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Rankine LJ, Lu J, Wang Z, Kelsey CR, Marks LB, Das SK, Driehuys B. Quantifying Regional Radiation-Induced Lung Injury in Patients Using Hyperpolarized 129Xe Gas Exchange Magnetic Resonance Imaging. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00359-6. [PMID: 38452858 DOI: 10.1016/j.ijrobp.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/05/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE Radiation-induced lung injury has been shown to alter regional ventilation and perfusion in the lung. However, changes in regional pulmonary gas exchange have not previously been measured. METHODS AND MATERIALS Ten patients receiving conventional radiation therapy (RT) for lung cancer underwent pre-RT and 3-month post-RT magnetic resonance imaging (MRI) using an established hyperpolarized 129Xe gas exchange technique to map lung function. Four patients underwent an additional 8-month post-RT MRI. The MR signal from inhaled xenon was measured in the following 3 pulmonary compartments: the lung airspaces, the alveolar membrane tissue, and the pulmonary capillaries (interacting with red blood cells [RBCs]). Thoracic 1H MRI scans were acquired, and deformable registration was used to transfer 129Xe functional maps to the RT planning computed tomography scan. The RT-associated changes in ventilation, membrane uptake, and RBC transfer were computed as a function of regional lung dose (equivalent dose in 2-Gy fractions). Pearson correlations and t tests were used to determine statistical significance, and weighted sum of squares linear regression subsequently characterized the dose dependence of each functional component. The pulmonary function testing metrics of forced vital capacity and diffusing capacity for carbon monoxide were also acquired at each time point. RESULTS Compared with pre-RT baseline, 3-month post-RT ventilation decreased by an average of -0.24 ± 0.05%/Gy (ρ = -0.88; P < .001), membrane uptake increased by 0.69 ± 0.14%/Gy (ρ = 0.94; P < .001), and RBC transfer decreased by -0.41 ± 0.06%/Gy (ρ = -0.92; P < .001). Membrane uptake maintained a strong positive correlation with regional dose at 8 months post-RT, demonstrating an increase of 0.73 ± 0.11%/Gy (ρ = 0.92; P = .006). Changes in membrane uptake and RBC transfer appeared greater in magnitude (%/Gy) for individuals with low heterogeneity in their baseline lung function. An increase in whole-lung membrane uptake showed moderate correlation with decreases in forced vital capacity (ρ = -0.50; P = .17) and diffusing capacity for carbon monoxide (ρ = -0.44; P = .23), with neither correlation reaching statistical significance. CONCLUSIONS Hyperpolarized 129Xe MRI measured and quantified regional, RT-associated, dose-dependent changes in pulmonary gas exchange. This tool could enable future work to improve our understanding and management of radiation-induced lung injury.
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Affiliation(s)
- Leith J Rankine
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina; Medical Physics Graduate Program.
| | | | - Ziyi Wang
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | | | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Shiva K Das
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Bastiaan Driehuys
- Medical Physics Graduate Program; Department of Biomedical Engineering, Duke University, Durham, North Carolina; Radiology, Duke University Medical Center, Durham, North Carolina
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Forghani F, Castillo R, Castillo E, PhD BJ, Rusthoven C, Kwak J, Moiseenko V, Grills I, Miften M, Vinogradskiy Y, Guerrero T. Is individual perfusion dose-response different than ventilation dose-response for lung cancer patients treated with radiotherapy? Br J Radiol 2023; 96:20220119. [PMID: 36633096 PMCID: PMC9975372 DOI: 10.1259/bjr.20220119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/18/2022] [Accepted: 11/18/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Current ventilation and perfusion dose-response studies focus on single-modalities (ventilation or perfusion) and perform pulmonary-toxicity assessment related to radiotherapy on a population-based basis. This study aims at quantitative and clinical evaluation of intrapatient differences between ventilation and perfusion dose-responses among lung cancer patients treated with radiotherapy. METHODS 20 patients enrolled on a prospective functional avoidance protocol underwent single photon emission computed tomography-CT ventilation and perfusion scans pre- and post-radiotherapy. Relative changes in pre- to post-treatment ventilation and perfusion in lung regions receiving ≥20 Gy were calculated. In addition, the slopes of the linear fit to the relative ventilation and perfusion changes in regions receiving 0-60 Gy were calculated. A radiologist read and assigned a functional defect score to pre- and post-treatment ventilation/perfusion scans. RESULTS 25% of patients had a difference >35% between ventilation and perfusion pre- to post-treatment changes and 20-30% of patients had opposite directions for ventilation and perfusion pre- to post-treatment changes. Using a semi-quantitative scale, radiologist assessment showed that 20% of patients had different pre- to post-treatment ventilation changes when compared to pre- to post-treatment perfusion changes. CONCLUSION Our data showed that ventilation dose-response can differ from perfusion dose-response for 20-30% of patients. Therefore, when performing thoracic dose-response in cancer patients, it is insufficient to look at ventilation or perfusion alone; but rather both modes of functional imaging may be needed when predicting for clinical outcomes. ADVANCES IN KNOWLEDGE The significance of this study can be highlighted by the differences between the intrapatient dose-response assessments of this analysis compared to existing population-based dose-response analyses. Elucidating intrapatient ventilation and perfusion dose-response differences may be valuable in predicting pulmonary toxicity in lung cancer patients post-radiotherapy.
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Affiliation(s)
| | | | - Edward Castillo
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, United States
| | - Bernard Jones PhD
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Chad Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Jennifer Kwak
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applies Sciences, University of California San Diego, San Diego, CA
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, United States
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | | | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, United States
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Abstract
Herein are presented the recommendations from the Société française de radiothérapie oncologique regarding indications and modalities of lung cancer radiotherapy. The recommendations for delineation of the target volumes and organs at risk are detailed.
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Affiliation(s)
- J Khalifa
- Département de radiothérapie, Institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France.
| | - D Lerouge
- Département de radiothérapie, centre François-Baclesse, 3, avenue du General-Harris, 14076 Caen, France
| | - C Le Péchoux
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - N Pourel
- Département de radiothérapie, institut Sainte-Catherine, 250, chemin de Baigne-Pieds, CS80005, 84918 Avignon cedex 9, France
| | - J Darréon
- Service de physique médicale, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - F Mornex
- Service de radiothérapie, CHU Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - P Giraud
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, Paris, France; Université de Paris, 85, boulevard Saint-Germain, 75006 Paris, France
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Porter EM, Myziuk NK, Quinn TJ, Lozano D, Peterson AB, Quach DM, Siddiqui ZA, Guerrero TM. Synthetic pulmonary perfusion images from 4DCT for functional avoidance using deep learning. Phys Med Biol 2021; 66. [PMID: 34293726 DOI: 10.1088/1361-6560/ac16ec] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/22/2021] [Indexed: 01/14/2023]
Abstract
Purpose.To develop and evaluate the performance of a deep learning model to generate synthetic pulmonary perfusion images from clinical 4DCT images for patients undergoing radiotherapy for lung cancer.Methods. A clinical data set of 58 pre- and post-radiotherapy99mTc-labeled MAA-SPECT perfusion studies (32 patients) each with contemporaneous 4DCT studies was collected. Using the inhale and exhale phases of the 4DCT, a 3D-residual network was trained to create synthetic perfusion images utilizing the MAA-SPECT as ground truth. The training process was repeated for a 50-imaging study, five-fold validation with twenty model instances trained per fold. The highest performing model instance from each fold was selected for inference upon the eight-study test set. A manual lung segmentation was used to compute correlation metrics constrained to the voxels within the lungs. From the pre-treatment test cases (N = 5), 50th percentile contours of well-perfused lung were generated from both the clinical and synthetic perfusion images and the agreement was quantified.Results. Across the hold-out test set, our deep learning model predicted perfusion with a Spearman correlation coefficient of 0.70 (IQR: 0.61-0.76) and a Pearson correlation coefficient of 0.66 (IQR: 0.49-0.73). The agreement of the functional avoidance contour pairs was Dice of 0.803 (IQR: 0.750-0.810) and average surface distance of 5.92 mm (IQR: 5.68-7.55).Conclusion. We demonstrate that from 4DCT alone, a deep learning model can generate synthetic perfusion images with potential application in functional avoidance treatment planning.
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Affiliation(s)
- Evan M Porter
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Nicholas K Myziuk
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Thomas J Quinn
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Daniela Lozano
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Avery B Peterson
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America
| | - Duyen M Quach
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Zaid A Siddiqui
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas M Guerrero
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
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Owen DR, Sun Y, Boonstra PS, McFarlane M, Viglianti BL, Balter JM, El Naqa I, Schipper MJ, Schonewolf CA, Ten Haken RK, Kong FMS, Jolly S, Matuszak MM. Investigating the SPECT Dose-Function Metrics Associated With Radiation-Induced Lung Toxicity Risk in Patients With Non-small Cell Lung Cancer Undergoing Radiation Therapy. Adv Radiat Oncol 2021; 6:100666. [PMID: 33817412 PMCID: PMC8010578 DOI: 10.1016/j.adro.2021.100666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose Dose to normal lung has commonly been linked with radiation-induced lung toxicity (RILT) risk, but incorporating functional lung metrics in treatment planning may help further optimize dose delivery and reduce RILT incidence. The purpose of this study was to investigate the impact of the dose delivered to functional lung regions by analyzing perfusion (Q), ventilation (V), and combined V/Q single-photon-emission computed tomography (SPECT) dose-function metrics with regard to RILT risk in patients with non-small cell lung cancer (NSCLC) patients who received radiation therapy (RT). Methods and Materials SPECT images acquired from 88 patients with locally advanced NSCLC before undergoing conventionally fractionated RT were retrospectively analyzed. Dose was converted to the nominal dose equivalent per 2 Gy fraction, and SPECT intensities were normalized. Regional lung segments were defined, and the average dose delivered to each lung region was quantified. Three functional categorizations were defined to represent low-, normal-, and high-functioning lungs. The percent of functional lung category receiving ≥20 Gy and mean functional intensity receiving ≥20 Gy (iV20) were calculated. RILT was defined as grade 2+ radiation pneumonitis and/or clinical radiation fibrosis. A logistic regression was used to evaluate the association between dose-function metrics and risk of RILT. Results By analyzing V/Q normalized intensities and functional distributions across the population, a wide range in functional capability (especially in the ipsilateral lung) was observed in patients with NSCLC before RT. Through multivariable regression models, global lung average dose to the lower lung was found to be significantly associated with RILT, and Q and V iV20 were correlated with RILT when using ipsilateral lung metrics. Through a receiver operating characteristic analysis, combined V/Q low-function receiving ≥20 Gy (low-functioning V/Q20) in the ipsilateral lung was found to be the best predictor (area under the curce: 0.79) of RILT risk. Conclusions Irradiation of the inferior lung appears to be a locational sensitivity for RILT risk. The multivariable correlation between ipsilateral lung iV20 and RILT, as well as the association of low-functioning V/Q20 and RILT, suggest that irradiating low-functioning regions in the lung may lead to higher toxicity rates.
