Addition of 18F-FDG-PET scans to radiotherapy planning of thoracic lymphoma.

BACKGROUND AND PURPOSE: FDG-PET possesses greater sensitivity and accuracy than computed tomography (CT) in detecting diseased lymph nodes. Though the FDG-PET scans are acquired for similar diagnostic reasons as CT, they are not used in the radiotherapy (RT) planning process. Successful tumourcidal dose is usually delivered but large volumes of normal and non-malignant tissues are irradiated due to the nature of lymphoma and also to the subjectivity of the field determining process. This study tries to lessen the subjectivity of the field determining process by the addition of currently acquired PET to the conventional thoracic lymphoma RT. The differences between retrospectively delineated volumes from CT and FDG-PET were compared and the effect of this additional information was evaluated. MATERIALS AND METHODS: Seventeen FDG-PET scans were registered to corresponding CT scans using rigid-body registration with negligible intra-observer variability. Comparisons were made between the volumes, lateral extensions and the most inferior point of the delineated gross tumour volumes (GTVs). RESULTS: For 1/17 patient data, no diseased volumes were delineated and in 6/17, no volumes were delineated on PET and yet in CT, masses up to 367.2 cm3 were outlined. From the 10 positive-CT and PET data, the GTV(PET) were smaller than GTV(CT) in six cases. Greater than 3.0 cm lateral disease extension differences were observed in 4/10 cases. Inferior tumour extents were confirmed in 6/10 cases whereas in 2/10 patients GTV(CT) was greater than 12.0 cm inferior compared to GTV(PET). CONCLUSIONS: FDG-PET data can be introduced to current thoracic lymphoma RT planning protocol with minimal intervention and changes. The subjectivity in the RT planning of thoracic lymphoma would be decreased with the addition of currently acquired FDG-PET data.

A novel four-dimensional image registration method for radionuclide therapy dosimetry.

A novel method for registering sequential SPECT scans (4DRRT) is described, whereby all sequential scans acquired in the course of a therapy or a pre-therapy tracer study may be registered in one pass. The method assumes that a monoexponential decay function can be fitted to the series of sequential SPECT scans. Multiple volumes, presenting with different decay rates, are fitted with different mono-exponential functions. The MSSE (mean sum of squared errors in the least-squares fit algorithm), over the volume used for registration, is the cost function minimized at registration. Simulated data were used to assess the effect of thresholding, smoothing, noise and the multi-exponential nature of the four-dimensional (4D) SPECT studies on the performance of 4DRRT, resulting in three-dimensional (3D) residual registration errors <3.5 mm. The 4DRRT method was then compared to the following 3D registration methods: the correlation coefficient, the sum of absolute differences, the variance of image ratios and the mutual information. The comparisons, using both simulated and clinical data, were based on the standard deviation of the effective decay time distribution, generated from the registered 4D dataset, and showed that image registration using 4DRRT is simpler and more robust compared to the 3D techniques, especially when multiple tumour sites with different decay rates are present.

RMDP: a dedicated package for 131I SPECT quantification, registration and patient-specific dosimetry.

The limitations of traditional targeted radionuclide therapy (TRT) dosimetry can be overcome by using voxel-based techniques. All dosimetry techniques are reliant on a sequence of quantitative emission and transmission data. The use of (131)I, for example, with NaI or mIBG, presents additional quantification challenges beyond those encountered in low-energy NM diagnostic imaging, including dead-time correction and additional photon scatter and penetration in the camera head. The Royal Marsden Dosimetry Package (RMDP) offers a complete package for the accurate processing and analysis of raw emission and transmission patient data. Quantitative SPECT reconstruction is possible using either FBP or OS-EM algorithms. Manual, marker- or voxel-based registration can be used to register images from different modalities and the sequence of SPECT studies required for 3-D dosimetry calculations. The 3-D patient-specific dosimetry routines, using either a beta-kernel or voxel S-factor, are included. Phase-fitting each voxel's activity series enables more robust maps to be generated in the presence of imaging noise, such as is encountered during late, low-count scans or when there is significant redistribution within the VOI between scans. Error analysis can be applied to each generated dose-map. Patients receiving (131)I-mIBG, (131)I-NaI, and (186)Re-HEDP therapies have been analyzed using RMDP. A Monte-Carlo package, developed specifically to address the problems of (131)I quantification by including full photon interactions in a hexagonal-hole collimator and the gamma camera crystal, has been included in the dosimetry package. It is hoped that the addition of this code will lead to improved (131)I image quantification and will contribute towards more accurate 3-D dosimetry.

