Lipiodol versus diaphragm in 4D-CBCT-guided stereotactic radiotherapy of hepatocellular carcinomas

Chan, Mark K.H.; Lee, Venus; Chiang, Chi Leung; Lee, Francis A. S.; Law, G; Sin, N. Y.; Siu, Kwong Lok; Wong, F.; Tung, Stewart Y.; Luk, Hollis; Blanck, Oliver

doi:10.1007/s00066-015-0929-9

Cited by 30 publications

(23 citation statements)

References 22 publications

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“…Despite optimal image quality that can be achieved with motion–corrected CBCT, the ability of direct tumor localization remains the most important aspects in SBRT, particular for HCC. We have shown in our previous study that additional margins as large as 5.9 (LR), 10.0 (CC), 2.9 (AP) mm are required to offset of GTV’s center of mass (CoM) from the liver contour’s CoM despite using online 4D–CBCT correction [5], which poses significant limitation to dose escalation to improve the clinical outcomes. The latest IG technology with linac–integrated magnetic resonance imaging (MRI) may be a promising solution for HCC patients without prior lipiodol and intolerable to other invasive procedure of fiducial implantation [27].…”

Section: Discussionmentioning

confidence: 99%

“…One advantage of sequencing TACE prior to radiotherapy is that the potential tumor shrinkage after TACE may allow the radiation field to be reduced, permitting higher tumor doses and/or lower risk of toxicity such as radiation–induced liver disease (RILD). In addition, the lipiodolized tumor after TACE can be exploited as a natural contrast medium for direct target localization in the subsequent SBRT to minimize geometric uncertainties from differential tumor position and/or motion of implanted fiducial markers or diaphragm frequently used as surrogates [4,5,6]. …”

Section: Introductionmentioning

confidence: 99%

“…On the other hand, improvement of HCC localization accuracy of 4D–CBCT under lipiodol–contrast guidance was evidenced by Chan et al . [5], showing a possible cranio–caudal margin reduction by up to 11.7 mm that was required to compensate for uncertainty from diaphragm surrogate. Nonetheless, the relative benefit of clinical implementation of 4D–CBCT to 3D–CBCT to improve the accuracy of localizing lipiodolized HCC during free–breathing SBRT remains unknown.…”

Section: Introductionmentioning

confidence: 99%

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Target localization of 3D versus 4D cone beam computed tomography in lipiodol-guided stereotactic radiotherapy of hepatocellular carcinomas

et al. 2017

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BackgroundAim of this study was to comparatively evaluate the accuracy of respiration–correlated (4D) and uncorrelated (3D) cone beam computed tomography (CBCT) in localizing lipiodolized hepatocellular carcinomas during stereotactic body radiotherapy (SBRT).Methods4D–CBCT scans of eighteen HCCs were acquired during free–breathing SBRT following trans–arterial chemo–embolization (TACE) with lipiodol. Approximately 1320 x–ray projections per 4D–CBCT were collected and phase–sorted into ten bins. A 4D registration workflow was followed to register the reconstructed time–weighted average CBCT with the planning mid–ventilation (MidV) CT by an initial bone registration of the vertebrae and then tissue registration of the lipiodol. For comparison, projections of each 4D–CBCT were combined to synthesize 3D–CBCT without phase–sorting. Using the lipiodolized tumor, uncertainties of the treatment setup estimated from the absolute and relative lipiodol position to bone were analyzed separately for 4D– and 3D–CBCT.ResultsQualitatively, 3D–CBCT showed better lipiodol contrast than 4D–CBCT primarily because of a tenfold increase of projections used for reconstruction. Motion artifact was observed to subside in 4D–CBCT compared to 3D–CBCT. Group mean, systematic and random errors estimated from 4D– and 3D–CBCT agreed to within 1 mm in the cranio–caudal (CC) and 0.5 mm in the anterior–posterior (AP) and left–right (LR) directions. Systematic and random errors are largest in the CC direction, amounting to 4.7 mm and 3.7 mm from 3D–CBCT and 5.6 mm and 3.8 mm from 4D–CBCT, respectively. Safety margin calculated from 3D–CBCT and 4D–CBCT differed by 2.1, 0.1 and 0.0 mm in the CC, AP, and LR directions.Conclusions3D–CBCT is an adequate alternative to 4D–CBCT when lipoid is used for localizing HCC during free–breathing SBRT. Similar margins are anticipated with 3D– and 4D–CBCT.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Target localization of 3D versus 4D cone beam computed tomography in lipiodol-guided stereotactic radiotherapy of hepatocellular carcinomas

et al. 2017

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“…Likewise, our research group has reported the ability of 4D‐CBCT to acquire highly accurate images from a respiratory motion phantom . Several studies have reported that 4D‐CBCT can be used to manage respiratory motion in clinical cases . They stated that 4D‐CBCT can observe the internal margin and the motion of a tumor during treatment with high accuracy, and that 4D‐CBCT can be used for stereotactic body radiotherapy as an IGRT device.…”

Section: Introductionmentioning

confidence: 93%

Estimation of effective imaging dose and excess absolute risk of secondary cancer incidence for four‐dimensional cone‐beam computed tomography acquisition

