IGRT (Image-Guided Radiotherapy) uses x-rays and scans before and during radiation therapy to more precisely target tumors and reduce radiation exposure to healthy tissues. IGRT allows doctors to detect and correct errors in patient positioning and account for changes in tumor size or position during treatment. This improves accuracy and allows higher radiation doses to tumors or reduced margins around tumors, lowering toxicity risks and improving patient outcomes and quality of life. While requiring additional resources, IGRT has become a standard part of radiation therapy by improving precision and reducing uncertainties.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
1.Aim of Radiotherapy
The goal of radiotherapy is to deliver a prescribed dose of radiation to the Target while sparing surrounding Healthy tissues to the largest extent possible
2.Organ Motion
Intra-fraction motion
during the fraction
Heartbeat
Swallowing
Coughing
Eye movement
Inter-fraction motion
- in between the fractions
Tumour change
Weight gain/loss
Positioning deviation
Breathing
Bowel and rectal filling
Bladder filling
Muscle relaxation/tension
3. Respiratory motion affects:
Respiratory motion affects all tumour sites in the thorax, abdomen and Pelvis. Tumours in the Lung, Liver, Pancreas, Oesophagus, Breast, Kidneys, prostate
Tumour displacement varies depending on the site and organ Location
Lung tumours can move several cm in any direction during irradiation
It is most prevalent and prominent in Lung cancers
4. Problems associated with respiratory motion during RT
Image acquisition limitations
Treatment planning limitations
Radiation delivery limitations
5. Methods to Account for Respiratory Motion
1. Motion encompassing methods
2. Respiratory gating methods
3. Breath hold methods
4. Forced shallow breathing with abdominal compression
5. Real-time tumor tracking methods
Summary:
The management of respiratory motion in radiation oncology is an evolving field
IGRT provides a solution for combating organ motion in radiotherapy
Delivering higher dose to tumor and less dose to normal tissue.
Limited clinical studies, needs to be studied further
IGRT – the future of radiotherapy
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
1.Aim of Radiotherapy
The goal of radiotherapy is to deliver a prescribed dose of radiation to the Target while sparing surrounding Healthy tissues to the largest extent possible
2.Organ Motion
Intra-fraction motion
during the fraction
Heartbeat
Swallowing
Coughing
Eye movement
Inter-fraction motion
- in between the fractions
Tumour change
Weight gain/loss
Positioning deviation
Breathing
Bowel and rectal filling
Bladder filling
Muscle relaxation/tension
3. Respiratory motion affects:
Respiratory motion affects all tumour sites in the thorax, abdomen and Pelvis. Tumours in the Lung, Liver, Pancreas, Oesophagus, Breast, Kidneys, prostate
Tumour displacement varies depending on the site and organ Location
Lung tumours can move several cm in any direction during irradiation
It is most prevalent and prominent in Lung cancers
4. Problems associated with respiratory motion during RT
Image acquisition limitations
Treatment planning limitations
Radiation delivery limitations
5. Methods to Account for Respiratory Motion
1. Motion encompassing methods
2. Respiratory gating methods
3. Breath hold methods
4. Forced shallow breathing with abdominal compression
5. Real-time tumor tracking methods
Summary:
The management of respiratory motion in radiation oncology is an evolving field
IGRT provides a solution for combating organ motion in radiotherapy
Delivering higher dose to tumor and less dose to normal tissue.
Limited clinical studies, needs to be studied further
IGRT – the future of radiotherapy
A summary of recent innovations in radiation oncology focussing on the priniciples of different techniques and their application. An overview of clinical results has also been given
Introduction to Medical Imaging, Basics of Medical Imaging, Fundamentals of Digital Image Processing, First chapter of Digital Image Processing Book by Rafael C. Gonzalez.
Image registration and data fusion techniques.pptx latest saveM'dee Phechudi
Medical imaging is the fundamental tool in conformal radiation therapy. Almost every aspect of patient management involves some form of two or three dimensional image data acquired using one or more modality.
Image data are now used for diagnosis and staging, for treatment planning and delivery and for monitoring patients after therapy.
