Hiroya Shiomi

Respiration tracking in radiosurgery

Respiratory motion is difficult to compensate for with conventional radiotherapy systems. An accurate tracking method for following the motion of the tumor is of considerable clinical relevance. We investigate methods to compensate for respiratory motion using robotic radiosurgery. In this system the therapeutic beam is moved by a robotic arm, and follows the moving target through a combination of infrared tracking and synchronized x-ray imaging. Infrared emitters are used to record the motion of the patients skin surface. The position of internal gold fiducials is computed repeatedly during treatment, via x-ray image processing. We correlate the motion between external and internal markers. From this correlation model we infer the placement of the internal target during time intervals where no x-ray images are taken. Fifteen patients with lung tumors have recently been treated with a fully integrated system implementing this new method. The clinical trials confirm our hypothesis that internal motion and external motion are indeed correlated. In a preliminar study we have extended our work to tracking without implanted fiducials, based on algorithms for computing deformation motions and digitally reconstructed radiographs.

HIGH-DOSE-RATE INTERSTITIAL BRACHYTHERAPY AS A MONOTHERAPY FOR LOCALIZED PROSTATE CANCER: TREATMENT DESCRIPTION AND PRELIMINARY RESULTS OF A PHASE I/II CLINICAL TRIAL

PURPOSE To improve results for localized prostate cancer, a prospective clinical trial of hyperfractionated Iridium-192 high-dose-rate (HDR) brachytherapy as a monotherapy was initiated. METHODS AND MATERIALS Between May 1995 and September 1998, 22 implants were performed on 22 patients with localized prostate cancer (T1:T2:T3:T4 = 4:6:9:3) at Osaka University Hospital. Nineteen patients, who had T3-T4 tumors or pretreatment PSA >/= 20.0 ng/mL, received hormone therapy. No patient had external beam radiation. Transperineal needle implants using real-time ultrasound guidance were performed, followed by dose optimization program. Patients were irradiated twice a day, with a time interval of more than 6 h. Total dose was 48 Gy/8 fractions/5 days or 54 Gy/9 fractions/5 days. Acute toxicity was scored using the Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring criteria. Median follow-up time was 31 months. RESULTS HDR brachytherapy as a monotherapy was well-tolerated. No significant intra- or peri-operative complications occurred. No patient experienced acute toxicity of grade 3 or more. PSA levels normalized in 95% of patients within 20 months after irradiation. Four-year clinical and biochemical relapse-free rates were 95% and 55%, respectively. CONCLUSION Acute toxicity with this method was acceptable. Further patient accrual and longer follow-up will allow comparison to other techniques.

Needle applicator displacement during high-dose-rate interstitial brachytherapy for prostate cancer

PURPOSE To introduce an effective ambulatory technique in high-dose-rate interstitial brachytherapy (HDR-ISBT) for prostate cancer, we investigated the displacement distance using our novel calculation method. METHODS AND MATERIALS Sixty-four patients treated with HDR-ISBT as monotherapy were examined. Of these, 4, 17, and 43 patients were administered treatment doses of 38 Gy (3 days), 49 Gy (4 days), and 54 Gy (5 days), respectively. For dose administration, we used 776 flexible applicators with a removable template (ambulatory technique). Using CT images, we calculated the relative coordinates of the metal markers and applicators. From these coordinates, to analyze displacement during treatment, we measured the distance between the tip of the needle applicator and the center of gravity of the markers along the average applicator vector. RESULTS The median displacement distance for all applicators was 7 mm (range, -14 to 24), and that of each treatment schedule was 4, 6, and 9 mm for 38, 49, and 54 Gy, respectively. Of the 776 applicators, displacement of >10 mm was seen in 198 (26%) applicators and >15 mm in 57 (7%) applicators. Body height (p<0.0001) and anticoagulant usage (p<0.0001) were significant factors influencing displacement. CONCLUSIONS We investigated needle applicator displacement using our unique method. Additional cranial margins are necessary if there is no repositioning of the dwell position. CT scanning should be performed daily during treatment for checking the position of the applicator to detect and rectify the issue of displacement.

