when using IGRT.
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Affiliation(s)
- Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany.
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Sara C Erridge
- Edinburgh Centre for Neuro-Oncology, University of Edinburgh, Western General Hospital, Edinburgh, EH4 1EU, UK
| | - Norbert Galldiks
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany; Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Duesseldorf, Germany
| | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS, Humanitas Research Hospital, Rozzano (MI), Italy
| | - Per Munck Af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, and Lund University, Lund, Sweden
| | | | | | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Giuseppe Minniti
- Dept. of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
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Comprehensive Analysis of Set-Up Gain of 6-Dimensional Cone-Beam CT Correction Method in Radiotherapy for Head and Neck and Brain Tumors. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2964023. [PMID: 36311255 PMCID: PMC9613383 DOI: 10.1155/2022/2964023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/01/2022] [Indexed: 11/18/2022]
Abstract
This study quantitatively analyzed the gain of the six-dimensional (6D) cone-beam CT (CBCT) correction method compared with the conventional set-up method in 60 patients who underwent radiation treatment of head and neck and brain tumors. The correction gain of CBCT was calculated for the translational and rotational motion components separately and in combination to evaluate the individual and overall effects of these motion components. Using a statistical simulation mimicking the actual set-up correction process, the effective gain of periodic CBCT correction during the entire treatment fraction was analyzed by target size and CBCT correction period under two different correction scenarios: translation alone and full 6D corrections. From the analyses performed in this study, the gain of CBCT correction was quantitatively determined for each situation, and the appropriate CBCT correction strategy was suggested based on treatment purpose and target size.
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Kim TH, Cho MS, Shin DS, Shin DH, Kim S. Development of a Real-Time Thermoplastic Mask Compression Force Monitoring System Using Capacitive Force Sensor. Front Robot AI 2022; 9:778594. [PMID: 35875702 PMCID: PMC9298856 DOI: 10.3389/frobt.2022.778594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: Thermoplastic masks keep patients in an appropriate position to ensure accurate radiation delivery. For a thermoplastic mask to maintain clinical efficacy, the mask should wrap the patient's surface properly and provide uniform pressure to all areas. However, to our best knowledge, no explicit method for achieving such a goal currently exists. Therefore, in this study, we intended to develop a real-time thermoplastic mask compression force (TMCF) monitoring system to measure compression force quantitatively. A prototype system was fabricated, and the feasibility of the proposed method was evaluated. Methods: The real-time TMCF monitoring system basically consists of four force sensor units, a microcontroller board (Arduino Bluno Mega 2560), a control PC, and an in-house software program. To evaluate the reproducibility of the TMCF monitoring system, both a reproducibility test using a micrometer and a setup reproducibility test using a head phantom were performed. Additionally, the reproducibility tests of mask setup and motion detection tests were carried out with a cohort of six volunteers. Results: The system provided stable pressure readings in all 10 trials during the sensor unit reproducibility test. The largest standard deviation (SD) among trials was about 36 gf/cm2 (∼2.4% of the full-scale range). For five repeated mask setups on the phantom, the compression force variation of the mask was less than 39 gf/cm2 (2.6% of the full-scale range). We were successful in making masks together with the monitoring system connected and demonstrated feasible utilization of the system. Compression force variations were observed among the volunteers and according to the location of the sensor (among forehead, both cheekbones, and chin). The TMCF monitoring system provided the information in real time on whether the mask was properly pressing the human subject as an immobilization tool. Conclusion: With the developed system, it is possible to monitor the effectiveness of the mask in real time by continuously measuring the compression force between the mask and patient during the treatment. The graphical user interface (GUI) of the monitoring system developed provides a warning signal when the compression force of the mask is insufficient. Although the number of volunteers participated in the study was small, the obtained preliminary results suggest that the system could ostensibly improve the setup accuracy of a thermoplastic mask.
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Affiliation(s)
- Tae-Ho Kim
- Proton Therapy Center, National Cancer Center, Goyang, South Korea
| | - Min-Seok Cho
- Department of Radiation Oncology, Yongin Severance Hospital, Yongin, South Korea
| | - Dong-Seok Shin
- Proton Therapy Center, National Cancer Center, Goyang, South Korea
| | - Dong Ho Shin
- Proton Therapy Center, National Cancer Center, Goyang, South Korea
| | - Siyong Kim
- Department of Radiation Oncology, Virginia Commonwealth University, Virginia, VA, United States
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Cumur C, Fujibuchi T, Hamada K. Dose estimation for cone-beam computed tomography in image-guided radiation therapy using mesh-type reference computational phantoms and assuming head and neck cancer. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:021533. [PMID: 35705020 DOI: 10.1088/1361-6498/ac7914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
This study aimed to estimate the additional dose the cone-beam computed tomography (CBCT) system integrated into the Varian TrueBeam linear accelerator delivers to a patient with head and neck cancer using mesh-type International Commission on Radiological Protection reference computational phantoms. In the first part, for use as a benchmark for the accuracy of the Monte Carlo geometry of CBCT, Particle and Heavy Ion Transport code System (PHITS) calculations were confirmed against measured lateral and depth dose profiles using a computed tomography dose profiler. After obtaining good agreement, organ dose calculations were performed by PHITS using mesh-type reference computational phantom (MRCP) and irradiating the neck region; the effective dose was calculated utilising absorbed organ doses and tissue weighting factors for male and female MRCP. Substantially, it has been found that the effective doses for male and female MRCP are 0.81 and 1.06 mSv, respectively. As this study aimed to assess the imaging dose from the CBCT system used in image-guided radiation therapy, it is required to take into account this dose in terms of both the target organ and surrounding tissues. Although the absorbed organ dose values and effective dose values obtained for both MRCP males and females were small, attention should be paid to the additional dose resulting from CBCT. This study can create awareness on the importance of doses arising from imaging techniques, especially CBCT.
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Affiliation(s)
- Ceyda Cumur
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka City 812-8582, Japan
| | - Toshioh Fujibuchi
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka City 812-8582, Japan
| | - Keisuke Hamada
- Department of Radiological Technology, National Hospital Organisation Kyushu Cancer Center, 3-1-1, Notame Minami-ku, Fukuoka City 811-1395, Japan
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Miron VM, Etzelstorfer T, Kleiser R, Raffelsberger T, Major Z, Geinitz H. Evaluation of novel 3D-printed and conventional thermoplastic stereotactic high-precision patient fixation masks for radiotherapy. Strahlenther Onkol 2022; 198:1032-1041. [PMID: 35697775 PMCID: PMC9581856 DOI: 10.1007/s00066-022-01963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/15/2022] [Indexed: 11/30/2022]
Abstract
Purpose For stereotactic radiation therapy of intracranial malignancies, a patient’s head needs to be immobilized with high accuracy. Fixation devices such as invasive stereotactic head frames or non-invasive thermoplastic mask systems are often used. However, especially stereotactic high-precision masks often cause discomfort for patients due to a long manufacturing time during which the patient is required to lie still and because the face is covered, including the mouth, nose, eyes, and ears. To avoid these issues, the target was to develop a non-invasive 3D-printable mask system with at least the accuracy of the high-precision masks, for producing masks which can be manufactured in the absence of patients and which allow the eyes, mouth, and nose to be uncovered during therapy. Methods For four volunteers, a personalized 3D-printed mask based on magnetic resonance imaging (MRI) data was designed and manufactured using fused filament fabrication (FFF). Additionally, for each of the volunteers, a conventional thermoplastic stereotactic high-precision mask from Brainlab AG (Munich, Germany) was fabricated. The intra-fractional fixation accuracy for each mask and volunteer was evaluated using the motion-correction algorithm of functional MRI measurements with and without guided motion. Results The average values for the translations and rotations of the volunteers’ heads lie in the range between ±1 mm and ±1° for both masks. Interestingly, the standard deviations and the relative and absolute 3D displacements are lower for the 3D-printed masks compared to the Brainlab masks. Conclusion It could be shown that the intra-fractional fixation accuracy of the 3D-printed masks was higher than for the conventional stereotactic high-precision masks.
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Affiliation(s)
- Veronika M Miron
- Institute of Polymer Product Engineering, Johannes Kepler University, Altenberger Str. 69, 4040, Linz, Austria.
| | - Tanja Etzelstorfer
- Abteilung für Radioonkologie, Ordensklinikum Linz Barmherzige Schwestern, Seilerstätte 4, 4010, Linz, Austria
| | - Raimund Kleiser
- Department of Neuroradiology, Johannes Kepler University Clinic, Wagner-Jauregg-Weg 15, 4020, Linz, Austria
| | - Tobias Raffelsberger
- Department of Neuroradiology, Johannes Kepler University Clinic, Wagner-Jauregg-Weg 15, 4020, Linz, Austria
| | - Zoltan Major
- Institute of Polymer Product Engineering, Johannes Kepler University, Altenberger Str. 69, 4040, Linz, Austria
| | - Hans Geinitz
- Abteilung für Radioonkologie, Ordensklinikum Linz Barmherzige Schwestern, Seilerstätte 4, 4010, Linz, Austria
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Individual 3D-printed fixation masks for radiotherapy: first clinical experiences. Int J Comput Assist Radiol Surg 2021; 16:1043-1049. [PMID: 34021859 PMCID: PMC8166668 DOI: 10.1007/s11548-021-02393-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/27/2021] [Indexed: 11/13/2022]
Abstract
Purpose To show the feasibility of 3D-printed fixation masks for whole brain radiation therapy in a clinical setting and perform a first comparison to an established thermoplastic mask system. Methods Six patients were irradiated with whole brain radiotherapy using individually 3D-printed masks. Daily image guidance and position correction were performed prior to each irradiation fraction. The vectors of the daily position correction were compared to two collectives of patients, who were irradiated using the standard thermoplastic mask system (one cohort with head masks; one cohort with head and neck masks). Results The mean systematic errors in the experimental cohort ranged between 0.59 and 2.10 mm which is in a comparable range to the control groups (0.18 mm–0.68 mm and 0.34 mm–2.96 mm, respectively). The 3D-printed masks seem to be an alternative to the established thermoplastic mask systems. Nevertheless, further investigation will need to be performed. Conclusion The prevailing study showed a reliable and reproducible interfractional positioning accuracy using individually 3D-printed masks for whole brain irradiation in a clinical routine. Further investigations, especially concerning smaller target volumes or other areas of the body, need to be performed before using the system on a larger basis.
