RESUMO
Using Monte Carlo simulation and a realistic patient model, it is shown that the volume of healthy tissue irradiated at therapeutic doses can be drastically reduced using a combination of standard megavoltage and kilovoltage X-ray beams with a contrast agent previously loaded into the tumor, without the need to reduce standard treatment margins. Four-dimensional computed tomography images of 2 patients with a centrally located and a peripherally located tumor were obtained from a public database and subsequently used to plan robotic stereotactic body radiotherapy treatments. Two modalities are assumed: conventional high-energy stereotactic body radiotherapy and a treatment with contrast agent loaded in the tumor and a kilovoltage X-ray beam replacing the megavoltage beam (contrast-enhanced radiotherapy). For each patient model, 2 planning target volumes were designed: one following the recommendations from either Radiation Therapy Oncology Group (RTOG) 0813 or RTOG 0915 task group depending on the patient model and another with a 2-mm uniform margin determined solely on beam penumbra considerations. The optimized treatments with RTOG margins were imparted to the moving phantom to model the dose distribution that would be obtained as a result of intrafraction motion. Treatment plans are then compared to the plan with the 2-mm uniform margin considered to be the ideal plan. It is shown that even for treatments in which only one-fifth of the total dose is imparted via the contrast-enhanced radiotherapy modality and with the use of standard treatment margins, the resultant absorbed dose distributions are such that the volume of healthy tissue irradiated to high doses is close to what is obtained under ideal conditions.
Assuntos
Neoplasias Pulmonares/radioterapia , Radiocirurgia , Planejamento da Radioterapia Assistida por Computador , Radioterapia Guiada por Imagem , Relação Dose-Resposta à Radiação , Humanos , Neoplasias Pulmonares/diagnóstico , Método de Monte Carlo , Movimento (Física) , Órgãos em Risco , Intensificação de Imagem Radiográfica , Radiocirurgia/métodos , Dosagem Radioterapêutica , Radioterapia Guiada por Imagem/métodos , Resultado do TratamentoRESUMO
PURPOSE: In the present study we compared three different Stereotactic body radiation therapy (SBRT) treatment delivery techniques in terms of treatment time (TT) and their relation with intrafraction variation (IFV). Besides that, we analyzed if different clinical factors could have an influence on IFV. Finally, we appreciated the soundness of our margins. MATERIALS AND METHODS: Forty-five patients undergoing SBRT for stage I lung cancer or lung metastases up to 5 cm were included in the study. All underwent 4DCT scan to create an internal target volume (ITV) and a 5 mm margin was added to establish the planning target volume (PTV). Cone-beam CTs (CBCTs) were acquired before and after each treatment to quantify the IFV. Three different treatment delivery techniques were employed: fixed fields (FF), dynamically collimated arcs (AA) or a combination of both (FA). We studied if TT was different among these modalities of SBRT and whether TT and IFV were correlated. Clinical data related to patients and tumors were recorded as potential influential factors over the IFV. RESULTS: A total of 52 lesions and 147 fractions were analyzed. Mean IFV for x-, y- and z-axis were 1 ± 1.16 mm, 1.29 ± 1.38 mm and 1.17 ± 1.08 mm, respectively. Displacements were encompassed by the 5 mm margin in 96.1 % of fractions. TT was significantly longer in FF therapy (24.76 ± 5.4 min), when compared with AA (15.30 ± 3.68 min) or FA (17.79 ± 3.52 min) (p < 0.001). Unexpectedly, IFV did not change significantly between them (p = 0.471). Age (p = 0.003) and left vs. right location (p = 0.005) were related to 3D shift ≥2 mm. In the multivariate analysis only age showed a significant impact on the IFV (OR = 1.07, p = 0.007). CONCLUSIONS: The choice of AA, FF or FA does not impact on IFV although FF treatment takes significantly longer treatment time. Our immobilization device offers enough accuracy and the 5 mm margin may be considered acceptable as it accounts for more than 95 % of tumor shifts. Age is the only clinical factor that influenced IFV significantly in our analysis.