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4dct Rt Planning Red 2006

4dct Rt Planning Red 2006

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Published by: Sayan Das on Jul 22, 2012
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doi:10.1016/j.ijrobp.2006.04.031
PHYSICS CONTRIBUTION
MID-VENTILATION CT SCAN CONSTRUCTION FROM FOUR-DIMENSIONALRESPIRATION-CORRELATED CT SCANS FOR RADIOTHERAPY PLANNINGOF LUNG CANCER PATIENTS
J
OCHEM
W. H. W
OLTHAUS
, M.S
C
., C
HRISTOPH
S
CHNEIDER
, P
H
.D., J
AN
-J
AKOB
S
ONKE
, P
H
.D.,M
ARCEL VAN
H
ERK
, P
H
.D., J
OSÉ
S. A. B
ELDERBOS
, M.D.,M
ADDALENA
M. G. R
OSSI
, D.C.R.(R), R.T.T., J
OOS
V. L
EBESQUE
, M.D., P
H
.D.,
AND
E
UGÈNE
M. F. D
AMEN
, P
H
.D.
Department of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital,Amsterdam, The Netherlands
Purpose: Four-dimensional (4D) respiration-correlated imaging techniques can be used to obtain (respiration)artifact-free computed tomography (CT) images of the thorax. Current radiotherapy planning systems, however,do not accommodate 4D-CT data. The purpose of this study was to develop a simple, new concept to incorporatepatient-specific motion information, using 4D-CT scans, in the radiotherapy planning process of lung cancerpatients to enable smaller error margins.Methods and Materials: A single CT scan was selected from the 4D-CT data set. This scan represented the tumorin its time-averaged position over the respiratory cycle (the mid-ventilation CT scan). To select the appropriateCT scan, two methods were used. First, the three-dimensional tumor motion was analyzed semiautomatically tocalculate the mean tumor position and the corresponding respiration phase. An alternative automated methodwas developed to select the correct CT scan using the diaphragm motion.Results: Owing to hysteresis, mid-ventilation selection using the three-dimensional tumor motion had a tumorposition accuracy (with respect to the mean tumor position) better than 1.1 1.1 mm for all three directions(inhalation and exhalation). The accuracy in the diaphragm motion method was better than 1.1 1.1 mm.Conventional free-breathing CT scanning had an accuracy better than 0 3.9 mm. The mid-ventilation conceptcan result in an average irradiated volume reduction of 20% for tumors with a diameter of 40 mm.Conclusion: Tumor motion and the diaphragm motion method can be used to select the (artifact-free) mid-ventilation CT scan, enabling a significant reduction of the irradiated volume. © 2006 Elsevier Inc.Computed tomography, Four-dimensional, Respiration-correlated, Breathing, Treatment planning, Lung can-cer, Mid-ventilation.
INTRODUCTION
Treatment outcomes for non–small-cell lung cancer usingconventional radiation doses are poor, and the local recur-rence rate is high. Tumor control can probably be improvedby increasing the dose (e.g.,1, 2). However, the surroundinghealthy lung tissue and the esophagus are dose limiting(e.g.,3, 4). To enable dose escalation, the irradiated sur- rounding normal tissue volume should be minimized. Onepossible approach is to reconsider the margins for the con-ventional planning target volume (PTV). The PTV is gen-erally defined as the clinical target volume (CTV) (visibletumor plus margin for microscopic extensions) plus a mar-gin to account for geometric uncertainties (5). The most important interfractional geometric uncertainties are patientsetup errors, tumor shrinkage or growth, and respiratorybaseline shifts (i.e., shifts in respiration levels). Intrafrac-tional geometric uncertainties are due to respiratory andcardiac motion. Eliminating geometric uncertainties allowsfor a reduction of the CTV to PTV margins, reducing thevolume of irradiated normal tissue and normal tissue com-plication probability and enabling dose escalation.A single free-breathing computed tomography (CT) scanis often used for radiotherapy planning for lung tumors.However, respiration-induced tumor motion (TM) duringacquisition causes artifacts in tumor shape and position(6,
Reprint requests to: Eugène M. F. Damen, Ph.D., Department of Radiation Oncology, The Netherlands Cancer Institute, Antoni vanLeeuwenhoek Hospital, Plesmanlaan 121, Amsterdam 1066 CX, TheNetherlands. Tel: (
ϩ
31) 20-512-2205; Fax: (
ϩ
31) 20–669–1101;E-mail: e.damen@nki.nlSupported by Grant NKI 03-2943 from the Dutch Cancer Society.
 Acknowledgments
—The authors thank Jasper Nijkamp for his clin-ical software development and Harry Bartelink, Ben Mijnheer, andLeah McDermott for critical reading of the manuscript.Received Jan 6, 2006, and in revised form April 10, 2006.Accepted for publication April 10, 2006.
Int. J. Radiation Oncology Biol. Phys., Vol. 65, No. 5, pp. 1560–1571, 2006Copyright © 2006 Elsevier Inc.Printed in the USA. All rights reserved0360-3016/06/$–see front matter
1560
 