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Affiliation(s)
- Daniel R Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Philip S Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Matthew McFarlane
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin L Viglianti
- Department of Radiology, University of Michigan, Ann Arbor, Michigan.,Veterans Administration, Nuclear Medicine Service, Ann Arbor Michigan
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | - Randall K Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Feng-Ming S Kong
- Hong Kong University Shenzhen Hospital and Queen Mary Hospital, Hong Kong University Li Ka Shing Medical School, Department of Clinical Oncology, Hong Kong.,Department of Radiation Oncology, Case Western Reserve University, Cleveland, Ohio
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Furukawa Y, Long DE, Ellsworth SG. Functional liver-image guided hepatic therapy (FLIGHT): A technique to maximize hepatic functional reserve. Med Dosim 2020; 45:117-20. [PMID: 31439270 DOI: 10.1016/j.meddos.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Radiation planning approaches for liver radiation often do not consider the regional variation that can exist in liver function. This study dosimetrically compares functional liver image-guided hepatic therapy (FLIGHT) to standard stereotactic body radiation therapy (SBRT) plans. In the FLIGHT plans, functional data from hepatobiliary iminodiacetic acid (HIDA) single photon emission computed tomography (SPECT) scans serve as a road map to guide beam arrangement. While meeting the same target volume coverage, plans are optimized to reduce dose to high-functioning liver. MATERIALS AND METHODS The study included 10 patients with hepatocellular carcinoma (HCC) with baseline HIDA SPECT imaging. Standard SBRT plans which did not systematically incorporate these scans had previously been completed on all 10 plans. Retrospectively, FLIGHT plans were created based on the use of contours of relative liver function from the HIDA SPECT as avoidance structures. Resulting dose to each relative functional liver structure was examined and compared qualitatively and using Wilcoxin rank-sum tests. Target coverage, doses to organs at risk (OARs), conformity index (CI), and gradient index (GI) were also evaluated. RESULTS While maintaining the same target coverage, FLIGHT plans reduced the mean dose to the high functioning liver by a median of 3.0 Gy (range 0.7 to 4.6 Gy), which represented a 31.4% mean reduction compared to standard planning. FLIGHT plans reduced the volume of high functioning liver receiving 15 Gy by a mean of 59.3 cc (range 7 to 170 cc), for a mean reduction of 41.9%. The mean dose to areas of liver function defined by 25% to 100% and 50% to 100% maximum was reduced with FLIGHT from 10.5 Gy to 8.5 Gy and from 10.5 Gy to 7.5 Gy, respectively (p < 0.005 for both comparisons). The FLIGHT plans' mean CI and GI did not differ significantly from the standard plans' (p = 0.721 and 0.169, respectively). CONCLUSION FLIGHT SBRT allows for field design and plan optimization individualized to a patient's baseline regional liver function to maximize hepatic functional reserve. This personalized approach is achieved without compromising target coverage or OAR sparing.
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Zanoni M, Cortesi M, Zamagni A, Tesei A. The Role of Mesenchymal Stem Cells in Radiation-Induced Lung Fibrosis. Int J Mol Sci 2019; 20:ijms20163876. [PMID: 31398940 PMCID: PMC6719901 DOI: 10.3390/ijms20163876] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023] Open
Abstract
Radiation therapy is one of the most important treatment modalities for thoracic tumors. Despite significant advances in radiation techniques, radiation-induced lung injury (RILI) still occurs in up to 30% of patients undergoing thoracic radiotherapy, and therefore remains the main dose-limiting obstacle. RILI is a potentially lethal clinical complication of radiotherapy that has 2 main stages: an acute stage defined as radiation pneumonitis, and a late stage defined as radiation-induced lung fibrosis. Patients who develop lung fibrosis have a reduced quality of life with progressive and irreversible organ malfunction. Currently, the most effective intervention for the treatment of lung fibrosis is lung transplantation, but the lack of available lungs and transplantation-related complications severely limits the success of this procedure. Over the last few decades, advances have been reported in the use of mesenchymal stem cells (MSCs) for lung tissue repair and regeneration. MSCs not only replace damaged lung epithelial cells but also promote tissue repair through the secretion of anti-inflammatory and anti-fibrotic factors. Here, we present an overview of MSC-based therapy for radiation-induced lung fibrosis, focusing in particular on the molecular mechanisms involved and describing the most recent preclinical and clinical studies carried out in the field.
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Affiliation(s)
- Michele Zanoni
- Bioscience Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy.
| | - Michela Cortesi
- Bioscience Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy
| | - Alice Zamagni
- Bioscience Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy
| | - Anna Tesei
- Bioscience Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy.
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Selvaraj J, Lebesque J, Hope A, Guckenberger M, Werner-wasik M, Peulen H, Giuliani M, Mantel F, Belderbos J, Grills I, Sonke J. Modeling radiation pneumonitis of pulmonary stereotactic body radiotherapy: The impact of a local dose–effect relationship for lung perfusion loss. Radiother Oncol 2019; 132:142-7. [DOI: 10.1016/j.radonc.2018.12.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/06/2018] [Accepted: 12/16/2018] [Indexed: 12/25/2022]
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Patton TJ, Gerard SE, Shao W, Christensen GE, Reinhardt JM, Bayouth JE. Quantifying ventilation change due to radiation therapy using 4DCT Jacobian calculations. Med Phys 2018; 45:4483-4492. [PMID: 30047588 PMCID: PMC6220845 DOI: 10.1002/mp.13105] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 05/10/2018] [Accepted: 06/24/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Regional ventilation and its response to radiation dose can be estimated using four-dimensional computed tomography (4DCT) and image registration. This study investigated the impact of radiation therapy (RT) on ventilation and the dependence of radiation-induced ventilation change on pre-RT ventilation derived from 4DCT. METHODS AND MATERIALS Three 4DCT scans were acquired from each of 12 subjects: two scans before RT and one scan 3 months after RT. The 4DCT datasets were used to generate the pre-RT and post-RT ventilation maps by registering the inhale phase image to the exhale phase image and computing the Jacobian determinant of the resulting transformation. The ventilation change between pre-RT and post-RT was calculated by taking a ratio of the post-RT Jacobian map to the pre-RT Jacobian map. The voxel-wise ventilation change between pre- and post-RT was investigated as a function of dose and pre-RT ventilation. RESULTS Lung regions receiving over 20 Gy exhibited a significant decrease in function (3.3%, P < 0.01) compared to those receiving less than 20 Gy. When the voxels were stratified into high and low pre-RT function by thresholding the Jacobian map at 10% volume expansion (Jacobian = 1.1), high-function voxels exhibited 4.8% reduction in function for voxels receiving over 20 Gy, a significantly greater decline (P = 0.037) than the 2.4% reduction in function for low-function voxels. Ventilation decreased linearly with dose in both high-function and low-function regions. High-function regions showed a significantly larger decline in ventilation (P ≪ 0.001) as dose increased (1.4% ventilation reduction/10 Gy) compared to low-function regions (0.3% ventilation reduction/10 Gy). With further stratification of pre-RT ventilation, voxels exhibited increasing dose-dependent ventilation reduction with increasing pre-RT ventilation, with the largest pre-RT Jacobian bin (pre-RT Jacobian between 1.5 and 1.6) exhibiting a ventilation reduction of 4.8% per 10 Gy. CONCLUSIONS Significant ventilation reductions were measured after radiation therapy treatments, and were dependent on the dose delivered to the tissue and the pre-RT ventilation of the tissue. For a fixed radiation dose, lung tissue with high pre-RT ventilation experienced larger decreases in post-RT ventilation than lung tissue with low pre-RT ventilation.
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Affiliation(s)
- Taylor J. Patton
- Department of Medical PhysicsUniversity of Wisconsin – MadisonMadisonWI53705USA
| | - Sarah E. Gerard
- Department of Biomedical EngineeringThe University of IowaIowa CityIA52242USA
| | - Wei Shao
- Department of Electrical and Computer EngineeringThe University of IowaIowa CityIA52242USA
| | - Gary E. Christensen
- Department of Electrical and Computer EngineeringThe University of IowaIowa CityIA52242USA
| | - Joseph M. Reinhardt
- Department of Biomedical EngineeringThe University of IowaIowa CityIA52242USA
| | - John E. Bayouth
- Department of Human OncologyUniversity of Wisconsin – MadisonMadisonWI53792USA
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Rankine LJ, Wang Z, Driehuys B, Marks LB, Kelsey CR, Das SK. Correlation of Regional Lung Ventilation and Gas Transfer to Red Blood Cells: Implications for Functional-Avoidance Radiation Therapy Planning. Int J Radiat Oncol Biol Phys 2018; 101:1113-1122. [PMID: 29907488 PMCID: PMC6689416 DOI: 10.1016/j.ijrobp.2018.04.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/02/2018] [Accepted: 04/05/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the degree to which lung ventilation and gas exchange are regionally correlated, using the emerging technology of hyperpolarized (HP)-129Xe magnetic resonance imaging (MRI). METHODS AND MATERIALS Hyperpolarized-129Xe MRI studies were performed on 17 institutional review board-approved human subjects, including 13 healthy volunteers, 1 emphysema patient, and 3 non-small cell lung cancer patients imaged before and approximately 11 weeks after radiation therapy (RT). Subjects inhaled 1 L of HP-129Xe mixture, followed by the acquisition of interleaved ventilation and gas exchange images, from which maps were obtained of the relative HP-129Xe distribution in three states: (1) gaseous, in lung airspaces; (2) dissolved interstitially, in alveolar barrier tissue; and (3) transferred to red blood cells (RBCs), in the capillary vasculature. The relative spatial distributions of HP-129Xe in airspaces (regional ventilation) and RBCs (regional gas transfer) were compared. Further, we investigated the degree to which ventilation and RBC transfer images identified similar functional regions of interest (ROIs) suitable for functionally guided RT. For the RT patients, both ventilation and RBC functional images were used to calculate differences in the lung dose-function histogram and functional effective uniform dose. RESULTS The correlation of ventilation and RBC transfer was ρ = 0.39 ± 0.15 in healthy volunteers. For the RT patients, this correlation was ρ = 0.53 ± 0.02 before treatment and ρ = 0.39 ± 0.07 after treatment; for the emphysema patient it was ρ = 0.24. Comparing functional ROIs, ventilation and RBC transfer demonstrated poor spatial agreement: Dice similarity coefficient = 0.50 ± 0.07 and 0.26 ± 0.12 for the highest-33%- and highest-10%-function ROIs in healthy volunteers, and in RT patients (before treatment) these were 0.58 ± 0.04 and 0.40 ± 0.04. The average magnitude of the differences between RBC- and ventilation-derived functional effective uniform dose, fV20Gy, fV10Gy, and fV5Gy were 1.5 ± 1.4 Gy, 4.1% ± 3.8%, 5.0% ± 3.8%, and 5.3% ± 3.9%, respectively. CONCLUSION Ventilation may not be an effective surrogate for true regional lung function for all patients.
