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Title: Use of Respiratory-Correlated Four-Dimensional Computed Tomography to Determine Acceptable Treatment Margins for Locally Advanced Pancreatic Adenocarcinoma

Abstract

Purpose: Respiratory-induced excursions of locally advanced pancreatic adenocarcinoma could affect dose delivery. This study quantified tumor motion and evaluated standard treatment margins. Methods and Materials: Respiratory-correlated four-dimensional computed tomography images were obtained on 30 patients with locally advanced pancreatic adenocarcinoma; 15 of whom underwent repeat scanning before cone-down treatment. Treatment planning software was used to contour the gross tumor volume (GTV), bilateral kidneys, and biliary stent. Excursions were calculated according to the centroid of the contoured volumes. Results: The mean +- standard deviation GTV excursion in the superoinferior (SI) direction was 0.55 +- 0.23 cm; an expansion of 1.0 cm adequately accounted for the GTV motion in 97% of locally advanced pancreatic adenocarcinoma patients. Motion GTVs were generated and resulted in a 25% average volume increase compared with the static GTV. Of the 30 patients, 17 had biliary stents. The mean SI stent excursion was 0.84 +- 0.32 cm, significantly greater than the GTV motion. The xiphoid process moved an average of 0.35 +- 0.12 cm, significantly less than the GTV. The mean SI motion of the left and right kidneys was 0.65 +- 0.27 cm and 0.77 +- 0.30 cm, respectively. At repeat scanning, no significant changes were seenmore » in the mean GTV size (p = .8) or excursion (p = .3). Conclusion: These data suggest that an asymmetric expansion of 1.0, 0.7, and 0.6 cm along the respective SI, anteroposterior, and medial-lateral directions is recommended if a respiratory-correlated four-dimensional computed tomography scan is not available to evaluate the tumor motion during treatment planning. Surrogates of tumor motion, such as biliary stents or external markers, should be used with caution.« less

Authors:
 [1]; ; ; ;  [2];  [2]
  1. Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, MD (United States)
  2. Department of Radiation Oncology and Molecular Radiation Sciences, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, MD (United States)
Publication Date:
OSTI Identifier:
21372078
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 76; Journal Issue: 2; Other Information: DOI: 10.1016/j.ijrobp.2009.06.009; PII: S0360-3016(09)00928-6; Copyright (c) 2010 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; CARCINOMAS; COMPUTERIZED TOMOGRAPHY; FOUR-DIMENSIONAL CALCULATIONS; MOTION; PANCREAS; PLANNING; BODY; DIAGNOSTIC TECHNIQUES; DIGESTIVE SYSTEM; DISEASES; ENDOCRINE GLANDS; GLANDS; NEOPLASMS; ORGANS; TOMOGRAPHY

