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Martins L, Couto JG, Barbosa B. Use of planar kV vs. CBCT in evaluation of setup errors in oesophagus carcinoma radiotherapy. Rep Pract Oncol Radiother 2015; 21:57-62. [PMID: 26900359 DOI: 10.1016/j.rpor.2015.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 07/20/2015] [Accepted: 10/21/2015] [Indexed: 01/22/2023] Open
Abstract
AIM The aim of this study is to evaluate differences in terms of the setup errors observed using kV planar image compared to CBCT for oesophageal cancer patients. BACKGROUND Planar kV images are quick to acquire but only allow the observation of bony structures. CBCT allows the evaluation of soft tissues, which includes the oesophagus (and tumour) and OAR, giving a more accurate verification of the positioning. MATERIALS AND METHODS All patients were imaged with both techniques between January 2012 and March 2014 were included in the study (16 patients, 212 kV images and 116 CBCT images). Differences between the setup errors observed on the two images modalities were studied. A correlation study between TNM staging, tumour location and immobilization systems with setup errors was also done. Finally, the calculation of systematic and random errors allowed to determine the CTV-PTV margin. RESULTS A significant discrepancy (p < 0.05) between the setup errors observed with kV and CBCT was observed in the lateral direction. No statistical correlation was found between setup errors and tumour location, immobilization system or TNM staging. The CTV-PTV margin was smaller with CBCT in the vertical (0.6 cm vs. 0.9 cm) and longitudinal (0.7 cm vs. 1 cm) directions and smaller with kV for the lateral directions (0.8 cm vs. 0.9 cm). CONCLUSIONS The chosen modality influences the setup error observed which will influence the correction applied. Allowing a better observation of the volumes of interest, CBCT should be the modality of choice in this pathology. The CTV-PTV margins could be shrunk if CBCT is used.
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Affiliation(s)
- Liliana Martins
- Radiotherapy Department - Escola Superior de Tecnologia da Saude do Porto, Rua Valente Perfeito, 322, 4400-330 Vila Nova de Gaia, Portugal
| | - Jose Guilherme Couto
- Radiotherapy Department - Escola Superior de Tecnologia da Saude do Porto, Rua Valente Perfeito, 322, 4400-330 Vila Nova de Gaia, Portugal; Radiotherapy Department - Instituto Portugues de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal; Radiography Department - Faculty of Health Sciences - University of Malta, Msida MSD 2080, Malta
| | - Barbara Barbosa
- Radiotherapy Department - Instituto Portugues de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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Jin P, van der Horst A, de Jong R, van Hooft JE, Kamphuis M, van Wieringen N, Machiels M, Bel A, Hulshof MCCM, Alderliesten T. Marker-based quantification of interfractional tumor position variation and the use of markers for setup verification in radiation therapy for esophageal cancer. Radiother Oncol 2015; 117:412-8. [PMID: 26475250 DOI: 10.1016/j.radonc.2015.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/30/2015] [Accepted: 10/04/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to quantify interfractional esophageal tumor position variation using markers and investigate the use of markers for setup verification. MATERIALS AND METHODS Sixty-five markers placed in the tumor volumes of 24 esophageal cancer patients were identified in computed tomography (CT) and follow-up cone-beam CT. For each patient we calculated pairwise distances between markers over time to evaluate geometric tumor volume variation. We then quantified marker displacements relative to bony anatomy and estimated the variation of systematic (Σ) and random errors (σ). During bony anatomy-based setup verification, we visually inspected whether the markers were inside the planning target volume (PTV) and attempted marker-based registration. RESULTS Minor time trends with substantial fluctuations in pairwise distances implied tissue deformation. Overall, Σ(σ) in the left-right/cranial-caudal/anterior-posterior direction was 2.9(2.4)/4.1(2.4)/2.2(1.8) mm; for the proximal stomach, it was 5.4(4.3)/4.9(3.2)/1.9(2.4) mm. After bony anatomy-based setup correction, all markers were inside the PTV. However, due to large tissue deformation, marker-based registration was not feasible. CONCLUSIONS Generally, the interfractional position variation of esophageal tumors is more pronounced in the cranial-caudal direction and in the proximal stomach. Currently, marker-based setup verification is not feasible for clinical routine use, but markers can facilitate the setup verification by inspecting whether the PTV covers the tumor volume adequately.
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Affiliation(s)
- Peng Jin
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands.