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Affiliation(s)
- Leith J Rankine
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Medical Physics Graduate Program, Duke University, Durham, North Carolina.
| | - Ziyi Wang
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Bastiaan Driehuys
- Medical Physics Graduate Program, Duke University, Durham, North Carolina; Department of Biomedical Engineering, Duke University, Durham, North Carolina; Radiology, Duke University, Durham, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Shiva K Das
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Long DE, Tann M, Huang KC, Bartlett G, Galle JO, Furukawa Y, Maluccio M, Cox JA, Kong FMS, Ellsworth SG. Functional liver image guided hepatic therapy (FLIGHT) with hepatobiliary iminodiacetic acid (HIDA) scans. Pract Radiat Oncol 2018; 8:429-436. [PMID: 29907502 DOI: 10.1016/j.prro.2018.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/05/2018] [Accepted: 04/25/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE Hepatobiliary iminodiacetic acid (HIDA) scans provide global and regional assessments of liver function that can serve as a road map for functional avoidance in stereotactic body radiation therapy (SBRT) planning. Functional liver image guided hepatic therapy (FLIGHT), an innovative planning technique, is described and compared with standard planning using functional dose-volume histograms. Thresholds predicting for decompensation during follow up are evaluated. METHODS AND MATERIALS We studied 17 patients who underwent HIDA scans before SBRT. All SBRT cases were replanned using FLIGHT. The following dosimetric endpoints were compared for FLIGHT versus standard SBRT planning: functional residual capacity <15 Gy (FRC15HIDA), mean liver dose (MLD), equivalent uniform dose (EUD), and functional EUD (FEUD). Receiver operating characteristics curves were used to evaluate whether baseline HIDA values, standard cirrhosis scoring, and/or dosimetric data predicted clinical decompensation. RESULTS Compared with standard planning, FLIGHT significantly improved FRC15HIDA (mean improvement: 5.3%) as well as MLD, EUD, and FEUD (P < .05). Considerable interindividual variations in the extent of benefit were noted. Decompensation during follow-up was associated with baseline global HIDA <2.915%/min/m2, FRC15HIDA <2.11%/min/m2, and MELD ≥11 (P < .05). CONCLUSIONS FLIGHT with HIDA-based parameters may complement blood chemistry-based assessments of liver function and facilitate individualized, adaptive liver SBRT planning.
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Affiliation(s)
- David E Long
- Indiana University, Department of Radiation Oncology, Indianapolis, Indiana
| | - Mark Tann
- Indiana University, Department of Nuclear Medicine, Indianapolis, Indiana
| | - Ke Colin Huang
- Indiana University, Department of Radiation Oncology, Indianapolis, Indiana
| | - Gregory Bartlett
- Indiana University, Department of Radiation Oncology, Indianapolis, Indiana
| | - James O Galle
- Indiana University, Department of Radiation Oncology, Indianapolis, Indiana
| | - Yukie Furukawa
- Columbus Regional Health, Department of Radiation Oncology, Columbus, Indiana
| | - Mary Maluccio
- Indiana University, Department of Surgery, Indianapolis, Indiana
| | - John A Cox
- Columbus Regional Health, Department of Radiation Oncology, Columbus, Indiana
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Owen DR, Boonstra PS, Viglianti BL, Balter JM, Schipper MJ, Jackson WC, El Naqa I, Jolly S, Ten Haken RK, Kong FS, Matuszak MM. Modeling Patient-Specific Dose-Function Response for Enhanced Characterization of Personalized Functional Damage. Int J Radiat Oncol Biol Phys 2018; 102:1265-75. [PMID: 30108006 DOI: 10.1016/j.ijrobp.2018.05.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Functional-guided radiation therapy (RT) plans have the potential to limit damage to normal tissue and reduce toxicity. Although functional imaging modalities have continued to improve, a limited understanding of the functional response to radiation and its application to personalized therapy has hindered clinical implementation. The purpose of this study was to retrospectively model the longitudinal, patient-specific dose-function response in non-small cell lung cancer patients treated with RT to better characterize the expected functional damage in future, unknown patients. METHODS AND MATERIALS Perfusion single-photon emission computed tomography/computed tomography scans were obtained at baseline (n = 81), midtreatment (n = 74), 3 months post-treatment (n = 51), and 1 year post-treatment (n = 26) and retrospectively analyzed. Patients were treated with conventionally fractionated RT or stereotactic body RT. Normalized perfusion single-photon emission computed tomography voxel intensity was used as a surrogate for local lung function. A patient-specific logistic model was applied to each individual patient's dose-function response to characterize functional reduction at each imaging time point. Patient-specific model parameters were averaged to create a population-level logistic dose-response model. RESULTS A significant longitudinal decrease in lung function was observed after RT by analyzing the voxelwise change in normalized perfusion intensity. Generated dose-function response models represent the expected voxelwise reduction in function, and the associated uncertainty, for an unknown patient receiving conventionally fractionated RT or stereotactic body RT. Differential treatment responses based on the functional status of the voxel at baseline suggest that initially higher functioning voxels are damaged at a higher rate than lower functioning voxels. CONCLUSIONS This study modeled the patient-specific dose-function response in patients with non-small cell lung cancer during and after radiation treatment. The generated population-level dose-function response models were derived from individual patient assessment and have the potential to inform functional-guided treatment plans regarding the expected functional lung damage. This type of patient-specific modeling approach can be applied broadly to other functional response analyses to better capture intrapatient dependencies and characterize personalized functional damage.
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Rajan Radha R, Chandrasekharan G. Pulmonary injury associated with radiation therapy - Assessment, complications and therapeutic targets. Biomed Pharmacother 2017; 89:1092-1104. [PMID: 28298070 DOI: 10.1016/j.biopha.2017.02.106] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 12/20/2022] Open
Abstract
Pulmonary injury is more common in patients undergoing radiation therapy for lungs and other thoracic malignancies. Recently with the use of most-advanced technologies powerful doses of radiation can be delivered directly to tumor site with exquisite precision. The awareness of technical and clinical parameters that influence the chance of radiation induced lung injury is important to guide patient selection and toxicity minimization strategies. At the cellular level, radiation activates free radical production, leading to DNA damage, apoptosis, cell cycle changes, and reduced cell survival. Preclinical research shows the potential for therapies targeting transforming growth factor-β (TGF-B), Toll like receptor (TLRs), Tumour necrosis factor-alpha (TNF-alpha), Interferon gamma (IFN-γ) and so on that may restore lung function. At present Amifostine (WR-2721) is the only approved broad spectrum radioprotector in use for patients undergoing radiation therapy. Newer techniques also offer the opportunity to identify new biomarkers and new targets for interventions to prevent or ameliorate these late effects of lung damage.
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Affiliation(s)
- Rasmi Rajan Radha
- Laboratory of Immunopharmacology and Experimental Therapeutics, Division of Cancer Research, Regional Cancer Centre, Trivandrum 695 011, Kerala, India
| | - Guruvayoorappan Chandrasekharan
- Laboratory of Immunopharmacology and Experimental Therapeutics, Division of Cancer Research, Regional Cancer Centre, Trivandrum 695 011, Kerala, India.
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Liss AL, Marsh RB, Kapadia NS, McShan DL, Rogers VE, Balter JM, Moran JM, Brock KK, Schipper MJ, Jagsi R, Griffith KA, Flaherty KR, Frey KA, Pierce LJ. Decreased Lung Perfusion After Breast/Chest Wall Irradiation: Quantitative Results From a Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2016; 97:296-302. [PMID: 27986344 DOI: 10.1016/j.ijrobp.2016.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/09/2016] [Accepted: 10/12/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To quantify lung perfusion changes after breast/chest wall radiation therapy (RT) using pre- and post-RT single photon emission computed tomography/computed tomography (SPECT/CT) attenuation-corrected perfusion scans; and correlate decreased perfusion with adjuvant RT dose for breast cancer in a prospective clinical trial. METHODS AND MATERIALS As part of an institutional review board-approved trial studying the impact of RT technique on lung function in node-positive breast cancer, patients received breast/chest wall and regional nodal irradiation including superior internal mammary node RT to 50 to 52.2 Gy with a boost to the tumor bed/mastectomy scar. All patients underwent quantitative SPECT/CT lung perfusion scanning before RT and 1 year after RT. The SPECT/CT scans were co-registered, and the ratio of decreased perfusion after RT relative to the pre-RT perfusion scan was calculated to allow for direct comparison of SPECT/CT perfusion changes with delivered RT dose. The average ratio of decreased perfusion was calculated in 10-Gy dose increments from 0 to 60 Gy. RESULTS Fifty patients had complete lung SPECT/CT perfusion data available. No patient developed symptoms consistent with pulmonary toxicity. Nearly all patients demonstrated decreased perfusion in the left lung according to voxel-based analyses. The average ratio of lung perfusion deficits increased for each 10-Gy increment in radiation dose to the lung, with the largest changes in regions of lung that received 50 to 60 Gy (ratio 0.72 [95% confidence interval 0.64-0.79], P<.001) compared with the 0- to 10-Gy region. For each increase in 10 Gy to the left lung, the lung perfusion ratio decreased by 0.06 (P<.001). CONCLUSIONS In the assessment of 50 patients with node-positive breast cancer treated with RT in a prospective clinical trial, decreased lung perfusion by SPECT/CT was demonstrated. Our study allowed for quantification of lung perfusion defects in a prospective cohort of breast cancer patients for whom attenuation-corrected SPECT/CT scans could be registered directly to RT treatment fields for precise dose estimates.
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Affiliation(s)
- Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Robin B Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Nirav S Kapadia
- Department of Radiation Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel L McShan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Virginia E Rogers
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - James M Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kristy K Brock
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matt J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Biostatistics Unit, University of Michigan, Ann Arbor, Michigan
| | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kirk A Frey
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Bibault JE, Arsène-Henry A, Durdux C, Mornex F, Hamza S, Trouette R, Thureau S, Faivre JC, Boisselier P, Lerouge D, Paragios N, Giraud P. Radiothérapie adaptative du carcinome bronchique non à petites cellules. Cancer Radiother 2015; 19:458-62. [DOI: 10.1016/j.canrad.2015.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
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Farr KP, Møller DS, Khalil AA, Kramer S, Morsing A, Grau C. Loss of lung function after chemo-radiotherapy for NSCLC measured by perfusion SPECT/CT: Correlation with radiation dose and clinical morbidity. Acta Oncol 2015. [PMID: 26203930 DOI: 10.3109/0284186x.2015.1061695] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The purpose of the study was to assess dose and time dependence of radiotherapy (RT)-induced changes in regional lung function measured with single photon emission computed tomography (SPECT) of the lung and relate these changes to the symptomatic endpoint of radiation pneumonitis (RP) in patients treated for non-small cell lung cancer (NSCLC). MATERIAL AND METHODS NSCLC patients scheduled to receive curative RT of minimum 60 Gy were included prospectively in the study. Lung perfusion SPECT/CT was performed before and three months after RT. Reconstructed SPECT/CT data were registered to treatment planning CT. Dose to the lung was segmented into regions corresponding to 0-5, 6-20, 21-40, 41-60 and > 60 Gy. Changes (%) in regional lung perfusion before and after RT were correlated with regional dose and symptomatic RP (CTC grade 2-5) outcome. RESULTS A total of 58 patients were included, of which 45 had three-month follow-up SPECT/CT scans. Analysis showed a statistically significant dose-dependent reduction in regional perfusion at three-month follow-up. The largest population composite perfusion loss was in 41-60 Gy (42.2%) and > 60 Gy (41.7%) dose bins. Lung regions receiving low dose of 0-5 Gy and 6-20 Gy had corresponding perfusion increase (-7.2% and -6.1%, respectively). Regional perfusion reduction was different in patients with and without RP with the largest difference in 21-40 Gy bin (p = 0.02), while for other bins the difference did not reach statistical significance. The risk of symptomatic RP was higher for the patients with perfusion reduction after RT (p = 0.02), with the relative risk estimate of 3.6 (95% CI 1.1-12). CONCLUSION Perfusion lung function changes in a dose-dependent manner after RT. The severity of radiation-induced lung symptoms is significantly correlated with SPECT perfusion changes. Perfusion reduction early after RT is associated with a high risk of later development of symptomatic RP.