7). The cause of these artifacts is that the CT scanneracquires a stack of images without time information fromthe moving tumor, thus obtaining a set of arbitrary snap-shots of moving structures. To overcome this problem,time-resolved four-dimensional (4D) scanning techniqueswere developed (8–13). Basically, all these methods are similar i.e., the acquired oversampled three-dimensional(3D) data are sorted by the patient’s respiratory phase usingan external breathing signal, yielding a set of 3D reconstruc-tions at different breathing phases. This set (i.e., 4D imagedata) provides temporal and spatial motion information thatcan be used to optimize treatment planning.Currently, however, available commercial treatment plan-ning systems cannot handle a 4D-CT data set as input fortreatment planning. Several strategies for the implementa-tion of 4D data sets in the treatment planning process havebeen published:Slow CT scan: Sörensen de Koste
et al.
(14)used a slow CT scan (which can be considered as the time average of the4D data set) to delineate the target volume encompassingthe tumor at any position during the breathing cycle(internal target volume). A 5 mm expansion was added tothe internal target volume to cover the CTV and a 5-mmexpansion was added from the CTV to the PTV.Maximal inhale and exhale composite delineation: Allen
et al.
(15)studied the delineation of the gross tumor volume (GTV) in a maximal inhale scan and a maximal exhalescan and created a composite of the two delineation setsfor planning (GTV to CTV margin recipe was not given).All-phase composite segmented tumor: Rietzel
et al.
(16)and Underberg
et al.
(17)proposed a method (based on maximal intensity projection) that automatically creates acomposite segmented CT scan of all respiratory phasescans (the full 4D set). From this composite CT scan, thecomposite GTV was delineated (GTV to CTV marginrecipe was not given).Breath-hold CT scan (with active breathing control): Wong
et al.
(18)and Rosenzweig
et al.
(19)studied breath-hold CT acquisition using the active breathing control deviceand voluntary breath-hold, respectively, to obtain a single3D scan without motion artifacts for treatment planningpurposes (GTV to CTV margin recipe was not given).Deformation dose mapping: Keall
et al.
(20)proposed a 4D dose calculation method based on 4D deformation mapsfrom the 4D-CT scan. The deformation maps were ap-plied to the peak inhale delineations of the tumor andother structures. For each respiratory phase of the 4D set,an optimized treatment plan was calculated.The first three methods can be summarized as compositetarget volume concepts, in which the target volumes areoften enlarged. Moreover, delineation of moving structuresin the slow CT method is difficult because of motion blurring.The second and third method need multiple reconstructions fortumor delineation and dose calculation. The breath-holdmethod is not applicable to all lung cancer patients because of their physical condition. Moreover, breathing control alsoneeds to be maintained during treatment. The effectiveness of the last method, by Keall
et al.
(20), was demonstrated in a feasibility study, but its clinical implementation is not yetpossible because of hardware limitations.In this report, we have proposed the selection of a singlewell-chosen CT scan from a 4D set. The choice of the singleCT scan was based on studies by Engelsman
et al.
(21)and Witte
et al.
(22). These studies showed that if the tumor is irradiated at its average position during the respiration cy-cle, because of the presence of the wide-beam penumbra inthe lung, good dose coverage would still be obtained even if the tumor was not fully within the high-dose region for asmall part of the breathing cycle (0.6% and 6% tumorcontrol probability loss for 5 mm and 15 mm motion am-plitude with 0 margin, respectively, and no setup errors).Such an approach makes margin reduction possible.The aim of this study was to eliminate the systematicerrors in the imaging process induced by respiratory motionand to obtain a more representative scan for delineation of the target area, normal structures, and dose calculation. Inthe presented approach, motion was not taken into accountwhen delineating the tumor (thus no internal target volume)but will be incorporated in the margin expansion from CTVto PTV. This margin included the dose blurring caused byrespiratory motion during treatment. SeeFig. 1for theclinical protocol for 4D analysis and scan selection cur-rently used in our hospital
METHODS AND MATERIALS
Patient group
Patients with a lung tumor who were scheduled for radiotherapyunderwent fluoroscopy to estimate the TM due to respiration. If thetumor was estimated to move
Ն
0.5 cm owing to respiration, thepatients were eligible for this study. All patients (12 men and 3women) included in the study gave written informed consent toparticipate. The local medical ethics committee approved the study.
 Respiration-correlated 4D-CT imaging
4D-CT scanning.
During 4D-CT scanning, the patient was in-structed to breath freely and normally. Patient respiration was regis-tered using a thermocouple (Type T, copper-constantan, S-CC-U-O-7/1,Volenec,HradecKrálové,CzechRepublic)insertedintotheentryofaregularoxygenmask,whichmeasurestemperaturechangesintheairflow during inhalation (cold) and exhalation (warm).During CT scanning, patients were positioned supine with theirarms raised above their head using an in-house developed forearmsupport. To obtain a position similar to that on the treatment couch,a flat tabletop (Sinmed, Reeuwijk, The Netherlands) was placed onthe couch of the CT scanner (20-slice Somatom Sensation Open,Siemens, Forchheim, Germany). The helical cardiac scanningmode of the CT scanner was used for the respiration-correlatedimaging. However, the thermocouple respiratory signal was usedfor data sorting, instead of the cardiac input signal.The scans were made at 120 kV, 1000 eff.mAs. The completethorax was scanned (30–35 cm) from 5 cm above the top of thelung down to 5 cm below the diaphragm in the inhale position. Thescan time was 60–70 s.
Scan reconstruction.
The beam-on signal of the CT scanner was
1561Clinical implementation of 4D-CT scans
J. W. H. W
OLTHAUS
et al.
 