Yuasa

Shiinoki

Onizuka

et al. 2019

J Applied Clin Med Phys

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This study was conducted to estimate the organ equivalent dose and effective imaging dose for four‐dimensional cone‐beam computed tomography (4D‐CBCT) using a Monte Carlo simulation, and to evaluate the excess absolute risk (EAR) of secondary cancer incidence. The EGSnrc/BEAMnrc were used to simulate the on‐board imager (OBI) from the TrueBeam linear accelerator. Specifically, the OBI was modeled based on the percent depth dose and the off‐center ratio was measured using a three‐dimensional (3D) water phantom. For clinical cases, 15 lung and liver cancer patients were simulated using the EGSnrc/DOSXYZnrc. The mean absorbed doses to the lung, stomach, bone marrow, esophagus, liver, thyroid, bone surface, skin, adrenal glands, gallbladder, heart, intestine, kidney, pancreas and spleen, were quantified using a treatment planning system, and the equivalent doses to each organ were calculated. Subsequently, the effective dose was calculated as the weighted sum of the equivalent dose, and the EAR of the secondary cancer incidence was determined for each organ with the use of the biologic effects of ionizing radiation (BEIR) VII model. The effective doses were 3.9 ± 0.5, 15.7 ± 2.0, and 7.3 ± 0.9 mSv, for the lung, and 4.2 ± 0.6, 16.7 ± 2.4, and 7.8 ± 1.1 mSv, for the liver in the respective cases of the 3D‐CBCT (thorax, pelvis) and 4D‐CBCT modes. The lung EARs for males and females were 7.3 and 10.7 cases per million person‐years, whereas the liver EARs were 9.9 and 4.5 cases per million person‐years. The EAR increased with increasing time since radiation exposure. In clinical studies, we should use 4D‐CBCT based on consideration of the effective dose and EAR of secondary cancer incidence.

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“… 25 , 26 Respiratory-sorted “four-dimensional” CT (4DCT), one of the most commonly used imaging technologies, also has been applied to quantify the motion magnitude of liver and liver tumor during pretreatment simulation and fractionated treatment. 27 – 29 However, due to the poor image contrast, surrogates such as implanted metal markers, lipiodol, or diaphragm/liver contour are necessary. 28 – 30 …”

Section: Introductionmentioning

confidence: 99%

Observation of different tumor motion magnitude within liver and estimate of internal motion margins in postoperative patients with hepatocellular carcinoma

Zhao¹,

Liu²,

Wu³

et al. 2017

CMAR

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AimsTo assess motion magnitude in different parts of the liver through surgical clips in postoperative patients with hepatocellular carcinoma and to examine the correlation between the clip and diaphragm motion.MethodsFour-dimensional computed tomography images from 30 liver cancer patients under thermoplastic mask immobilization were selected for this study. Three to seven surgical clips were placed in the resection cavity of each patient. The liver volume on computed tomography image was divided into the right upper (RU), right middle (RM), right lower (RL), hilar, and left lobes. Agreement between the clip and diaphragm motion was assessed by calculating intraclass correlation coefficient, and Bland–Altman analysis (Diff). Furthermore, population-based and patient-specific margins for internal motion were evaluated.ResultsThe clips located in the RU lobe showed the largest motion, (7.5±1.6) mm, which was significantly more than in the RM lobe (5.7±2.8 mm, p=0.019), RL lobe (4.8±3.3 mm, p=0.017), and hilar lobe (4.7±2.7 mm, p<0.001) in the cranial–caudal direction. The mean intraclass correlation coefficient values between the clip and diaphragm motion were 0.915, 0.735, 0.678, 0.670, and the mean Diff values between them were 0.1±0.8 mm, 2.3±1.4 mm, 3.1±2.0 mm, 2.4±1.5 mm, when clips were located in the RU lobe, RM lobe, RL lobe, and hilar lobe, respectively. The clip and diaphragm motions had high concordance when clips were located in the RU lobe. Internal margin can be reduced from 5 mm in the cranial–caudal direction based on patient population average and to 3 mm based on patient-specific margins.ConclusionsThe motion magnitude of clips varied significantly depending on their location within the liver. The diaphragm was a more appropriate surrogate for tumor located in the RU lobe than for other lobes.

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Lipiodol versus diaphragm in 4D-CBCT-guided stereotactic radiotherapy of hepatocellular carcinomas

Abstract: Image-guidance combining lipiodol with 4D-CBCT enabled accurate localization of HCC and thus margin reduction. A major limitation was the degraded lipiodol contrast on 4D-CBCT.

Cited by 30 publications

References 22 publications

Target localization of 3D versus 4D cone beam computed tomography in lipiodol-guided stereotactic radiotherapy of hepatocellular carcinomas

Target localization of 3D versus 4D cone beam computed tomography in lipiodol-guided stereotactic radiotherapy of hepatocellular carcinomas

Estimation of effective imaging dose and excess absolute risk of secondary cancer incidence for four‐dimensional cone‐beam computed tomography acquisition

Observation of different tumor motion magnitude within liver and estimate of internal motion margins in postoperative patients with hepatocellular carcinoma

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