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Affiliation(s)
- Katherina P Farr
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
| | - Ditte S Møller
- b Department of Medical Physics , Aarhus University Hospital , Aarhus C , Denmark
| | - Azza A Khalil
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
| | - Stine Kramer
- c Department of Nuclear Medicine and PET Centre , Aarhus University Hospital , Aarhus C , Denmark
| | - Anni Morsing
- c Department of Nuclear Medicine and PET Centre , Aarhus University Hospital , Aarhus C , Denmark
| | - Cai Grau
- a Department of Oncology , Aarhus University Hospital , Aarhus C , Denmark
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Latifi K, Dilling TJ, Feygelman V, Moros EG, Stevens CW, Montilla-soler JL, Zhang GG. Impact of dose on lung ventilation change calculated from 4D-CT using deformable image registration in lung cancer patients treated with SBRT. ACTA ACUST UNITED AC 2015; 4:265-70. [DOI: 10.1007/s13566-015-0200-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scheenstra AE, Rossi MM, Belderbos JS, Damen EM, Lebesque JV, Sonke J. Alpha/Beta Ratio for Normal Lung Tissue as Estimated From Lung Cancer Patients Treated With Stereotactic Body and Conventionally Fractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2014; 88:224-8. [DOI: 10.1016/j.ijrobp.2013.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/27/2013] [Accepted: 10/09/2013] [Indexed: 11/23/2022]
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Yamamoto T, Kabus S, von Berg J, Lorenz C, Chung MP, Hong JC, Loo BW, Keall PJ. Reproducibility of four-dimensional computed tomography-based lung ventilation imaging. Acad Radiol 2012; 19:1554-65. [PMID: 22975070 PMCID: PMC5357435 DOI: 10.1016/j.acra.2012.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 07/11/2012] [Accepted: 07/20/2012] [Indexed: 12/13/2022]
Abstract
RATIONALE AND OBJECTIVES A novel ventilation imaging method based on four-dimensional (4D) computed tomography (CT) has been applied to the field of radiation oncology. Understanding its reproducibility is a prerequisite for clinical applications. The purpose of this study was to quantify the reproducibility of 4D CT ventilation imaging over different days and the same session. MATERIALS AND METHODS Two ventilation images were created from repeat 4D CT scans acquired over the average time frames of 15 days for 6 lung cancer patients and 5 minutes for another 6 patients. The reproducibility was quantified using the voxel-based Spearman rank correlation coefficients for all lung voxels and Dice similarity coefficients (DSC) for the spatial overlap of segmented high-, moderate-, and low-functional lung volumes. Furthermore, the relationship between the variation in abdominal motion range as a measure of the depth of breathing and variation in ventilation was evaluated using linear regression. RESULTS The voxel-based correlation between the two ventilation images was moderate on average (0.50 ± 0.15). The DSCs were also moderate for the high- (0.60 ± 0.08), moderate- (0.46 ± 0.06), and low-functional lung (0.58 ± 0.09). No patients demonstrated strong correlations. The relationship between the motion range variation and ventilation variation was found to be moderate and significant. CONCLUSIONS We investigated the reproducibility of 4D CT ventilation imaging over the time frames of 15 days and 5 minutes and found that it was only moderately reproducible. Respiratory variation during 4D CT scans was found to deteriorate the reproducibility. Improvement of 4D CT imaging is necessary to increase the reproducibility of 4D CT ventilation imaging.
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Affiliation(s)
- Tokihiro Yamamoto
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Dr., Stanford, CA 94305-5847, USA
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Wang D, Sun J, Zhu J, Li X, Zhen Y, Sui S. Functional dosimetric metrics for predicting radiation-induced lung injury in non-small cell lung cancer patients treated with chemoradiotherapy. Radiat Oncol 2012; 7:69. [PMID: 22594342 PMCID: PMC3434088 DOI: 10.1186/1748-717x-7-69] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 04/28/2012] [Indexed: 11/10/2022] Open
Abstract
Background Radiation-induced lung injury (RILI) is an important dose-limiting toxicity during thoracic radiotherapy. The purpose of this study is to investigate single photon emission computed tomography (SPECT) perfusion-weighted functional dose-volume histogram (FDVH) for predicting RILI in non-small cell lung cancer (NSCLC) patients treated with definitive chemoradiotherapy. Methods Fifty-seven locally advanced NSCLC patients receiving chemoradiotherapy were enrolled prospectively. Patients had treatment scans and dose calculations to provide a standard dose-volume histogram (DVH). Fusion of SPECT and computed tomography scans provided perfusion-weighted FDVH and associated functional dosimetric parameters (relative volumes of functional lung receiving more than a threshold dose of 5 – 60 Gy at increments of 5 Gy [FV5 – FV60]). The predictive abilities of FDVH and DVH were calculated and compared based on the area under receiver operating characteristic (ROC) curve (AUC). Results The accumulative incidence of ≥ 2 grade RILI was 19.3% with a median follow-up of 12 months. Univariate analysis showed that the functional (FV5 – FV60) and standard (V5 – V40) parameters were associated with RILI (all value of p < 0.05). Close correlations between a variety of functional and standard parameters were found. By ROC curve analysis, functional metrics (AUCs were 0.784 – 0.869) provided similarly (p value 0.233 – 1.000) predictive outcome to standard metrics (AUCs were 0.695 – 0.902) in lower – median dose level parameters (FV5 – FV40). However, FDVH seemed to add some predictive value in higher dose level, the best statistical significance for comparing FV60 with V60 was 0.693 vs. 0.511 (p = 0.055). Conclusions Functional metrics are identified as reliable predictors for RILI, however, this observation still needs to be further verified using a larger sample size.
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Affiliation(s)
- Dongqing Wang
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, People’s Republic China
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Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, Macvittie TJ, Aleman BM, Edgar AB, Mabuchi K, Muirhead CR, Shore RE, Wallace WH. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012; 41:1-322. [PMID: 22925378 DOI: 10.1016/j.icrp.2012.02.001] [Citation(s) in RCA: 771] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.
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Wang D, Li B, Wang Z, Zhu J, Sun H, Zhang J, Yin Y. Functional dose-volume histograms for predicting radiation pneumonitis in locally advanced non-small cell lung cancer treated with late-course accelerated hyperfractionated radiotherapy. Exp Ther Med 2011; 2:1017-1022. [PMID: 22977614 DOI: 10.3892/etm.2011.301] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 06/23/2011] [Indexed: 12/25/2022] Open
Abstract
The aim of this study was to determine whether functional dose-volume histograms (FDVHs) are valuable for predicting radiation pneumonitis (RP), and to identify whether FDVHs have advantages over conventional dose-volume histograms (DVHs) for the prediction of RP in patients with locally advanced non-small cell lung cancer (LANSCLC). Fifty-seven patients with LANSCLC undergoing functional image-guided late-course accelerated hyperfractionated radiotherapy were enrolled. The grade of RP was evaluated according to the Common Toxicity Criteria 3.0. To identify predictive factors of RP, the FDVHs, including the volume of the functional lung receiving 5 Gy (FV(5)) through 50 Gy (FV(50)), mean perfusion-weighted lung dose (MPWLD) and functional normal tissue complication probability (FNTCP), were analyzed and compared to their counterparts [total lung receiving 5 Gy (V(5)) through 50 Gy (V(50)), mean lung dose (MLD) and normal tissue complication probability (NTCP)] derived from conventional DVHs. Univariate analysis revealed that V(5)-V(40), MLD, NTCP and FV(5)-FV(50), MPWLD, FNTCP were all statistically significant relative to the development of RP (all p<0.05). Multivariate analysis showed that only MLD and FV(15) were associated with RP (p=0.001 and 0.044, respectively). Receiver operator characteristic curve anaysis indicated that almost all of the FDVHs had larger areas under the curve compared to the DVHs, although no statistically significant difference was observed (p-value ranged from 0.066 to 0.951). FDVHs are valuable for predicting RP with the predictive efficiency equivalent to or slightly advantageous over conventional DVHs. More homogeneous studies involving larger numbers of patients are required to further assess the value of FDVHs for predicting RP.
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Affiliation(s)
- Dongqing Wang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital
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Zhang J, Ma J, Zhou S, Hubbs JL, Wong TZ, Folz RJ, Evans ES, Jaszczak RJ, Clough R, Marks LB. Radiation-Induced Reductions in Regional Lung Perfusion: 0.1–12 Year Data From a Prospective Clinical Study. Int J Radiat Oncol Biol Phys 2010; 76:425-32. [DOI: 10.1016/j.ijrobp.2009.02.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 01/28/2009] [Accepted: 02/03/2009] [Indexed: 11/27/2022]
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Ma J, Zhang J, Zhou S, Hubbs JL, Foltz RJ, Hollis DR, Light KL, Wong TZ, Kelsey CR, Marks LB. Regional Lung Density Changes After Radiation Therapy for Tumors in and Around Thorax. Int J Radiat Oncol Biol Phys 2010; 76:116-22. [DOI: 10.1016/j.ijrobp.2009.01.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Revised: 01/08/2009] [Accepted: 01/19/2009] [Indexed: 11/22/2022]
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Gayed IW, Chang J, Kim EE, Nuñez R, Chasen B, Liu HH, Kobayashi K, Zhang Y, Liao Z, Gohar S, Jeter M, Henderson L, Erwin W, Komaki R. Lung perfusion imaging can risk stratify lung cancer patients for the development of pulmonary complications after chemoradiation. J Thorac Oncol 2008; 3:858-64. [PMID: 18670303 DOI: 10.1097/JTO.0b013e31818020d5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION We investigated the value of lung perfusion imaging in predicting the risk of developing pulmonary complications after chemoradiation (CRT) or radiation therapy (RT) for lung cancer. METHODS Fifty patients who underwent lung perfusion imaging before RT for lung cancer were included. Planar and single photon emission computed tomography/computed tomography images of the lungs were obtained. Lung perfusion score (LPS) was developed to visually grade localized perfusion defect per lung on a scale of 0 to 4 and perfusion pattern in the remaining lungs on a scale of 1 to 4. The LPS is the sum of the score for the localized perfusion defect in each lung plus the score for the remaining lungs perfusion. LPSs were correlated with pulmonary function tests and the patients were followed for 8 months after therapy to determine the incidence of grade 2 to 5 symptomatic therapy related pulmonary complications according to the common terminology criteria for adverse events (CTCAE 3.0). RESULTS Thirty-four patients underwent CRT and 16 underwent RT. The mean total radiation dose delivered was 56.1 +/- 10.4 Gy. Eighteen patients (36%) suffered from pulmonary complications at a mean interval of 3.4 months after therapy. Nine patients had grade 2, 7 had grade 3, 1 had grade 4, and 1 had grade 5 pulmonary complications. The mean LPS was 4.9 in patients who developed pulmonary complications versus 3.5 in patients who did not (p = 0.01). There were no significant difference between pulmonary function tests in the patients with pulmonary complications and the patient without. In addition, there were no significant differences between the mean lung radiation dose, the volume of lung irradiated or the percentage of lung receiving greater than 20 Gy between the two groups. CONCLUSIONS LPS using lung perfusion imaging is useful for predicting possible pulmonary complications after CRT or RT in lung cancer patients.
