Quantification and Assessment of Interfraction Setup Errors Based on Cone Beam CT and Determination of Safety Margins for Radiotherapy

Introduction To quantify interfraction patient setup-errors for radiotherapy based on cone-beam computed tomography and suggest safety margins accordingly. Material and Methods Positioning vectors of pre-treatment cone-beam computed tomography for different treatment sites were collected (n = 9504). For each patient group the total average and standard deviation were calculated and the overall mean, systematic and random errors as well as safety margins were determined Results The systematic (and random errors) in the superior-inferior, left-right and anterior-posterior directions were: for prostate, 2.5(3.0), 2.6(3.9) and 2.9(3.9) mm; for prostate bed, 1.7(2.0), 2.2(3.6) and 2.6(3.1) mm; for cervix, 2.8(3.4), 2.3(4.6) and 3.2(3.9) mm; for rectum, 1.6(3.1), 2.1(2.9) and 2.5(3.8) mm; for anal, 1.7(3.7), 2.1(5.1) and 2.5(4.8) mm; for head and neck, 1.9(2.3), 1.4(2.0) and 1.7(2.2) mm; for brain, 1.0(1.5), 1.1(1.4) and 1.0(1.1) mm; and for mediastinum, 3.3(4.6), 2.6(3.7) and 3.5(4.0) mm. The CTV-to-PTV margins had the smallest value for brain (3.6, 3.7 and 3.3mm) and the largest for mediastinum (11.5, 9.1 and 11.6mm). For pelvic treatments the means (and standard deviations) were 7.3 (1.6), 8.5 (0.8) and 9.6 (0.8) mm. Conclusions Systematic and random setup-errors were smaller than 5mm. The largest errors were found for organs with higher motion probability. The suggested safety margins were comparable to published values in previous but often smaller studies

Radiotherapy for tumors of the stomach and gastroesophageal junction - a review of its role in multimodal therapy

There is broad consensus on surgical resection being the backbone of curative therapy of gastric- and gastroesophageal junction carcinoma. Nevertheless, details on therapeutic approaches in addition to surgery, such as chemotherapy, radiotherapy or radiochemotherapy are discussed controversially; especially whether external beam radiotherapy should be applied in addition to chemotherapy and surgery is debated in both entities and differs widely between regions and centers. Early landmark trials such as the Intergroup-0116 and the MAGIC trial must be interpreted in the context of potentially insufficient lymph node resection. Despite shortcomings of both trials, benefits on overall survival by radiochemotherapy and adjuvant chemotherapy were confirmed in populations of D2-resected gastric cancer patients by Asian trials. Recent results on junctional carcinoma patients strongly suggest a survival benefit of neoadjuvant radiochemotherapy in curatively resectable patients. An effect of chemotherapy in the perioperative setting as given in the MAGIC study has been confirmed by the ACCORD07 trial for junctional carcinomas; however both the studies by Stahl et al. and the excellent outcome in the CROSS trial as compared to all other therapeutic approaches indicate a superiority of neoadjuvant radiochemotherapy as compared to perioperative chemotherapy in junctional carcinoma patients. Surgery alone without neoadjuvant or perioperative therapy is considered suboptimal in patients with locally advanced disease. In gastric carcinoma patients, perioperative chemotherapy has not been compared to adjuvant radiochemotherapy in a randomized setting. Nevertheless, the results of the recently published ARTIST trial and the Chinese data by Zhu and coworkers, indicate a superiority of adjuvant radiochemotherapy as compared to adjuvant chemotherapy in terms of disease free survival in Asian patients with advanced gastric carcinoma. The ongoing CRITICS trial is supposed to provide reliable conclusions about which therapy should be preferred in Western patients with gastric carcinoma. If radiotherapy is performed, modern approaches such as intensity-modulated radiotherapy and image guidance should be applied, as these methods reduce dose to organs at risk and provide a more homogenous coverage of planning target volumes