Citation Formats

Goldstein, Seth D., Ford, Eric C., Duhon, Mario, McNutt, Todd, Wong, John, and Herman, Joseph M., E-mail: jherma15@jhmi.ed. Use of Respiratory-Correlated Four-Dimensional Computed Tomography to Determine Acceptable Treatment Margins for Locally Advanced Pancreatic Adenocarcinoma. United States: N. p., 2010. Web. doi:10.1016/j.ijrobp.2009.06.009.
Goldstein, Seth D., Ford, Eric C., Duhon, Mario, McNutt, Todd, Wong, John, & Herman, Joseph M., E-mail: jherma15@jhmi.ed. Use of Respiratory-Correlated Four-Dimensional Computed Tomography to Determine Acceptable Treatment Margins for Locally Advanced Pancreatic Adenocarcinoma. United States. doi:10.1016/j.ijrobp.2009.06.009.
Goldstein, Seth D., Ford, Eric C., Duhon, Mario, McNutt, Todd, Wong, John, and Herman, Joseph M., E-mail: jherma15@jhmi.ed. 2010. "Use of Respiratory-Correlated Four-Dimensional Computed Tomography to Determine Acceptable Treatment Margins for Locally Advanced Pancreatic Adenocarcinoma". United States. doi:10.1016/j.ijrobp.2009.06.009.
@article{osti_21372078,
title = {Use of Respiratory-Correlated Four-Dimensional Computed Tomography to Determine Acceptable Treatment Margins for Locally Advanced Pancreatic Adenocarcinoma},
author = {Goldstein, Seth D. and Ford, Eric C. and Duhon, Mario and McNutt, Todd and Wong, John and Herman, Joseph M., E-mail: jherma15@jhmi.ed},
abstractNote = {Purpose: Respiratory-induced excursions of locally advanced pancreatic adenocarcinoma could affect dose delivery. This study quantified tumor motion and evaluated standard treatment margins. Methods and Materials: Respiratory-correlated four-dimensional computed tomography images were obtained on 30 patients with locally advanced pancreatic adenocarcinoma; 15 of whom underwent repeat scanning before cone-down treatment. Treatment planning software was used to contour the gross tumor volume (GTV), bilateral kidneys, and biliary stent. Excursions were calculated according to the centroid of the contoured volumes. Results: The mean +- standard deviation GTV excursion in the superoinferior (SI) direction was 0.55 +- 0.23 cm; an expansion of 1.0 cm adequately accounted for the GTV motion in 97% of locally advanced pancreatic adenocarcinoma patients. Motion GTVs were generated and resulted in a 25% average volume increase compared with the static GTV. Of the 30 patients, 17 had biliary stents. The mean SI stent excursion was 0.84 +- 0.32 cm, significantly greater than the GTV motion. The xiphoid process moved an average of 0.35 +- 0.12 cm, significantly less than the GTV. The mean SI motion of the left and right kidneys was 0.65 +- 0.27 cm and 0.77 +- 0.30 cm, respectively. At repeat scanning, no significant changes were seen in the mean GTV size (p = .8) or excursion (p = .3). Conclusion: These data suggest that an asymmetric expansion of 1.0, 0.7, and 0.6 cm along the respective SI, anteroposterior, and medial-lateral directions is recommended if a respiratory-correlated four-dimensional computed tomography scan is not available to evaluate the tumor motion during treatment planning. Surrogates of tumor motion, such as biliary stents or external markers, should be used with caution.},
doi = {10.1016/j.ijrobp.2009.06.009},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 2,
volume = 76,
place = {United States},
year = 2010,
month = 2
}
  • Purpose: To compare conformal radiotherapy (CRT), intensity-modulated radiotherapy (IMRT), and respiration-gated radiotherapy (RGRT) planning techniques for pancreatic cancer. All target volumes were determined using four-dimensional computed tomography scans (4D CT). Methods and Materials: The pancreatic tumor and enlarged regional lymph nodes were contoured on all 10 phases of a planning 4D CT scan for 10 patients, and the planning target volumes (PTV{sub allphases}) were generated. Three consecutive respiratory phases for RGRT delivery in both inspiration and expiration were identified, and the corresponding PTVs (PTV{sub inspiration} and PTV{sub expiration}) and organ at risk volumes created. Treatment plans using CRT and IMRT,more » with and without RGRT, were created for each PTV. Results: Compared with the CRT plans, IMRT significantly reduced the mean volume of right kidney exposed to 20 Gy from 27.7% {+-} 17.7% to 16.0% {+-} 18.2% (standard deviation) (p < 0.01), but this was not achieved for the left kidney (11.1% {+-} 14.2% to 5.7% {+-} 6.5%; p = 0.1). The IMRT plans also reduced the mean gastric, hepatic, and small bowel doses (p < 0.01). No additional reductions in the dose to the kidneys or other organs at risk were seen when RGRT plans were combined with either CRT or IMRT, and the findings for RGRT in end-expiration and end-inspiration were similar. Conclusion: 4D CT-based IMRT plans for pancreatic tumors significantly reduced the radiation doses to the right kidney, liver, stomach, and small bowel compared with CRT plans. The additional dosimetric benefits from RGRT appear limited in this setting.« less
  • Purpose: To determine whether lung tumor respiratory excursion at simulation is predictive of excursion during radiation and whether phase offsets between tumor and surrogate markers are constant throughout treatment. Methods and Materials: Respiration-correlated CT scans and two rescans (using a Brilliance Big Bore spiral CT simulator; Philips, Inc.) were obtained from 20 patients at simulation. Gross tumor volume (GTV) was contoured on 10 phases of the respiratory cycle, and excursions were calculated. Diaphragm and xyphoid motion were quantified. Phase offsets, DELTAPHI, were calculated for patients with a GTV motion of >3 mm. Interfraction differences in excursions between simulation and rescansmore » and magnitudes of variation in phase offset between fractions were evaluated. Results: Mean GTV excursions at simulation in superior-inferior, anterior-posterior, and medial-lateral directions were 0.67, 0.29, and 0.21 cm, respectively. The magnitude of superior-inferior GTV excursion correlated with tumor location (upper vs. lower lobe, p = 0.011). GTV excursions between simulation and rescan 1 (p = 0.115) and between simulation and rescan 2 (p = 0.071) were stable. Fourteen patients were analyzed for variations in phase offsets. GTV-xyphoid phase offset changed significantly between simulation and rescan 1 (p = 0.007) and simulation and rescan 2 (p = 0.008), with mean DELTAPHI values of 13.2% (rescan 1) and 14.3% (rescan 2). Xyphoid-diaphragm offset changed between simulation and rescan 1 (p = 0.004) and between simulation and rescan 2 (p = 0.012), with mean DELTAPHI values of 14.5% (rescan 1) and 7.6% (rescan 2). Conclusions: Interfraction consistency in tumor excursion suggests tumor excursion at simulation may direct therapy. Significant variations in phase lag between GTV and other anatomic structures throughout treatment have important implications for techniques that rely on surrogate structures to predict tumor motion« less