Radiation Oncology in 21st Century - Changing the ParadigmsApollo Hospitals
Since its inception radiation therapy has been used as one of
the essential treatment options in the management of malignant and some benign tumors. With better understanding of tumor biology many new molecules have been added to the armamentarium of an oncologist. There is continuous improvement in surgical techniques with more emphasis on minimally invasive, organ- and function-preserving techniques. Neoadjuvant chemotherapy with or without addition of radiation therapy has helped surgeon downsizing the tumor and obtaining clearer margins.
Evolving Role of Radiation Therapists & Concernment of Risk Management in Mod...Subrata Roy
Radiation therapists, also known as therapeutic radiographers, work with oncology teams in order to determine the best course of radiation treatment for patients. They work under the guidance of a radiation oncologist and play a pivotal role in the planning and execution of radiation treatments. With additional training and experience, a therapist can become a certified medical dosimetrist. A dosimetrist calculates the correct dose of radiation treating cancer patients. Other therapists advance to administrative positions or to management positions such as a chief therapist or education director.
Calypso Medical's Prostate Cancer Treatment: Imaging Technology NewsCalypso Medical
A thorough explanation of image guided radiation therapy for prostate cancer, prostate cancer side effects associated with prostate radiation treatment, and how Calypso GPS for the Body technology greatly reduces the risk of side effects.
The vital importance of imaging techniques in radiation oncology now extends beyond diagnostic evaluation and treatment planning. Radiotherapy requires input from imaging for treatment planning and execution, when the treatment target is not located on the surface and, inspection and visual confirmation are not feasible. Traditional radiotherapy practices incorporate use of anatomic surface landmarks as well as radiologic correlation with 2D imaging in the form of port films or fluoroscopic imaging. Targets to be irradiated and normal tissues to be spared are delineated on CT scans in the planning process. Recent technical advances have enabled the integration of various imaging modalities into the everyday practice of radiotherapy directly at the linear accelerator. IGRT seeks to address geometric uncertainties in dose placement for target and normal tissues. It has become a routine part of current RT practice. Safe application of IGRT technology requires additional training and careful integration into the clinical process. IGRT reveals changes in anatomy during treatment which challenges conventional practices. IGRT facilitates the precise application of specialized irradiation techniques with narrow safety margins to radiosensitive organs.
Advances of Radiation Oncology in CancManagement: Vision for Role of Theranos...CrimsonpublishersCancer
Significant computational and technological advances in radiation therapy have enhanced our ability to more accurately plan and deliver increasing doses of radiation therapy to limited target volumes in many patients with cancer. Recent developments on magnetic resonance on-line imaging and use of implanted markers allow more precise on-time tumor localization with lower doses delivered to surrounding organs at risk leading to less treatment morbidity. Biological markers and molecular imaging (theranostics) will add new dimensions and precision to radiation therapy techniques. Nanoparticles are promising tools in therapeutic programs. Further research in efficacy, safety, cost utility (value) and institution of robust quality assurance programs will be necessary to optimize these contributions in clinical practice.
1. THE RATIONALE AND BENEFITS OF IMAGE-GUIDED
RADIOTHERAPY
Written by Melissa McClement
Application Specialist - Oncology, Tecmed Africa
April 2013
2. INTRODUCTION
The vital importance of imaging techniques in radiation oncology now extends
beyond diagnostic evaluation and treatment planning.
IGRTis currently a solid tool to tackle the problemof radiotherapy accuracy
(reduction in systematic errors).
Imaging is central to radiation oncology practice, with advances in radiation
oncology occurring in parallel to advances in imaging. Targets to be irradiated
and normaltissues to be spared are delineated on CT scans in the planning
process. Recent technical advances haveenabled the integration of various
imaging modalities into the everyday practiceof radiotherapy directly at the
linear accelerator.
IGRTis used to delineate target volume and organs at risk. Identify and correct
problems arising frominter- and intrafractional variation in patient setup,
anatomy, target volume and organs at risk.
3. WHATIS IGRT?
IGRT(Image-Guided Radiotherapy)is a way of using x-rays and scans before
and during radiotherapy treatment.
The radiation treatment units are now recognized as state-of-the-artrobotics
capable of three-dimensional softtissueimaging immediately before, during or
after radiation delivery, improving the localization of the target at the time of
radiation delivery, to ensurethat radiation therapy is delivered as planned.
Frequent imaging in the treatment room during a courseof radiation therapy
with decisions made on the basis of imaging, is referred to as IGRT.