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Alcorn SR, Zhou XC, Bojechko C, Rubo RA, Chen MJ, Dieckmann K, Ermoian RP, Ford EC, Kobyzeva D, MacDonald SM, McNutt TR, Nechesnyuk A, Nilsson K, Sjostrand H, Smith KS, Stock M, Tryggestad EJ, Villar RC, Winey BA, Terezakis SA. Low-Dose Image-Guided Pediatric CNS Radiation Therapy: Final Analysis From a Prospective Low-Dose Cone-Beam CT Protocol From a Multinational Pediatrics Consortium. Technol Cancer Res Treat 2020; 19:1533033820920650. [PMID: 32329413 PMCID: PMC7225835 DOI: 10.1177/1533033820920650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Lower-dose cone-beam computed tomography protocols for image-guided radiotherapy may permit target localization while minimizing radiation exposure. We prospectively evaluated a lower-dose cone-beam protocol for central nervous system image-guided radiotherapy across a multinational pediatrics consortium. Methods: Seven institutions prospectively employed a lower-dose cone-beam computed tomography central nervous system protocol (weighted average dose 0.7 mGy) for patients ≤21 years. Treatment table shifts between setup with surface lasers versus cone-beam computed tomography were used to approximate setup accuracy, and vector magnitudes for these shifts were calculated. Setup group mean, interpatient, interinstitution, and random error were estimated, and clinical factors were compared by mixed linear modeling. Results: Among 96 patients, with 2179 pretreatment cone-beam computed tomography acquisitions, median age was 9 years (1-20). Setup parameters were 3.13, 3.02, 1.64, and 1.48 mm for vector magnitude group mean, interpatient, interinstitution, and random error, respectively. On multivariable analysis, there were no significant differences in mean vector magnitude by age, gender, performance status, target location, extent of resection, chemotherapy, or steroid or anesthesia use. Providers rated >99% of images as adequate or better for target localization. Conclusions: A lower-dose cone-beam computed tomography protocol demonstrated table shift vector magnitude that approximate clinical target volume/planning target volume expansions used in central nervous system radiotherapy. There were no significant clinical predictors of setup accuracy identified, supporting use of this lower-dose cone-beam computed tomography protocol across a diverse pediatric population with brain tumors.
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Affiliation(s)
| | - Xian Chiong Zhou
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Michael J Chen
- Grupo de Apoio ao Adolescente e à Criança com Câncer, São Paulo, Brazil
| | - Karin Dieckmann
- Universität Klinik Für Strahlentherapie und Strahlenbiologie, Vienna, Austria
| | | | | | - Daria Kobyzeva
- Federal Scientific Clinical Center of Children's Hematology, Oncology and Immunology, Moscow, Russia
| | | | | | - Alexey Nechesnyuk
- Federal Scientific Clinical Center of Children's Hematology, Oncology and Immunology, Moscow, Russia
| | | | | | | | - Markus Stock
- Universität Klinik Für Strahlentherapie und Strahlenbiologie, Vienna, Austria
| | | | | | | | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, University of Minnesota, Minneapolis, MN, USA
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Gamma Knife radiosurgery: Scenarios and support for re-irradiation. Phys Med 2019; 68:75-82. [PMID: 31760329 DOI: 10.1016/j.ejmp.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 09/16/2019] [Accepted: 11/01/2019] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) involves the focal delivery of large, cytotoxic doses of radiation to small targets within the brain, often located in close proximity to radiosensitive normal tissue structures and requiring very low procedural uncertainties to perform safely. Historically, neurosurgeons considered SRS as a one-time, single session procedure. However therapeutic advances and a better understanding of the clinical response to SRS have caused a renewal of interest in a variety of re-irradiation scenarios; including re-irradiation of the same target after prior SRS, SRS treatments after prior broad-field radiation, hypofractionated treatments, and volume-staged treatments. Re-irradiation may in some cases require even greater effort towards minimizing treatment uncertainties as compared to one-time-only treatments. Gamma Knife radiosurgery (GKRS) has evolved over time in ways that directly supports many re-irradiation scenarios while helping to minimize overall procedural uncertainty.
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Mandija S, D'Agata F, Navest RJM, Sbrizzi A, Tijssen RHN, Philippens MEP, Raaijmakers CPJ, Seravalli E, Verhoeff JJC, Lagendijk JJW, van den Berg CAT. Brain and Head-and-Neck MRI in Immobilization Mask: A Practical Solution for MR-Only Radiotherapy. Front Oncol 2019; 9:647. [PMID: 31380283 PMCID: PMC6650525 DOI: 10.3389/fonc.2019.00647] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/02/2019] [Indexed: 01/08/2023] Open
Abstract
In brain/head-and-neck radiotherapy (RT), thermoplastic immobilization masks guarantee reproducible patient positioning in treatment position between MRI, CT, and irradiation. Since immobilization masks do not fit in the diagnostic MR head/head-and-neck coils, flexible surface coils are used for MRI imaging in clinical practice. These coils are placed around the head/neck, in contact with the immobilization masks. However, the positioning of these flexible coils is technician dependent, thus leading to poor image reproducibility. Additionally, flexible surface coils have an inferior signal-to-noise-ratio (SNR) compared to diagnostic coils. The aim of this work was to create a new immobilization setup which fits into the diagnostic MR coils in order to enhance MR image quality and reproducibility. For this purpose, a practical immobilization setup was constructed. The performances of the standard clinical and the proposed setups were compared with four tests: SNR, image quality, motion restriction, and reproducibility of inter-fraction subject positioning. The new immobilization setup resulted in 3.4 times higher SNR values on average than the standard setup, except directly below the flexible surface coils where similar SNR was observed. Overall, the image quality was superior for brain/head-and-neck images acquired with the proposed RT setup. Comparable motion restriction in feet-head/left-right directions (maximum motion ≈1 mm) and comparable inter-fraction repositioning accuracy (mean inter-fraction movement 1 ± 0.5 mm) were observed for the standard and the new setup.
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Affiliation(s)
- Stefano Mandija
- Computational Imaging Group for MRI Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Federico D'Agata
- Computational Imaging Group for MRI Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Neurosciences, University of Turin, Turin, Italy
| | - Robin J M Navest
- Computational Imaging Group for MRI Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alessandro Sbrizzi
- Computational Imaging Group for MRI Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob H N Tijssen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Enrica Seravalli
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan J W Lagendijk
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cornelis A T van den Berg
- Computational Imaging Group for MRI Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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12
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Brecht S, Boda-Heggemann J, Budjan J, Siebenlist K, Stieler F, Steil V, Wenz F, Lohr F, Buergy D. Radiation-induced optic neuropathy after stereotactic and image guided intensity-modulated radiation therapy (IMRT). Radiother Oncol 2019; 134:166-177. [PMID: 31005211 DOI: 10.1016/j.radonc.2019.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/03/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND/PURPOSE To quantify the risk of radiation-induced optic neuropathy (RION) after stereotactic/image-guided positioning and intensity-modulated radiotherapy (IMRT) with ≥50 Gy to the anterior visual pathway (AVP). METHODS Patients irradiated with ≥50 Gy to the AVP using stereotactic/image-guided positioning between 2002 and 2011 in Mannheim were identified. Detailed dosimetric data were collected and patients or family members were retrospectively asked to rate visual acuity and visual disorders. RESULTS 125 patients fulfilled the eligibility criteria. Average maximum equivalent point dose (Dmax-EQD-2[α/β=1.6]) to the AVP was 53.1 ± 3.9 Gy. 99 patients received ≥50 Gy bilaterally (chiasm or both optic nerves), resulting in 224 (99x2 bilateral plus 26 unilateral) visual-fields-at-risk (VFAR) for RION. Eighty-two patients provided pre/post-IMRT visual status information (n = 151 VFARs). Permanent visual deterioration occurred in 18 (22%) patients. In seven, visual deterioration was possibly related to radiotherapy (two-sided deterioration in one patient) for a crude incidence of 8.5% (7/82 patients) and 5.3% (8/151 VFARs). Two cases were caused by chronic keratitis/conjunctivitis; in five patients RION could not be excluded (one two-sided). In one of 13 patients with Dmax-EQD-2 > 58 Gy, RION could not be excluded. In all affected patients, visual acuity post-IMRT had decreased only mildly (1-2 points on the 5-point-scale). One patient with relevant baseline visual impairment (3/5) developed unilateral blindness (crude incidence of blindness on patient-/VFAR-level: 1.2% and 0.66%; competing risk-adjusted/actuarial 24-month incidence: patient/VFAR-level: 1.8% and 0.95%). CONCLUSION Risk of RION was low in this cohort with accurate positioning and precise dosimetric information. Less conservative tolerance doses may be considered in patients with high risk of recurrence.
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Affiliation(s)
- Susan Brecht
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Johannes Budjan
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany.
| | - Kerstin Siebenlist
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Florian Stieler
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Volker Steil
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Frank Lohr
- Struttura Complessa di Radioterapia, Dipartimento di Oncologia, Azienda Universitario-Ospedaliera, Modena, Italy.
| | - Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; Heinrich-Lanz-Center for Digital Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
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13
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Divneet M, Quoc-Anh H, Betsy W, Gia J, Denise R, Christopher W, Yi SK. Comparison of two thermoplastic immobilization mask systems in daily volumetric image guided radiation therapy for head and neck cancers. Biomed Phys Eng Express 2018. [DOI: 10.1088/2057-1976/aad574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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14
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Ohira S, Ueda Y, Akino Y, Hashimoto M, Masaoka A, Hirata T, Miyazaki M, Koizumi M, Teshima T. HyperArc VMAT planning for single and multiple brain metastases stereotactic radiosurgery: a new treatment planning approach. Radiat Oncol 2018; 13:13. [PMID: 29378610 PMCID: PMC5789615 DOI: 10.1186/s13014-017-0948-z] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/18/2017] [Indexed: 11/10/2022] Open
Abstract
Purpose The HyperArc VMAT (HA-VMAT) planning approach was newly developed to fulfill the demands of dose delivery for brain metastases stereotactic radiosurgery. We compared the dosimetric parameters of the HA-VMAT plan with those of the conventional VMAT (C-VMAT). Material and methods For 23 patients (1–4 brain metastases), C-VMAT and HA-VMAT plans with a prescription dose of 20–24 Gy were retrospectively generated, and dosimetric parameters for PTV (homogeneity index, HI; conformity index, CI; gradient index, GI) and brain tissue (V2Gy-V16Gy) were evaluated. Subsequently, the physical characteristics (modulation complexity score for VMAT, MCSV; Monitor unit, MU) of both treatment approaches were compared. Results HA-VMAT provided higher HI (1.41 ± 0.07 vs. 1.24 ± 0.07, p < 0.01), CI (0.93 ± 0.02 vs. 0.90 ± 0.05, p = 0.01) and lower GI (3.06 ± 0.42 vs. 3.91 ± 0.55, p < 0.01) values. Moderate-to-low dose spreads (V4Gy-V16Gy) were significantly reduced (p < 0.01) in the HA-VMAT plan over that of C-VMAT. HA-VMAT plans resulted in more complex MLC patterns (lower MCSV, p < 0.01) and higher MU (p < 0.01). Conclusions HA-VMAT plans provided significantly higher conformity and rapid dose falloff with respect to the C-VMAT plans.