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Stroian G, Martens C, Souhami L, Collins DL, Seuntjens J. Local Correlation Between Monte-Carlo Dose and Radiation-Induced Fibrosis in Lung Cancer Patients. Int J Radiat Oncol Biol Phys 2008; 70:921-30. [DOI: 10.1016/j.ijrobp.2007.10.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Revised: 09/13/2007] [Accepted: 10/06/2007] [Indexed: 11/29/2022]
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Cao Y, Pan C, Balter JM, Platt JF, Francis IR, Knol JA, Normolle D, Ben-Josef E, Ten Haken RK, Lawrence TS. Liver function after irradiation based on computed tomographic portal vein perfusion imaging. Int J Radiat Oncol Biol Phys 2007; 70:154-60. [PMID: 17855011 PMCID: PMC2714771 DOI: 10.1016/j.ijrobp.2007.05.078] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 05/23/2007] [Accepted: 05/24/2007] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine whether individual and regional liver sensitivity to radiation could be assessed by measuring liver perfusion during a course of treatment using dynamic contrast-enhanced computed tomography scanning. METHODS AND MATERIALS Patients with intrahepatic cancer undergoing conformal radiotherapy underwent dynamic contrast-enhanced computed tomography (to measure perfusion distribution) and an indocyanine extraction study (to measure liver function) before, during, and 1 month after treatment. We hoped to determine whether the residual functioning liver (i.e., those regions showing portal vein perfusion) could be used to predict overall liver function after irradiation. RESULTS Radiation doses from 45 to 84 Gy resulted in undetectable regional portal vein perfusion 1 month after treatment. The volume of each liver with undetectable portal vein perfusion ranged from 0 to 39% and depended both on the patient's sensitivity and on dose distribution. There was a significant correlation between indocyanine green clearance and the mean of the estimated portal vein perfusion in the functional liver parenchyma (p < 0.001). CONCLUSION This study reveals substantial individual variability in the sensitivity of the liver to irradiation. In addition, these findings suggest that hepatic perfusion imaging may be a marker for liver function and has the potential to be a tool for individualizing therapy.
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Affiliation(s)
- Yue Cao
- Department of Radiation Oncology, University of Michigan, UH-B2C432, Box 0010, Ann Arbor, MI 48109-0010, USA.
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Cao Y, Platt JF, Francis IR, Balter JM, Pan C, Normolle D, Ben-Josef E, Haken RKT, Lawrence TS. The prediction of radiation-induced liver dysfunction using a local dose and regional venous perfusion model. Med Phys 2007; 34:604-12. [PMID: 17388178 DOI: 10.1118/1.2431081] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We have shown that high dose conformal radiation combined with chemotherapy appears to prolong the survival of patients with unresectable intrahepatic cancers. The ability to safely deliver higher doses is primarily limited by the development of radiation-induced liver disease, characterized by venous occlusion. In this study, we investigated whether portal venous perfusion measured prior to the end of radiation therapy (RT) together with dose could predict liver venous perfusion dysfunction after treatment. Ten patients with unresectable intrahepatic cancer participated in an IRB-approved computer tomography (CT) perfusion study. Hepatic arterial and portal vein perfusion distributions were estimated by using dynamic contrast enhanced CT and the single compartmental model. Scans were obtained at four time points: prior to treatment, after 15 and 30 fractions of 1.5 Gy treatments, and one month following the completion of RT. Multivariant linear regression was used to determine covariances among the first three time point measurements plus dose for prediction of the post RT measurement. The reduction in the regional venous perfusion one month following RT was predicted by the local accumulated dose and the change in the regional venous perfusion after -30 fractions (F=90.6,p <0.000 01). Each Gy produced an approximately 1.2% of reduction in the venous perfusion. This local dose and venous perfusion model has the potential to predict individual sensitivity to radiation. This is the first step toward developing a method to deliver higher and potentially more curative radiation doses to the patients who can safely receive these higher doses.
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Affiliation(s)
- Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109-0010, USA.
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Kocak Z, Borst GR, Zeng J, Zhou S, Hollis DR, Zhang J, Evans ES, Folz RJ, Wong T, Kahn D, Belderbos JSA, Lebesque JV, Marks LB. Prospective assessment of dosimetric/physiologic-based models for predicting radiation pneumonitis. Int J Radiat Oncol Biol Phys 2007; 67:178-86. [PMID: 17189069 PMCID: PMC1829491 DOI: 10.1016/j.ijrobp.2006.09.031] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Revised: 08/14/2006] [Accepted: 09/16/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE Clinical and 3D dosimetric parameters are associated with symptomatic radiation pneumonitis rates in retrospective studies. Such parameters include: mean lung dose (MLD), radiation (RT) dose to perfused lung (via SPECT), and pre-RT lung function. Based on prior publications, we defined pre-RT criteria hypothesized to be predictive for later development of pneumonitis. We herein prospectively test the predictive abilities of these dosimetric/functional parameters on 2 cohorts of patients from Duke and The Netherlands Cancer Institute (NKI). METHODS AND MATERIALS For the Duke cohort, 55 eligible patients treated between 1999 and 2005 on a prospective IRB-approved study to monitor RT-induced lung injury were analyzed. A similar group of patients treated at the NKI between 1996 and 2002 were identified. Patients believed to be at high and low risk for pneumonitis were defined based on: (1) MLD; (2) OpRP (sum of predicted perfusion reduction based on regional dose-response curve); and (3) pre-RT DLCO. All doses reflected tissue density heterogeneity. The rates of grade > or =2 pneumonitis in the "presumed" high and low risk groups were compared using Fisher's exact test. RESULTS In the Duke group, pneumonitis rates in patients prospectively deemed to be at "high" vs. "low" risk are 7 of 20 and 9 of 35, respectively; p = 0.33 one-tailed Fisher's. Similarly, comparable rates for the NKI group are 4 of 21 and 6 of 44, respectively, p = 0.41 one-tailed Fisher's. CONCLUSION The prospective model appears unable to accurately segregate patients into high vs. low risk groups. However, considered retrospectively, these data are consistent with prior studies suggesting that dosimetric (e.g., MLD) and functional (e.g., PFTs or SPECT) parameters are predictive for RT-induced pneumonitis. Additional work is needed to better identify, and prospectively assess, predictors of RT-induced lung injury.
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Affiliation(s)
- Zafer Kocak
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Trakya University Hospital, Edirne, Turkey
| | - Gerben R. Borst
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leewenhoek Hospital, Amsterdam, The Netherlands
| | - Jing Zeng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Sumin Zhou
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Donna R. Hollis
- Cancer Center Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Junan Zhang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth S. Evans
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Rodney J. Folz
- Pulmonary Medicine, Duke University Medical Center, Durham, North Carolina
| | - Terrence Wong
- Radiology-Nuclear Medicine Division, Duke University Medical Center, Durham, North Carolina
| | - Daniel Kahn
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jose S. A. Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leewenhoek Hospital, Amsterdam, The Netherlands
| | - Joos V. Lebesque
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leewenhoek Hospital, Amsterdam, The Netherlands
| | - Lawrence B. Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Buus S, Grau C, Munk OL, Rodell A, Jensen K, Mouridsen K, Keiding S. Individual radiation response of parotid glands investigated by dynamic 11C-methionine PET. Radiother Oncol 2006; 78:262-9. [PMID: 16545879 DOI: 10.1016/j.radonc.2006.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 02/08/2006] [Accepted: 02/24/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Previously, we showed that the net metabolic clearance of 11C-methionine of the parotid gland, K, calculated from dynamic 11C-methionine PET, can be used as a measure of parotid gland function. The aim of this study was to investigate by dynamic 11C-methionine PET the individual radiation dose response relationship of parotid glands in head and neck cancer patients. PATIENTS AND METHODS Twelve head and neck cancer patients were examined by dynamic 11C-methionine PET after radiotherapy. Parametric images of K were generated, co-registered and compared voxel-by-voxel with the 3D radiation dose plan within the parotid gland to assess the individual radiation dose-function relationship. RESULTS In each patient, voxel-values of K decreased with increasing radiation dose. Population based analysis showed a sigmoid dose response relationship of parotid gland, from which we estimated a threshold radiation dose of 16 Gy and a mean TD50 of 30 Gy. TD50 ranged from 7 to 50 Gy in the group of patients. CONCLUSIONS Individual radiation dose response of parotid glands can be measured by dynamic 11C-methionine PET. The dose response analysis revealed a sigmoid relationship, a threshold radiation dose of 16 Gy, and a mean TD50 of 30 Gy.
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Affiliation(s)
- Simon Buus
- PET Centre, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
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Miften MM, Das SK, Su M, Marks LB. Incorporation of functional imaging data in the evaluation of dose distributions using the generalized concept of equivalent uniform dose. Phys Med Biol 2004; 49:1711-21. [PMID: 15152926 DOI: 10.1088/0031-9155/49/9/009] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Advances in the fields of IMRT and functional imaging have greatly increased the prospect of escalating the dose to highly active or hypoxic tumour sub-volumes and steering the dose away from highly functional critical structure regions. However, current clinical treatment planning and evaluation tools assume homogeneous activity/function status in the tumour/critical structures. A method was developed to incorporate tumour/critical structure heterogeneous functionality in the generalized concept of equivalent uniform dose (EUD). The tumour and critical structures functional EUD (FEUD) values were calculated from the dose-function histogram (DFH), which relates dose to the fraction of total function value at that dose. The DFH incorporates flouro-deoxyglucose positron emission tomography (FDG-PET) functional data for tumour, which describes the distribution of metabolically active tumour clonogens, and single photon emission computed tomography (SPECT) perfusion data for critical structures. To demonstrate the utility of the method, the lung dose distributions of two non-small cell lung cancer patients, who received 3D conformal external beam radiotherapy treatment with curative intent, were evaluated. Differences between the calculated lungs EUD and FEUD values of up to 50% were observed in the 3D conformal plans. In addition, a non-small cell lung cancer patient was inversely planned with a target dose prescription of 76 Gy. Two IMRT plans (plan-A and plan-B) were generated for the patient based on the CT, FDG-PET and SPECT treatment planning images using dose-volume objective functions. The IMRT plans were generated with the goal of achieving more critical structures sparing in plan-B than plan-A. Results show the target volume EUD in plan-B is lower than plan-A by 5% with a value of 73.31 Gy, and the FEUD in plan-B is lower than plan-A by 2.6% with a value of 75.77 Gy. The FEUD plan-B values for heart and lungs were lower than plan-A by 22% and 18%, respectively. While EUD values show plan-A is marginally better than plan-B in terms of target volumetric coverage, the FEUD plan-B values show adequate target function coverage with significant critical structure function sparing. In conclusion, incorporating functional data in the calculation of EUD is important in evaluating the biological merit of treatment plans.
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Affiliation(s)
- Moyed M Miften
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Great technologic progress has been made in the last decade in the radiation treatment of lung cancer. In particular, the widespread use of 3D conformal therapy has the potential to escalate the dose to the tumor while sparing dose to normal tissue. Current technology, however, has yet to impact local control and survival. It could be hypothesized that this is due to geographic misses because of poor target definition, movement of the tumor due to respiration, and dose/ fractionation levels. Several emerging technologies that are described in this article have the potential to address these problems, with results expected in the near future. The technical delivery of radiation has not reached its limit.
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Affiliation(s)
- Mary K Martel
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, 5758 South Maryland Avenue, Room MC9006, Chicago, IL 60637, USA.