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Rianne de Jong
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Martijn Kamphuis
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Niek van Wieringen
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Melanie Machiels
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
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Wang J, Lin SH, Dong L, Balter P, Mohan R, Komaki R, Cox JD, Starkschall G. Quantifying the interfractional displacement of the gastroesophageal junction during radiation therapy for esophageal cancer. Int J Radiat Oncol Biol Phys 2012; 83:e273-80. [PMID: 22440040 DOI: 10.1016/j.ijrobp.2011.12.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/09/2011] [Accepted: 12/12/2011] [Indexed: 01/30/2023]
Abstract
PURPOSE Accounting for interfractional changes in tumor location improves the accuracy of radiation treatment delivery. The purpose of this study was to quantify the interfractional displacement of the gastroesophageal junction (GEJ) based on standard treatment setup in patients with esophageal cancer undergoing radiation therapy. METHODS AND MATERIALS Free-breathing four-dimensional computed tomography (4D-CT) datasets were acquired weekly from 22 patients during treatment for esophageal adenocarcinoma. Scans were registered to baseline (simulation) 4D-CT scans by using bony landmarks. The distance between the center of the GEJ contour on the simulation scan and the mean location of GEJ centers on subsequent scans was used to assess changes in GEJ location between fractions; displacement was also correlated with clinical and respiratory variables. RESULTS The mean absolute random error was 1.69 mm (range, 0.11-4.11 mm) in the lateral direction, 1.87 mm (range, 0.51-4.09 mm) in the anterior-posterior (AP) direction, and 3.09 mm (range, 0.99-6.16 mm) in the superior-inferior (SI) direction. The mean absolute systemic GEJ displacement between fractions was 2.88 mm lateral (≥ 5 mm in 14%), mostly leftward; 2.90 mm (≥ 5 mm in 14%) AP, mostly anterior; and 6.77 mm (≥ 1 cm in 18%) SI, mostly inferior. Variations in tidal volume and diaphragmatic excursion during treatment correlated strongly with systematic SI GEJ displacement (r = 0.964, p < 0.0001; and r = 0.944, p < 0.0001, respectively) and moderately with systematic AP GEJ displacement (r = 0.678, p = 0.0005; r = 0.758, p < 0.0001, respectively). Systematic displacement in the inferior direction resulted in higher-than-intended doses (≥ 60 Gy) to the GEJ, with increased hot-spot to the adjacent stomach and lung base. CONCLUSION We found large (>1-cm) interfractional displacements in the GEJ in the SI (especially inferior) direction that was not accounted for when skeletal alignment alone was used for patient positioning. Because systematic displacement in the SI direction had dosimetric impact and correlated with tidal volume, better accounting for depth of breathing is needed to reduce interfractional variability.
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Affiliation(s)
- Jingya Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Yamashita H, Kida S, Sakumi A, Haga A, Ito S, Onoe T, Okuma K, Ino K, Akahane M, Ohtomo K, Nakagawa K. Four-dimensional measurement of the displacement of internal fiducial markers during 320-multislice computed tomography scanning of thoracic esophageal cancer. Int J Radiat Oncol Biol Phys 2010; 79:588-95. [PMID: 20678869 DOI: 10.1016/j.ijrobp.2010.03.045] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 03/18/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the three-dimensional movement of internal fiducial markers placed near esophageal cancers using 320-multislice CT. METHODS AND MATERIALS This study examined 22 metal markers in the esophageal wall near the primary tumors of 12 patients treated with external-beam photon radiotherapy. Motion assessment was analyzed in 41 respiratory phases during 20 s of cine CT in the radiotherapy position. RESULTS Motion in the cranial-caudal (CC) direction showed a strong correlation (R(2) > 0.4) with the respiratory curve in most markers (73%). The average absolute amplitude of the marker movement was 1.5 ± 1.6 mm, 1.6 ± 1.7 mm, and 3.3 ± 3.3 mm in the left-right (LR), anterior-posterior (AP), and CC directions, respectively. The average marker displacements in the CC direction between peak exhalation and inhalation for the 22 clips were 1.1 mm (maximum, 5.5 mm), 3.0 mm (14.5 mm), and 5.1 mm (16.3 mm) for the upper, middle, and lower thoracic esophagus, respectively. CONCLUSIONS Motion in primary esophagus tumor was evaluated with 320-multislice CT. According to this study, 4.3 mm CC, 1.5 mm AP, and 2.0 mm LR in the upper, 7.4 mm CC, 3.0 mm AP, and 2.4 mm LR in the middle, and 13.8 mm CC, 6.6 mm AP, and 6.8 mm LR in the lower thoracic esophagus provided coverage of tumor motion in 95% of the cases in our study population.