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Affiliation(s)
- Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan.,Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan
| | - Yuichi Akino
- Division of Medical Physics, Oncology Center, Osaka University Hospital, 2-2 (D10) Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Misaki Hashimoto
- Department of Radiation Oncology, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Akira Masaoka
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan
| | - Takero Hirata
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan.
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15
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Dincoglan F, Beyzadeoglu M, Sager O, Oysul K, Sirin S, Surenkok S, Gamsiz H, Uysal B, Demiral S, Dirican B. Image-Guided Positioning in Intracranial Non-Invasive Stereotactic Radiosurgery for the Treatment of Brain Metastasis. TUMORI JOURNAL 2018; 98:630-5. [DOI: 10.1177/030089161209800514] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims and background The aim of the study was to examine the feasibility of non-invasive image-guided radiosurgery to improve patient comfort and quality of life in stereotactic radiosurgery planning and treatment of patients with brain metastasis. Precise immobilization is a rule of thumb for stereotactic radiosurgery. Non-invasive immobilization techniques have the potential of improved quality of life compared with invasive procedures. Methods and study design A total of 92 lesions from 42 patients with brain metastasis were included in the study. After immobilization with a thermoplastic mask and a bite-block unlike the invasive frame-based procedure, planning computed tomography images were acquired and fused with magnetic resonance images. After contouring, intensity-modulated stereotactic radiosurgery (IM-SRS) planning was done, and the patients were re-immobilized on the treatment couch for the therapy procedures. While patients were on the treatment couch, kilovoltage-cone beam computed tomography images were acquired to determine setup errors and achieve on-line correction and then repeated after on-line correction to confirm precise tumor localization. The patients then underwent single-fraction definitive treatment. Results For the 92 lesions treated, mean ± SD values of translational setup corrections in X (lateral), Y (longitudinal), and Z (vertical) dimensions were 0.7 ± 0.7 mm, 0.8 ± 0.7 mm, and 0.6 ± 0.5 mm, and rotational set-up corrections were 0.5 ± 1.1°, 0.06 ± 1.1°, and -0.1 ± 1.1° in X (pitch), Y (roll), and Z (yaw), respectively. The mean three-dimensional correction vector was 1.2 ± 1.1 mm. Conclusions Non-invasive image-guided radiosurgery for brain metastasis is feasible, and the non-invasive treatment approach can be routinely used in clinical practice to improve patientís quality of life.
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Affiliation(s)
- Ferrat Dincoglan
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Murat Beyzadeoglu
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Omer Sager
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Kaan Oysul
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Sait Sirin
- Neurosurgery Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Serdar Surenkok
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Hakan Gamsiz
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Bora Uysal
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Selcuk Demiral
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
| | - Bahar Dirican
- Radiation Oncology Department, Gulhane Military Faculty of Medicine, Ankara, Turkey
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16
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Haefner MF, Giesel FL, Mattke M, Rath D, Wade M, Kuypers J, Preuss A, Kauczor HU, Schenk JP, Debus J, Sterzing F, Unterhinninghofen R. 3D-Printed masks as a new approach for immobilization in radiotherapy - a study of positioning accuracy. Oncotarget 2018; 9:6490-6498. [PMID: 29464087 PMCID: PMC5814227 DOI: 10.18632/oncotarget.24032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 01/02/2018] [Indexed: 11/25/2022] Open
Abstract
We developed a new approach to produce individual immobilization devices for the head based on MRI data and 3D printing technologies. The purpose of this study was to determine positioning accuracy with healthy volunteers. 3D MRI data of the head were acquired for 8 volunteers. In-house developed software processed the image data to generate a surface mesh model of the immobilization mask. After adding an interface for the couch, the fixation setup was materialized using a 3D printer with acrylonitrile butadiene styrene (ABS). Repeated MRI datasets (n=10) were acquired for all volunteers wearing their masks thus simulating a setup for multiple fractions. Using automatic image-to-image registration, displacements of the head were calculated relative to the first dataset (6 degrees of freedom). The production process has been described in detail. The absolute lateral (x), vertical (y) and longitudinal (z) translations ranged between −0.7 and 0.5 mm, −1.8 and 1.4 mm, and −1.6 and 2.4 mm, respectively. The absolute rotations for pitch (x), yaw (y) and roll (z) ranged between −0.9 and 0.8°, −0.5 and 1.1°, and −0.6 and 0.8°, respectively. The mean 3D displacement was 0.9 mm with a standard deviation (SD) of the systematic and random error of 0.2 mm and 0.5 mm, respectively. In conclusion, an almost entirely automated production process of 3D printed immobilization masks for the head derived from MRI data was established. A high level of setup accuracy was demonstrated in a volunteer cohort. Future research will have to focus on workflow optimization and clinical evaluation.
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Affiliation(s)
- Matthias Felix Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Frederik Lars Giesel
- Department of Nuclear Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Matthias Mattke
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Daniel Rath
- Department of Nuclear Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Moritz Wade
- Department of Nuclear Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany.,Institute of Antropomatics and Robotics, Karlsruhe Institute of Technology (KIT), 76131 Karlsruhe, Germany
| | - Jacob Kuypers
- Department of Nuclear Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany.,Institute of Antropomatics and Robotics, Karlsruhe Institute of Technology (KIT), 76131 Karlsruhe, Germany
| | - Alan Preuss
- Department of Nuclear Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany.,Institute of Antropomatics and Robotics, Karlsruhe Institute of Technology (KIT), 76131 Karlsruhe, Germany
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jens-Peter Schenk
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Florian Sterzing
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,Department of Radiation Oncology Kempten, 87439 Kempten, Germany
| | - Roland Unterhinninghofen
- Institute of Antropomatics and Robotics, Karlsruhe Institute of Technology (KIT), 76131 Karlsruhe, Germany.,Institute of Robotics and Mechatronics, German Aerospace Center, 82234 Oberpfaffenhofen-Weßling, Germany
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17
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Goldsworthy S, Leslie-Dakers M, Higgins S, Barnes T, Jankowska P, Dogramadzi S, Latour JM. A Pilot Study Evaluating the Effectiveness of Dual-Registration Image-Guided Radiotherapy in Patients with Oropharyngeal Cancer. J Med Imaging Radiat Sci 2017; 48:377-384. [PMID: 31047473 DOI: 10.1016/j.jmir.2017.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of the article was to determine the impact of Dual Registration (DR) image-guided radiotherapy (IGRT) on clinical judgement and treatment delivery for patients with oropharyngeal cancer before implementation. METHODS Ninety cone beam computed tomography images from 10 retrospective patients were matched using standard clipbox registration (SCR) and DR. Three IGRT specialist radiographers performed all registrations and evaluated by intraclass correlation to determine inter-rater agreement, Bland-Altman with 95% limits of agreement to determine differences between SCR and DR procedures, changes in clinical judgment, time taken to perform registrations, and radiographer satisfaction. RESULTS Inter-rater agreement between radiographers using both SCR and DR was high (0.867 and 0.917, P ≤ .0001). The 95% limits of agreement between SCR and DR procedures in the mediolateral, cranial-caudal, and ventrodorsal translational directions were -6.40 to +4.91, -7.49 to +6.05, and -7.00 to +5.44 mm, respectively. The mediolateral direction demonstrated significant proportional bias (P ≤ .001) suggesting non-agreement between SCR and DR. Eighty percent of DR matches resulted in a change in clinical judgement to ensure maximum target coverage. Mean registration times for SCR and DR were 94 and 115 seconds, respectively, and radiographers found DR feasible and satisfactory. CONCLUSION The standard method using SCR in patients with oropharyngeal cancer underestimates the deviation in the lower neck. In these patients, DR is an effective IGRT tool to ensure target coverage of the inferior neck nodes and has demonstrated acceptability to radiotherapy clinical practice.
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Affiliation(s)
- Simon Goldsworthy
- Radiotherapy, Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK; Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.
| | - Marcus Leslie-Dakers
- Radiotherapy, Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Steven Higgins
- Radiotherapy, Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Terri Barnes
- Radiotherapy, Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Petra Jankowska
- Radiotherapy, Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Sanja Dogramadzi
- Bristol Robotics laboratory, University of the West of England, Bristol, UK
| | - Jos M Latour
- Clinical School, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK; School of Nursing and Midwifery, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
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18
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Rubinstein AE, Ingram WS, Anderson BM, Gay SS, Fave XJ, Ger RB, McCarroll RE, Owens CA, Netherton TJ, Kisling KD, Court LE, Yang J, Li Y, Lee J, Mackin DS, Cardenas CE. Cost-effective immobilization for whole brain radiation therapy. J Appl Clin Med Phys 2017; 18:116-122. [PMID: 28585732 PMCID: PMC5874864 DOI: 10.1002/acm2.12101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/24/2017] [Accepted: 04/05/2017] [Indexed: 11/23/2022] Open
Abstract
To investigate the inter‐ and intra‐fraction motion associated with the use of a low‐cost tape immobilization technique as an alternative to thermoplastic immobilization masks for whole‐brain treatments. The results of this study may be of interest to clinical staff with severely limited resources (e.g., in low‐income countries) and also when treating patients who cannot tolerate standard immobilization masks. Setup reproducibility of eight healthy volunteers was assessed for two different immobilization techniques. (a) One strip of tape was placed across the volunteer's forehead and attached to the sides of the treatment table. (b) A second strip was added to the first, under the chin, and secured to the table above the volunteer's head. After initial positioning, anterior and lateral photographs were acquired. Volunteers were positioned five times with each technique to allow calculation of inter‐fraction reproducibility measurements. To estimate intra‐fraction reproducibility, 5‐minute anterior and lateral videos were taken for each technique per volunteer. An in‐house software was used to analyze the photos and videos to assess setup reproducibility. The maximum intra‐fraction displacement for all volunteers was 2.8 mm. Intra‐fraction motion increased with time on table. The maximum inter‐fraction range of positions for all volunteers was 5.4 mm. The magnitude of inter‐fraction and intra‐fraction motion found using the “1‐strip” and “2‐strip” tape immobilization techniques was comparable to motion restrictions provided by a thermoplastic mask for whole‐brain radiotherapy. The results suggest that tape‐based immobilization techniques represent an economical and useful alternative to the thermoplastic mask.
