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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

Table of Contents

Abstract Aims .

.2 2 .. 2 .. 3

Subject & Method Introduction

IGRT technology and its benefits .... 5 The modality used in IGRT Fluoroscopy CT CBCT MVCT Optical Tracking Clinical applications of IGRT Prostate Conclusion The references . .. . .. . 10 ..10 11 12 .12 .13 ..14 15 17 .19

RAD 462

Image Guided Radiotherapy

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

Abstract IGRT is the most advanced technology to track cancer and spare normal tissues. This advanced technology allows radiation to be delivered to tumors with more precision than was traditionally possible. The ability to define a more precise location of the tumor, means a smaller radiation field can be used, so there is less radiation damage done to normal tissue. This technology decreases the radiation dose to normal tissue, thus decreasing side effects and improving outcomes. Computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), ultrasound (US) and x-ray imaging may be used for IGRT. AIMS  Disscues the IGRT technology and its benefits.  List the modalities used in IGRT.  Identify the clinical application of IGRT. Subject & Method The data is obtained by secondary data from several websites and online journals. Introduction

The Image Guided Radiation Therapy (IGRT) is now widely appreciated in the radiotherapy community.
RAD 462 Image Guided Radiotherapy 2

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

Image guided radiation therapy is a major technical innovation of radiotherapy. It allows locating the tumor under the linear accelerator just before the irradiation, by direct visualization (3D mode soft tissue) or indirect visualization (2D mode and radio-opaque markers). The technical implementation of IGRT is done by very different complex devices. The most common modality is the cone beam CT, because it's available in any new accelerator. These advances allowed radiation oncologists to better see and target tumors, which have resulted in better treatment outcomes, more organ preservation and fewer side effects. IGRT enables patients to be repositioned to improve their setup accuracy, and the accuracy of their treatment, immediately before the radiation dose is delivered. IGRT produces planar images, on film or digital detectors, to image the bony anatomy and so verify the position of the treatment fields. This method assumes the position and shape of the tumor and critical surrounding normal tissues are fixed with respect to the bony anatomy, which is often not the case, and relies on planar megavoltage images which are not very clear. Both of these problems have been solved by the advent of IGRT in which kilovoltage imaging equipment, as used in diagnostic radiology, has been attached to the LINAC to produce planar images at the time of treatment which are superior to the traditional megavoltage images. This latest technology can also be used to generate conebeam CT (CBCT) images to visualize the tumour and surrounding healthy tissue and daily changes in shape
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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

and position of both immediately prior to each treatment. The use of IGRT, including CBCT, enables patients to be repositioned to improve their setup accuracy, and the accuracy of their treatment, immediately before the radiation dose is delivered.

IGRT technology and its benefits Guiding the placement of the treatment field is not a new concept. Since the advent of fractionated radiation therapy for the treatment of disease, techniques have been employed to help ensure the accurate placement of a treatment field. In general, at the time of 'planning' (whether a clinical mark up or a full simulation) the intended area for treatment is outlined by the radiation oncologist. Once the area of treatment was determined, marks were placed on the skin. The purpose of the ink marks was to align and position the patient daily for treatment to improve reproducibility of field placement. By aligning the markings with the radiation field (or its representation) in the radiation therapy treatment room, the correct placement of the treatment field could be identified. Over time, with improvement in technology light fields with cross hairs, isocentric lasers and with the shift to the practice of 'tattooing' - a procedure where
RAD 462 Image Guided Radiotherapy 4

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

ink markings are replaced with a permanent mark by the application of ink just under the first layer of skin using a needle in documented locations - the reproducibility of the patients setup improved. Delivery of radiation therapy requires a treatment team, including a radiation oncologist, therapeutic medical physicist, dosimetrist and radiation therapists. The radiation oncologist is a physician who evaluates the patient and determines the appropriate therapy or combination of therapies. The physician determines what area to treat and what dose to deliver. Together with the therapeutic medical physicist and the dosimetrist, the radiation oncologist determines what techniques to use to deliver the prescribed dose. The physicist and the dosimetrist then make detailed treatment calculations. Radiation therapists are specially trained technologists who acquire images and deliver the daily treatments.Regardint to IGRT, The equipment is operated by a radiation therapist, a highly trained technologist. The overall treatment plan is created and supervised by the radiation oncologist, a highly trained physician specializing in treating cancer with radiotherapy. The linear accelerator, are equipped with imaging technology so that the physician can image the tumor immediately before or even during the time radiation is delivered, while the patient is positioned on the treatment table. Using specialized computer software, these images are then compared to the images taken during simulation. Any necessary adjustments are then made to the patient's position and/or radiation beams in order to more
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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

precisely target radiation at the tumor and avoid healthy surrounding tissue. Computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), ultrasound (US) and x-ray imaging may be used for IGRT. there is no specific preparation for IGRT, other than the preparation for routine radiation therapy delivery

