A (short) history of image-guided radiotherapy

doi:10.1016/j.radonc.2007.11.023

Radiotherapy and Oncology

Volume 86, Issue 1, January 2008, Pages 4-13

https://doi.org/10.1016/j.radonc.2007.11.023 Get rights and content

Abstract

Progress in radiotherapy is guided by the need to realize improved dose distributions, i.e. the ability to reduce the treatment volume toward the target volume and still ensuring coverage of that target volume in all dimensions. Poor ability to control the tumour’s location limits the accuracy with which radiation can be delivered to tumour-bearing tissue. Image-guided radiation therapy (IGRT) aims at in-room imaging guiding the radiation delivery based on instant knowledge of the target location and changes in tumour volume during treatment. Advancements are usually not to be attributed to a single event, but rather a combination of many small improvements that together enable a superior result. Image-guidance is an important link in the treatment chain and as such a major factor in this synergetic process. A historic review shows that many of the so-called new developments are not so new at all, but did not make it into mainstream radiotherapy practice at that time. Recent developments in improved IT infrastructures, novel irradiation techniques, and better knowledge of functional and morphologic information may have created the need and optimal environment to revive the interest in IGRT.

Section snippets

Some clinical perspectives on IGRT

The history of radiation oncology follows a distinct path of evolutions driven by the willingness to improve health care and providing optimal treatment quality for every patient. Radiation oncology represents a perfect example of evolution theory in that the most adapted technology survived. Unfortunately, herein lies one of the major frustrations of the discipline as developments have been introduced gradually, hampering randomised trials proving an evidence-based benefit with clinically

Technological development of image-guidance in radiotherapy

When reviewing literature it becomes clear that although without doubt some kind of IGRT must have been developed in the early days of kV-therapy, a generally accepted “culture” of IGRT was non-existing until the last decades of the previous century. In general practice, the emphasis of positioning accuracy was mostly focussed towards immobilization and applying conservative margins ensuring coverage of the target volume, rather than imaging. To quote Perez and Brady: “Therefore in fractionated

Currently available image-guidance techniques

As this is a review on IGRT, immobilization techniques and margin recipes will not be covered. Yet, it is important to realize that in order to obtain its full potential, IGRT will need to be combined optimally with both concepts: immobilization devices to help the patient maintain a certain position (IGRT has shown that immobilization techniques on their own are no guarantee for high accuracy [62], [76], [77], [78]); and margins counteracting inter-observer variability in volume delineation,

Future perspectives

The steep dose gradients encountered in IMRT and SBRT have encouraged the research in IGRT as the need for very high precision in target localization became apparent. Indeed studies demonstrating the necessity for in-room image-guidance in daily practice are emerging [62]. This development will continue with the current interest in proton and heavy ion therapy where the high physical and (possibly) radiobiological selectivity demands technological solutions for a reliable monitoring of dose

Summary

Over the last 50–60 years treatment volumes have been reduced stepwise and with success: kV X-ray units were replaced by tele-Cobalt and then linear accelerators; large rectangular fields were replaced by smaller fields shaped to accord with the particular features in the individual patient; conformity increased with IMRT, and delivering partial tumour boosts became realistic. These technical developments have been implemented successfully in the clinic because of greater ability to define the

References (114)

