Sergej Schneider1,2,3, Sarah Stefanowicz1,3,4, Christina Jentsch1,4,5, Fabian Lohaus4, Chiara Valentini4, Esther G. C. Troost1,3,4,5,6, and Aswin L. Hoffmann1,3,4
1Oncoray – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany, 2Technische Universität Dresden, Carl Gustav Carus Faculty of Medicine, Dresden, Germany, 3Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany, 4Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, 5National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany, German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany, 6German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
Synopsis
Particle beam therapy (PBT) is extremely
sensitive to patient setup uncertainties and anatomical variations prior to and
during dose delivery. Organ motion mitigation strategies are hence required to
deliver the dose with high precision and accuracy. In this study, an MR- and
PBT-compatible patient-individualized abdominal corset was developed and tested
in 9 patients with abdominal cancer for its efficacy to reduce
respiratory-induced motion. Pancreas motion was analyzed with and without
corset by means of orthogonal 2D-cine and 4D-MRI.
Introduction
In particle beam therapy (PBT) respiratory-induced tumor
motion is commonly accounted for by the definition of an internal target volume1
to cover the tumor in all respiratory phases. Consequentially, also a
relatively large volume of healthy tissue surrounding the tumor is exposed to radiation.
An appropriate immobilization of the target volume can improve the sparing of
healthy tissues. Immobilization of target volumes located in the upper
gastro-intestinal tract has been accomplished through abdominal compression
bands or pressure plates. These, however, can exacerbate the proton beam range
uncertainties when these devices extend into the treatment fields, thereby
compromising an accurate dose delivery2. For this study, an MR-
and PBT-compatible patient-individualized abdominal corset was developed to
test its efficacy to reduce respiratory-induced pancreas motion as measured by
means of orthogonal 2D-cine and 4D-MRI.Methods
Nine
patients (6 female, 3 male; average age 72.9 ± 9.6 years)
with abdominal tumors of the pancreas (7 patients), gallbladder (1 patient), or
liver (1 patient) provided written informed consent to be included in a
clinical study (study number DRKS00010966) after study approval by the local
Ethics Committee. Patients were scanned by means of orthogonal 2D-cine (2 min
acquisition time) and 4D-MRI (9 min acquisition time) utilizing a balanced
steady-state free precession sequence. For 2D-cine MRI coronal and sagittal
slices were positioned at the pancreatic head. The 4D-MRI dataset was
reconstructed by retrospectively resorting a multi-slice 2D acquisition into 10
respiratory phases by amplitude based sorting3, thereby imaging the
full volume of the pancreas. Two MRI scans were acquired per patient, one without
and one with a patient-individualized abdominal corset to reduce respiratory
motion. The corset was manufactured from polyethylene (Orthopädie- und
Rehatechnik Dresden GmbH, Dresden, Germany) based on
an optical 3D-surface scan of the patient (Artec Eva®, Artec3D, Luxembourg, Luxemburg).
From the nine patients, eight orthogonal 2D-cine datasets and seven 4D-MRI
datasets were successfully acquired on a 3.0T MRI scanner (Ingenuity TF PET/MR
scanner, Philips Healthcare, Best, The Netherlands). The patients were scanned
in supine position on a flat tabletop using an anterior coil holder to avoid
anatomical deformations of the chest wall due to the weight of the receiver
coils. Pancreas motion was determined as center-of-mass displacement in three orthogonal
directions (inferior-superior (IS), anterior-posterior (AP), left-right (LR))
for both orthogonal 2D-cine and 4D-MRI (Fig. 1). The motion amplitude extracted
from the 2D-cine dataset was evaluated as the mean peak-to-peak amplitude M95,
for which the lower and upper 2.5 % of the data was discarded to reduce the
effect of possible outliers.Results
Orthogonal 2D-cine MRI showed that pancreas motion was dominant
in IS direction (Fig. 2). For the 8 patients analyzed, the abdominal corset reduced
the motion M95 in IS direction by in average 42 % (5 mm ± 3.7 mm
(standard deviation) without corset, 3.8 mm ± 1.1 mm with corset; p<0.05). Similarly, the patients’ intrafraction
motion variability decreased by 40 % (from in average 1.5 mm ± 0.4 mm to 0.9 mm
± 0.2 mm, p<0.01). Pancreas motion
in AP and LR direction was small without corset (1.5 mm ± 0.2 mm and 1.8 mm ± 0.7
mm for AP and LR, respectively) and was not significantly reduced by the use of
the corset (Fig. 2).
In general, 4D-MRI (Fig. 3) showed larger motion amplitudes
than 2D-cine MRI. For the 7 patients analyzed based on 4D-MRI, mean peak-to-peak
motion in IS direction was reduced from 8.6
mm ± 3.7 mm without corset to 5.0 mm ± 2.4 mm with corset (42 % reduction, p<0.05).Discussion
Both
orthogonal 2D-cine and 4D-MRI show that by use of a patient-individualized abdominal
corset, respiratory-induced pancreas motion as well as the patient’s
intrafraction motion variability can be significantly reduced in IS direction.
The slightly different results retrieved with 2D-cine and 4D-MRI can be
attributed to the different volume of the pancreas imaged in the respective
modality. However, the main effect explaining this difference seems to be the amplitude-based
sorting algorithm used for 4D-MRI, which naturally reflects larger motion
amplitudes.Conclusion
MRI-based motion analysis showed that respiratory-induced
pancreas motion could be significantly reduced in IS direction by the use of a patient-individualized
MR- and PTB-compatible abdominal corset. The results suggest that patients
would benefit from a patient-individualized abdominal corset allowing for
improved healthy tissue sparing due to the consequentially smaller margins
surrounding the target volume.Acknowledgements
No acknowledgement found.References
1 Chang JY, Zhang X, Knopf A et al. Consensus Guidelines for Implementing Pencil-Beam Scanning
Proton Therapy for Thoracic Malignancies on Behalf of the PTCOG Thoracic and
Lymphoma Subcommittee. Int J Radiat Oncol Biol Phys 2017; 99(1): 41-50.
2 Wroe AJ, Bush DA and Slater JD. Immobilization Considerations for Proton
Radiation
Therapy. Technol Cancer Res Treat 2014; 13: 217–226.
3 Von Siebenthal K, Székely G, Gamper U,
Boesiger P, Lomax A and Cattin P. 4D
MR imaging of respiratory organ motion its variability. Phys Med Biol 2007; 52: 1547–64.