Clinical experiences with online adaptive radiotherapy of vulvar carcinoma.

BACKGROUND AND PURPOSE: Radiotherapy for vulvar carcinoma is challenging due to relatively high risk of locoregional disease recurrence, a technically challenging target, and postoperative lymphocele, and a high risk radiation sequelae. We aim to explore, if it is possible to reduce dose to normal tissue, while maintaining CTV coverage for this patient group with online adaptive radiotherapy. MATERIALS AND METHODS: 20 patients with vulvar carcinoma (527 fractions) were treated with online adaptation on a Varian Ethos accelerator. Setup CBCTs were acquired daily for adaptive planning. Verification CBCTs were acquired immediately prior to dose delivery. CTV dose coverage and dose to bladder and rectum were extracted from the scheduled and adapted plans as well as from adapted plans recalculated based on verification CBCTs. In addition, analysis of the decision of the adaptive procedure was performed for 17 patients (465 fractions). RESULTS: Mean CTV D95% and standard deviation was 98% ± 5% for the scheduled plan compared to 100.0 ± 0.3% and 100.0 ± 0.8% for the adapted plan on the setup and verification CBCT respectively. Dose to OARs varied substantially and did not show any benefit from adaption itself, however a margin reduction was implemented after the first patients treated. The adapted plan was chosen for 63.5% of the fractions and dominant reasons for not adapting were 'no significant dosimetric gain' (75 fractions, 14%) and 'Medical doctor (MD) not available for treatment' (50 fractions, 9.5%). The median adaption time was 15 min and the 25th and 75th percentile was 12 and 17 min, respectively. CONCLUSION: CTVs and PTVs dose coverage were significantly improved with adaptation compared to image-guided RT. This gain was robust during the treatment time.

Multi-frequency bioelectrical impedance analysis (BIA) compared to magnetic resonance imaging (MRI) for estimation of fat-free mass in colorectal cancer patients treated with chemotherapy.

BACKGROUND: Changes in body composition in cancer patients during chemotherapy are associated with treatment related toxicities or mortalities. Thus, it is relevant to identify accessible, relatively inexpensive, portable and reliable tools for evaluation of body composition in cancer patients during the course of their treatments. OBJECTIVE: To examine relationships between single cross-sectional thighs magnetic resonance imaging (MRI), skeletal muscle mass (SM) as reference and multi-frequency bioelectrical impedance analysis (BIA) fat free mass (FFM) in patients with colorectal cancer undergoing chemotherapy. DESIGN: In an observational, prospective study we examine the relationships between single cross-sectional thighs MRI (T1-weighted (1.5 T) SM compared to FFM BIA (8-electrodes multi-frequency Tanita MC780MA)) and FFM skin-fold thickness (ST) (4-points (Harpenden, Skinfold Caliper)) and SM equation for non-obese persons from Lee et al. 2000 (L2000) (based on age, height, weight, sex and race). FFM and SM (kg) were calculated based on either area (MRI) or weight. RESULTS: 18 CRC patients (10 males and 8 females) with mean (SD) age 67 yr (6) were measured at baseline, and 13 were available for follow-up. BIA overestimated FFM kg for all 31 measurements with mean (SD) 18.0 kg (6.0) compared to the MRI. ST overestimated FFM kg with mean 12.4 kg (6.2) and L2000 underestimated SM kg in 18 measurements and overestimated in 13 with a total mean of -4.3 kg (6.8). CONCLUSIONS: BIA and ST were the best alternatives to MRI as they showed constant and thereby correctable errors. The equation, L2000, carried the smallest average measurement error but it was non-constant.

Assessment of contrast enhanced respiration managed cone-beam CT for image guided radiotherapy of intrahepatic tumors.