New Approach for Treatment of Vertebral Metastases Using Intensity-Modulated Radiotherapy*

AbstractPurpose:To perform aggressive radiotherapy for vertebral metastases. Using very steep dose gradients from intensity-modulated radiotherapy (IMRT), a protocol based on the concept of partial volume dose to the spinal cord was evaluated.Patients and Methods:50 patients with vertebral metastases were treated using IMRT. In previously unirradiated cases, where a prescribed dose of 80 Gy (BED10) was delivered, the constraint to the spinal cord should be less than 100 Gy (BED2). For previously irradiated cases, on the other hand, the dose is the same as in the previously unirradiated case; however, constraints for the spinal cord are a cumulative BED2 of less than 150 Gy, BED2 of less than 100 Gy in each instance, and a treatment gap of more than 6 months. There were 6 patients considered for a partial volume dose to the spinal cord. They all received higher BED2, ranging from 51–157 Gy of D1cc.Results:Among the 24 patients who survived longer than 1 year, there was 1 case of transient radiation myelitis. There were no other cases of spinal cord sequelae.Conclusion:Based on the present results, we recommend a BED2 of 100 Gy or less at D1cc as a constraint for the spinal cord in previously unirradiated cases, and a cumulative BED2 of 150 Gy or less at D1cc in previously irradiated cases, when the interval was not shorter than 6 months and the BED2 for each session was 100 Gy or less. The prescribed BED10 of 80 Gy could be safely delivered to the vertebral lesions.ZusammenfassungHintergrund und Ziel:Aggressive Strahlentherapie bei vertebralen Metastasen. Unter Einsatz sehr steiler Dosisgradienten intensitätsmodulierter Strahlentherapie (IMRT) Evaluierung eines Therapieprotokolls basierend auf dem Konzept der partiellen Volumendosierung am Rückenmark.Patienten und Methodik:Wir behandelten mit IMRT 50 Patienten mit Wirbelsäulenmetastasen. In Fällen ohne vorangegangene Strahlentherapie, bei denen eine verordnete Dosis von 80 Gy BED10 appliziert wurde, sollte die Belastung des Rückenmarks weniger als 100 Gy BED2 betragen. In Fällen mit vorheriger Strahlentherapie wurde die gleiche Dosis appliziert, wobei allerdings die Belastung des Rückenmarks kumulativ unter 150 Gy BED2 und in der Einzelapplikation bei weniger als 100 Gy BED2 lag, außerdem die Behandlungspause mehr als 6 Monate betrug. Für die partielle Volumendosierung am Rückenmark kamen 6 Patienten in Frage. Alle erhielten die höhere BED2 von mehr als 51 Gy bis zu 157 Gy D1cc.Ergebnisse:Unter 24 Patienten, die länger als ein Jahr überlebten, gab es einen Fall vorübergehender Strahlenmyelitis. Es wurden keine weiteren Fälle von Bestrahlungsfolgen am Rückenmark beobachtet.Schlussfolgerung:Auf Basis der vorliegenden Ergebnissen würden wir eine BED2 von 100 Gy oder weniger bei D1cc am Rückenmark in Fällen ohne vorangegangene Strahlentherapie empfehlen und in Fällen mit vorheriger Strahlentherapie eine kumulative BED2 von 150 Gy oder weniger bei D1cc, wenn das Behandlungsintervall nicht kürzer als 6 Monate war und die Dosis der Einzelapplikation bei einer BED2 von 100 Gy oder weniger lag. Die verordnete Dosis einer BED10 von 80 Gy bei Wirbelsäulenläsionen ließ sich sicher applizieren.

Clinical introduction of Monte Carlo treatment planning for lung stereotactic body radiotherapy