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De Jaeger K, Hoogeman MS, Engelsman M, Seppenwoolde Y, Damen EMF, Mijnheer BJ, Boersma LJ, Lebesque JV. Incorporating an improved dose-calculation algorithm in conformal radiotherapy of lung cancer: re-evaluation of dose in normal lung tissue. Radiother Oncol 2003; 69:1-10. [PMID: 14597351 DOI: 10.1016/s0167-8140(03)00195-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The low density of lung tissue causes a reduced attenuation of photons and an increased range of secondary electrons, which is inaccurately predicted by the algorithms incorporated in some commonly available treatment planning systems (TPSs). This study evaluates the differences in dose in normal lung tissue computed using a simple and a more correct algorithm. We also studied the consequences of these differences on the dose-effect relations for radiation-induced lung injury. MATERIALS AND METHODS The treatment plans of 68 lung cancer patients initially produced in a TPS using a calculation model that incorporates the equivalent-path length (EPL) inhomogeneity-correction algorithm, were recalculated in a TPS with the convolution-superposition (CS) algorithm. The higher accuracy of the CS algorithm is well-established. Dose distributions in lung were compared using isodoses, dose-volume histograms (DVHs), the mean lung dose (MLD) and the percentage of lung receiving >20 Gy (V20). Published dose-effect relations for local perfusion changes and radiation pneumonitis were re-evaluated. RESULTS Evaluation of isodoses showed a consistent overestimation of the dose at the lung/tumor boundary by the EPL algorithm of about 10%. This overprediction of dose was also reflected in a consistent shift of the EPL DVHs for the lungs towards higher doses. The MLD, as determined by the EPL and CS algorithm, differed on average by 17+/-4.5% (+/-1SD). For V20, the average difference was 12+/-5.7% (+/-1SD). For both parameters, a strong correlation was found between the EPL and CS algorithms yielding a straightforward conversion procedure. Re-evaluation of the dose-effect relations showed that lung complications occur at a 12-14% lower dose. The values of the TD(50) parameter for local perfusion reduction and radiation pneumonitis changed from 60.5 and 34.1 Gy to 51.1 and 29.2 Gy, respectively. CONCLUSIONS A simple tissue inhomogeneity-correction algorithm like the EPL overestimates the dose to normal lung tissue. Dosimetric parameters for lung injury (e.g. MLD, V20) computed using both algorithms are strongly correlated making an easy conversion feasible. Dose-effect relations should be refitted when more accurate dose data is available.
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Affiliation(s)
- Katrien De Jaeger
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Deasy JO, Niemierko A, Herbert D, Yan D, Jackson A, Ten Haken RK, Langer M, Sapareto S. Methodological issues in radiation dose-volume outcome analyses: summary of a joint AAPM/NIH workshop. Med Phys 2002; 29:2109-27. [PMID: 12349932 DOI: 10.1118/1.1501473] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This report represents a summary of presentations at a joint workshop of the National Institutes of Health and the American Association of Physicists in Medicine (AAPM). Current methodological issues in dose-volume modeling are addressed here from several different perspectives. Areas of emphasis include (a) basic modeling issues including the equivalent uniform dose framework and the bootstrap method, (b) issues in the valid use of statistics, including the need for meta-analysis, (c) issues in dealing with organ deformation and its effects on treatment response, (d) evidence for volume effects for rectal complications, (e) the use of volume effect data in liver and lung as a basis for dose escalation studies, and (f) implications of uncertainties in volume effect knowledge on optimized treatment planning. Taken together, these approaches to studying volume effects describe many implications for the development and use of this information in radiation oncology practice. Areas of significant interest for further research include the meta-analysis of clinical data; interinstitutional pooled data analyses of volume effects; analyses of the uncertainties in outcome prediction models, minimal parameter number outcome models for ranking treatment plans (e.g., equivalent uniform dose); incorporation of the effect of motion in the outcome prediction; dose-escalation/isorisk protocols based on outcome models; the use of functional imaging to study radioresponse; and the need for further small animal tumor control probability/normal tissue complication probability studies.
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Affiliation(s)
- Joseph O Deasy
- Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Bhatnagar A, Flickinger JC, Bahri S, Deutsch M, Belani C, Luketich JD, Greenberger JS. Update on Results of Multifield Conformal Radiation Therapy of Non—Small-Cell Lung Cancer Using Multileaf Collimated Beams. Clin Lung Cancer 2002; 3:259-64. [PMID: 14662034 DOI: 10.3816/clc.2002.n.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We evaluated the treatment outcome for 5-field 3-dimensional conformal radiation therapy (3D-CRT) in 46 consecutive patients with unresectable, nonmetastatic non-small-cell lung cancer treated from 1993-2001. Four percent of the patients had stage I tumors, 6% had stage II, 44% had stage IIIA, and 46% had stage IIIB tumors. The median radiation therapy (RT) dose to the gross tumor volume with a median of 467.5 cc (range, 75.0-3073.0 cc) was 6120 cGy (range, 3000-6840 cGy). Thirty-one of 46 patients (67.4%) received combined chemoradiotherapy. Mean follow-up was 13.2 months (range, 3-159 months). Survival for stage III patients was 48.7% +/-9.1% at 1 year and 25.0% +/-8.4% at 2 years, with a median survival of 12.0 months+/-4.4 months. The local control rate for stage III patients was 66.8%+/- 9.4% at 1 year and 28.5%+/- 10.4% at 2 years. Patients who received chemotherapy had better survival (P = 0.0533) and local control (P = 0.0984) compared with patients receiving RT alone. Esophageal toxicity >or= grade 3 was significantly greater in combined chemoradiotherapy patients (29% early, 13% late) compared to the patients receiving RT alone (0% early and late). Pulmonary toxicity (early and late) was limited to grades 1/2 in 24% of patients and early grade 3 in 2% of patients. Chemotherapy appears to improve survival and local control when added to 3D-CRT in this series. The addition of concurrent chemotherapy to RT significantly increased esophageal toxicity (within acceptable levels) and did not effect pulmonary toxicity in this series.
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Affiliation(s)
- Ajay Bhatnagar
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Woel RT, Munley MT, Hollis D, Fan M, Bentel G, Anscher MS, Shafman T, Coleman RE, Jaszczak RJ, Marks LB. The time course of radiation therapy-induced reductions in regional perfusion: a prospective study with >5 years of follow-up. Int J Radiat Oncol Biol Phys 2002; 52:58-67. [PMID: 11777622 DOI: 10.1016/s0360-3016(01)01809-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the time-dependence of radiation therapy (RT)-induced reductions in regional lung perfusion, as measured by single photon emission computed tomography (SPECT) lung perfusion scans. METHODS AND MATERIALS Between 1991 and 1999, 79 patients had SPECT lung perfusion scans before and serially after RT. Changes in regional perfusion were correlated with regional dose using 3D planning tools and image fusion (PLUNC-Plan UNC). Multiple post-RT follow-up scans were evaluated to determine the temporal nature of RT-induced regional perfusion changes. To facilitate the comparison of dose-response curves (DRCs) at different post-RT intervals, each DRC was fit to a linear model and thus described by its slope. RESULTS There was a dose-dependent reduction in regional perfusion at nearly all time points post-RT (p = 0.0001). The slope of the DRCs for RT-induced reductions in regional perfusion became steeper at essentially each successive follow-up interval (p = 0.0001). However, the increases in slope became progressively smaller at later follow-up intervals. Overall, about 80% of the long-term RT-induced regional perfusion injury was manifest within 12 months post-RT. CONCLUSION There is a progression of RT-induced reductions in regional perfusion, with most of this injury manifest within 12 months post-RT. Additional regional injury appears to evolve for years.
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Affiliation(s)
- Roxanne T Woel
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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Fan M, Marks LB, Hollis D, Bentel GG, Anscher MS, Sibley G, Coleman RE, Jaszczak RJ, Munley MT. Can we predict radiation-induced changes in pulmonary function based on the sum of predicted regional dysfunction? J Clin Oncol 2001; 19:543-50. [PMID: 11208849 DOI: 10.1200/jco.2001.19.2.543] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether changes in whole-lung pulmonary function test (PFT) values are related to the sum of predicted radiation therapy (RT)-induced changes in regional lung perfusion. PATIENTS AND METHODS Between 1991 and 1998, 96 patients (61% with lung cancer) who were receiving incidental partial lung irradiation were studied prospectively. The patients were assessed with pre- and post-RT PFTs (forced expiratory volume in one second [FEV1] and diffusion capacity for carbon monoxide [DLCO]) for at least a 6-month follow-up period, and patients were excluded if it was determined that intrathoracic recurrence had an impact on lung function. The maximal declines in PFT values were noted. A dose-response model based on RT-induced reduction in regional perfusion (function) was used to predict regional dysfunction. The predicted decline in pulmonary function was calculated as the weighted sum of the predicted regional injuries: equation [see text] where Vd is the volume of lung irradiated to dose d, and Rd is the reduction in regional perfusion anticipated at dose d. RESULTS The relationship between the predicted and measured reduction in PFT values was significant for uncorrected DLCO (P = .005) and borderline significant for DLCO (P = .06) and FEV1 (P = .08). However, the correlation coefficients were small (range,.18 to.30). In patients with lung cancer, the correlation coefficients improved as the number of follow-up evaluations increased (range,.43 to.60), especially when patients with hypoperfusion in the lung adjacent to a central mediastinal/hilar thoracic mass were excluded (range,.59 to.91). CONCLUSION The sum of predicted RT-induced changes in regional perfusion is related to RT-induced changes in pulmonary function. In many patients, however, the percentage of variation explained is small, which renders accurate predictions difficult.
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Affiliation(s)
- M Fan
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Radiation therapy (RT) is frequently used to treat patients with tumors in and around the thorax. Clinical radiation pneumonitis is a common side effect, occurring in 5% to 20% of patients. Efforts to identify patients at risk for pneumonitis have focused on physical factors, such as dose and volume. Recently, the underlying molecular biological mechanisms behind RT-induced lung injury have come under study. Improved knowledge of the molecular events associated with RT-induced lung injury may translate into a better ability to individualized therapy. This review discusses our current understanding of the physical and molecular factors contributing to RT-induced pulmonary injury.
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Affiliation(s)
- Z Vujaskovic
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Theuws JC, Seppenwoolde Y, Kwa SL, Boersma LJ, Damen EM, Baas P, Muller SH, Lebesque JV. Changes in local pulmonary injury up to 48 months after irradiation for lymphoma and breast cancer. Int J Radiat Oncol Biol Phys 2000; 47:1201-8. [PMID: 10889373 DOI: 10.1016/s0360-3016(00)00546-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To assess the recovery from early local pulmonary injury after irradiation and to determine whether regional differences exist. METHODS For 110 patients treated for breast cancer or malignant lymphoma, single photon emission computed tomography (SPECT) perfusion and ventilation scans and CT scans were made before, 3, 18, and 48 months after radiotherapy. Dose-effect relations for changes in local perfusion, ventilation, and density were determined for each individual patient using spatially correlated SPECT and CT data sets, for each follow-up period. Average dose-effect relations for both subgroups were determined, as well as dose-effect relations for different regions. RESULTS In general, partial improvement of local pulmonary injury was observed between 3 and 18 months for each of the three endpoints. After 18 months, no further improvement was seen. Patients with breast cancer and malignant lymphoma showed a similar improvement (except for the perfusion parameter), which was attributed to a recovery from the early radiation response and could not be explained by contraction effects of fibrosis of lung parenchyma. No regional differences in radiosensitivity 18 months after treatment were observed, except for the dorsal versus ventral region. This difference was attributed to a gravity-related effect in the measuring procedure. CONCLUSION For all patients, a partial recovery from early local perfusion, ventilation, and density changes, was seen between 3 and 18 months after radiotherapy. After 18 months, local lung function did not further improve (lymphoma patients).