C.C. Ling et al.
From IMRT to IGRT: frontierland or neverland?
Radiother Oncol
(2006)
L. Xing et al.
Overview of image-guided radiation therapy
Med Dosim
(2006)
I. Rabinowitz et al.
Accuracy of radiation field alignment in clinical practice
Int J Radiat Oncol Biol Phys
(1985)
J.E. Marks et al.
The effect of immobilisation on localisation error in the radiotherapy of head and neck cancer
Clin Radiol
(1976)
A. Pollack et al.
Dosimetry and preliminary acute toxicity in the first 100 men treated for prostate cancer on a randomized hypofractionation dose escalation trial
Int J Radiat Oncol Biol Phys
(2006)
E.H. Pow et al.
Xerostomia and quality of life after intensity-modulated radiotherapy vs. conventional radiotherapy for early-stage nasopharyngeal carcinoma: Initial report on a randomized controlled clinical trial
Int J Radiat Oncol Biol Phys
(2006)
G.H. Fletcher
Hypofractionation: lessons from complications
Radiother Oncol
(1991)
D. Harrison et al.
Hypofractionation reduces the therapeutic ratio in early glottic carcinoma
Int J Radiat Oncol Biol Phys
(1988)
Y. Nagata et al.
Clinical outcomes of a phase I/II study of 48 Gy of stereotactic body radiotherapy in 4 fractions for primary lung cancer using a stereotactic body frame
Int J Radiat Oncol Biol Phys
(2005)
D. Thorwarth et al.
Hypoxia dose painting by numbers: a planning study
Int J Radiat Oncol Biol Phys
(2007)

C.C. Ling et al.

Towards multidimensional radiotherapy (MD-CRT): biological imaging and biological conformality

Int J Radiat Oncol Biol Phys

(2000)

S.M. Bentzen

Theragnostic imaging for radiation oncology: dose-painting by numbers

Lancet Oncol

(2005)

W.A. Tome et al.

Selective boosting of tumor subvolumes

Int J Radiat Oncol Biol Phys

(2000)

J.O. Deasy

Partial tumor boosts: even more attractive than theory predicts?

Int J Radiat Oncol Biol Phys

(2001)

J.C. Chu et al.

Patterns of change in the physics and technical support of radiation therapy in the USA 1975–1986

Int J Radiat Oncol Biol Phys

(1989)

R.W. Byhardt et al.

Weekly localization films and detection of field placement errors

Int J Radiat Oncol Biol Phys

(1978)

L.J. Verhey et al.

Precise positioning of patients for radiation therapy

Int J Radiat Oncol Biol Phys

(1982)

P.J. Biggs et al.

A diagnostic X ray field verification device for a 10 MV linear accelerator

Int J Radiat Oncol Biol Phys

(1985)

M. Van Herk et al.

A matrix ionisation chamber imaging device for on-line patient setup verification during radiotherapy

Radiother Oncol

(1988)

W. De Neve et al.

Routine clinical on-line portal imaging followed by immediate field adjustment using a tele-controlled patient couch

Radiother Oncol

(1992)

A. Ezz et al.

Daily monitoring and correction of radiation field placement using a video-based portal imaging system: a pilot study

Int J Radiat Oncol Biol Phys

(1992)

A. Bel et al.

Setup deviations in wedged pair irradiation of parotid gland and tonsillar tumors, measured with an electronic portal imaging device

Radiother Oncol

(1995)

M. Van Herk et al.

Inclusion of geometric uncertainties in treatment plan evaluation

Int J Radiat Oncol Biol Phys

(2002)

F. Van den Heuvel et al.

Clinical application of a repositioning scheme, using gold markers and electronic portal imaging

Radiother Oncol

(2006)

A.T. Redpath et al.

CT-guided intensity-modulated radiotherapy for bladder cancer: isocentre shifts, margins and their impact on target dose

Radiother Oncol

(2006)

F. Van den Heuvel et al.

Clinical implementation of an objective computer-aided protocol for intervention in intra-treatment correction using electronic portal imaging

Radiother Oncol

(1995)

D.S. Fritsch et al.

Core-based portal image registration for automatic radiotherapy treatment verification

Int J Radiat Oncol Biol Phys

(1995)

D.A. Jaffray et al.