Gamma-Spektrometrie zur digitalen Bodenkartierung auf Feld- und Landschaftsskala

Die feldskalige Variation von Bodeneigenschaften wird zunehmend durch geophysikalische Sensor-Erkundung abgebildet (Bodenradar, elektrische Leitfähigkeit/Widerstand). Dabei gewinnt auch die Anwendung Gamma-spektrometrischer Verfahren an Bedeutung. Sowohl boden- als auch luftgestützte kontinuierliche Messungen der natürlichen Radionuklide sind als gute Proxies für Oberbodeneigenschaften bekannt, müssen jedoch auf ihre Anwendbarkeit und Übertragbarkeit innerhalb einer Skala (z.B. Feld) und über Skalengrenzen hinweg (regionale Ansätze) getestet werden. Es soll die Frage beantwortet werden, ob Bodeneigenschaften und ihre räumliche Verteilung innerhalb der Nordostdeutschen Jungmoränenlandschaft bei vergleichbarem geologischem Ausgangsgestein durch die Gamma-Spektrometrie abgebildet und quanifiziert werden können. Zwei Landschaftsausschnitte in der Uckermark (Kraatz, 10 km² und Dedelow, 12 km²) wurden im Herbst 2014 durch eine Hubschrauberbefliegung kartiert. Innerhalb dieser beiden Gebiete wurde jeweils ein Feld (25 ha) annähernd zeitgleich mit einem Traktor-gestützten Messsystem befahren und durch Bodenuntersuchungen an 120 Referenzpunkten begleitet. Auf der Feldskala wurden die boden- und luftgestützten Gamma-spektrometrischen Verteilungskarten für die Gesamtzählraten, K, U und Th mit den punktspezifischen Bodeninformationen in Beziehung gesetzt. Für die Gebietsskala wurden vorhandene Bodenkartenwerke mit den Hubschrauber-spektrometrischen Karten verglichen. Karten unterschiedlicher Rasterzellgrößen wurden auf ihre räumliche Beziehung zu Bodentextureigenschaften an den Referenzpunkten und deren Gültigkeit bzw. Übertragbarkeit auf andere Felder untersucht. Auf der Feldskala waren die bodengestützten Gamma-Informationen in ihrer Genauigkeit an den Referenzpunkten den luftgestützten Informationen überlegen (größerer räumlicher Footprint der Hubschraubermessung). Unabhängig davon sind luftgestützte Gamma-spektroskopische Kartierungen das Mittel der Wahl, um räumliche Muster größerer Landschaftsausschnitte zu kartieren

The SBRT database initiative of the German Society for Radiation Oncology (DEGRO): patterns of care and outcome analysis of stereotactic body radiotherapy (SBRT) for liver oligometastases in 474 patients with 623 metastases

Background: The intent of this pooled analysis as part of the German society for radiation oncology (DEGRO)stereotactic body radiotherapy (SBRT) initiative was to analyze the patterns of care of SBRT for liver oligometastases and to derive factors influencing treated metastases control and overall survival in a large patient cohort. Methods: From 17 German and Swiss centers, data on all patients treated for liver oligometastases with SBRT since its introduction in 1997 has been collected and entered into a centralized database. In addition to patient and tumor characteristics, data on immobilization, image guidance and motion management as well as dose prescription and fractionation has been gathered. Besides dose response and survival statistics, time trends of the aforementioned variables have been investigated. Results: In total, 474 patients with 623 liver oligometastases (median 1 lesion/patient; range 1–4) have been collected from 1997 until 2015. Predominant histologies were colorectal cancer (n= 213 pts.; 300 lesions) and breast cancer (n= 57; 81 lesions). All centers employed an SBRT specific setup. Initially, stereotactic coordinates and CT simulation were used for treatment set-up (55%), but eventually were replaced by CBCT guidance (28%) or more recently robotic tracking (17%). High variance in fraction (fx) number (median 1 fx; range 1–13) and dose per fraction (median: 18.5 Gy; range 3–37.5 Gy) was observed, although median BED remained consistently high after an initial learning curve. Median follow-up time was 15 months; median overall survival after SBRT was 24 months. One- and 2-year treated metastases control rate of treated lesions was 77% and 64%; if maximum isocenter biological equivalent dose (BED) was greater than 150 Gy EQD2Gy, it increased to 83% and 70%, respectively. Besides radiation dose colorectal and breast histology and motion management methods were associated with improved treated metastases control

Intrafraction motion of the prostate during an IMRT session: a fiducial-based 3D measurement with Cone-beam CT

Background: Image-guidance systems allow accurate interfractional repositioning of IMRT treatments, however, these may require up to 15 minutes. Therefore intrafraction motion might have an impact on treatment precision. 3D geometric data regarding intrafraction prostate motion are rare; we therefore assessed its magnitude with pre- and post-treatment fiducial-based imaging with cone-beam-CT (CBCT). Methods: 39 IMRT fractions in 5 prostate cancer patients after (125)I-seed implantation were evaluated. Patient position was corrected based on the (125)I-seeds after pre-treatment CBCT. Immediately after treatment delivery, a second CBCT was performed. Differences in bone- and fiducial position were measured by seed-based grey-value matching. Results: Fraction time was 13.6 +/- 1.6 minutes. Median overall displacement vector length of (125)Iseeds was 3 mm (M = 3 mm, Sigma = 0.9 mm, sigma = 1.7 mm; M: group systematic error, Sigma: SD of systematic error, sigma: SD of random error). Median displacement vector of bony structures was 1.84 mm (M = 2.9 mm, Sigma = 1 mm, sigma = 3.2 mm). Median displacement vector length of the prostate relative to bony structures was 1.9 mm (M = 3 mm, Sigma = 1.3 mm, sigma = 2.6 mm). Conclusion: a) Overall displacement vector length during an IMRT session is < 3 mm. b) Positioning devices reducing intrafraction bony displacements can further reduce overall intrafraction motion. c) Intrafraction prostate motion relative to bony structures is < 2 mm and may be further reduced by institutional protocols and reduction of IMRT duration