used to synchronize the respiration signal with the CT data. Thetime delay (response time) between the movement of the internalstructures of the lung and the external (thermocouple) breathingsignal (0.4 s, see Appendix) was corrected by back shifting therespiratory signal with respect to the beam-on signal. After thistime-delay correction, the respiratory signal should, in principle,be in phase with the CT data of the internal structures. Therespiration-correlated protocol on the scanner, an adaptation of thecardiac protocol, uses the peaks (maximal inhalation) of the res-piration signal to sort the raw CT data. Between the peaks, therespiratory cycle is divided into 10 equidistant time-percentagebins (0% at maximal inhalation to 90%). Within one cycle, thetime bins are equidistant, but from cycle to cycle, the exact lengthof a certain bin may vary owing to variations in the breathingperiod. Using equidistant time bins, which is equal to linear datasampling, the asymmetry between inhalation and exhalation lengthis incorporated in the fourth dimension of the resulting 4D scan byhaving a different number of—generally more—3D-CT frames inthe exhalation phase than in the inhalation phase.For each table position (every 3 mm) and time-percentagewithin the breathing cycle, the corresponding location in the CTsinogram (as a function of table position and gantry angle) wasdetermined. A slice was reconstructed using data from
Ϫ
110° to
ϩ
110° (180° plus fan angle) from the determined gantry angle.The number of slices within one time bin was approximately 100for the chosen slice thickness of 3 mm.
Choice of CT acquisition parameters.
The quality of 4D scan-ning in the helical mode depends critically on the interplay be-tween the breathing characteristics of the patient and the acquisi-tion parameters used for scanning. According to Ford
et al.
(9), complete coverage of moving structures over a full breathingcycle is obtained when
CL
Gantry-rotation
ϭ
pitch
ϫ
CL
 Respiration
,where
CL
 Respiration
is the breathing cycle length of the patient and
CL
Gantry-rotation
is the gantry rotation time. If the
CL
Gantry-rotation
isshorter than the
pitch
ϫ
CL
 Respiration
, undersampling of the datawill occur, leading to gaps in the 4D data for particular phases. If the
CL
Gantry-rotation
is longer, oversampling will occur and motionwill be blurred in the slice. The Somatom 20-slice scanner allowsgantry rotation times of 0.5 and 1.0 s. We therefore used twodifferent sets of acquisition parameters. When the average
CL
 Respiration
ϩ
1 standard deviation was less than 5 s, a
CL
Gantry-rotation
of 0.5 s and pitch of 0.1 was used, otherwise a
CL
Gantry-rotation
of 1.0 s and pitch of 0.15 was used. This procedureprevented undersampling of a breathing period up to 6.7 s. The
at the CT scanner oxygen maskwith thermocoupleis placed on the patientpre-acquisition of respirationsignalcomputemean & std.dev.cycle lengthstd.dev.cycle length?mean+std.dev.cycle length?set CT gantry rotationto 0.5 spitch = 0.10set CT gantry rotationto 1.0 spitch = 0.15scan patientreconstruct scan> ~ 2 s< ~ 2 s> 5 s< 5 safter scanningexamine tumor motion(TM) of 4D scanvisuallycranio-caudalTM amplitude?determinediaphragm motiondetermine(cranio-caudal)tumor motioncompute mid-ventilationtime-percentageduring exhalereconstructMidV CT scan> ~ 2 cm< ~ 2 cmverify visually ingreen/purple compositeviewer if scan is adequate
Fig. 1. Considerations presented in this report can be summarized in the following clinical protocol currently in use at ourinstitution. The protocol is divided into two parts: during and after scanning. 4D
ϭ
four-dimensional; MidV
ϭ
mid-ventilation.
1562 I. J. Radiation Oncology
Biology
Physics Volume 65, Number 5, 2006

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