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Positioning and margin determination

Martijn Kamphuis MSc


Research Radiation Therapist IGRT
Department of Radiotherapy
Amsterdam, the Netherlands

Content of the presentation


Why do we need imaging?
Imaging modalities
How do the work?
Why do we need them?
Pros and cons

Summary

Why
y do we need imaging?
g g
How does the patient look like?
Size and shape
Localisation of the tumour
Position of the critical structures

To be able to model the interaction of


the radiation
Size and shape
p
Differences in tissue
Density differences

Imaging
g g modalities
Conventional
Simulator
Radiology
CT (3D and 4D)
MR

Nuclear medicine
PET

Note: only the role in


RT will discussed

Computed Tomography
g
y ((CT))

How does it work?


kV-source

Detector array

http://radiographics.rsna.org

Multi slice detector

http://radiographics.rsna.org

Helical acquisition

http://radiographics rsna org


http://radiographics.rsna.org

Multi slice acquisition

http://radiographics.rsna.org

((Filtered)) back project


j

Attenuation of X-ray
y
Photoelectric effect
Energy transfer from
to elektron
Mainlyy with inner
shell (80%)

Core
Photon
Electron

Atomic number
Change of
interaction
(Z)

Attenuation of the X-ray


y
High contrast
imaging
Hounsfield Units:
: attenuation
coefficient

On the linac: dose calculation


Compton effect
dominates
Foton loses only
small part of its
energy

Electron
Core

Photon

Lineair relation with


Atomic number Z
Corresponds to the
elektron densityy (ED)
( )

Scattered
Photon

In the TPS
Transition from houndsfield units to electron
density

Differences between
diagnostic CT and CT
CT-simulation
simulation
Large bore
Positioning devices
Complete patient
contour

Flat table top


Laser markers

4D-computed tomography
g
y
3D-imaging
sufficient for many
treatment sites
Artifacts caused by
moving targets
causes

Pros and cons


Pro
Essential for dose
calculation
Good representation
p
of the geometry

Cons
Limited anatomical
and/or pathological
quality
No functional
information

Positron Emission Tomography (CT)

Positron Emission Tomography (CT)


A way of imaging
Organ function
Cellular function
Subcellular function

Labelling
g and injecting
j
g
PET-CT uses probes
Molecule containing a
positron emitters
E.g fluoro-deoxy-glucose
(FDG)

Probes takes part in


normal physiology
FDG goes to cells with high
metabolism
E.g.tumour cells

How does it work?: decay


y

How does it work?: detection

Why
y do we need it?
Three main reasons*:
High sensitivity for tumour tissue
Visualize biological pathways
Hypoxia
Enable dose painting

Monitor
M it ttreatment
t
t response
Window for Adaptive treatment

*Anca-Ligia
g Grosu et al.,, IGRT a clinical perspective
p p

High sensitivity for tumour tissue

Case*
67 Year old male
3 Nodules
Tumour, Infarct &
Benigne Hamartoma

AMC
Lung
g NSCLC
Cervical cancer
Anal canal
Vulva carcinoma

*http://www.wvm.petctmobile.com/zportal/portals/phys/clinical/petct_case_studies/lung/lung_case3

Delineation variation: CT versus CT + PET

CT (T2N2)

CT + PET (T2N1)

SD 7
7.5
5 mm

SD 3
3.5
5 mm

Pros and cons


Pro
Functional
information
Improved
p
tumour
definition

Cons
Not enough data for
simulation
Small bore
No ED data
Acquisition time

Magnetic
g
Resonance Imaging
g g

How does it work?

MRI signal: Hydrogen in the human body


In water (H2O),
~ 80% of the body

In fatty tissue,
tissue (CH2)

How does it work? Magnetization


Hydrogen (H)
Most common atom
Proton:
positively charged
proton turns around own axis

Hydrogen
y g also have spin
p

Spin
p + charge
g = mini-magnet
g

MRI signal: Netto-magnetisation


Outside magnetic
g
field
Magnetisch moment = 0

Volume within magnetic


g
field ((B0)
Magnetisch moment 0
spin-up & spin-down

B0

MRI signal
g
B0

Strong magnetic field

Butstill no signal

B0

Netto magnetisation
Netto-magnetisation

MRI Creating
g the image
g
Major steps
Excitation
Relaxation
Acquisition
Reconstruction

What is resonance?
Every system has its
own natural
frequency
External input can
lead to larger
amplitude.
p
Objects are moving
in the same phase
TACOMA BRIDGE

MRI - Excitation
z

B0

M0

B0
Mxy
y

Netto-magnetisation
In z-direction impossible to
measure the size of B0

Excitation using a RF-pulse


Resonance changes
g
in xy-direactions
y
Netto-magnetisation
Possible to measure

MRI - Relaxation
After RF excitation:
Loss of equilibrium
Relaxation to initial state
Two independent processes
T1 relaxation
T2 relaxation

Mxy
y
x

MRI - T1 relaxation

t=0

T1 relaxation

t ~ 1 sec

MRI - T2 relaxation
z

Mxy
y
x

t=0

Excitatie

T2 relaxation
Spins are in phase by RF pulse
Spins are running out of phase (Mxy),
T2 is tissue specific
Independent of T1 relaxation

T2 relaxatie

t ~ 100 msec

MRI Contrast
MR image shows the differences of
relaxation
l
ti att a certain
t i time
ti
point
i t
Depending on tissue type
Fatty tissue
Water

MRI T1 and T2 contrast

CT

T1-weighted MRI

T2-weighted MRI

TE 30 ms; TR 566 ms

TE 120 ms; TR 8400 ms

Rule of thumb: T1 for anatomy, T2 for pathology

Why
y do we need it?
MR containts excellent soft tissue information.
Improves delineation process

Commonly used in
Prostate
Brain

Example: prostate cancer

www.umcutrecht.nl

Pros and cons


Pro

Cons

Superior soft tissue


imaging
Spatial
p
resolution is
high
Improved tumour
d fi iti
definition
Patient safety
Lower contrast
reaction

Acquisition time
Geometrical
deformation
No ED information
Problems with table
top and
immobilization
devices
Small bore

Putting
g it all together
g
CT-simulation
Still the fundament of current RT treatment
Essential for dose calculation

PET
Sensitive for tumour activityy
Decreases interobserver variability

MR
Soft tissue imaging