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Affiliation(s)
- Ashley E Rubinstein
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - W Scott Ingram
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Brian M Anderson
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Skylar S Gay
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xenia J Fave
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Rachel B Ger
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Rachel E McCarroll
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Constance A Owens
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Tucker J Netherton
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Kelly D Kisling
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Yuting Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Joonsang Lee
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dennis S Mackin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos E Cardenas
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate School of Biomedical Sciences, The University of Texas Health Sciences Center, Houston, TX, USA
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19
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Three-dimensional Image Fusion Guidance for Transjugular Intrahepatic Portosystemic Shunt Placement. Cardiovasc Intervent Radiol 2017; 40:1732-1739. [DOI: 10.1007/s00270-017-1699-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 05/09/2017] [Indexed: 12/14/2022]
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20
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Lin CG, Xu SK, Yao WY, Wu YQ, Fang JL, Wu VWC. Comparison of set up accuracy among three common immobilisation systems for intensity modulated radiotherapy of nasopharyngeal carcinoma patients. J Med Radiat Sci 2016; 64:106-113. [PMID: 27741377 PMCID: PMC5454330 DOI: 10.1002/jmrs.189] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 07/20/2016] [Accepted: 07/22/2016] [Indexed: 12/25/2022] Open
Abstract
Introduction In intensity modulated radiotherapy (IMRT) of nasopharyngeal carcinoma (NPC) patients, an effective immobilisation system is important to minimise set up deviation. This study evaluated the effectiveness of three immobilisation systems by assessing their set up deviations. Methods Patients were randomly assigned to one of the three immobilisation systems: (1) supine on head rest and base plate (HB); (2) supine with alpha cradle supporting the head and shoulder (AC); (3) supine with vacuum bag supporting the head and shoulder (VB). CBCT was conducted weekly for each patient on the linear accelerator. Image registration was conducted at the nasopharynx (NP) and cervical regions. The translational displacements (latero‐medial, antero‐posterior and cranio‐caudal), rotational displacements (pitch, yaw and roll) and 3D vectors obtained at the NP and cervical regions were recorded and compared among the three systems. Results The mean translational and rotational deviations were within 3 mm and 2°, respectively, and the range of 3D vector was 1.53–3.47 mm. At the NP region, the AC system demonstrated the smallest translational and rotational deviations and 3D vector. The differences were significant except for the latero‐medial, yaw and roll directions. Similarly, at the cervical region, the AC system showed smaller translational and rotational deviations and 3D vector, with only the cranio‐caudal and yaw deviations that did not reach statistical significance. Conclusions Set up deviation was greater in the neck than the NP region. The set up accuracy of the AC system was better than the other two systems, and it is recommended for IMRT of NPC patients in our institution.
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Affiliation(s)
- Cheng-Guang Lin
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Sen-Kui Xu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wen-Yan Yao
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu-Qi Wu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian-Lan Fang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Vincent W C Wu
- Department of Health Technology and Informatics, Hong Kong Polytechnic University, Hung Hom, Hong Kong
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A focus group consultation round exploring patient experiences of comfort during radiotherapy for head and neck cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396916000066] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeThe aim of this study was to consult patients about their experiences of comfort while wearing a thermoplastic mask during head and neck radiotherapy before designing a study to develop a comfort scale for radiotherapy.MethodsA qualitative method using a focus group of patients receiving radiotherapy for head and neck cancer was deployed. Five patients were invited and agreed to participate. Semi-structured questions guided the focus group interview. Thematic analysis was used to identify themes.FindingsThree patients participated in the focus group. Three main themes were identified: Physical comfort, Mental perception, Passivity. Physical comfort derived from feelings of pressure, unpleasantness, and generally being uncomfortable. Mental perception derived from how the physical comfort was perceived and derived from feelings of shock, anxiety, indifference and sensory systems. Passivity arose from feelings such as the ‘doctor knows best’, ‘putting up with it’, and ‘being taken for a ride’.ConclusionThe insight of patient’s comfort and experiences are valuable for clinicians to provide patient-centred care. Findings of this study implicate further investigation of how the themes of patient comfort can be measured in radiotherapy to improve the patient experience.
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Niyazi M, Brada M, Chalmers AJ, Combs SE, Erridge SC, Fiorentino A, Grosu AL, Lagerwaard FJ, Minniti G, Mirimanoff RO, Ricardi U, Short SC, Weber DC, Belka C. ESTRO-ACROP guideline “target delineation of glioblastomas”. Radiother Oncol 2016; 118:35-42. [DOI: 10.1016/j.radonc.2015.12.003] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/13/2015] [Indexed: 11/26/2022]
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Huang Y, Zhao B, Chetty IJ, Brown S, Gordon J, Wen N. Targeting Accuracy of Image-Guided Radiosurgery for Intracranial Lesions: A Comparison Across Multiple Linear Accelerator Platforms. Technol Cancer Res Treat 2015; 15:243-8. [PMID: 25759427 DOI: 10.1177/1533034615574385] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/29/2015] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate the overall positioning accuracy of image-guided intracranial radiosurgery across multiple linear accelerator platforms. METHODS A computed tomography scan with a slice thickness of 1.0 mm was acquired of an anthropomorphic head phantom in a BrainLAB U-frame mask. The phantom was embedded with three 5-mm diameter tungsten ball bearings, simulating a central, a left, and an anterior cranial lesion. The ball bearings were positioned to radiation isocenter under ExacTrac X-ray or cone-beam computed tomography image guidance on 3 Linacs: (1) ExacTrac X-ray localization on a Novalis Tx; (2) cone-beam computed tomography localization on the Novalis Tx; (3) cone-beam computed tomography localization on a TrueBeam; and (4) cone-beam computed tomography localization on an Edge. Each ball bearing was positioned 5 times to the radiation isocenter with different initial setup error following the 4 image guidance procedures on the 3 Linacs, and the mean (µ) and one standard deviation (σ) of the residual error were compared. RESULTS Averaged overall 3 ball bearing locations, the vector length of the residual setup error in mm (µ ± σ) was 0.6 ± 0.2, 1.0 ± 0.5, 0.2 ± 0.1, and 0.3 ± 0.1 on ExacTrac X-ray localization on a Novalis Tx, cone-beam computed tomography localization on the Novalis Tx, cone-beam computed tomography localization on a TrueBeam, and cone-beam computed tomography localization on an Edge, with their range in mm being 0.4 to 1.1, 0.4 to 1.9, 0.1 to 0.5, and 0.2 to 0.6, respectively. The congruence between imaging and radiation isocenters in mm was 0.6 ± 0.1, 0.7 ± 0.1, 0.3 ± 0.1, and 0.2 ± 0.1, for the 4 systems, respectively. CONCLUSIONS Targeting accuracy comparable to frame-based stereotactic radiosurgery can be achieved with image-guided intracranial stereotactic radiosurgery treatment.
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Affiliation(s)
- Yimei Huang
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Bo Zhao
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Stephen Brown
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - James Gordon
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, USA
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Baron CA, Awan MJ, Mohamed ASR, Akel I, Rosenthal DI, Gunn GB, Garden AS, Dyer BA, Court L, Sevak PR, Kocak-Uzel E, Fuller CD. Estimation of daily interfractional larynx residual setup error after isocentric alignment for head and neck radiotherapy: quality assurance implications for target volume and organs-at-risk margination using daily CT on- rails imaging. J Appl Clin Med Phys 2014; 16:5108. [PMID: 25679151 PMCID: PMC5016194 DOI: 10.1120/jacmp.v16i1.5108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 10/13/2014] [Accepted: 10/08/2014] [Indexed: 12/25/2022] Open
Abstract
Larynx may alternatively serve as a target or organs at risk (OAR) in head and neck cancer (HNC) image-guided radiotherapy (IGRT). The objective of this study was to estimate IGRT parameters required for larynx positional error independent of isocentric alignment and suggest population-based compensatory margins. Ten HNC patients receiving radiotherapy (RT) with daily CT on-rails imaging were assessed. Seven landmark points were placed on each daily scan. Taking the most superior-anterior point of the C5 vertebra as a reference isocenter for each scan, residual displacement vectors to the other six points were calculated postisocentric alignment. Subsequently, using the first scan as a reference, the magnitude of vector differences for all six points for all scans over the course of treatment was calculated. Residual systematic and random error and the necessary compensatory CTV-to-PTV and OAR-to-PRV margins were calculated, using both observational cohort data and a bootstrap-resampled population estimator. The grand mean displacements for all anatomical points was 5.07 mm, with mean systematic error of 1.1 mm and mean random setup error of 2.63 mm, while bootstrapped POIs grand mean displacement was 5.09 mm, with mean systematic error of 1.23 mm and mean random setup error of 2.61 mm. Required margin for CTV-PTV expansion was 4.6 mm for all cohort points, while the bootstrap estimator of the equivalent margin was 4.9 mm. The calculated OAR-to-PRV expansion for the observed residual setup error was 2.7 mm and bootstrap estimated expansion of 2.9 mm. We conclude that the interfractional larynx setup error is a significant source of RT setup/delivery error in HNC, both when the larynx is considered as a CTV or OAR. We estimate the need for a uniform expansion of 5 mm to compensate for setup error if the larynx is a target, or 3 mm if the larynx is an OAR, when using a nonlaryngeal bony isocenter.
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Cheng KF, Wu VWC. Comparison of the effectiveness of different immobilization systems in different body regions using daily megavoltage CT in helical tomotherapy. Br J Radiol 2014; 87:20130494. [PMID: 24398111 DOI: 10.1259/bjr.20130494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Effective immobilization is crucial for the accurate delivery of radiotherapy. This study aimed to compare the effectiveness of the commonly used immobilization systems for different body regions using megavoltage CT (MVCT). METHODS Daily treatment set-up data from 212 patients treated by helical tomotherapy (Accuray, Sunnyvale, CA) in 6 body regions (52 head and neck, 41 chest, 38 abdomen, 36 pelvis, 18 breast and 27 cranium) were obtained. Based on a verification tool using the pre-treatment MVCT, set-up corrections for each patient were recorded. Mean systematic and random errors of lateral, longitudinal, vertical and roll directions and three-dimensional vectors were compared between immobilization systems of each region. RESULTS Smaller set-up deviations were observed in the Orfit system (Orfit Industries NV, Wijnegem, Belgium) of the head and neck region, while the performance of immobilization systems for the chest, abdomen and pelvis regions was similar. Larger differences were noted in the breast group, where the prone BodyFIX® system (Medical Intelligence, Medizintechnik GmbH, Schwabmünchen, Germany) was less stable than the supine VacLok® system (CIVCO Medical Solutions, Orange City, IA). CONCLUSION Differences were found between the immobilization systems in the head and neck region, in which the Orfit system was relatively more effective, whereas the VacLok and BodyFIX systems performed similarly in the chest, abdomen and pelvis regions. For the breast case, the supine position with VacLok was much more stable than the prone breast technique. The results provided references for the estimation of clinical target volume-planning target volume margins. ADVANCES IN KNOWLEDGE This is the first article on comprehensive comparisons performed in immobilization systems for main body regions that provides some practical recommendations.