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Cohen RJ, Paskalev K, Litwin S, Price R, Feigenberg SJ, Konski A. Esophageal motion during radiotherapy: quantification and margin implications. Dis Esophagus 2010; 23:473-9. [PMID: 20095993 PMCID: PMC2933373 DOI: 10.1111/j.1442-2050.2009.01037.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose was to evaluate interfraction and intrafraction esophageal motion in the right-left (RL) and anterior-posterior (AP) directions using computed tomography (CT) in esophageal cancer patients. Eight patients underwent CT simulation and CT-on-rails imaging before and after radiotherapy. Interfraction displacement was defined as differences between pretreatment and simulation images. Intrafraction displacement was defined as differences between pretreatment and posttreatment images. Images were fused using bone registries, adjusted to the carina. The mean, average of the absolute, and range of esophageal motion were calculated in the RL and AP directions, above and below the carina. Thirty-one CT image sets were obtained. The incidence of esophageal interfraction motion > or =5 mm was 24% and > or =10 mm was 3%; intrafraction motion > or =5 mm was 13% and > or =10 mm was 4%. The average RL motion was 1.8 +/- 5.1 mm, favoring leftward movement, and the average AP motion was 0.6 +/- 4.8 mm, favoring posterior movement. Average absolute motion was 4.2 mm or less in the RL and AP directions. Motion was greatest in the RL direction above the carina. Coverage of 95% of esophageal mobility requires 12 mm left, 8 mm right, 10 mm posterior, and 9 mm anterior margins. In all directions, the average of the absolute interfraction and intrafraction displacement was 4.2 mm or less. These results support a 12 mm left, 8 mm right, 10 mm posterior, and 9 mm anterior margin for internal target volume (ITV) and can guide margins for future intensity modulated radiation therapy (IMRT) trials to account for organ motion and set up error in three-dimensional planning.
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Affiliation(s)
- Randi J. Cohen
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, 19111, U.S.A
| | - Kamen Paskalev
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, 19111, U.S.A
| | - Samuel Litwin
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania, 19111, U.S.A
| | - Robert Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, 19111, U.S.A
| | - Steven J. Feigenberg
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, 19111, U.S.A
| | - Andre Konski
- Department of Radiation Oncology, Wayne State University, Detroit, Michigan, 48201, U.S.A
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Yamashita H, Haga A, Hayakawa Y, Okuma K, Yoda K, Okano Y, Tanaka KI, Imae T, Ohtomo K, Nakagawa K. Patient setup error and day-to-day esophageal motion error analyzed by cone-beam computed tomography in radiation therapy. Acta Oncol 2010; 49:485-90. [PMID: 20230211 DOI: 10.3109/02841861003652574] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little has been reported on the errors of setup and daily organ motion that occur during radiation therapy (RT) for esophageal cancer. The purpose of this paper was to determine the margins of esophageal motion during RT. METHODS AND MATERIALS The shift of the esophagus was analyzed in 20 consecutive patients treated with RT for esophageal cancer from November 2007. CT images for RT planning were used as the primary image series. Computed tomography (CT) images were acquired using an Elekta Synergy System, equipped with a kilovoltage-based cone-beam CT (CBCT) unit. The subsequent CBCT image series used for daily RT setup were compared with the primary image series to analyze esophageal motion. CBCT was performed before treatment sessions a total of 10 times in each patient twice a week. The outer esophageal wall was contoured on the CBCT images of all 200 sets. RESULTS In the 200 sets of CBCT images, the mean (absolute) +/- standard deviation (SD) of setup errors were 2 +/- 2 mm (max, 8 mm) in the lateral direction, 4 +/- 3 mm (max, 11 mm) in the longitudinal direction, and 4 +/- 3 mm (max, 13 mm) in the vertical direction. Additionally, the mean +/- SD values of daily esophageal motion comparing the CBCT with RT planning CT were 5 +/- 3 mm (max, 15 mm) in the lateral direction and 5 +/- 3 mm (max, 15 mm) in the vertical direction. CONCLUSIONS Our data support the use of target margins (between the clinical target volume and planning target volume) of 9 mm for day-to-day esophageal motion and 8 mm for patient setup in all directions, respectively.
