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Overview
Thisprotocolisdesignedtobeusedasaneducationalresourceand provideanoverviewtoImageGuidedRadiotherapy(IGRT)principlesand practices. IGRTinvolvesdailyimagingandpositioninginterventionto accuratelytargetthetumour. IGRT deliveryhasdevelopedquicklyforsometreatmentsites.The inherentcomplexityofIGRTforeachtreatmentsiteisvariableand dependentonfactorssuchastargetdose,organsatrisk(OAR)doses, stabilityofpositionandinternalorganmotion. Advancesinavailabletechnology,suchasremotecouchmotion,andthe capabilityforkVimagingonmodernlinearacceleratorshavefacilitated IGRTdevelopment. Naturally,astechnologyevolvessodothemodalitiestoperformIGRT.In 2011, IGRTmightbeperformedbasedonarangeofimagingmodalities includingelectronicportalimaging(EPID),megavoltageconebeamCT (MVCBCT),kVimages,kVCBCT,ultrasoundandrespiratorymotion sensors.
Key References:
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TG104TheRoleofInroomkVXRayImagingforpatientsetupand targetlocalisationDec2009 TG144KlienE,HanleyJ,BayouthJ,YinFF,SimonW,DresserS,Serago C,AguirreF,MaL,ArjomandyB,LiuC.AAPMTaskGroupReport144 Qualityassuranceofmedicalaccelerators2009 TG101BenedictS,YeniceK,FollowillD,GalvinJ,HinsonW,KavanaghB, KeallP,LovelockM,MeeksS,Papiez,PurdieT,SadagopanR,SchellM, SalterB,SchiesingerD,ShiuA,SolbergT,SongD,StieberV,TimermanR, TomeW,VerellenD,WangL,YinFF.Stereotacticbodyradiationtherapy: ThereportofAAPMTaskgroup101.MedPhys37(8)2010 TG75MurphyM,BalterJ,BalterS,BenComoJ,DasI,JiangS,MCM, OlivieraG,RodebaughR,RuchalaK,ShiratoH,YinFF.Themanagement ofimagingdoseduringimageguidedradiotherapy:ReportoftheAAPM TaskGroup75MedPhys34(10)2007 TG111AAPMTaskGroup111ReportComprehensiveMethodologyforthe evaluationofRadiationDoseinXRayComputedTomography:TheFuture ofCTdosimetryFeb2010 SeminarsinRadiationOncologyIGRTspecial2004.Vol14,(1):1100 IMRT,IGRT,SBRTAdvancesintheTreatmentplanningandDeliveryof Radiotherapy.EdJohnLMeyer.Kargerpublishing.
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ImagingModality
1.ElectronicPortalImaging(EPI) Mostlinearaccelerators haveanelectronicimagingpanelattachedtocapturetreatment verificationimagesusingthetreatmentbeam.
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Exampleofimages
theuseofMV reducesstreakingartefact forhighZ materialsthatwouldbepresentwithkVimaging,but lowerscontrastforneartissuematerialsanddosehas beenreportedtobehigherthankVCBCT itshouldbenoted,thatsomelinearaccelerator(linac) manufacturersnowoffera lowMV(13MV)imagingbeam thathasahighercontrastthanthe6MVbeam potentially,suchalowMV beam mightbesynchronised betweenthe6MV treatmentpulsesfor"liveimaging" duringatreatmentandthiswouldhavevarious applications typical 6MVdoserangeforMVCBCTis510cGy1
thisdevicecanbeusedtoacquireradiographicor fluoroscopicimagesforpatientalignment thehighimagequalityandminimaldose(oftheorderof 1/100cGy)havemadeorthogonalkVimagingthecurrent standardforIGRT standalone(roommounted)systemslikeBrainlab Exactrachavefloorandceilingmountedxraysystems thatprovideatrueroomseyeviewindependentofthe treatmentsystem onedisadvantageof kVimagingisthatitisdifficult to incorporatetheimagingrelateddose intoplanned treatmentdose,duetothe differenceinbiological effects betweenkVandMVbeams
theseprovidehighqualityimageforpositioning,however
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5.UltrasoundUltrasoundimagesprovidearadiationfreeimage.
