Analyzing human decisions in IGRT of head-and-neck cancer patients to teach image registration algorithms what experts know

Background: In IGRT of deformable head-and-neck anatomy, patient setup corrections are derived by rigid registration methods. In practice, experienced radiation therapists often correct the resulting vectors, thus indicating a different prioritization of alignment of local structures. Purpose of this study is to transfer the knowledge experts apply when correcting the automatically generated result (pre-match) to automated registration. Methods: Datasets of 25 head-and-neck-cancer patients with daily CBCTs and corresponding approved setup correction vectors were analyzed. Local similarity measures were evaluated to identify the criteria for human corrections with regard to alignment quality, analogous to the radiomics approach. Clustering of similarity improvement patterns is applied to reveal priorities in the alignment quality. Results: The radiation therapists prioritized to align the spinal cord closest to the high-dose area. Both target volumes followed with second and third highest priority. The bony pre-match influenced the human correction along the crania-caudal axis. Based on the extracted priorities, a new rigid registration procedure is constructed which is capable of reproducing the corrections of experts. Conclusions: The proposed approach extracts knowledge of experts performing IGRT corrections to enable new rigid registration methods that are capable of mimicking human decisions. In the future, the deduction of knowledge-based corrections for different cohorts can be established automating such supervised learning approaches

Long term outcome of adolescent and adult patients with pineal parenchymal tumors treated with fractionated radiotherapy between 1982 and 2003 -- a single institution's experience

Background: To evaluate the effectivity of fractionated radiotherapy in adolescent and adult patients with pineal parenchymal tumors (PPT). Methods: Between 1982 and 2003, 14 patients with PPTs were treated with fractionated radiotherapy. 4 patients had a pineocytoma (PC), one a PPT with intermediate differentiation (PPTID) and 9 patients a pineoblastoma (PB), 2 of which were recurrences. All patients underwent radiotherapy to the primary tumor site with a median total dose of 54 Gy. In 9 patients with primary PB treatment included whole brain irradiation (3 patients) or irradiation of the craniospinal axis (6 patients) with a median total dose of 35 Gy. Results: Median follow-up was 123 months in the PC patients and 109 months in the patients with primary PB. 7 patients were free from relapse at the end of follow-up. One PC patient died from spinal seeding. Among 5 PB patients treated with radiotherapy without chemotherapy, 3 developed local or spinal tumor recurrence. Both patients treated for PB recurrences died. The patient with PPTID is free of disease 7 years after radiotherapy. Conclusion: Local radiotherapy seems to be effective in patients with PC and some PPTIDs. Diagnosis and treatment of patients with more aggressive variants of PPTIDs as well as treatment of PB need to be further improved, since local and spinal failure even despite craniospinal irradiation (CSI) is common. As PPT are very rare tumors, treatment within multi-institutional trials remains necessary

Comparison of Safety Margin Generation Concepts in Image Guided Radiotherapy to Account for Daily Head and Neck Pose Variations.

PURPOSE:Intensity modulated radiation therapy (IMRT) of head and neck tumors allows a precise conformation of the high-dose region to clinical target volumes (CTVs) while respecting dose limits to organs a risk (OARs). Accurate patient setup reduces translational and rotational deviations between therapy planning and therapy delivery days. However, uncertainties in the shape of the CTV and OARs due to e.g. small pose variations in the highly deformable anatomy of the head and neck region can still compromise the dose conformation. Routinely applied safety margins around the CTV cause higher dose deposition in adjacent healthy tissue and should be kept as small as possible. MATERIALS AND METHODS:In this work we evaluate and compare three approaches for margin generation 1) a clinically used approach with a constant isotropic 3 mm margin, 2) a previously proposed approach adopting a spatial model of the patient and 3) a newly developed approach adopting a biomechanical model of the patient. All approaches are retrospectively evaluated using a large patient cohort of over 500 fraction control CT images with heterogeneous pose changes. Automatic methods for finding landmark positions in the control CT images are combined with a patient specific biomechanical finite element model to evaluate the CTV deformation. RESULTS:The applied methods for deformation modeling show that the pose changes cause deformations in the target region with a mean motion magnitude of 1.80 mm. We found that the CTV size can be reduced by both variable margin approaches by 15.6% and 13.3% respectively, while maintaining the CTV coverage. With approach 3 an increase of target coverage was obtained. CONCLUSION:Variable margins increase target coverage, reduce risk to OARs and improve healthy tissue sparing at the same time

Phagocytosis and Killing of Bacteria by Professional Phagocytes and Dendritic Cells

Dendritic cells (DC) represent a class of professional antigen-presenting cells whose primary function is to alert the immune system, not to clear invading microorganisms. The objective of our study was to compare the abilities of polymorphonuclear neutrophilic leukocytes (PMN), monocytes, monocyte-derived macrophages (MDM), monocyte-derived immature DC (imDC), and mature DC (maDC) to ingest and destroy Staphylococcus aureus and Escherichia coli. Acridine orange staining and fluorescence microscopy demonstrated that MDM, followed by monocytes, imDC, and PMN, internalized bacteria well but that maDC exhibited less pronounced phagocytic activity. PMN, monocytes, and MDM exhibited a much higher capacity to kill ingested bacteria than both imDC and maDC. In summary, these data are in agreement with the generally accepted idea that different types of leukocytes fulfill specialized tasks in antigen presentation and killing of pathogens

Mean distance between ITV and transformed spinal cord d_SC(z) of different margin approaches for all patients.

<p>Mean distance between ITV and transformed spinal cord d_SC(z) of different margin approaches for all patients.</p

The finite element model of the patient is deformed.

<p>Left: the finite element mesh model of the patient’s skin in the planning configuration (grey) and the selected anatomical landmarks (green) as well as their position in the fraction control CT image (red). The patient model is deformed by a force based boundary condition between the landmarks. Right: Landmarks were pulled towards their position in the fraction CT, the mesh is deformed resulting in rising of the right shoulder.</p

Clinical Target Volume (CTV) of a head and neck cancer patient.

<p>Left: Volume rendering of the planning CT image for an exemplary head and neck cancer patient receiving an IMRT treatment under daily image guidance. The clinical target volume (CTV) is displayed in red, brainstem in green. The stereotactic external frame is used as positioning device. Center: A transversal CT slice of the same patient of the mandibular region is displayed. The clinical target volume (CTV, red) and the spinal cord (green) as organ at risk are shown as planning contours. Right: CTV contours of different treatment days are plotted on the same planning CT slice to visualize daily variations.</p