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Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo, Japan.
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Chen YJ, Han C, Liu A, Schultheiss TE, Kernstine KH, Shibata S, Vora NL, Pezner RD, Wong JYC. Setup variations in radiotherapy of esophageal cancer: evaluation by daily megavoltage computed tomographic localization. Int J Radiat Oncol Biol Phys 2007; 68:1537-45. [PMID: 17531399 DOI: 10.1016/j.ijrobp.2007.04.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2006] [Revised: 03/21/2007] [Accepted: 04/11/2007] [Indexed: 12/21/2022]
Abstract
PURPOSE To use pretreatment megavoltage computed tomography (MVCT) scans to evaluate setup variations in anterior-posterior (AP), lateral, and superior-inferior (SI) directions and rotational variations, including pitch, roll, and yaw, for esophageal cancer patients treated with helical tomotherapy. METHODS AND MATERIALS Ten patients with locally advanced esophageal cancer treated by combined chemoradiation using helical tomotherapy were selected. After patients were positioned using their skin tattoos/marks, MVCT scans were performed before every treatment and automatically registered to planning kilovoltage CT scans according to bony landmarks. Image registration data were used to adjust patient setups before treatment. A total of 250 MVCT scans were analyzed. Correlations between setup variations and body habitus, including height, weight, relative weight change, body surface area, and patient age, were evaluated. RESULTS The standard deviations for systematic setup corrections in AP, lateral, and SI directions and pitch, roll, and yaw rotations were 1.5, 3.7, and 4.8 mm and 0.5 degrees, 1.2 degrees, and 0.8 degrees, respectively. The appropriate averages of random setup variations in AP, lateral, and SI directions and pitch, roll, and yaw rotations were 2.9, 5.2, and 4.4 mm, and 1.0 degrees, 1.2 degrees, and 1.1 degrees, respectively. Setup variations were stable throughout the entire course of radiotherapy in all three translational and three rotational displacements, with little change in magnitude. No significant correlations were found between setup variations and body habitus variables. CONCLUSIONS Daily MVCT scans before each treatment can effectively detect setup errors and thereby reduce planning target volume (PTV) margins. This will reduce radiation dose to critical organs and may translate into lower treatment-related toxicities.
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Affiliation(s)
- Yi-Jen Chen
- Division of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010-3000, USA
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Dieleman EMT, Senan S, Vincent A, Lagerwaard FJ, Slotman BJ, van Sörnsen de Koste JR. Four-dimensional computed tomographic analysis of esophageal mobility during normal respiration. Int J Radiat Oncol Biol Phys 2007; 67:775-80. [PMID: 17293234 DOI: 10.1016/j.ijrobp.2006.09.054] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2006] [Revised: 09/18/2006] [Accepted: 09/19/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemo-radiotherapy for thoracic tumors can result in high-grade radiation esophagitis. Treatment planning to reduce esophageal irradiation requires organ motion to be accounted for. In this study, esophageal mobility was assessed using four-dimensional computed tomography (4DCT). METHODS AND MATERIALS Thoracic 4DCT scans were acquired on a 16-slice CT scanner in 29 patients. The outer esophageal wall was contoured in two extreme phases of respiration in 9 patients with nonesophageal malignancies. The displacement of the center of contour was measured at 2-cm intervals. In 20 additional patients with Stage I lung cancer, the esophagus was contoured in all 10 phases of each 4DCT at five defined anatomic levels. Both approaches were then applied to 4DCT scans of 4 patients who each had two repeat scans performed. A linear mixed effects model was constructed with fixed effects: measurement direction, measurement type, and measurement location along the cranio-caudal axis. RESULTS Measurement location and direction were significant descriptive parameters (Wald F-tests, p < 0.001), and the interaction term between the two was significant (p = 0.02). Medio-lateral mobility exceeded dorso-ventral mobility in the lower half of the esophagus but was of a similar magnitude in the upper half. Margins that would have incorporated all movement in medio-lateral and dorso-ventral directions were 5 mm proximally, 7 mm and 6 mm respectively in the mid-esophagus, and 9 mm and 8 mm respectively in the distal esophagus. CONCLUSIONS The distal esophagus shows more mobility. Margins for mobility that can encompass all movement were derived for use in treatment planning, particularly for stereotactic radiotherapy.
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Affiliation(s)
- Edith M T Dieleman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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