Remote verification in radiotherapy using digitally reconstructed radiography (DRR) and portal images: a pilot study

DRR and portal image registration for automatic patient positioning in radiotherapy treatment

Image processing turns out to be essential in the planning and verification of radiotherapy treatments. Before applying a radiotherapy treatment, a dosimetry planning must be performed. Usually, the planning is done by means of an X-ray volumetric analysis using computerized tomography, where the area to be radiated is marked out. During the treatment phase, it is necessary to place the patient under the particle accelerator exactly as considered in the dosimetry stage. Coarse alignment is achieved using fiduciary markers placed over the patient's skin as external references. Later, fine alignment is provided by comparing a digitally reconstructed radiography (DRR) from the planning stage and a portal image captured by the accelerator in the treatment stage. The preprocessing of DRR and portal images, as well as the minimization of the non-shared information between both kinds of images, is mandatory for the correct operation of the image registration algorithm. With this purpose, mathematical morphology and image processing techniques have been used. The present work describes a fully automatic method to calculate more accurately the necessary displacement of the couch to place the patient exactly at the planned position. The proposed method to achieve the correct positioning of the patient is based on advanced image registration techniques. Preliminary results show a perfect match with the displacement estimated by the physician.

Tolerance of organs at risk in small-volume, hypofractionated, image-guided radiotherapy for primary and metastatic lung cancers

PURPOSE

To determine the organ at risk and the maximum tolerated dose (MTD) of radiation that could be delivered to lung cancer using small-volume, image-guided radiotherapy (IGRT) using hypofractionated, coplanar, and noncoplanar multiple fields.

MATERIALS AND METHODS

Patients with measurable lung cancer (except small-cell lung cancer) 6 cm or less in diameter for whom surgery was not indicated were eligible for this study. Internal target volume was determined using averaged CT under normal breathing, and for patients with large respiratory motion, using two additional CT scans with breath-holding at the expiratory and inspiratory phases in the same table position. Patients were localized at the isocenter after three-dimensional treatment planning. Their setup was corrected by comparing two linacographies that were orthogonal at the isocenter with corresponding digitally reconstructed images. Megavoltage X-rays using noncoplanar multiple static ports or arcs were used to cover the parenchymal tumor mass. Prophylactic nodal irradiation was not performed. The radiation dose was started at 60 Gy in 8 fractions over 2 weeks (60 Gy/8 Fr/2 weeks) for peripheral lesions 3.0 cm or less, and at 48 Gy/8 Fr/2 weeks at the isocenter for central lesions or tumors more than 3.0 cm at their greatest dimension.

RESULTS

Fifty-seven lesions in 45 patients were treated. Tumor size ranged from 0.6 to 6.0 cm, with a median of 2.6 cm. Using the starting dose, 1 patient with a central lesion died of a radiation-induced ulcer in the esophagus after receiving 48 Gy/8 Fr at isocenter. Although the contour of esophagus received 80% or less of the prescribed dose in the planning, recontouring of esophagus in retrospective review revealed that 1 cc of esophagus might have received 42.5 Gy, with the maximum dose of 50.5 Gy. One patient with a peripheral lesion experienced Grade 2 pain at the internal chest wall or visceral pleura after receiving 54 Gy/8 Fr. No adverse respiratory reaction was noted in the symptoms or respiratory function tests. The 3-year local control rate was 80.4% +/- 7.1% (a standard error) with a median follow-up period of 17 months for survivors. Because of the Grade 5 toxicity, we have halted this Phase I/II study and are planning to rearrange the protocol setting accordingly. The 3-year local control rate was 69.6 +/- 10.6% for patients who received 48 Gy and 100% for patients who received 60 Gy (p = 0.0442).

CONCLUSIONS

Small-volume IGRT using 60 Gy in eight fractions is highly effective for the local control of lung tumors, but MTD has not been determined in this study. The organs at risk are extrapleural organs such as the esophagus and internal chest wall/visceral pleura rather than the pulmonary parenchyma in the present protocol setting. Consideration of the uncertainty in the contouring of normal structures is critically important, as is uncertainty in setup of patients and internal organ in the high-dose hypofractionated IGRT.

Basic science in digital imaging: digital dynamic radiography, multimedia, and their potential uses for orthopaedics and arthroscopic surgery

In this article, we discuss the different types of up-to-date tools available to understand multimedia and its applications, imaging manipulation, digital video, and new approaches to surgical planning, digital dynamic radiography, and patient education aided by digital technology.