  • Purpose: We compared respiratory-gated and respiratory-ungated treatment strategies using four-dimensional (4D) scattered carbon ion beam distribution in pancreatic 4D computed tomography (CT) datasets. Methods and Materials: Seven inpatients with pancreatic tumors underwent 4DCT scanning under free-breathing conditions using a rapidly rotating cone-beam CT, which was integrated with a 256-slice detector, in cine mode. Two types of bolus for gated and ungated treatment were designed to cover the planning target volume (PTV) using 4DCT datasets in a 30% duty cycle around exhalation and a single respiratory cycle, respectively. Carbon ion beam distribution for each strategy was calculated as a function ofmore » respiratory phase by applying the compensating bolus to 4DCT at the respective phases. Smearing was not applied to the bolus, but consideration was given to drill diameter. The accumulated dose distributions were calculated by applying deformable registration and calculating the dose-volume histogram. Results: Doses to normal tissues in gated treatment were minimized mainly on the inferior aspect, which thereby minimized excessive doses to normal tissues. Over 95% of the dose, however, was delivered to the clinical target volume at all phases for both treatment strategies. Maximum doses to the duodenum and pancreas averaged across all patients were 43.1/43.1 GyE (ungated/gated) and 43.2/43.2 GyE (ungated/gated), respectively. Conclusions: Although gated treatment minimized excessive dosing to normal tissue, the difference between treatment strategies was small. Respiratory gating may not always be required in pancreatic treatment as long as dose distribution is assessed. Any application of our results to clinical use should be undertaken only after discussion with oncologists, particularly with regard to radiotherapy combined with chemotherapy.« less
  • Purpose: To evaluate the respiratory motion of primary esophageal cancers and pathologic celiac-region lymph nodes using time-resolved four-dimensional computed tomography (4D CT). Methods and Materials: Respiration-synchronized 4D CT scans were obtained to quantify the motion of primary tumors located in the proximal, mid-, or distal thoracic esophagus, as well as any involved celiac-region lymph nodes. Respiratory motion was measured in the superior-inferior (SI), anterior-posterior (AP), and left-right (LR) directions and was analyzed for correlation with anatomic location. Recommended margin expansions were determined for both primary and nodal targets. Results: Thirty patients underwent 4D CT scans at Massachusetts General Hospital formore » planned curative treatment of esophageal cancer. Measurements of respiratory tumor motion were obtained for 1 proximal, 4 mid-, and 25 distal esophageal tumors, as well as 12 involved celiac-region lymph nodes. The mean (SD) peak-to-peak displacements of all primary tumors in the SI, AP, and LR dimensions were 0.80 (0.45) cm, 0.28 (0.20) cm, and 0.22 (0.23) cm, respectively. Distal tumors were found to have significantly greater SI and AP motion than proximal or mid-esophageal tumors. The mean (SD) SI, AP, and LR peak-to-peak displacements of the celiac-region lymph nodes were 0.92 (0.56) cm, 0.46 (0.27) cm, and 0.19 (0.26) cm, respectively. Conclusions: Margins of 1.5 cm SI, 0.75 cm AP, and 0.75 cm LR would account for respiratory tumor motion of >95% of esophageal primary tumors in the dataset. All celiac-region lymph nodes would be adequately covered with SI, AP, and LR margins of 2.25 cm, 1.0 cm, and 0.75 cm, respectively.« less
  • Purpose: To assess the diagnostic performance of pretreatment {sup 18}F-fluorodeoxyglucose positron emission tomography/computed tomography ({sup 18}F-FDG PET/CT) and its impact on radiation therapy treatment decisions in patients with locally advanced breast cancer (LABC). Methods and Materials: Patients with LABC with Eastern Cooperative Oncology Group performance status <2 and no contraindication to neoadjuvant chemotherapy, surgery, and adjuvant radiation therapy were enrolled on a prospective trial. All patients had pretreatment conventional imaging (CI) performed, including bilateral breast mammography and ultrasound, bone scan, and CT chest, abdomen, and pelvis scans performed. Informed consent was obtained before enrolment. Pretreatment whole-body {sup 18}F-FDG PET/CT scansmore » were performed on all patients, and results were compared with CI findings. Results: A total of 154 patients with LABC with no clinical or radiologic evidence of distant metastases on CI were enrolled. Median age was 49 years (range, 26-70 years). Imaging with PET/CT detected distant metastatic disease and/or locoregional disease not visualized on CI in 32 patients (20.8%). Distant metastatic disease was detected in 17 patients (11.0%): 6 had bony metastases, 5 had intrathoracic metastases (pulmonary/mediastinal), 2 had distant nodal metastases, 2 had liver metastases, 1 had pulmonary and bony metastases, and 1 had mediastinal and distant nodal metastases. Of the remaining 139 patients, nodal disease outside conventional radiation therapy fields was detected on PET/CT in 15 patients (10.8%), with involvement of ipsilateral internal mammary nodes in 13 and ipsilateral level 5 cervical nodes in 2. Conclusions: Imaging with PET/CT provides superior diagnostic and staging information in patients with LABC compared with CI, which has significant therapeutic implications with respect to radiation therapy management. Imaging with PET/CT should be considered in all patients undergoing primary staging for LABC.« less