PURPOSE: Contrast enhancement and respiration management are widely used during image acquisition for radiotherapy treatment planning of liver tumors along with respiration management at the treatment unit. However, neither respiration management nor intravenous contrast is commonly used during cone-beam CT (CBCT) image acquisition for alignment prior to radiotherapy. In this study, the authors investigate the potential gains of injecting an iodinated contrast agent in combination with respiration management during CBCT acquisition for liver tumor radiotherapy. METHODS: Five rabbits with implanted liver tumors were subjected to CBCT with and without motion management and contrast injection. The acquired CBCT images were registered to the planning CT to determine alignment accuracy and dosimetric impact. The authors developed a simulation tool for simulating contrast-enhanced CBCT images from dynamic contrast enhanced CT imaging (DCE-CT) to determine optimal contrast injection protocols. The tool was validated against contrast-enhanced CBCT of the rabbit subjects and was used for five human patients diagnosed with hepatocellular carcinoma. RESULTS: In the rabbit experiment, when neither motion management nor contrast was used, tumor centroid misalignment between planning image and CBCT was 9.2 mm. This was reduced to 2.8 mm when both techniques were employed. Tumors were not visualized in clinical CBCT images of human subjects. Simulated contrast-enhanced CBCT was found to improve tumor contrast in all subjects. Different patients were found to require different contrast injections to maximize tumor contrast. CONCLUSIONS: Based on the authors' animal study, respiration managed contrast enhanced CBCT improves IGRT significantly. Contrast enhanced CBCT benefits from patient specific tracer kinetics determined from DCE-CT.

Dynamic contrast enhanced CT aiding gross tumor volume delineation of liver tumors: an interobserver variability study.

PURPOSE: To evaluate the application of perfusion CT for gross tumor volume (GTV) delineation for radiotherapy of intrahepatic tumors. MATERIALS AND METHODS: 15 radiotherapy patients with confirmed liver tumors underwent contrast enhanced 4D-CT (Philips Brilliance Big-bore) as well as dynamic contrast enhanced (DCE) CT (GE 750HD). Perfusion maps were generated with CT perfusion v5 from GE. Five observers delineated GTVs of all intrahepatic foci on the 4D-CT, time-averaged DCE-CT and perfusion CT for every patient. STAPLE consensus contours were generated. Dice's coefficients were compared between GTVs generated by observers on each image set and the corresponding consensus GTVs. Comparisons were also performed with patients stratified by hepatocellular carcinoma (HCC) metastatic tumors, and by tumor volume. RESULTS: Overall, mean Dice's coefficients were 0.81±0.14, 0.84±0.10, and 0.81±0.14 for 4D-CT, DCECT and perfusion. DCE-CT performed significantly better than 4D-CT and perfusion (p=0.005 and p=0.01 respectively). For patients with HCC, DCE-CT reduced interobserver variability significantly compared to 4D-CT (Dice's coefficients 0.87 vs. 0.84, p<0.05). For patients with metastatic disease time-averaged DCE-CT images decreased variability compared to 4D-CT (Dice's coefficient 0.81 vs. 0.76, p<0.05), especially true for tumors<100cc. The smaller tumors results are important to be included here. CONCLUSIONS: DCE-CT imaging of liver perfusion reduced interobserver variability in GTV delineation for both HCC and metastatic liver tumors.

Prediction and reduction of motion artifacts in free-breathing dynamic contrast enhanced CT perfusion imaging of primary and metastatic intrahepatic tumors.

RATIONALE AND OBJECTIVE: To develop and evaluate a method for predicting and reducing motion artifacts in free-breathing liver perfusion computed tomography (CT) scanning with couch shuttling and to compare tumor and liver parenchyma perfusion values. MATERIALS AND METHODS: Thirty patients (23 males, 7 females, median age of 74 years) with primary or metastatic intrahepatic tumors underwent dynamic contrast enhanced CT scans with axial shuttling. A semiautomatic respiratory motion correction algorithm was applied to align the acquired images along the z-axis. Perfusion maps were generated using the dual-input Johnson-Wilson model. Root mean squared deviation (RMSD) maps of the model fit to the pixel time-density curves were calculated. RESULTS: Precorrection RMSD correlated positively with magnitude of change in functional values resulting from motion. Blood flow, arterial blood flow, and permeability surface product were significantly increased in tumor compared to normal tissue (P < .05), blood volume was significantly reduced in tumor compared to normal tissue (P < .05). In a subgroup of patients with high-amplitude motion significant difference was observed between uncorrected and motion correction blood flow maps. CONCLUSIONS: Patients can breathe freely during hepatic perfusion imaging if retrospective motion correction is applied to reduce motion artifacts. RMSD provides a regional assessment of motion induced artifacts in liver perfusion maps.