IGRTcan broaden the application of proven therapies, and also permit new
therapies that are intolerant to geometric imprecision. Itenables the
application of special radiotherapeutic techniques with narrow safety margins
in the vicinity of radiosensitiveorgans.
IGRTuses advanced imaging techniques to verify patient and tumour position.
Knowing exactly where the tumour is, allows clinicians to reduce the volume of
tissueirradiated, targeting only the tumour and sparing the surrounding
normal tissue.
Anatomical changes that take place over the courseof radiotherapy, such as
weight loss and tumour shrinkagecan be detected as they occur and can be
accounted for in dosimetric calculations. Particularly during courses of
treatment extending over a number of weeks, substantialchanges can occur;
with no modification of the original treatment plan, there may be pronounced
deviations in dosedistribution, tumour control, and the likelihood of adverse
effects.
IGRTis very important in the following circumstances:
- Modern high-precision techniques with individual dose distribution
- Escalation of dosein the target volume
- Sparing of adjacentradiosensitiveorgans
4. In these situations small deviations in positioning can lead to large deviations
in dose distribution.
ORGANMOBILITY
The mobility of organs is a variable. Even with perfect positioning of skeletal
structures, theposition of the kidney, to name but one organ, can vary up to
severalcentimeters.
In the case of ventral displacement, radiotherapy of the para-aortic lymph
nodes can result in renal damage.
In the thorax, the oesophagus can show enormous variation in position. A
highly conformaltreatment plan that does not involvetargeting of the whole
mediastinum is sensitiveto this lateral displacement of the oesophagus.
In radiotherapy of the prostate, variation in the filling status of the rectum can
have a considerableeffect on the prostatedose and on rectal exposure. In the
case of high risk prostate cancers, the desired therapeutic doseis as high as
80Gy. To minimize acute and chronic gastrointestinal toxicity, the rectum is
spared by means of techniques such as intensity- modulated radiotherapy or
volumetric modulated arc therapy. An excessively full rectum is displaced
forward into the high-dosezone, possibly resulting in much higher exposureof
the anterior rectal wall. With image guidance this can be recognized in time
and the treatment can be carried out later under better conditions.
ANATOMICVARIATIONS DURING TREATMENT
As well as weight loss, changes in tumour volumecan also have a significant
impact. Lymphomas, for instance, may decrease rapidly in sizeafter the
commencement of radiotherapy. Should such a lymphoma lie directly
adjacent to a radiosensitivestructure, tumour shrinkagemay reduce
attenuation of the x-ray beam and conceivably lead to increased exposure of
5. the neighbouring entity. Growth in tumour sizeduring radiotherapy also has
consequences. An increase in volume owing to an inflammatory reaction or
bleeding may lead to expansion of the tumour out of the target area, so that it
does not receive the envisaged dose. If true tumour progression occurs during
a courseof irradiation, consideration should be given to discontinuing
treatment. Without image guidance in such a situation, the treatment would
be continued and the patient subjected to ineffective therapy with
inappropriateexposure to radiation.
PATIENTBENEFITS
Through more precisetargeting of the beam, dosagelevels can be increased
and target volumes can be reduced - so tumours get a higher dose of radiation
and healthy surrounding tissues getvery little. Irradiating less normal tissue
reduces the toxicity of radiotherapy, improving the patient's quality of life. In
some cases, improved targeting may make it possibleto deliver higher
radiation doses to the tumour and thereby increase the likelihood of local
tumour control.
Increased precision and accuracy of radiotherapy are expected to augment
tumour control, reduce incidence and severity of toxic effects after
radiotherapy, and facilitate development of moreefficient shorter schedules
than currently available.
State-of-the-artmotion management techniques allow patient to breathe
naturally during treatment sessions, increasing treatmentaccuracy, reducing
stress and increasing patient comfort.
Thus for the patient, IGRTincreases both the quality and probability of
successfultreatment.
6. IGRTPROCESSES
IGRTreduces, but does not eliminate geometric uncertainties. Reduced
geometric uncertainties may allow reduced PTV margins. But, that being said,
there are parallel or related processes to this: IGRThas to be the treatment
method and quality assuranceor uncertainty management must be in place.
Generation 1 technology includes kV imaging (such as Brainlab's ExacTrac x-
ray), and Portal Imaging Devices. Generation 2 technology includes kV imaging
with On Board Imagers (OBI) and Cone- Beam CT's (CBCT).