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thesedevicescanuseinfraredtodetectthepositionof markersplacedonthepatientrelativetoisocentre (Brainlab,VarianOpticalGuidancePlatform)or,couldread thedeformationofagridprojectedontothepatient(Align RT) othersystems,likeVarianRealtimePosition Management(RPM),ElektaActiveBreathingCoordinator andANSAIbeltsarespecificallydesignedtogatethe treatmentdeliveryortheimageacquisitiontoaccountfor breathingmotion
ResidualaccuracyoftheIGRTsystem
WhileitisimportanttosetupathoroughQAregimentotestallcomponentsoftheIGRTprocess,thereareresidual uncertaintieswithinthesystemthatshouldalsobecarefullyconsideredbyyourIGRTteam.Residualuncertaintiesarecovered bythePTVmargin(encompassingtheinternaltargetvolume(ITV)andwillinclude:
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Thesemaybedifficulttoaddressbutmustbeconsideredbytheteam.
ImageRegistration
Increasingly,theplanningCTimageisbeingfusedwithothermodalities(CBCT,MRIandPET)tobetteridentifytargets,and reducecontouringuncertainty.Insomecases,theimagesacquiredoutsidetheradiotherapydepartmentwillnotbeacquired withthepatientinthetreatmentpositionandthiscomplicatestheregistrationprocess.Mostradiotherapyplanningsystems haverigidregistrationandmanywillhaveautomatedprocesses. However,deformableregistrationmaybemoreusefulin overcomingmisregistrationduetopatientpositionand isparticularlyusefulinadaptiveradiotherapy (seebelow).
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CBCTImagingDose
ThedosetothepatientfromakVCBCTacquisitionmaybehighly variable,and differsignificantlyfromthevendorspublished values. ItisimportanttohaveagoodunderstandingofthemetricsusedbyvendorstodescribepatientdosefromCBCTand tounderstandthelimitsofthatmetric. Doserelatedquantitiesthatmightbeusedinclude:
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MostofthevendorswillpublishadoseincGyandaCTDIwtheformerisacentraldosepointmeasuredinaunitdensity
cylindricalphantomandthesecondisaweightedaverageofmeasureddosecentrallyandperipherally.Bothofthesemetrics wereoriginallydesignedforhelicalCTanddodemonstratesomeshortcomingsfromCBCTastheoffaxisbeamquality hardens.FurtherdetailonthesequantitiescanbeobtainedfromAAPMTG111:thefutureofCTDosimetryFeb20103.See alsoPoint/CounterpointbyBrenner2006.4 Itisgoodpractisetomeasurethedoseinarangeofscenarioswithvariousphantomgeometrieslocally.FornewIGRT techniquesitmaybeusefultocalculateaCBCTdosefactorastheratioofdosemeasuredintheparticulargeometryand techniquetoastandardgeometry/technique. CBCTdoseshouldbemeasuredwithanappropriatedetectorthatwillexhibitlowenergydependence,highreproducibility,low stemeffect(readingfromdetectorsteminfield),highsignal/noiseratio,lowdoserateeffects.Beawareofvaryingdoserate, chambervolumeandtheatomicnumberofthematerialusedfortheionchamberscentralelectrode.Severalstudieshave showncomputersimulations(MonteCarlomodelling)ofkVCBCTdosedistributions23, 24. Forsomesiteswithsmallhighorlow densityvolumes(likepelvis),thekVdosedistributioninthepatientfromCBCThasbeenreportedtobefairlyuniform.Itmight bereasonableinsuchcasestoattributeasingle dosevalueperCBCTforthesepatients(basedonmeasurementinthe centreofacylindricalphantomofsuitabledimension). The patientimagingdose foraCBCTacquisitionwillvaryduetofiltersinthebeam,aperturedimension,beamsettings, geometryofsubject,anddensityofinternalstructures. Someoftheseparameterscanbeexploitedtoreducethedose,togetherwithpostprocessing.
