Abstract
Purpose
The purpose of this work was to investigate the potential of lipiodol as a direct tumor surrogate alternative to the diaphragm surrogate on four-dimensional cone-beam computed tomography (4D-CBCT) image guidance for stereotactic radiotherapy of hepatocellular carcinomas.
Methods
A total of 29 hepatocellular carcinomas (HCC) patients treated by stereotactic radiotherapy following transarterial chemoembolization (TACE) with homogeneous or partial defective lipiodol retention were included. In all, 4–7 pretreatment 4D-CBCT scans were selected for each patient. For each scan, either lipiodol or the diaphragm was used for 4D registration. Resulting lipiodol/diaphragm motion ranges and position errors relative to the reconstructed midventilation images were analyzed to obtain the motion variations, and group mean (ΔM), systematic (Σ), and random (σ) errors of the treatment setup.
Results
Of the lipiodolized tumors, 55 % qualified for direct localization on the 4D-CBCT. Significant correlations of lipiodol and diaphragm positions were found in the left–right (LR), craniocaudal (CC), and anteroposterior (AP) directions. ΔM and σ obtained with lipiodol and diaphragm were similar, agreed to within 0.5 mm in the LR and AP, and 0.3 mm in the CC directions, and Σ differed by 1.4 (LR), 1.1 (CC), and 0.6 (AP) mm. Variations of diaphragm motion range > 5 mm were not observed with lipiodol and in one patient with diaphragm. The margin required for the tumor prediction error using the diaphragm surrogate was 6.7 (LR), 11.7 (CC), and 4.1 (AP) mm.
Conclusion
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.
Zusammenfassung
Hintergrund
Ziel dieser Studie war es, das Potential von Lipiodol als direktes Tumorsurrogat alternativ zum Zwerchfellsurrogat für die vierdimensionale Cone-beam-Computertomographie (4D-CBCT) in der stereotaktischen Strahlentherapie von hepatozellulären Karzinomen (HCC) zu analysieren.
Methoden
Eingeschlossen wurden 29 HCC-Patienten, die mittels stereotaktischer Strahlentherapie nach transarterieller Chemoembolisation (TACE) mit homogener oder teilweise defekter Lipiodolspeicherung behandelt wurden. Für jeden Patienten wurden 4–7 4D-CBCT-Scans vor der Behandlung ausgewählt. Für jeden Scan wurde eine 4-D-Registrierung unter Verwendung von Lipiodol oder Zwerchfell als Registrierungsmaske durchgeführt. Die resultierenden Lipiodol- bzw. Zwerchfellbewegungen und Positionsfehler relativ zu den rekonstruierten MidP-Bildern (MidV, midventilation images) wurden analysiert, um Veränderungen in den Bewegungen, Gruppen- (ΔM), systematische (Σ) und zufällige (σ) Fehler in der Patientenlagerung sowie notwendige Sicherheitssäume (M) beurteilen zu können.
Ergebnisse
Für die direkte Lokalisierung auf den 4D-CBCT waren 55 % der Tumoren mit Lipiodol geeignet. Signifikante Korrelationen von Lipiodol- und Zwerchfellpositionen wurden in links-rechts (LR), kraniokaudalen (CC) und anteroposterioren (AP) Richtungen gefunden. Die ΔM- und σ-Fehler mit Lipiodol und Zwerchfell stimmten mit Abweichungen von 0,5 mm in LR- und AP- sowie mit 0,3 mm in CC-Richtung überein; der Σ-Fehler unterschied sich um 1,4 mm (LR), 1,1 mm (CC) und 0,6 mm (AP). Veränderungen der Zwerchfellbewegung > 5 mm wurden bei keinem Patienten mit Lipiodol und bei einem Patienten mit Zwerchfell als Registrierungsmaske beobachtet. Der notwendige Sicherheitssaum, um den Tumorvorhersagefehler für das alleinige Zwerchfellsurrogat auszugleichen, betrug 6,7 mm (LR), 11,1 mm (CC) und 4,1 mm (AP).
Schlussfolgerung
Bildregistrierungsprotokolle mit Lipiodol in Kombination mit 4D-CBCT ermöglichen die genaue Lokalisierung von HCC und somit die signifikante Reduktion von Sicherheitssäumen. Haupteinschränkungen dieser Technik sind bereits abgebaute Lipiodolanreicherungen auf dem 4D-CBCT.
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M.K.H. Chan, V. Lee, CL. Chiang, F.A.S. Lee, G. Law, N.Y. Sin, K.L. Sui, F.C.S. Wong, S.Y. Tung, H. Luk, and O. Blanck state that there are no conflicts of interest. Part of the results of this work has been presented at the ESTRO 3rd forum.
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Chan, M., Lee, V., Chiang, C. et al. Lipiodol versus diaphragm in 4D-CBCT-guided stereotactic radiotherapy of hepatocellular carcinomas. Strahlenther Onkol 192, 92–101 (2016). https://doi.org/10.1007/s00066-015-0929-9
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DOI: https://doi.org/10.1007/s00066-015-0929-9
Keywords
- Image-guided radiotherapy
- 4D cone beam CT
- Stereotactic body radiotherapy
- Contrast media
- Planning techniques