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Affiliation(s)
- J C Theuws
- Departments of Radiotherapy, The Netherlands Cancer Institute, Amsterdam
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Seppenwoolde Y, Muller SH, Theuws JC, Baas P, Belderbos JS, Boersma LJ, Lebesque JV. Radiation dose-effect relations and local recovery in perfusion for patients with non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2000; 47:681-90. [PMID: 10837952 DOI: 10.1016/s0360-3016(00)00454-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE To determine local dose-effect relations for lung perfusion and density changes due to irradiation for patients with non-small-cell lung cancer (NSCLC) and to quantify the effect of reperfusion. METHODS AND MATERIALS For 25 NSCLC patients and a reference group of 81 patients with healthy lungs, registered single photon emission computed tomography (SPECT) lung perfusion and CT scans were made, before and after radiotherapy. Average dose-effect relations for perfusion and CT-density changes were calculated and compared with the dose-effect relation of the reference group. On the basis of these dose-effect relations, the post-RT perfusion was predicted for each patient and compared to the measured post-RT perfusion. RESULTS Well-perfused lung regions of the NSCLC patients showed the same dose-effect relation as the reference patients. By comparing predicted and measured post-treatment perfusion scans, regions of reperfusion could be determined for 18 of 25 NSCLC patients but for none of the reference patients. CONCLUSION Well-perfused lung tissue of patients with NSCLC behaves like healthy lung tissue with respect to radiation. The dose-effect relation for perfusion and CT density was extended for doses up to 80 Gy. Radiation damage in poorly perfused lung regions was less than predicted as a consequence of local reperfusion.
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Affiliation(s)
- Y Seppenwoolde
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
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41
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Bahri S, Flickinger JC, Kalend AM, Deutsch M, Belani CP, Sciurba FC, Luketich JD, Greenberger JS. Results of multifield conformal radiation therapy of nonsmall-cell lung carcinoma using multileaf collimation beams. Radiat Oncol Investig 1999; 7:297-308. [PMID: 10580899 DOI: 10.1002/(sici)1520-6823(1999)7:5<297::aid-roi5>3.0.co;2-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A five-field conformal technique with three-dimensional radiation therapy treatment planning (3-DRTP) has been shown to permit better definition of the target volume for lung cancer, while minimizing the normal tissue volume receiving greater than 50% of the target dose. In an initial study to confirm the safety of conventional doses, we used the five-field conformal 3-DRTP technique. We then used the technique in a second study, enhancing the therapeutic index in a series of 42 patients, as well as to evaluate feasibility, survival outcome, and treatment toxicity. Forty-two consecutive patients with nonsmall-cell lung carcinoma (NSCLC) were evaluated during the years 1993-1997. The median age was 60 years (range 34-80). The median radiation therapy (RT) dose to the gross tumor volume was 6,300 cGy (range 5,000-6,840 cGy) delivered over 6 to 6.5 weeks in 180-275 cGy daily fractions, 5 days per week. There were three patients who received a split course treatment of 5,500 cGy in 20 fractions, delivering 275 cGy daily with a 2-week break built into the treatment course after 10 fractions. The stages of disease were II in 2%, IIIA in 40%, IIIB in 42.9%, and recurrent disease in 14.3% of the patients. The mean tumor volume was 324.14 cc (range 88.3-773.7 cc); 57.1% of the patients received combined chemoradiotherapy, while the others were treated with radiation therapy alone. Of the 42 patients, 7 were excluded from the final analysis because of diagnosis of distant metastasis during treatment. Two of the patients had their histology reinterpreted as being other than NSCLC, 2 patients did not complete RT at the time of analysis, and 1 patient voluntarily discontinued treatment because of progressive deterioration. Median follow-up was 11.2 months (range 3-32.5 months). Survival for patients with Stage III disease was 70.2% at 1 year and 51.5% at 2 years, with median survival not yet reached. Local control for the entire series was 23.3+/-11.4% at 2 years. However, for Stage III patients, local control was 50% at 1 year and 30% at 2 years. Patients who received concurrent chemotherapy had significantly improved survival (P = 0.002) and local control (P = 0.004), compared with RT alone. Late esophageal toxicity of > or =Grade 3 occurred in 14.1+/-9.3% of patients (3 of 20) receiving combined chemoradiotherapy, but in none of the 15 patients treated with RT alone. Pulmonary toxicity limited to Grades 1-2 occurred in 6.8% of the patients, and none developed > or =Grade 3 pulmonary toxicity. Patients with locally advanced NSCLC, who commonly have tumor volumes in excess of 200 cc, presenta challenge for adequate dose delivery without significant toxicity. Our five-field conformal 3-DRTP technique, which incorporates treatment planning by dose/volume histogram (DVH) was associated with minimal toxicity and may facilitate dose escalation to the gross tumor.
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MESH Headings
- Adenocarcinoma/pathology
- Adenocarcinoma/radiotherapy
- Adenocarcinoma/secondary
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma/pathology
- Carcinoma/radiotherapy
- Carcinoma/secondary
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/radiotherapy
- Carcinoma, Non-Small-Cell Lung/secondary
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Squamous Cell/secondary
- Chemotherapy, Adjuvant
- Disease-Free Survival
- Dose Fractionation, Radiation
- Feasibility Studies
- Follow-Up Studies
- Humans
- Lung/radiation effects
- Lung Neoplasms/pathology
- Lung Neoplasms/radiotherapy
- Middle Aged
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Staging
- Radiotherapy Dosage
- Radiotherapy Planning, Computer-Assisted/instrumentation
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/instrumentation
- Radiotherapy, Conformal/methods
- Remission Induction
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- S Bahri
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pennsylvania, USA.
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42
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Theuws JC, Muller SH, Seppenwoolde Y, Kwa SL, Boersma LJ, Hart GA, Baas P, Lebesque JV. Effect of radiotherapy and chemotherapy on pulmonary function after treatment for breast cancer and lymphoma: A follow-up study. J Clin Oncol 1999; 17:3091-100. [PMID: 10506604 DOI: 10.1200/jco.1999.17.10.3091] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the changes in pulmonary function tests (PFTs) 0 to 48 months after treatment for breast cancer and lymphoma. PATIENTS AND METHODS The alveolar volume (V(A)), vital capacity, forced expiratory volume in 1 second, and corrected transfer factor of carbon monoxide (T(L,COc)) were measured in 69 breast cancer and 41 lymphoma patients before treatment and 3, 18, and 48 months after treatment with radiotherapy alone or radiotherapy in combination with chemotherapy (mechlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine; cyclophosphamide, epidoxorubicin, fluorouracil; cyclophosphamide, thiotepa, carboplatin; cyclophosphamide, methotrexate, fluorouracil). The three-dimensional dose distribution in the lung of each patient was converted to the mean lung dose. Statistical analysis was used to evaluate the changes in PFT values over time in relation to age, sex, smoking, chemotherapy, and the mean lung dose. RESULTS After an initial reduction in PFT values at 3 months, significant recovery was seen at 18 months for all patients. Thereafter, no further improvement could be demonstrated. Reductions in spirometry values and V(A) were related to the mean lung dose only (0.9% per Gy at 3 months and 0.4% per Gy mean dose at 18 months). T(L,COc) decreased 1. 1% per Gy mean dose and additionally decreased 6% when chemotherapy was given after radiotherapy. Chemotherapy administered before radiotherapy reduced baseline T(L,COc) values by 8% to 21%. All patients showed an improvement of 5% at 18 months. CONCLUSION On the basis of the mean lung dose and the chemotherapy regimen, the changes in PFT values can be estimated before treatment within 10% of the values actually observed in 72% to 85% of our patients with healthy lungs.
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Affiliation(s)
- J C Theuws
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
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43
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Garipagaoglu M, Munley MT, Hollis D, Poulson JM, Bentel GC, Sibley G, Anscher MS, Fan M, Jaszczak RJ, Coleman RE, Marks LB. The effect of patient-specific factors on radiation-induced regional lung injury. Int J Radiat Oncol Biol Phys 1999; 45:331-8. [PMID: 10487553 DOI: 10.1016/s0360-3016(99)00201-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess the impact of patient-specific factors on radiation (RT)-induced reductions in regional lung perfusion. METHODS Fifty patients (32 lung carcinoma, 7 Hodgkin's disease, 9 breast carcinoma and 2 other thoracic tumors) had pre-RT and > or = 24-week post-RT single photon emission computed tomography (SPECT) perfusion images to assess the dose dependence of RT-induced reductions in regional lung perfusion. The SPECT data were analyzed using a normalized and non-normalized approach. Furthermore, two different mathematical methods were used to assess the impact of patient-specific factors on the dose-response curve (DRC). First, DRCs for different patient subgroups were generated and compared. Second, in a more formal statistical approach, individual DRCs for regional lung injury for each patient were fit to a linear-quadratic model (reduction = coefficient 1 x dose + coefficient 2 x dose2). Multiple patient-specific factors including tobacco history, pre-RT diffusion capacity to carbon monoxide (DLCO), transforming growth factor-beta (TGF-beta), chemotherapy exposure, disease type, and mean lung dose were explored in a multivariate analysis to assess their impact on the coefficients. RESULTS None of the variables tested had a consistent impact on the radiation sensitivity of regional lung (i.e., the slope of the DRC). In the formal statistical analysis, there was a suggestion of a slight increase in radiation sensitivity in the dose range >40 Gy for nonsmokers (vs. smokers) and in those receiving chemotherapy (vs. no chemotherapy). However, this finding was very dependent on the specific statistical and normalization method used. CONCLUSION Patient-specific factors do not have a dramatic effect on RT-induced reduction in regional lung perfusion. Additional studies are underway to better clarify this issue. We continue to postulate that patient-specific factors will impact on how the summation of regional injury translates into whole organ injury. Refinements in our methods to generate and compare SPECT scans are needed.
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Affiliation(s)
- M Garipagaoglu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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44
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Scarfone C, Jaszczak RJ, Gilland DR, Greer KL, Munley MT, Marks LB, Coleman RE. Quantitative pulmonary single photon emission computed tomography for radiotherapy applications. Med Phys 1999; 26:1579-88. [PMID: 10501058 DOI: 10.1118/1.598653] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pulmonary imaging using single photon emission computed tomography (SPECT) is the focus of current radiotherapy research, including dose-response analysis and three-dimensional (3D) radiation treatment planning. Improvement in the quantitative capability of SPECT may help establish its potential role in this application as well as others requiring accurate knowledge of pulmonary blood flow. The purposes of this study were to quantitatively evaluate SPECT filtered backprojection (FBP) and ordered subset-expectation maximization (OS-EM) reconstruction implementations for measuring absolute activity concentration in lung phantom experiments, and to incorporate quantitative SPECT techniques in 3D-RTP for lung cancer. Quantitative FBP (nonuniform iterative Chang attenuation compensation, scatter correction, and 3D postreconstruction Metz filtering) and OS-EM implementations were compared with a "clinical" implementation of FBP (uniform multiplicative Chang attenuation compensation and post-reconstruction von Hann filtering), for their ability to improve quantification of inactive and active spherical defects in the lungs of an anthropomorphic torso phantom. Activity concentration estimates were found to depend on many factors, such as region of interest size, scatter subtraction constant (k), postreconstruction deconvolution filtering and, in the case of OS-EM, total number of iterations. In general, reconstruction implementations incorporating compensation for nonuniform attenuation and scatter provided reduced bias relative to the clinical implementation. Potential applications to lung radiotherapy, including dose-functional histograms and treatment planning are also discussed. SPECT has the potential to provide accurate estimates of lung activity distributions that, together with improved image quality, may be useful for the study and prediction of therapeutic response.