Flat-panel cone-beam computed tomography for image-guided radiation therapy

Int J Radiat Oncol Biol Phys

(2002)

D. Verellen et al.

Quality assurance of a system for improved target localization and patient set-up that combines real-time infrared tracking and stereoscopic X-ray imaging

Radiother Oncol

(2003)

D. Verellen et al.

Optimal control of set-up margins and internal margins for intra- and extracranial radiotherapy using stereoscopic kilovoltage imaging

Cancer Radiother

(2006)

G. Soete et al.

Setup accuracy of stereoscopic X-ray positioning with automated correction for rotational errors in patients treated with conformal arc radiotherapy for prostate cancer

Radiother Oncol

(2006)

N. Linthout et al.

Assessment of secondary patient motion induced by automated couch movement during on-line 6 dimensional repositioning in prostate cancer treatment

Radiother Oncol

(2007)

M. Guckenberger et al.

Precision required for dose-escalated treatment of spinal metastases and implications for image-guided radiation therapy (IGRT)

Radiother Oncol

(2007)

H. Shirato et al.

Four-dimensional treatment planning and fluoroscopic real-time tumor tracking radiotherapy for moving tumor

Int J Radiat Oncol Biol Phys

(2000)

H. Shirato et al.

Physical aspects of a real-time tumor-tracking system for gated radiotherapy

Int J Radiat Oncol Biol Phys

(2000)

M.J. Murphy et al.

The effectiveness of breath-holding to stabilize lung and pancreas tumors during radiosurgery

Int J Radiat Oncol Biol Phys

(2002)

D. Verellen et al.

Importing measured field fluences into the treatment planning system to validate a breathing synchronized DMLC-IMRT irradiation technique

Radiother Oncol

(2006)

T.R. Mackie et al.

Image guidance for precise conformal radiotherapy

Int J Radiat Oncol Biol Phys

(2003)

L.N. McDermott et al.

Anatomy changes in radiotherapy detected using portal imaging

Radiother Oncol

(2006)

P.Y. Song et al.

A comparison of four patient immobilization devices in the treatment of prostate cancer patients with three dimensional conformal radiotherapy

Int J Radiat Oncol Biol Phys

(1996)

J. Wulf et al.

Stereotactic radiotherapy of extracranial targets: CT-simulation and accuracy of treatment in the stereotactic body frame

Radiother Oncol

(2000)

M. van Zijtveld et al.

Dosimetric pre-treatment verification of IMRT using an EPID; clinical experience

Radiother Oncol

(2006)

D. Vetterli et al.

Daily organ tracking in intensity-modulated radiotherapy of prostate cancer using an electronic portal imaging device with a dose saving acquisition mode

Radiother Oncol

(2006)

Y. Takai et al.

Development of a new linear accelerator mounted with dual X-ray fluorosocpy using amorphous silicon flat panel X-ray sensors to detect a gold seed in a tumor at real treatment position

Int J Radiat Oncol Biol Phys

(2001)

A.S. Shiu et al.

Technique for verifying treatment fields using portal images with diagnostic quality

Int J Radiat Oncol Biol Phys

(1987)

I.C. Gibbs et al.

Image-guided robotic radiosurgery for spinal metastases

Radiother Oncol

(2007)

K.M. Langen et al.

Organ motion and its management

Int J Radiat Oncol Biol Phys

(2001)

K. Kuriyama et al.

A new irradiation unit constructed of self-moving gantry-CT and linac

Int J Radiat Oncol Biol Phys

(2003)

M. Uematsu et al.

Intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy for lung or liver cancers with a fusion of CT and linear accelerator (FOCAL) unit

Int J Radiat Oncol Biol Phys

(2000)

J. Pouliot et al.

Low-dose megavoltage cone-beam CT for radiation therapy

Int J Radiat Oncol Biol Phys

(2005)