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Affiliation(s)
- K-F Cheng
- Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong
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Leitzen C, Wilhelm-Buchstab T, Garbe S, Lütter C, Müdder T, Simon B, Schild H, Schüller H. Quality of patient positioning during cerebral tomotherapy irradiation using different mask systems. Strahlenther Onkol 2013; 190:382-5. [DOI: 10.1007/s00066-013-0496-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/24/2013] [Indexed: 12/25/2022]
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Amelio D, Winter M, Habermehl D, Jäkel O, Debus J, Combs SE. Analysis of inter- and intrafraction accuracy of a commercial thermoplastic mask system used for image-guided particle radiation therapy. JOURNAL OF RADIATION RESEARCH 2013; 54 Suppl 1:i69-i76. [PMID: 23824130 PMCID: PMC3700507 DOI: 10.1093/jrr/rrt038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/11/2013] [Accepted: 03/21/2013] [Indexed: 06/02/2023]
Abstract
The present paper reports and discusses the results concerning both the inter- and intrafraction accuracy achievable combining the immobilization system employed in patients with head-and-neck, brain and skull base tumors with image guidance at our particle therapy center. Moreover, we investigated the influence of intrafraction time on positioning displacements. A total of 41 patients treated between January and July 2011 represented the study population. All the patients were immobilized with a tailored commercial thermoplastic head mask with standard head-neck rest (HeadSTEP(®), IT-V). Patient treatment position was verified by two orthogonal kilovoltage images acquired through a ceiling imaging robot (Siemens, Erlangen, Germany). The analysis of the applied daily corrections during the first treatment week before and after treatment delivery allowed the evaluation of the interfraction and intrafraction reproducibility of the thermoplastic mask, respectively. Concerning interfraction reproducibility, translational and rotational systematic errors (Σs) were ≤ 2.2 mm and 0.9º, respectively; translational and rotational random errors (σs) were ≤ 1.6 mm and 0.6º, respectively. Regarding the intrafraction accuracy translational and rotational Σs were ≤ 0.4 mm and 0.4º, respectively; translational and rotational σs were ≤ 0.5 mm and 0.3º, respectively. Concerning the time-intrafraction displacements correlation Pearson coefficient was 0.5 for treatment fractions with time between position checks less than or equal to median value, and 0.2 for those with time between position controls longer than the median figure. These results suggest that intrafractional patient motion is smaller than interfractional patient motion. Moreover, we can state that application of different imaging verification protocols translate into a relevant difference of accuracy for the same immobilization device. The magnitude of intrafraction displacements correlates with the time for short treatment sessions or during the early phase of long treatment delivery.
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Affiliation(s)
- Dante Amelio
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.
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Rosenfelder NA, Corsini L, McNair H, Pennert K, Aitken A, Lamb CM, Long M, Clarke E, Murcia M, Schick U, Burke K, Ashley S, Khoo, V, Brada M. Comparison of setup accuracy and intrafraction motion using stereotactic frame versus 3-point thermoplastic mask-based immobilization for fractionated cranial image guided radiation therapy. Pract Radiat Oncol 2013; 3:171-179. [DOI: 10.1016/j.prro.2012.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 06/07/2012] [Accepted: 06/11/2012] [Indexed: 11/24/2022]
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Haertl PM, Loeschel R, Repp N, Pohl F, Koelbl O, Dobler B. Frameless fractionated stereotactic radiation therapy of intracranial lesions: impact of cone beam CT based setup correction on dose distribution. Radiat Oncol 2013; 8:153. [PMID: 23800172 PMCID: PMC3707816 DOI: 10.1186/1748-717x-8-153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 05/26/2013] [Indexed: 11/29/2022] Open
Abstract
Background The purpose of this study was to evaluate the impact of Cone Beam CT (CBCT) based setup correction on total dose distributions in fractionated frameless stereotactic radiation therapy of intracranial lesions. Methods Ten patients with intracranial lesions treated with 30 Gy in 6 fractions were included in this study. Treatment planning was performed with Oncentra® for a SynergyS® (Elekta Ltd, Crawley, UK) linear accelerator with XVI® Cone Beam CT, and HexaPOD™ couch top. Patients were immobilized by thermoplastic masks (BrainLab, Reuther). After initial patient setup with respect to lasers, a CBCT study was acquired and registered to the planning CT (PL-CT) study. Patient positioning was corrected according to the correction values (translational, rotational) calculated by the XVI® system. Afterwards a second CBCT study was acquired and registered to the PL-CT to confirm the accuracy of the corrections. An in-house developed software was used for rigid transformation of the PL-CT to the CBCT geometry, and dose calculations for each fraction were performed on the transformed CT. The total dose distribution was achieved by back-transformation and summation of the dose distributions of each fraction. Dose distributions based on PL-CT, CBCT (laser set-up), and final CBCT were compared to assess the influence of setup inaccuracies. Results The mean displacement vector, calculated over all treatments, was reduced from (4.3 ± 1.3) mm for laser based setup to (0.5 ± 0.2) mm if CBCT corrections were applied. The mean rotational errors around the medial-lateral, superior-inferior, anterior-posterior axis were reduced from (−0.1 ± 1.4)°, (0.1 ± 1.2)° and (−0.2 ± 1.0)°, to (0.04 ± 0.4)°, (0.01 ± 0.4)° and (0.02 ± 0.3)°. As a consequence the mean deviation between planned and delivered dose in the planning target volume (PTV) could be reduced from 12.3% to 0.4% for D95 and from 5.9% to 0.1% for Dav. Maximum deviation was reduced from 31.8% to 0.8% for D95, and from 20.4% to 0.1% for Dav. Conclusion Real dose distributions differ substantially from planned dose distributions, if setup is performed according to lasers only. Thermoplasic masks combined with a daily CBCT enabled a sufficient accuracy in dose distribution.
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Cronin B, McCarthy A, Claire K, Starling P, Deegan T, Owen R, Roberts L, McQuitty S. Quality Improvement Investigation for Head and Neck Stabilization in Radiotherapy Using Setup Tattoos. J Med Imaging Radiat Sci 2013; 44:92-99. [PMID: 31051939 DOI: 10.1016/j.jmir.2012.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 11/07/2012] [Accepted: 11/15/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Highly complex planning techniques and delivery methods in the treatment of head and neck cancer require an advanced level of accuracy and reproducibility. AIM To determine if the addition of tattoos placed on the chest inferior to the CIVCO Vac-Lok stabilization system improves accuracy and reproducibility of patient set up. METHODS Eighteen patients with head and neck cancer were studied. Nine underwent radical treatment using the routine CIVCO stabilization system. The second group of nine used the same stabilization device but were positioned daily with the use of tattoos. Daily orthogonal kilovoltage setup images were used to calculate setup errors. Displacements in the left/right (Lt/Rt), superior/inferior (Sup/Inf), and anterior/posterior (Ant/Post) directions were determined as well as pitch and yaw rotational errors. RESULTS Five hundred and twenty-three image pairs were analysed. Clinically significant differences were found in yaw error, Lt/Rt displacement, and Sup/Inf displacement in the tattooed patients. The median (interquartile range) absolute yaw error was larger for patients without tattoos: 1.4° (1.4° to 2.1°) compared to 0.8° (0.8° to 1.4°) for patients with tattoos. The percentage of both Sup/Inf and Lt/Rt errors >3 mm was also greater for patients without tattoos: 23.7% of Sup/Inf errors were >3 mm compared with 17.3% for patients with tattoos, and 22.3% of Lt/Rt errors were >3 mm compared with 10.0% for patients with tattoos. CONCLUSION The addition of chest tattoos resulted in clinically relevant improvements in Lt/Rt and Sup/Inf translational displacements and variations in yaw for head and neck cancer patients.
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Affiliation(s)
- Brenda Cronin
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia.
| | - Alicia McCarthy
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
| | - Kathleen Claire
- Clinical Research Support Unit, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Phoebe Starling
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
| | - Timothy Deegan
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
| | - Rebecca Owen
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
| | - Lisa Roberts
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
| | - Simon McQuitty
- Radiation Therapy Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Health Service District, South Brisbane, Queensland, Australia
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Partridge M, Powell C, Koopman M, Humbert Vidan L, Newbold K. Technical note: 9-month repositioning accuracy for functional response assessment in head and neck chemoradiotherapy. Br J Radiol 2012; 85:1576-80. [PMID: 23175480 PMCID: PMC3611716 DOI: 10.1259/bjr/47081873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 05/03/2012] [Accepted: 05/29/2012] [Indexed: 01/08/2023] Open
Abstract
The use of thermoplastic immobilisation masks in head and neck radiotherapy is now common practice. The accuracy of these systems has been widely studied, but always within the context and time frame of the radiation delivery-some 6-8 weeks. There is growing current interest in the use of functional imaging to assess the response to treatment, particularly in the head and neck. It is therefore of interest to determine the accuracy with which functional images can be registered to baseline CT over the extended periods of time used for functional response assessment: 3-6 months after radiotherapy. In this study, repeated contrast-enhanced diagnostic quality CT and mid-quality localisation CT from a positron emission tomography/CT scanner were available for five time points over a period of 9 months (before, during and up to 6 months after chemoradiotherapy) for a series of eight patients enrolled in a clinical pilot study. All images were acquired using thermoplastic immobilisation masks. The overall set-up accuracy obtained from this 9-month study of 5.5 ± 3.2 mm (1 standard deviation) and 1.9 ± 1.3° (1 standard deviation) is in agreement with published data acquired over 6-8 weeks. No statistically significant change in set-up error was seen with time. This work indicates that thermoplastic immobilisation masks can be used to accurately align multimodality functional image data for assessment of the response to treatment in head and neck patients over extended follow-up periods.
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Affiliation(s)
- M Partridge
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, UK.