SitespecificIGRT Prostate
ProstatetumourswereanearlyproponentforIGRTbecause: 1. 2. 3. 4. Theprostateisamobileorgan(requiringdailytargeting) FiducialmarkersarevisibleinEPIDacquisitions(allowingtargeting) Improvedtargetingaidsindoseescalation Queriesaroundtheprostatessensitivitytofractionation(a/ratio)leadingtotheattractionofhypofractionation
Theprostatewilldeformandmoveandsowillthesurroundingnormaltissue.Therehavebeenmanystudiesshowing potentialgeographicmissesfrompositioningbasedonbonymatches.Thecurrentstandardisdailyorthogonalimaging, which is generallykVimaging.CBCTmayprovidefurtherinformation oncompliancewithbladder/rectumprotocols,patient contourvariationsand patienttilt. Fiducialmarkersareimplantedusingtransrectalultrasound(TRUS)1weekpriortosimulation,allowinganyswellingtoreduce priortoCTsimulation.Usually34markers(each~1x3mm)areimplantedforeasyvisualisationinpretreatmentimages. Stability ofthesemarkers(nonmigration)throughacourseoftreatmenthasbeenestablished19 20. Fiducialmarkersarenow widelythoughtofasastandardofcareforintactprostateRT. Markersmaybe accidentallyimplantedintherectalwallorseminalvesicles(SV). Thesemaybeusedforpositioning ifthey remaininsitu, butextremecareshouldbetakentoidentifythecorrectmarker andsomesofttissuereferencemightbeuseful. IfamarkerisplacedintheSV'sorrectalwallitshouldbeclearlynoted,soitcan beignoredduringonlineregistration. DosecalculationsmaybeperformedonCBCTimagesinsomesituationsandthiswilldependonthedoseaccuracyrequired.It
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HeadandNeck
IGRThasbeenrapidly developedforheadandneckradiotherapybecause rapidtumourproliferation/shrinkageduring treatment,andpatientweightlossduetopoordietinducedbytreatment/tumoursideeffectsresultsinlargechangesin patientanatomy. Thesepatientsaregenerallywellfixatedandthereislittleintrafractionvariation(exceptforswallowingaction). TheIGRT imagingoptionsthatarebestsuitedinclude
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LungandBreastIGRT
BothlungandbreastIGRTrequiremanagementofrespiratorymotion.Theoptionsavailableincludereducingthemotion, gatingdelivery,accountingformotioninPTVexpansionandtracking.Organmotionmaybereducedbyabdominal compression,breathholdandcoachingofthepatient,activebreathingcontrolandbiofeedbacktechnologies. Bothofthesesitesarechallengingfordosecalculation(duetotangentialbeams,lung/boneinterfaces,smallfields)and generallyhavepoorCBCTimagequality.Theseissuesremainanactiveareaofinvestigationandwillneedtoberesolvedprior toeffectiveimplementationofhighprecisionradiotherapytechniquesforlungandbreastradiotherapy.
StereotacticBodyRadiotherapy(SBRT)
SBRTinvolvesextracranialhypofractionatedtreatments(<5fractions) thatrequiretheprecisionaccuracyofIGRT.Likecranial stereotactic,theIGRTmethodsaretrendingawayfromtheoriginsofusingastereotacticframeboltedtothepatienttowards imageguidance.Theneedfor imageguidanceaccuracyisheightenedforthesetreatments,asdemonstratedinAAPMReport 144 15 byaseparatelistofrequirementsforthismodalitycomparedagainstconventionalradiotherapy.(SeealsoAAPMTG101 SBRT16) TheliteratureshowsseveralsitescurrentlybeingtreatedwithSBRTincludingliver,lung,spineandprostate.Notethatmany ofthesepublicationsreporttreatmentwithanAccurayCyberknifedevice,noneofwhicharecurrentlypresentin