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Magnetic resonance-guided radiation therapy (MRgRT) utilization is rapidly expanding worldwide, driven by advanced capabilities including continuous intrafraction visualization, automatic triggered beam delivery, and on-table adaptive replanning (oART). Our objective was to describe patterns of 0.35Tesla(T)-MRgRT (MRIdian) utilization in the United States (US) among early adopters of this novel technology.
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Seventeen systems at 16 centers delivered 5736 courses and 36,389 fractions (fraction details unavailable for 1223 cobalt courses), of which 21.1% were adapted. Ultra-hypofractionation (UHfx) (1–5 fractions) was used in 70.3% of all courses. At least one adaptive fraction was used for 38.5% of courses (average 1.7 adapted fractions/course), with higher oART use in UHfx dose schedules (47.7% of courses, average 1.9 adapted fractions per course). The most commonly treated organ sites were pancreas (20.7%), liver (16.5%), prostate (12.5%), breast (11.5%), and lung (9.4%). Temporal trends show a compounded annual growth rate (CAGR) of 59.6% in treatment courses delivered, with a dramatic increase in use of UHfx to 84.9% of courses in 2020 and similar increase in use of oART to 51.0% of courses.
This is the first comprehensive study reporting patterns of utilization among early adopters of MRIdian in the US. Intrafraction MR image-guidance, advanced motion management, and increasing adoption of adaptive radiation therapy has led to a substantial transition to ultra-hypofractionated regimens. 0.35 T-MRgRT has been predominantly used to treat abdominal and pelvic tumors with increasing use of on-table adaptive replanning, which represents a paradigm shift in radiation therapy.
Pediatric radiotherapy for thoracic and abdominal targets: Organ motion, reported margin sizes, and delineation variations – A systematic review
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For radiotherapy of thoracic and abdominal tumors safety margins are applied to address geometrical uncertainties caused by e.g. set-up errors, organ motion and delineation variability. For pediatric patients no standardized margins are defined. Moreover, studies on these geometrical uncertainties are relatively scarce. Therefore, this systematic review presents an overview of organ motion, applied margin sizes and delineation variability in patients <18 years. A search from January 2000 to March 2021 in Medline, Embase, Web of Science, ClinicalTrials.gov and the International Trials Registry Platform resulted in the inclusion of 117 studies reporting on organ motion, margin sizes and/or delineation variability. Studies were heterogeneous concerning age, tumor types, the use of general anesthesia, imaging modalities; image guidance techniques were reported in 39% of the studies. Inter- and intrafractional motion as reported for different organs was largest in cranio-caudal direction and ranged from −9.1 to 10.0 mm and −4.4 to 19.5 mm, respectively. Motion quantification methodologies differed between studies regarding measures of displacement and definitions of motion direction. Reported CTV–PTV margins varied from 3 to 20 mm for both thoracic and abdominal targets, and for spinal and pelvic from 3to 15 mm and 3 to 10 mm, respectively. Studies reported wide variation in interobserver variability of target volume delineation, which may affect dose distributions to both target volumes and organs at risk. Results of this review indicate possible reduction of margin sizes for children, however, wide variation in organ motion and delineation variability caused by differences in methodologies and outcomes hamper the use of standardized margins.
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Citation Excerpt :
Recently, the FLAME randomized phase III trial demonstrated that focal radiotherapy boost to the DIL in addition to standard prostate radiotherapy can improve biochemical disease-free survival in patients with localized prostate cancer [7]. Biology-guided radiotherapy (BgRT) (RefleXion Medical Inc., Hayward, USA) is a novel technology that uses positron emission tomography (PET) from patient’s cancer cells to guide radiation treatment [8–10]. Potential advantages of this technique include real-time tracking of a tumour, which can improve the accurate targeting of the tumour, and the ability to treat many tumours in a single session [11–14].
Biology-guided radiotherapy (BgRT) delivers dose to tumours triggered from positron emission tomography (PET) detection. Prostate specific membrane antigen (PSMA) PET uptake is abundant in the dominant intraprostatic lesion (DIL). This study investigates the feasibility of BgRT to PSMA-avid subvolume in the prostate region.
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ReviewA (short) history of image-guided radiotherapy

Abstract

Section snippets

Some clinical perspectives on IGRT

Technological development of image-guidance in radiotherapy

Currently available image-guidance techniques

Future perspectives

Summary

Radiother Oncol

Med Dosim

Int J Radiat Oncol Biol Phys

Clin Radiol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Lancet Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Cancer Radiother

Radiother Oncol

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Review
A (short) history of image-guided radiotherapy