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Dhabaan A, Schreibmann E, Siddiqi A, Elder E, Fox T, Ogunleye T, Esiashvili N, Curran W, Crocker I, Shu HK. Six degrees of freedom CBCT-based positioning for intracranial targets treated with frameless stereotactic radiosurgery. J Appl Clin Med Phys 2012; 13:3916. [PMID: 23149782 PMCID: PMC5718543 DOI: 10.1120/jacmp.v13i6.3916] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 06/22/2012] [Accepted: 06/29/2012] [Indexed: 11/23/2022] Open
Abstract
Frameless radiosurgery is an attractive alternative to the framed procedure if it can be performed with comparable precision in a reasonable time frame. Here, we present a positioning approach for frameless radiosurgery based on in-room volumetric imaging coupled with an advanced six-degrees-of-freedom (6 DOF) image registration technique which avoids use of a bite block. Patient motion is restricted with a custom thermoplastic mask. Accurate positioning is achieved by registering a cone-beam CT to the planning CT scan and applying all translational and rotational shifts using a custom couch mount. System accuracy was initially verified on an anthropomorphic phantom. Isocenters of delineated targets in the phantom were computed and aligned by our system with an average accuracy of 0.2 mm, 0.3 mm, and 0.4 mm in the lateral, vertical, and longitudinal directions, respectively. The accuracy in the rotational directions was 0.1°, 0.2°, and 0.1° in the pitch, roll, and yaw, respectively. An additional test was performed using the phantom in which known shifts were introduced. Misalignments up to 10 mm and 3° in all directions/rotations were introduced in our phantom and recovered to an ideal alignment within 0.2 mm, 0.3 mm, and 0.4 mm in the lateral, vertical, and longitudinal directions, respectively, and within 0.3° in any rotational axis. These values are less than couch motion precision. Our first 28 patients with 38 targets treated over 63 fractions are analyzed in the patient positioning phase of the study. Mean error in the shifts predicted by the system were less than 0.5 mm in any translational direction and less than 0.3° in any rotation, as assessed by a confirmation CBCT scan. We conclude that accurate and efficient frameless radiosurgery positioning is achievable without the need for a bite block by using our 6DOF registration method. This system is inexpensive compared to a couch-based 6 DOF system, improves patient comfort compared to systems that utilize a bite block, and is ideal for the treatment of pediatric patients with or without general anesthesia, as well as of patients with dental issues. From this study, it is clear that only adjusting for 4 DOF may, in some cases, lead to significant compromise in PTV coverage. Since performing the additional match with 6 DOF in our registration system only adds a relatively short amount of time to the overall process, we advocate making the precise match in all cases.
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Affiliation(s)
- Anees Dhabaan
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Abstract
Radiotherapy technology has improved rapidly over the past two decades. New imaging modalities, such as positron emission (computed) tomography (PET, PET-CT) and high-resolution morphological and functional magnetic resonance imaging (MRI) have been introduced into the treatment planning process. Image-guided radiation therapy (IGRT) with 3D soft tissue depiction directly imaging target and normal structures, is currently replacing patient positioning based on patient surface markers, frame-based intracranial and extracranial stereotactic treatment and partially also 2D field verification methods. On-line 3D soft tissue-based position correction unlocked the full potential of new delivery techniques, such as intensity-modulated radiotherapy, by safely delivering highly conformal dose distributions that facilitate dose escalation and hypofractionation. These strategies have already resulted in better clinical outcomes, e.g. in prostate and lung cancer and are expected to further improve radiotherapy results.
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Rosenfelder NA, Corsini L, McNair H, Pennert K, Burke K, Lamb CM, Aitken A, Ashley S, Khoo V, Brada M. Achieving the relocation accuracy of stereotactic frame-based cranial radiotherapy in a three-point thermoplastic shell. Clin Oncol (R Coll Radiol) 2012; 25:66-73. [PMID: 22795232 DOI: 10.1016/j.clon.2012.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 03/25/2012] [Accepted: 06/26/2012] [Indexed: 12/25/2022]
Abstract
AIMS To compare the accuracy of fractionated cranial radiotherapy in a standard three-point thermoplastic shell using daily online correction with accuracy in a Gill-Thomas-Cosman relocatable stereotactic frame. MATERIALS AND METHODS All patients undergoing fractionated radiotherapy for benign intracranial tumours between March 2009 and August 2010 were included. Patients were immobilised in the frame with those unable to tolerate it immobilised in the shell. The ExacTrac imaging system was used for verification/correction. Daily online imaging before and after correction was carried out for shell patients and systematic and random population set-up errors calculated. These were compared with frame patients who underwent standard departmental imaging/correction with fractions 1-3 and weekly thereafter. Set-up margins were calculated from population errors. RESULTS Systematic and random errors were 0.3-0.7 mm/° before correction and 0.1-0.2 mm/° after correction in all axes in the frame, and 0.6-1.5 mm/° before correction and 0.1-0.4 mm/° after correction in the shell. Isotropic margins required for patient set-up could be reduced from 2 mm to <1 mm in the frame and from 5 mm to <1 mm in the shell. CONCLUSION Similar set-up accuracy can be achieved in the standard thermoplastic shell as in a relocatable frame despite less precise immobilisation. The use of daily online correction precludes the need for larger set-up margins.
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Affiliation(s)
- N A Rosenfelder
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust, London, UK.
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Morley L, Waldron J, Dawson L, Bayley A, Ringash J, Cummings B, Kim J, O'Sullivan B, Breen SL. The Effect of Registration Volume Extent on Residual Errors Assessed Using Cone-Beam Computed Tomography in Radiation Treatment of Head and Neck Cancer. J Med Imaging Radiat Sci 2012; 43:95-102. [PMID: 31052032 DOI: 10.1016/j.jmir.2012.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 01/09/2012] [Accepted: 01/09/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of this study was to investigate the effect of the varying extent of cone-beam computed tomography (CBCT) registration volumes (RVs) on setup errors for head and neck (H&N) radiotherapy. METHODS AND MATERIALS Daily CBCT images for 31 patients receiving H&N intensity-modulated radiotherapy (IMRT) were reviewed. Registrations using anatomically defined RVs with a fixed superior border at base of sella and varying inferior extent were used retrospectively to evaluate patient setup. The inferior extent was defined as the number of cervical bodies included, from none (C0) to six (C6). The frequency of residual displacements at four landmarks (clivus, vertebral bodies C5-C6, manubrium-sterni, and anterior body of mandible) was assessed. RESULTS Expansion of the RVs inferiorly reduced the occurrence of residual displacements for the C5-C6 vertebral bodies (from 57% to 93% of fractions with residual displacements ≤ 3 mm) and increased the rate of simultaneous positioning of C5-C6 and clivus (from 41% to 76%). Maximum residual displacements for mandible (48%-64% ≤ 3 mm) and manubrium (73%-81% ≤ 3 mm) varied somewhat by the inferior extent of the RV. Residual displacements for clivus were small (88%-96% ≤ 3 mm) in all cases. Random and systematic errors were clinically acceptable for a 5-mm planning margin around the clinical targets. CONCLUSIONS In conclusion, expansion of the RV inferiorly to include C6 will improve the positioning of structures in the C5-C6 region (adjacent nodal zones 3 and 4) without compromising clival positioning. Insufficient inferior extent of the RV reduces reliability of low neck positioning. Substantial variability can occur for structures not included in the RV. Based on these data, we use the C6 RV except in cases with planning concerns outside this volume.
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Affiliation(s)
- Lyndon Morley
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - John Waldron
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura Dawson
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Bayley
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jolie Ringash
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bernard Cummings
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian O'Sullivan
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen L Breen
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Cassol E, Bonnet J, Porcheron D, Mazeron JJ, Peiffert D, Alapetite C. [Ballistic quality assurance]. Cancer Radiother 2012; 16 Suppl:S30-7. [PMID: 22632786 DOI: 10.1016/j.canrad.2011.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 06/30/2011] [Indexed: 10/28/2022]
Abstract
This review describes the ballistic quality assurance for stereotactic intracranial irradiation treatments delivered with Gamma Knife® either dedicated or adapted medical linear accelerators. Specific and periodic controls should be performed in order to check the mechanical stability for both irradiation and collimation systems. If this step remains under the responsibility of the medical physicist, it should be done in agreement with the manufacturer's technical support. At this time, there are no recent published guidelines. With technological developments, both frequency and accuracy should be assessed in each institution according to the treatment mode: single versus hypofractionnated dose, circular collimator versus micro-multileaf collimators. In addition, "end-to-end" techniques are mandatory to find the origin of potential discrepancies and to estimate the global ballistic accuracy of the delivered treatment. Indeed, they include frames, non-invasive immobilization devices, localizers, multimodal imaging for delineation and in-room positioning imaging systems. The final precision that could be reasonably achieved is more or less 1mm.
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Affiliation(s)
- E Cassol
- Unité de radiophysique et de radioprotection des hôpitaux de Toulouse, Hôtel Dieu Saint-Jacques, 2 rue Viguerie,Toulouse cedex 9, France.
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Guckenberger M, Roesch J, Baier K, Sweeney RA, Flentje M. Dosimetric consequences of translational and rotational errors in frame-less image-guided radiosurgery. Radiat Oncol 2012; 7:63. [PMID: 22531060 PMCID: PMC3441228 DOI: 10.1186/1748-717x-7-63] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 04/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate geometric and dosimetric accuracy of frame-less image-guided radiosurgery (IG-RS) for brain metastases. METHODS AND MATERIALS Single fraction IG-RS was practiced in 72 patients with 98 brain metastases. Patient positioning and immobilization used either double- (n = 71) or single-layer (n = 27) thermoplastic masks. Pre-treatment set-up errors (n = 98) were evaluated with cone-beam CT (CBCT) based image-guidance (IG) and were corrected in six degrees of freedom without an action level. CBCT imaging after treatment measured intra-fractional errors (n = 64). Pre- and post-treatment errors were simulated in the treatment planning system and target coverage and dose conformity were evaluated. Three scenarios of 0 mm, 1 mm and 2 mm GTV-to-PTV (gross tumor volume, planning target volume) safety margins (SM) were simulated. RESULTS Errors prior to IG were 3.9 mm ± 1.7 mm (3D vector) and the maximum rotational error was 1.7° ± 0.8° on average. The post-treatment 3D error was 0.9 mm ± 0.6 mm. No differences between double- and single-layer masks were observed. Intra-fractional errors were significantly correlated with the total treatment time with 0.7 mm ± 0.5 mm and 1.2 mm ± 0.7 mm for treatment times ≤23 minutes and >23 minutes (p<0.01), respectively. Simulation of RS without image-guidance reduced target coverage and conformity to 75% ± 19% and 60% ± 25% of planned values. Each 3D set-up error of 1 mm decreased target coverage and dose conformity by 6% and 10% on average, respectively, with a large inter-patient variability. Pre-treatment correction of translations only but not rotations did not affect target coverage and conformity. Post-treatment errors reduced target coverage by >5% in 14% of the patients. A 1 mm safety margin fully compensated intra-fractional patient motion. CONCLUSIONS IG-RS with online correction of translational errors achieves high geometric and dosimetric accuracy. Intra-fractional errors decrease target coverage and conformity unless compensated with appropriate safety margins.