OBI is fully automated real-time imaging systemwhich enables clinicians to
pinpoint tumour sites, adjustpositioning, and complete a treatment all within
the standard time slot. OBI operates along 3 axes of motion for optimum
positioning. The OBI is capable of radiographic 2D imaging, fluoroscopy and 3D
CBCT for fine tuning patient position.
After positioning the patient, the image is acquired. This image is aligned to
the referenceimage used in planning. The error is estimated, and if larger
than the tolerance, adjustments aremade.
Positioning is a crucial factor. Accuracy and reproducibility of position are
strongly dependent on the anatomic region involved and on the positioning
aids used. Positioning methods depend on surfacemarkings, butthe actual
position inside the body of, for instance, a lung tumour or an abdominal organ
can change considerably.
Indexed immobilization reduces set-up times and ensures reproducibility.
Where the dose of IGRTis concerned, currently it is not possibleto compareor
combine effective doses fromimaging and therapeutic procedures. The
American Association of Physicists in Medicine states: "Becausethis
comparison appears to be of great interest to the therapy community, we
consider that theoretical and/or empirical estimates of effective dose fromthe
therapy beam during treatment should be made".
7. INTEGRATIONINTO CLINICAL RADIOTHERAPY
IGRTis a complex modality. Itrequires special technical facilities and
represents a challenge in terms of financial and personnelresources. The
currentstandard consists in reducing the variations that occur to a minimum
and accounting for them when selecting safety margins.
According to many, IGRTdoes not to be done on every patient. In my opinion,
it should. Yes, there are certain anatomical sites, mentioned earlier, which are
very proneto movement, but each and every treatment site, each and every
patient deserves to havethe most preciseand correcttreatment possible. This
entails that each and every patient should have IGRTif there is the capability.
The additional doseenables narrower safety margins and guarantees precise
administration of the therapeutic radiation at the correct site, the overall
exposurewill be lower and the risk to the patient smaller. A reduction of
safety margins can reduce the exposureof adjacent structures and thus lower
the likelihood of adverseeffects.
8. CONCLUSION
The whole chain of interventions in the RT process should be prospectively
assessed. This is particularly important becauseother steps in the RT process
(eg contouring or valid measurements of toxicity) are at least as important as
high geometric precision.
IGRTseeks to address geometric uncertainties in doseplacement for target
and normaltissues. Ithas become a routine part of currentRT practice. Safe
application of IGRTtechnology requires additional training and careful
integration into the clinical process. IGRTreveals changes in anatomy during
treatment which challenges conventional practices.
Developments in medical imaging are integral to radiation oncology, both for
design of treatment plans and to localise the target for precise administration
of radiation. At planning, definition of the tumour and healthy tissueis based
on CT. At treatment, 3D softtissue imaging can also be used to localise the
target . These developments allow changes in tumour position, sizeand shape
that take place during radiotherapy to be measured and accounted for to
boostgeometric accuracy and precision of radiation delivery.
IGRTfacilitates the precise application of specialized irradiation techniques
with narrow safety margins to radiosensitiveorgans.
9. REFERENCES
1) Image- Guided Radiotherapy: A New dimension in Radiation Oncology.
Sterzing, F. Engenhart - Cabillic, R., Flentje, M. et al.
www.ncbi.nlm.nih.gov/pmc/articles/PMC3097488/
2)ImageGuided Radiation Therapy: Benefits and Limitations. Khan, F.
Professor University of Minnesota, Minneapolis, Minnesota.
3) Advances in Image-Guided Radiation Therapy. Dawson, L. and Jaffray, D.
jco.ascopubs.org/content/25/8/938.abstract
4) ImageGuided Radiotherapy: Rationale, Benefits and Limitations. Dawson,
L. and Sharpe, M. www.ncbi.nlm.nih.gov/pubmed/17012047
5) IGRTTreatment Process
www.varian.com/us/oncology/treatments/treatment_techniques/IGRT/
benefits.html#
6) ImageGuided Radiation Therapy: A refresher. Jaffray, D. Princess
MargaretHospital / Ontario Cancer Institute, University of Toronto.
7) Whatis ImageGuided Radiotherapy? www.cancerresearchuk.org/cancer-
help/about-cancer/cancer questions/what-is-image-guided-
radiotherapy#benefits.