Absorbed dose ratios for repeated therapy of neuroblastoma with I-131 mIBG.

Patients undergoing targeted radionuclide therapy (TRT) may receive a series of two or more treatment administrations at varying intervals. However, the level of activity administered and the frequency of administration can vary widely from centre to centre for the same therapy. Tumour dosimetry is seldom employed to determine the optimum treatment plan mainly due to the potential inaccuracies of image quantification. In this work 3D dose distributions obtained from repeated therapies have been registered to enable the dose ratios to be determined. These ratios are independent of errors in image quantification and, since the same target volume can be transferred from one distribution to the next, independent of inconsistencies in outlining these volumes. These techniques have initially been applied to ten sets of I-131 mIBG therapy scan data from five patients, each undergoing two therapies. It was found that where a similar level of activity was administered for the second therapy, a similar tumour dose was delivered, and in two cases where a higher level of activity was administered for the second treatment, a correspondingly higher absorbed dose was delivered. This justifies an approach of administering activities based on individual patient kinetics rather than administering standard activities to all patients.

Radiotherapy treatment planning of prostate cancer using magnetic resonance imaging alone.

PURPOSE: Accurate anatomical delineation of the gross tumour volume (GTV) is crucial for effective radiotherapy (RT) treatment of prostate cancers. Although reference to pelvic magnetic resonance (MR) for improved delineation of the prostate is a regular practice in some clinics, MR has not replaced CT due to its geometrical distortions and lack of electron-density information. The possibility and practicality of using MR only for RT treatment planning were studied. MATERIALS AND METHODS: The addition of electron-density information to MR images for conformal radiotherapy (CRT) planning of the prostate was quantified by comparing dose distributions created on the homogeneous density- and bulk-density assigned images to original CT for four patients. To quantify the MR geometrical distortions measurements of a phantom imaged in CT (Siemens Somatom Plus 4) and FLASH 3D T1-weighted MR (1.5 T whole body Siemens Magnetom Vision) were compared. Dose statistics from CRT treatment plans made on CT and MR for five patient data were compared to determine if MR-only treatment plans can be made. RESULTS: The differences between dose-plans on bulk-density assigned images when compared to CT were less than 2% when water and bone values were assigned. Dose differences greater than 2% were observed when images of homogeneous-density assignment were compared to the CT. Phantom measurements showed that the distortions in the FLASH 3D T1-weighted MR averaged 2 mm in the volume of interest for prostate RT planning. For the CT and MR prostate planning study, doses delivered to the planning target volume (PTV) in CT and MR were always inside a 93-107% dose range normalised to the isocentre. Also, the doses to the organs-at-risk in the MR images were similar to the doses delivered to the volumes in the registered CT image when the organ volumes between the two images were similar. CONCLUSIONS: Negligible differences were observed in dose distribution between CRT plans using bone+water CT number bulk-assigned image and original CT. Also, the MR distortions were reduced to negligible amounts using large bandwidth MR sequence for prostate CRT planning. MR treatment planning was demonstrated using a large bandwidth sequence and bulk-assigned images. The development of higher quality, low distortion MR sequence will allow regular practice of this technique.

Estimation and implications of random errors in whole-body dosimetry for targeted radionuclide therapy.

For targeted radionuclide therapy, the level of activity to be administered is often determined from whole-body dosimetry performed on a pre-therapy tracer study. The largest potential source of error in this method is due to inconsistent or inaccurate activity retention measurements. The main aim of this study was to develop a simple method to quantify the uncertainty in the absorbed dose due to these inaccuracies. A secondary aim was to assess the effect of error propagation from the results of the tracer study to predictive absorbed dose estimates for the therapy as a result of using different radionuclides for each. Standard error analysis was applied to the MIRD schema for absorbed dose calculations. An equation was derived to describe the uncertainty in the absorbed dose estimate due solely to random errors in activity-time data, requiring only these data as input. Two illustrative examples are given. It is also shown that any errors present in the dosimetry calculations following the tracer study will propagate to errors in predictions made for the therapy study according to the ratio of the respective effective half-lives. If the therapy isotope has a much longer physical half-life than the tracer isotope (as is the case, for example, when using 123I as a tracer for 131I therapy) the propagation of errors can be significant. The equations derived provide a simple means to estimate two potentially large sources of error in whole-body absorbed dose calculations.