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Hypofractionated frameless stereotactic intensity-modulated radiotherapy with whole brain radiotherapy for the treatment of 1-3 brain metastases. Neurol Sci 2012; 34:647-53. [PMID: 22526765 DOI: 10.1007/s10072-012-1091-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
The aim of the study is to evaluate the efficacy and toxicity of hypofractionated frameless stereotactic radiotherapy (HSRT) with whole brain radiotherapy (WBRT) for the treatment of 1-3 brain metastases. 38 patients with a total of 58 brain metastases were treated at Ghent University Hospital with WBRT (10 × 3 Gy) followed by HSRT (5 × 6 Gy). Patients with RPA class I (n = 8) and II (n = 30) were eligible for HSRT. Acute toxicity was scored with the RTOG toxicity criteria. Response rates were scored every 3 months using the McDonald criteria. Overall survival (OS), brain-specific survival, local and distant brain control were calculated using the Kaplan-Meier method. Patient (age, Karnofsky performance score, KPS, RPA class) and tumor characteristics (number of lesions, extracranial metastases, brain tumor volume, primary cancer status, histology) were tested in univariate and multivariate analysis. Survival at 6 and 12 months was 65 and 35 %, respectively. On univariate analysis KPS < 90, number of lesions, a histologic diagnosis of adenocarcinoma and uncontrolled primary cancer status were statistic significant predictors for poor OS. Four patients (11 %) developed a grade 3 toxicity. Rates of complete remission, partial remission, no change and progressive disease were 30, 40, 23 and 5 %, respectively. Median survival was 7.6 months. The actuarial brain-specific survival was 97 % at 6 months and 91 % at 1 year of follow-up. The 1-year actuarial local and distant brain control was 66 and 75 %, respectively. WBRT + HSRT is an effective treatment for patients with up to three brain metastases.
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Ingrosso G, Miceli R, Fedele D, Ponti E, Benassi M, Barbarino R, Di Murro L, Giudice E, Santarelli F, Santoni R. Cone-beam computed tomography in hypofractionated stereotactic radiotherapy for brain metastases. Radiat Oncol 2012; 7:54. [PMID: 22462491 PMCID: PMC3364849 DOI: 10.1186/1748-717x-7-54] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 04/01/2012] [Indexed: 11/10/2022] Open
Abstract
Background To assess interfraction translational and rotational setup errors, in patients treated with image-guded hypofractionated stereotactic radiotherapy, immobilized by a thermoplastic mask and a bite-block and positioned using stereotactic coordinates. Methods 37 patients with 47 brain metastases were treated with hypofractionated stererotactic radiotherapy. All patients were immobilized with a combination of a thermoplastic mask and a bite-block fixed to a stereotactic frame support. Daily cone-beam CT scans were acquired for every patient before the treatment session and were matched online with planning CT images, for 3D image registration. The mean value and standard deviation of all translational (X, Y, Z) and rotational errors (θx, θy, θz) were calculated for the matching results of bone matching algorithm. Results A total of 194 CBCT scans were analyzed. Mean +/- standard deviation of translational errors (X, Y, Z) were respectively 0.5 +/- 1.6 mm (range -5.7 and 5.9 mm) in X; 0.4 +/- 2.7 mm (range -8.2 and 12.1 mm) in Y; 0.4 +/- 1.9 mm (range -7.0 and 14 mm) in Z; median and 90th percentile were respectively within 0.5 mm and 2.4 mm in X, 0.3 mm and 3.2 mm in Y, 0.3 mm and 2.2 mm in Z. Mean +/- standard deviation of rotational errors (θx, θy, θz) were respectively 0.0 degrees+/- 1.3 degrees (θx) (range -6.0 degrees and 3.1 degrees); -0.1 degrees +/- 1.1 degrees (θy) (range -3.0 degrees and 2.4 degrees); -0.6 degrees +/- 1.4 degrees (θz) (range -5.0 degrees and 3.3 degrees). Median and 90th percentile of rotational errors were respectively within 0.1 degrees and 1.4 degrees (θx), 0.0 degrees and 1.2 degrees (θy), 0.0 degrees and 0.9 degrees (θz). Mean +/- SD of 3D vector was 3.1 +/- 2.1 mm (range 0.3 and 14.9 mm); median and 90th percentile of 3D vector was within 2.7 mm and 5.1 mm. Conclusions Hypofractionated stereotactic radiotherapy have the significant limitation of uncertainty in interfraction repeatability of the patient setup; image-guided radiotherapy using cone-beam computed tomography improves the accuracy of the treatment delivery reducing set-up uncertainty, giving the possibility of 3-dimensional anatomic informations in the treatment position.
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Jeon W, Wu HG, Song SH, Kim JI. Radial displacement of clinical target volume in node negative head and neck cancer. Radiat Oncol J 2012; 30:36-42. [PMID: 23120742 PMCID: PMC3475961 DOI: 10.3857/roj.2012.30.1.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 03/20/2012] [Accepted: 03/22/2012] [Indexed: 11/04/2022] Open
Abstract
Purpose To evaluate the radial displacement of clinical target volume in the patients with node negative head and neck (H&N) cancer and to quantify the relative positional changes compared to that of normal healthy volunteers. Materials and Methods Three node-negative H&N cancer patients and five healthy volunteers were enrolled in this study. For setup accuracy, neck thermoplastic masks and laser alignment were used in each of the acquired computed tomography (CT) images. Both groups had total three sequential CT images in every two weeks. The lymph node (LN) level of the neck was delineated based on the Radiation Therapy Oncology Group (RTOG) consensus guideline by one physician. We use the second cervical vertebra body as a reference point to match each CT image set. Each of the sequential CT images and delineated neck LN levels were fused with the primary image, then maximal radial displacement was measured at 1.5 cm intervals from skull base (SB) to caudal margin of LN level V, and the volume differences at each node level were quantified. Results The mean radial displacements were 2.26 (±1.03) mm in the control group and 3.05 (±1.97) in the H&N cancer patients. There was a statistically significant difference between the groups in terms of the mean radial displacement (p = 0.03). In addition, the mean radial displacement increased with the distance from SB. As for the mean volume differences, there was no statistical significance between the two groups. Conclusion This study suggests that a more generous radial margin should be applied to the lower part of the neck LN for better clinical target coverage and dose delivery.
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Affiliation(s)
- Wan Jeon
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
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Jensen AD, Winter M, Kuhn SP, Debus J, Nairz O, Münter MW. Robotic-based carbon ion therapy and patient positioning in 6 degrees of freedom: setup accuracy of two standard immobilization devices used in carbon ion therapy and IMRT. Radiat Oncol 2012; 7:51. [PMID: 22458824 PMCID: PMC3337272 DOI: 10.1186/1748-717x-7-51] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 03/29/2012] [Indexed: 11/10/2022] Open
Abstract
Purpose To investigate repositioning accuracy in particle radiotherapy in 6 degrees of freedom (DOF) and intensity-modulated radiotherapy (IMRT, 3 DOF) for two immobilization devices (Scotchcast masks vs thermoplastic head masks) currently in use at our institution for fractionated radiation therapy in head and neck cancer patients. Methods and materials Position verifications in patients treated with carbon ion therapy and IMRT for head and neck malignancies were evaluated. Most patients received combined treatment regimen (IMRT plus carbon ion boost), immobilization was achieved with either Scotchcast or thermoplastic head masks. Position corrections in robotic-based carbon ion therapy allowing 6 DOF were compared to IMRT allowing corrections in 3 DOF for two standard immobilization devices. In total, 838 set-up controls of 38 patients were analyzed. Results Robotic-based position correction including correction of rotations was well tolerated and without discomfort. Standard deviations of translational components were between 0.5 and 0.8 mm for Scotchcast and 0.7 and 1.3 mm for thermoplastic masks in 6 DOF and 1.2 - 1.4 mm and 1.0 - 1.1 mm in 3 DOF respectively. Mean overall displacement vectors were between 2.1 mm (Scotchcast) and 2.9 mm (thermoplastic masks) in 6 DOF and 3.9 - 3.0 mm in 3 DOF respectively. Displacement vectors were lower when correction in 6 DOF was allowed as opposed to 3 DOF only, which was maintained at the traditional action level of > 3 mm for position correction in the pre-on-board imaging era. Conclusion Setup accuracy for both systems was within the expected range. Smaller shifts were required when 6 DOF were available for correction as opposed to 3 DOF. Where highest possible positioning accuracy is required, frequent image guidance is mandatory to achieve best possible plan delivery and maintenance of sharp gradients and optimal normal tissue sparing inherent in carbon ion therapy.
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Affiliation(s)
- Alexandra D Jensen
- Department of Radiation Oncology, University of Heidelberg, INF 400, Heidelberg 69120, Germany.
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Historical Development of Stereotactic Ablative Radiotherapy. STEREOTACTIC BODY RADIATION THERAPY 2012. [DOI: 10.1007/174_2012_540] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kim H, Park YK, Kim IH, Lee K, Ye SJ. Development of an optical-based image guidance system: technique detecting external markers behind a full facemask. Med Phys 2011; 38:3006-12. [PMID: 21815374 DOI: 10.1118/1.3589137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Optical image-guided systems (e.g., AlignRT, frameless SonArray, ExacTrac) have been used with advantages of avoiding excessive radiation exposure and real-time patient monitoring. Although these systems showed proven accuracy, they need to modify a full facemask for patients with H&N cancer and brain tumor. We developed an optical-based guidance system to manage interfractional and intrafractional setup errors by tracking external markers behind a full facemask. METHODS Infra-red (IR) reflecting markers were attached on the face of a head phantom and then the phantom was immobilized by a full face thermoplastic mask. A stereo camera system consisting of two CCD cameras was mounted on the inferior wall of treatment room. The stereo camera system was calibrated to reconstruct 3D coordinates of multiple markers with respect to the isocenter using the direct linear transform (DLT) algorithm. The real-time position of the phantom was acquired, through the stereo camera system, by detecting the IR markers behind the full facemask. The detection errors with respect to the reference positions of planning CT images were calculated in six degrees of freedom (6-DOF) by a rigid-body registration technique. RESULTS The calibration accuracy of the system was in submillimeter (0.33 mm +/- 0.27 mm), which was comparable to others. The mean distance between each of marker positions of optical images and planning CT images was 0.50 mm +/- 0.67 mm. The maximum deviations of 6-DOF registration were less than 1 mm and 1 degrees for the couch translation and rotation, respectively. CONCLUSIONS The developed system showed the accuracy and consistency comparable to the commercial optical guided systems, while allowing us to simultaneously immobilize patients with a full face thermoplastic mask.