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MESH Headings
- Algorithms
- Biophysical Phenomena
- Biophysics
- Evaluation Studies as Topic
- Humans
- Image Processing, Computer-Assisted
- Lung/diagnostic imaging
- Lung Neoplasms/radiotherapy
- Phantoms, Imaging
- Radiographic Image Interpretation, Computer-Assisted
- Radiotherapy Planning, Computer-Assisted/methods
- Scattering, Radiation
- Tomography, Emission-Computed, Single-Photon/methods
- Tomography, Emission-Computed, Single-Photon/statistics & numerical data
- Tomography, X-Ray Computed/instrumentation
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Affiliation(s)
- C Scarfone
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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45
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Cai J, Chu JC, Recine D, Sharma M, Nguyen C, Rodebaugh R, Saxena VA, Ali A. CT and PET lung image registration and fusion in radiotherapy treatment planning using the chamfer-matching method. Int J Radiat Oncol Biol Phys 1999; 43:883-91. [PMID: 10098445 DOI: 10.1016/s0360-3016(98)00399-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We present a validation study of CT and PET lung image registration and fusion based on the chamfer-matching method. METHODS AND MATERIALS The contours of the lung surfaces from CT and PET transmission images were automatically segmented by the thresholding technique. The chamfer-matching technique was then used to register the extracted lung surfaces. Arithmetic means of distance between the two data sets of the pleural surfaces were used as the cost function. Matching was then achieved by iteratively minimizing the cost function through three-dimensional (3D) translation and rotation with an optimization method. RESULTS Both anatomic thoracic phantom images and clinical patient images were used to evaluate the performance of our registration system. Quantitative analysis from five patients indicates that the registration error in translation was 2-3 mm in the transverse plane, 3-4 mm in the longitudinal direction, and about 1.5 degree in rotation. Typical computing time for chamfer matching is about 1 min. The total time required to register a set of CT and PET lung images, including contour extraction, was generally less than 30 min. CONCLUSION We have implemented and validated the chamfer-matching method for CT and PET lung image registration and fusion. Our preliminary results show that the chamfer-matching method for CT and PET images in the lung area is feasible. The described registration system has been used to facilitate target definition and treatment planning in radiotherapy.
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Affiliation(s)
- J Cai
- Department of Radiation Oncology and Medical Physics, Rush Presbyterian St. Luke's Medical Center, Rush Medical College, Chicago, IL 60612, USA.
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46
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Abstract
The dose-volume histogram (DVH) has gained wide acceptance as a mechanism for reducing the voluminous data of a three-dimensional dose distribution into a two-dimensional graph. These graphs are often converted to a single figure of merit. This data reduction technique is used both for clinical treatment plan evaluation and as part of proposed systems for estimating control and complication probabilities. It has long been recognized that a major shortcoming of the DVH as an analysis tool is that all spatial information is discarded. A subtler problem, which is addressed in this work, is that the DVH also implies homogeneity of biological consequence of irradiation in what may be a functionally heterogeneous volume of tissue. An extension to the DVH, the functional dose-volume histogram, or dose-function histogram (DFH), is proposed, that explicitly includes quantitative three-dimensional functional information. The concept is illustrated by the use of SPECT imaging to assess the functional status of irradiated lung.
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Affiliation(s)
- L B Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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47
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Theuws JC, Kwa SL, Wagenaar AC, Seppenwoolde Y, Boersma LJ, Damen EM, Muller SH, Baas P, Lebesque JV. Prediction of overall pulmonary function loss in relation to the 3-D dose distribution for patients with breast cancer and malignant lymphoma. Radiother Oncol 1998; 49:233-43. [PMID: 10075256 DOI: 10.1016/s0167-8140(98)00117-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To predict the changes in pulmonary function tests (PFTs) 3-4 months after radiotherapy based on the three-dimensional (3-D) dose distribution and taking into account patient- and treatment-related factors. METHODS For 81 patients with malignant lymphoma and breast cancer, PFTs (VA, VC, FEV1 and TL,COc) were performed prior to and 3-4 months after irradiation and dose-effect relations for early changes in local perfusion, ventilation and air-filled fraction were determined using correlated CT and SPECT data. The 3-D dose distribution of each patient was converted into four different dose-volume parameters, i.e. the mean dose in the lung and three overall response parameters (ORPs, which represent the average local injury over the complete lung). ORPs were determined using the dose-effect relations for early changes in local perfusion, ventilation and air-filled fraction. Correlation coefficients were calculated between these dose-volume parameters and the changes in PFTs. In addition, the impact of the variables chemotherapy (MOPP/ABV and CMF), tamoxifen, smoking, age and gender on the relation between the mean lung dose and the relative changes in PFTs following radiotherapy was studied using multiple regression analysis. RESULTS The mean lung dose proved to be the easiest parameter to predict the reduction in PFTs 3-4 months following radiotherapy. For all patients the relation between the mean lung dose and the changes in PFTs could be described with one regression line through the origin and a slope of 1% reduction in PFT for each increase of 1 Gy in mean lung dose. Smoking and CMF chemotherapy influenced the reduction in PFTs significantly for VA and TL,COc, respectively. Patients treated with MOPP/ABV prior to radiotherapy had lower pre-radiotherapy PFTs than other patient groups, but did not show further deterioration after radiotherapy (at 3-4 months). CONCLUSIONS The relative reduction in VA, VC, FEV1 and TL,COc 3-4 months after radiotherapy for breast cancer and malignant lymphoma can be estimated before radiotherapy based on the mean lung dose of each individual patient and taking into account the use of chemotherapy and smoking habits of the patient.
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Affiliation(s)
- J C Theuws
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Huis, Amsterdam
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48
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Abstract
PURPOSE To better understand the dose dependence of radiation therapy (RT)-induced changes in regional lung perfusion and tissue density, using a manual method to reduce inaccuracies that might be present in previously described automated methods. MATERIALS AND METHODS Patients who were to receive RT for tumors in and around the thorax, wherein portions of healthy lung would be incidentally irradiated, were prospectively studied. Changes in regional perfusion and tissue density were assessed by comparison of pre- and post-RT single photon emission computed tomography (SPECT), lung perfusion scans and computed tomography (CT) scans, respectively. The three-dimensional dose distribution was calculated on the pre-RT CT scan and correlated to the other scans via image registration. Study volumes were defined by hand and individually visualized on pre- and post-RT scans. The manually generated dose response data were compared to data generated using automated methods. The relationship between CT density and SPECT perfusion was also determined. RESULTS Thirteen patients with lung cancer were evaluated for changes in tissue density and 11 patients were evaluated for changes in regional perfusion at 12 months post-RT. In general, density increases with increasing regional dose, with marked changes at >60 Gy. Regional perfusion decreases with increasing regional dose. In the low dose regions, relative perfusion increases by 35% on average. Manually measured dose responses correlated well with those determined automatically. The relationship between regional perfusion and CT density indicates a wide range of perfusion over a narrow range of CT density, with markedly reduced perfusion at CT densities of > -600 and < -900 H. CONCLUSIONS The manually generated CT density dose response data broadly agree with data previously generated using automated methods. The manually generated perfusion dose response data are in fairly good agreement with automated data, lending credibility to the accuracy of the automated methods. Regional perfusion is markedly diminished where CT density is outside the range of normal lung tissue.
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Affiliation(s)
- B Levinson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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49
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Theuws JC, Kwa SL, Wagenaar AC, Boersma LJ, Damen EM, Muller SH, Baas P, Lebesque JV. Dose-effect relations for early local pulmonary injury after irradiation for malignant lymphoma and breast cancer. Radiother Oncol 1998; 48:33-43. [PMID: 9756170 DOI: 10.1016/s0167-8140(98)00019-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To quantify the influence of treatment- and patient-related factors on the severity of early local pulmonary injury and to establish whether regional differences are present for local dose-effect relations for early radiation-induced pulmonary injury. METHODS Forty-two patients with malignant lymphoma and 40 breast cancer patients were examined prior to and 3 months after radiotherapy. The lymphoma patients were irradiated with mantle fields to an average dose of 38 Gy and the breast cancer patients were irradiated with internal mammary node fields with or without tangential breast fields to an average dose of 50 Gy. Dose-effect relations for local perfusion, ventilation and density changes were determined using correlated single photon emission computed tomography (SPECT) and CT data. A multivariate analysis was performed to study the influence of irradiated volume, chemotherapy (CMF and MOPP/ABV), smoking, age and gender. In addition, dose-effect relations for different regions in the lung were determined. RESULTS A similar and almost linear increase of early functional changes as a function of radiation dose was observed for perfusion and ventilation, whereas the shape of the dose-effect relation and the magnitude of early structural changes were different for density. For the three end-points studied, regional differences in radiosensitivity could not be demonstrated. For the posterior lung region compared to the anterior lung region, however, a difference was observed, which could be attributed to a gravity-related effect in the measuring procedure. Local structural changes (density) were significantly smaller for smokers (P = 0.002) and young patients (P = 0.007), whereas the CMF chemotherapy regimen given after radiotherapy (P = 0.017) significantly increased the amount of functional changes (perfusion). The magnitude of local pulmonary changes was independent of the irradiated volume, the MOPP/ABV chemotherapy regimen and gender. CONCLUSION The dose-effect relations for early radiation-induced local pulmonary changes were independent of the irradiated volume, MOPP/ABV, gender and lung region. CMF, smoking and age influenced the magnitude of early pulmonary changes and should be taken into account in dose-escalation protocols.
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Affiliation(s)
- J C Theuws
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Huis, Amsterdam
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50
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de Munck JC, Verster FC, Dubois EA, Habraken JB, Boltjes B, Claus JJ, van Herk M. Registration of MR and SPECT without using external fiducial markers. Phys Med Biol 1998; 43:1255-69. [PMID: 9623654 DOI: 10.1088/0031-9155/43/5/015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of our work is to present, test and validate an automated registration method used for matching brain SPECT scans with corresponding MR scans. The method was applied on a data set consisting of ten brain IDEX SPECT scans and ten T1- and T2-weighted MR scans of the same subjects. Of two subjects a CT scan was also made. (Semi-) automated algorithms were used to extract the brain from the MR, CT and SPECT images. Next, a surface registration technique called chamfer matching was used to match the segmented brains. A perturbation study was performed to determine the sensitivity of the matching results to the choice of the starting values. Furthermore, the SPECT segmentation threshold was varied to study its effect on the resulting parameters and a comparison between the use of MR T1- and T2-weighted images was made. Finally, the two sets of CT scans were used to estimate the accuracy by matching MR to CT and comparing the MR-SPECT match to the SPECT-CT match. The perturbation study showed that for initial perturbations up to 6 cm the algorithm fails in less than 4% of the cases. A variation of the SPECT segmentation threshold over a realistic range (25%) caused an average variation in the optimal match of 0.28 cm vector length. When T2 is used instead of T1 the stability of the algorithm is comparable but the results are less realistic due the large deformations. Finally, a comparison of the direct SPECT-MR match and the indirect match with CT as intermediate yields a discrepancy of 0.4 cm vector length. We conclude that the accuracy of our automatic matching algorithm for SPECT and MR, in which no external markers were used, is comparable to the accuracies reported in the literature for non-automatic methods or methods based on external markers. The proposed method is efficient and insensitive to small variations in SPECT segmentation.
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Affiliation(s)
- J C de Munck
- The Netherlands Cancer Institute (Antoni van Leeuwenhoek Huis), Radiotherapy Department, Amsterdam.
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