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LungRTOG0813isadoseescalationstudystartingwith 5x10Gy. RTOG0915compares1x34Gyvs4x12Gy.Thereis alsoaTROGTrialTROG0902CHISELcomparing3x20Gyagainstconventional30x2Gy.SomeoftheIGRTissuesspecific tolungSBRTinclude: G requirementfora4DCTdatasetforplanningwithanITVcreatedfromthemaximumintensityprojection(MIP) andiftreatingfreebreathing,thenthedoseiscalculatedonthemeanCTdataset. G option forgatingafreebreathingtreatmentortreatingduring breathholdtoreduceITV andplannedlungdose. G thereareanumberofgatingsignalsthatcouldbeusedincludingaRPMmarkerblock,Ansaibelt,surfacecontour AlignRTorrespiratoryoutput.Exhalebreatheholdisgenerallyconsideredmorestablethaninhale,butmaybe difficultforthepatientgiventhattheyhavelungdisease.Thebreatheholdcanbeguidedbyaudioand/orvisual assistance.TheAutomatedBreathingControl(ABC)devicewillrestrictbreathingremotely. G treatmentplanningusuallyrequiresa714noncoplanarbeamarrangement.However,thereisliterature investigatingtheroleof VolumetricModulatedArctherapy(VMAT).Anearlyconcernaroseregardinginterplayfor dMLCdeliverywithbreathingmotionbuttheliteratureisnotconclusiveeitherwayonthispoint.During treatment,thesimulationsetupwillbereproducedandforfreebreathing,verifiedwithmultipleCBCTimages duringeachfractionasthereisevidenceofbaselineshiftingafterabout6minutesoftreatment. Treatmenttime canbeextensiveduetothecomplexityofthedelivery(manynoncoplanarbeams,largeMU,andcarefulsetup). SpineAnablativedoseisdeliveredtospinemetastasesavoidingthespinalcord.RTOG0631iscomparingasingle 16Gyfractiontothestandard8Gyfraction.SomeoftheIGRTissuesspecifictospineSBRTinclude: G highlyaccuratepatientsetupwiththePTVoftenonly12mmfromthespinalcordoritsplanningriskvolume (PRV). G theuseofanablativedoseinasinglefractionshouldbedifferentiatedfromtheexistingspinalcordtolerance dataon2Gyfractions ProstateThereisemergingevidenceforprostatetreatmentsof35Gy45Gyin5fractions.Themostmaturedatais fromMSKCCandStanford.SomeIGRTissuesspecifictoprostateSBRTinclude: G potentialforrapidanderraticprostatemovementintrafraction(evidencesfromCalypsodata) G requirementforintrafractionmotiondetectionandaction.Actionsmightincludegatingthetreatmentortracking thecouch/MLCto'follow'themotion G mostofthepublisheddataisfromcentresusingtheAccuray Cyberknifedevicethathasregularintrafraction imagingandtrackingcapability
QAofanIGRTsystem
ThereisguidanceinthreemainreferencesYooetal6,Verellenetal7 andAAPMTG134(2009).TheQAprogramwilldepend ontheuseandthesystem.TheQAprogramwillincludemechanicalsystemtests,imagequalitytests, daily,monthly,and treatmenttypetests.
ClinicalTrials
Increasingly,clinicaltrialsinvolvehighdosesthatrequireprecisetargeting.Uniformityintheapplicationoftheseprotocols across participatingsitesiscriticaltoavoidmisadministrationandconsistencyforaccuratereporting. InAustraliaandNewZealand,IGRTisconsideredexplicitlythroughtheTROGIGRTworkingparty.Astandardquestionnaire hasbeenimplementedinthePROFIT,trialanddevelopedfurtherforRAVESandCHISELtorequirestringentcredentialing activities.ThecredentialingactivitieshaveincludedsubmissionofIGRTprotocols,dummyruns,dosemeasurements,setup accuracymeasurementsandviewingofIGRTsystemsinplay.Inthefuture,credentialingactivitiesmightbeperformedbythe newlysetupAustralianClinicalDosimetry Service(ACDS),similartoRTOGwhousetheRPCforcredentialing.
Advancedresearchtopics AdaptiveRadiotherapyART
Adaptiveradiotherapyistheconceptofadaptingthetreatmentplanbasedonthegeometryontheday.Thebasicsteps for onlineARTinclude
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4Dplanning
Thisresearchareainvolvesplanningatreatmentdeliverythathasatimecomponentandmightinvolvetrackingthetumourin realtimeie:movingcouch/MLCto'follow'thetumourusingavarietyofimagingmodalities.Theplanningprocesswillrequire eitherasurrogateformotion(externalmarkerblock,skinsurfaceinfraredinternalfiducial)orawayofvisualisingthesoft tissue,generallythroughimaging.Verificationmayusefluoroscopicimaging,and/or4DCBCT.
References
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Thecurrencyofthisinformationisguaranteedonlyupuntilthedateofprinting,foranyupdatespleasecheckwww.eviq.org.au 02Apr2013
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