The purpose of this study was to investigate the impact of Monte Carlo (MC) calculations and optimized dose definitions in stereotactic body radiotherapy (SBRT) for lung cancer patients. We used a retrospective patient review and basic virtual phantom to determine dose prescriptions. Fifty‐three patients underwent SBRT. A basic virtual phantom had a gross tumor volume (GTV) of 10.0 mm with equivalent water density of 1.0 g/cm3, which was surrounded by equivalent lung surrounding the GTV of 0.25 g/cm3. D95 of the planning target volume (PTV) and D99 of the GTV were evaluated with different GTV sizes (5.0 to 30.0 mm) and different lung densities (0.05 to 0.45 g/cm3). Prescribed dose was defined as 95% of the PTV should receive 100% of the dose (48 Gy/4 fractions) using pencil beam (PB) calculation and recalculated using MC calculation. In the patient study, average doses to the D95 of the PTV and D99 of the GTV using the MC calculation plan were 19.9% and 10.2% lower than those by the PB calculation plan, respectively. In the phantom study, decreased doses to the D95 of the PTV and D99 of the GTV using the MC calculation plan were accompanied with changes GTV size from 30.0 to 5.0 mm, which was decreased from 8.4% to 19.6% for the PTV and from 17.4% to 27.5% for the GTV Similar results were seen with changes in lung density from 0. 45 to 0.05 g/cm3, with doses to the D95 of the PTV and D99 of the GTV were decreased from 12.8% to 59.0% and from 7.6% to 44.8%, respectively. The decrease in dose to the PTV with MC calculation was strongly dependent on lung density. We suggest that dose definition to the GTV for lung cancer SBRT be optimized using MC calculation. Our current clinical protocol for lung SBRT is based on a prescribed dose of 44 Gy in 4 fractions to the GTV using MC calculation. PACS number: 87.55.D‐, 87.55.K‐

Quantitative assessment of inter-observer variability in target volume delineation on stereotactic radiotherapy treatment for pituitary adenoma and meningioma near optic tract

BackgroundTo assess inter-observer variability in delineating target volume and organs at risk in benign tumor adjacent to optic tract as a quality assurance exercise.MethodsWe quantitatively analyzed 21 plans made by 11 clinicians in seven CyberKnife centers. The clinicians were provided with a raw data set (pituitary adenoma and meningioma) including clinical information, and were asked to delineate the lesions and create a treatment plan. Their contouring and plans (10 adenoma and 11 meningioma plans), were then compared. In addition, we estimated the influence of differences in contouring by superimposing the respective contours onto a default plan.ResultsThe median planning target volume (PTV) and the ratio of the largest to the smallest contoured volume were 9.22 cm3 (range, 7.17 - 14.3 cm3) and 1.99 for pituitary adenoma, and 6.86 cm3 (range 6.05 - 14.6 cm3) and 2.41 for meningioma. PTV volume was 10.1 ± 1.74 cm3 for group 1 with a margin of 1 -2 mm around the CTV (n = 3) and 9.28 ± 1.8 cm3(p = 0.51) for group 2 with no margin (n = 7) in pituitary adenoma. In meningioma, group 1 showed larger PTV volume (10.1 ± 3.26 cm3) than group 2 (6.91 ± 0.7 cm3, p = 0.03). All submitted plan keep the irradiated dose to optic tract within the range of 50 Gy (equivalent total doses in 2 Gy fractionation). However, contours superimposed onto the dose distribution of the default plan indicated that an excessive dose 23.64 Gy (up to 268% of the default plan) in pituitary adenoma and 24.84 Gy (131% of the default plan) in meningioma to the optic nerve in the contours from different contouring.ConclusionQuality assurance revealed inter-observer variability in contour delineation and their influences on planning for pituitary adenoma and meningioma near optic tract.

Feasibility of four-dimensional conformal planning for robotic radiosurgery.

Organ motion can have a severe impact on the dose delivered by radiation therapy, and different procedures have been developed to address its effects. Conventional techniques include breath hold methods and gating. A different approach is the compensation for target motion by moving the treatment beams synchronously. Practical results have been reported for robot based radiosurgery, where a linear accelerator mounted on a robotic arm delivers the dose. However, not all organs move in the same way, which results in a relative motion of the beams with respect to the body and the tissues in the proximity of the tumor. This relative motion can severely effect the dose delivered to critical structures. We propose a method to incorporate motion in the treatment planning for robotic radiosurgery to avoid potential overdosing of organs surrounding the target. The method takes into account the motion of all considered volumes, which is discretized for dose calculations. Similarly, the beam motion is taken into account and the aggregated dose coefficient over all discrete steps is used for planning. We simulated the treatment of a moving target with three different planning methods. First, we computed beam weights based on a 3D planning situation and simulated treatment with organ motion and the beams moving synchronously to the target. Second, beam weights were computed by the 4D planning method incorporating the organ and beam motion and treatment was simulated for beams moving synchronously to the target. Third, the beam weights were determined by the 4D planning method with the beams fixed during planning and simulation. For comparison we also give results for the 3D treatment plan if there was no organ motion and when the plan is delivered by fixed beams in the presence of organ motion. The results indicate that the new 4D method is preferable and can further improve the overall conformality of motion compensated robotic radiosurgery.