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Affiliation(s)
- Hwiyoung Kim
- Department of Radiation Applied Life Science, Seoul National University, Seoul 110-744, Korea
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Tryggestad E, Christian M, Ford E, Kut C, Le Y, Sanguineti G, Song DY, Kleinberg L. Inter- and Intrafraction Patient Positioning Uncertainties for Intracranial Radiotherapy: A Study of Four Frameless, Thermoplastic Mask-Based Immobilization Strategies Using Daily Cone-Beam CT. Int J Radiat Oncol Biol Phys 2011; 80:281-90. [PMID: 20951506 DOI: 10.1016/j.ijrobp.2010.06.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 05/21/2010] [Accepted: 06/08/2010] [Indexed: 10/18/2022]
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Boda-Heggemann J, Lohr F, Wenz F, Flentje M, Guckenberger M. kV Cone-Beam CT-Based IGRT. Strahlenther Onkol 2011; 187:284-91. [PMID: 21533757 DOI: 10.1007/s00066-011-2236-4] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/21/2011] [Indexed: 12/25/2022]
Affiliation(s)
- Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
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Li S, Kleinberg LR, Rigamonti D, Wharam MD, Rashid A, Jackson J, Djajaputra D, He S, Creasey T, DeWeese TL. Clinical results of a pilot study on stereovision-guided stereotactic radiotherapy and intensity modulated radiotherapy. Technol Cancer Res Treat 2011; 9:603-17. [PMID: 21070083 DOI: 10.1177/153303461000900609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Real-time stereovision-guidance has been introduced for efficient and convenient fractionated stereotactic radiotherapy (FSR) and image-guided intensity-modulated radiation therapy (IMRT). This first pilot study is to clinically evaluate its accuracy and precision as well as impact on treatment doses. Sixty-one FSR patients wearing stereotactic masks (SMs) and nine IMRT patients wearing flexible masks (FMs), were accrued. Daily target reposition was initially based-on biplane-radiographs and then adjusted in six degrees of freedom under real-time stereovision guidance. Mean and standard deviation of the head displacements measured the accuracy and precision. Head positions during beam-on times were measured with real-time stereovisions and used for determination of delivered doses. Accuracy ± ± precision in direction with the largest errors shows improvement from 0.4 ± 2.3 mm to 0.0 ± 1.0 mm in the inferior-to-superior direction for patients wearing SM or from 0.8 ± 4.3 mm to 0.4 ± 1.7 mm in the posterior-to-anterior direction for patients wearing FM. The image-guidance increases target volume coverage by >30% for small lesions. Over half of head position errors could be removed from the stereovision-guidance. Importantly, the technique allows us to check head position during beam-on time and makes it possible for having frameless head refixation without tight masks.
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Affiliation(s)
- Shidong Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
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Boda-Heggemann J, Fleckenstein J, Lohr F, Wertz H, Nachit M, Blessing M, Stsepankou D, Löb I, Küpper B, Kavanagh A, Hansen VN, Brada M, Wenz F, McNair H. Multiple breath-hold CBCT for online image guided radiotherapy of lung tumors: simulation with a dynamic phantom and first patient data. Radiother Oncol 2011; 98:309-16. [PMID: 21345509 DOI: 10.1016/j.radonc.2011.01.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 01/14/2011] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Computer controlled breath-hold effectively reduces organ motion for image-guided precision radiotherapy of lung tumors. However, the acquisition time of 3D cone-beam-CT (CBCT) exceeds maximum breath-hold times. We have developed an approach enabling online verification using CBCT image acquisition with ABC®-based breath-hold. METHODS Patient CBCT images were acquired with ABC®-based repeat breath-hold. The clinical situation was also simulated with a Motion Phantom. Reconstruction of patient and phantom images with selection of free-breathing and breath-hold projections only was performed. RESULTS CBCT-imaging in repeat breath-hold resulted in a precisely spherical appearance of a tumor-mimicking structure in the phantom. A faint "ghost" structure (free-breathing phases) can be clearly discriminated. Mean percentage of patient breath-hold time was 66%. Reconstruction based on free-breathing-only shows blurring of both tumor and diaphragm, reconstruction based on breath-hold projections only resulted in sharp contours of the same structures. From the phantom experiments, a maximal repositioning error of 1mm in each direction can be estimated. DISCUSSION AND CONCLUSION CBCT during repetitive breath hold provides reliable soft-tissue-based positioning. Fast 3D-imaging during one breath-hold is currently under development and has the potential to accelerate clinical linac-based volume imaging.
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Affiliation(s)
- Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, Mannheim, Germany.
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Takagi H, Obata Y, Kobayashi H, Takenaka K, Hirose Y, Goto H, Hattori T. Clinical usefulness of a newly developed body surface navigation and monitoring system in radiotherapy. J Appl Clin Med Phys 2011; 12:3400. [PMID: 21587188 PMCID: PMC5718662 DOI: 10.1120/jacmp.v12i2.3400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 12/08/2010] [Accepted: 01/10/2011] [Indexed: 11/23/2022] Open
Abstract
In radiotherapy, setup precision has great influence on the therapeutic effect. In addition, body movements during the irradiation and physical alternations during the treatment period might cause deviation from the planned irradiation dosage distribution. Both of these factors could undesirably influence the dose absorbed by the target. In order to solve these problems, we developed the "body surface navigation and monitoring system" (hereafter referred to as "Navi-system"). The purpose of this study is to review the precision of the Navi-system as well as its usefulness in clinical radiotherapy. The Navi-system consists of a LED projector, a CCD camera, and a personal computer (PC). The LED projector projects 19 stripes on the patient's body and the CCD camera captures these stripes. The processed image of these stripes in color can be displayed on the PC monitor along with the patient's body surface image, and the digitalized results can be also displayed on the same monitor. The Navi-system calculates the height of the body contour and the transverse height centroid for the 19 levels and compares them with the reference data to display the results on the monitor on a real-time basis. These results are always replaced with new data after they are used for display; so, if the results need to be recorded, such recording commands should be given to the computer. 1) Evaluating the accuracy of the body surface height measurement: from the relationship between actual height changes and calculated height changes with torso surface by the Navi-system, for the height changes from 0.0 mm to ± 10.0mm, the changes show the underestimation of 1.0-1.5 mm and for ± 11.0mm to ± 20.0 mm, the underestimation of 1.5-3.0 mm. 2) Evaluating the accuracy of the transverse height centroid measurement: displacement of the inclined flat panel to the right by 5.0 mm, 10.0 mm, 15.0 mm and 20.0 mm showed the transverse height centroid calculated by the Navi-system for 0.024 ± 0.007 line/pair (mean ± SD), 0.045 ± 0.006 line/pair, 0.066 ± 0.006 line/pair and 0.089 ± 0.007 line/pair, respectively. Also, displacement of the inclined flat panel to the left by 5.0 mm, 10.0 mm, 15.0mm and 20.0 mm showed the transverse height centroid calculated by the Navi-system for 0.015 ± 0.007 line/pair (mean ± SD), 0.034 ± 0.007 line/pair, 0.053 ± 0.008 line/pair and 0.071 ± 0.007 line/pair, respectively. 3) Clinical usefulness of the Navi-system: on using the Navi-system, the frequency of radiotherapy replanning increased from 5.2% to 21.8%, especially in pelvic or abdominal irradiation. We developed a new navigation system for the purpose of compensating for the weakness of MVCT, CBCT and other systems, as well as for having a screening function. This Navi-system can monitor the patient continuously and measure change in height of the patient's body surface from the basic plane, in real time. It can also show the results both qualitatively and quantitatively on the PC monitor.
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Affiliation(s)
- Hitoshi Takagi
- Nagoya University Postgraduate School of Health Sciences, Nagoya, Japan.
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Kang H, Lovelock DM, Yorke ED, Kriminski S, Lee N, Amols HI. Accurate positioning for head and neck cancer patients using 2D and 3D image guidance. J Appl Clin Med Phys 2010. [PMID: 21330971 PMCID: PMC3065820 DOI: 10.1120/jacmp.v12i1.3270] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Our goal is to determine an optimized image‐guided setup by comparing setup errors determined by two‐dimensional (2D) and three‐dimensional (3D) image guidance for head and neck cancer (HNC) patients immobilized by customized thermoplastic masks. Nine patients received weekly imaging sessions, for a total of 54, throughout treatment. Patients were first set up by matching lasers to surface marks (initial) and then translationally corrected using manual registration of orthogonal kilovoltage (kV) radiographs with DRRs (2D‐2D) on bony anatomy. A kV cone beam CT (kVCBCT) was acquired and manually registered to the simulation CT using only translations (3D‐3D) on the same bony anatomy to determine further translational corrections. After treatment, a second set of kVCBCT was acquired to assess intrafractional motion. Averaged over all sessions, 2D‐2D registration led to translational corrections from initial setup of 3.5±2.2 (range 0–8) mm. The addition of 3D‐3D registration resulted in only small incremental adjustment (0.8±1.5mm). We retrospectively calculated patient setup rotation errors using an automatic rigid‐body algorithm with 6 degrees of freedom (DoF) on regions of interest (ROI) of in‐field bony anatomy (mainly the C2 vertebral body). Small rotations were determined for most of the imaging sessions; however, occasionally rotations >3° were observed. The calculated intrafractional motion with automatic registration was <3.5 mm for eight patients, and <2° for all patients. We conclude that daily manual 2D‐2D registration on radiographs reduces positioning errors for mask‐immobilized HNC patients in most cases, and is easily implemented. 3D‐3D registration adds little improvement over 2D‐2D registration without correcting rotational errors. We also conclude that thermoplastic masks are effective for patient immobilization. PACS number: 87.53.Kn
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Affiliation(s)
- Hyejoo Kang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Ruschin M, Nayebi N, Carlsson P, Brown K, Tamerou M, Li W, Laperriere N, Sahgal A, Cho YB, Ménard C, Jaffray D. Performance of a Novel Repositioning Head Frame for Gamma Knife Perfexion and Image-Guided Linac-Based Intracranial Stereotactic Radiotherapy. Int J Radiat Oncol Biol Phys 2010; 78:306-13. [DOI: 10.1016/j.ijrobp.2009.11.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 11/03/2009] [Accepted: 11/04/2009] [Indexed: 11/29/2022]
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