High dose rate versus low dose rate interstitial radiotherapy for carcinoma of the floor of mouth

PURPOSE Patients with cancer of the floor of mouth are treated with radiation because of functional and cosmetic reasons. We evaluate the treatment results of high dose rate (HDR) and low dose rate (LDR) interstitial radiation for cancer of the floor of mouth. METHODS AND MATERIALS From January 1980 through March 1996, 41 patients with cancer of the floor of mouth were treated with LDR interstitial radiation using 198Au grains, and from April 1992 through March 1996 16 patients with HDR interstitial radiation. There were 26 T1 tumors, 30 T2 tumors, and 1 T3 tumor. For 21 patients treated with interstitial radiation alone, a total radiation dose of interstitial therapy was 60 Gy/10 fractions/6-7 days in HDR and 85 Gy within 1 week in LDR. For 36 patients treated with a combination therapy, a total dose of 30 to 40 Gy of external radiation and a total dose of 48 Gy/8 fractions/5-6 days in HDR or 65 Gy within 1 week in LDR were delivered. RESULTS Two- and 5-year local control rates of patients treated with HDR interstitial radiation were 94% and 94%, and those with LDR were 75% and 69%, respectively. Local control rate of patients treated with HDR brachytherapy was slightly higher than that with 198Au grains (p = 0.113). For late complication, bone exposure or ulcer occurred in 6 of 16 (38%) patients treated with HDR and 13 of 41 (32%) patients treated with LDR. CONCLUSION HDR fractionated interstitial brachytherapy can be an alternative to LDR brachytherapy for cancer of the floor of mouth and eliminate radiation exposure for the medical staff.

New ambulatory implant technique of high-dose-rate interstitial brachytherapy for prostate cancer

PurposeThe aim of this study was to improve the performance status of prostate cancer patients during high-dose-rate interstitial brachytherapy (HDR-ISBT). To this end, we have developed a new ambulatory implant technique.Materials and methodsTen prostate cancer patients were treated with HDR-ISBT as monotherapy from October 2003 until March 2004. We utilized a new removable template, a flexible applicator with a nonmetallic bead and button stopper, and an inner catheter connecting the applicator and the transfer tube of the brachytherapy unit. We shortened the connector end of the flexible applicator to enable the patient to sit down and walk freely during the treatment time.ResultsAll 10 patients could walk without any support. No problem in the application was observed.ConclusionOur new ambulatory implant technique for HDR-ISBT was able to improve the performance status of prostate cancer patients.

Radiotherapy of early tongue cancer in patients less than 40 years old

PURPOSE To evaluate the results of treatment for early mobile tongue cancer in patients less than 40 years. METHODS AND MATERIALS Between January 1967 and September 1992, 70 patients less than 40 years old (young age group) with early tongue cancer (T1-2N0M0) were treated with low-dose-rate (LDR) interstitial radiotherapy at the Osaka University Hospital (OUH). All patients had a minimum 2-year follow-up (median: 13 years). External radiotherapy (median: 30 Gy) was combined in 25 cases. The treatment results were compared with those for two older age groups (middle age: 40-64 years old; old age: 65 years old or more). RESULTS The 5-year probability of cause-specific survival (CSS) rate for the young age group was 80%, which was not significantly different from the two older groups: 81% for middle age and 71% for old age. However, male patients of young age showed significantly worse rates than those of middle and old age (p = 0.02). The 5-year local control rate for the young age group was 78%. It was not significantly different from the two older groups: 81% for middle age and 70% for old age. The incidence of regional lymph node metastasis was 32% for T1, 48% for T2, 56% for males, and 24% for females. The regional failure rate of young males was significantly higher than those of the two older groups: 32% for middle and 22% for old age (p = 0.001). CONCLUSION The overall treatment results for patients with early tongue cancer less than 40 years old were not worse than those of older age groups. However, male gender was a risk factor for lymph node metastasis and CSS.