IGRT is used to treat tumors in areas of the body that are prone to movement, such as the lungs (affected by breathing) and prostate gland, as well tumors located close to critical organs and tissues. It is often used in conjunction with intensity-modulated radiation therapy (IMRT), an advanced mode of high-precision radiotherapy that utilizes computer-controlled x-ray accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. Local or regional control of a tumor is the ultimate goal of an overall treatment strategy, especially for a patient with cancer. Failure to achieve tumor control can result in a greater likelihood of developing distant metastases, continued tumor growth, severe debilitation or even death of the patient . IGRT also can be used to measure and correct positional errors for target and critical structures immediately prior to or during treatment delivery. The patient is localized in the treatment room in the same position as planned from the reference imaging dataset. An example of ThreeRAD 462 Image Guided Radiotherapy 6

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

dimensional (3D) IGRT would include localization of a cone-beam computed tomography (CBCT) dataset with the planning computed tomography (CT) dataset from planning. Similarly Two-dimensional (2D) IGRT would include matching planar kilovoltage (kV) radiographs fluoroscopy or megavoltage (MV) images with digital reconstructed radiographs (DRRs) from the planning CT. Before treatment, the patient is simulated on an Xray machine or CT scanner for treatment planning. The patients skin is marked with ink or a small tattoo at a specific point in 3-D space so that a treatment plan may be specifically designed to fit each patient. The images from simulation are sent to a computer brought back on a different for planning and the patient is day for the start of the actual treatments. Prior to each daily treatment, the radiation oncology team aligns the patient with room alignment lasers pointed at the patients skin marks. Traditionally, portal films were taken once a week to ensure that the patients skin marks are still in alignment with bony anatomy. The accuracy of traditional radiation therapy is five to 10 millimeters. With IGRT, daily setup error has been reduced to within one to two millimeters

RAD 462

Image Guided Radiotherapy

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

In addition, daily (instead of weekly) images are taken to assist with accuracy.

The goal of the IGRT process is to improve the accuracy of the radiation field placement, and to reduce the exposure of healthy tissue during radiation treatments. By improving precision and accuracy through IGRT, radiation is decreased to surrounding healthy tissues, allowing for increased radiation to the tumour for control. The clinical benefit for the patient is the ability to monitor and adapt to changes that may occur during the course of radiation treatment. Such changes can include tumour shrinkage or expansion, or changes in shape of the tumour and surrounding anatomy. The used modalities for IGRT Fluoroscopy Fluoroscopy is an imaging technique that uses a fluoroscope, in coordination with either a screen or image-capturing device to create real-time images of patients internal structures. Computed tomography (CT)
RAD 462 Image Guided Radiotherapy 8

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

A medical imaging method employing tomography where digital geometry processing is used to generate a three-dimensional image of the internal structures of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation. CT produces a volume of data, which can be manipulated, through a process known as windowing, in order to demonstrate various structures based on their ability to attenuate and prevent transmission of the incident X-ray beam. Conventional CT With the growing recognition of the utility of CT imaging in using guidance strategies to match treatment volume position and treatment field placement, several systems have been designed that place an actual conventional 2-D CT machine in the treatment room alongside the treatment linear accelerator. The advantage is that the conventional CT provides accurate measure of tissue attenuation, which is important for dose calculation. Cone beam cone-beam computed tomography (CBCT) based image guided systems have been integrated with medical linear accelerators to great success. With improvements in flatpanel technology, CBCT has been able to provide volumetric imaging, and allows for radiographic or fluoroscopic monitoring throughout the treatment process. Cone beam CT acquires many projections over then entire volume of interest in each projection. Using reconstruction strategies pioneered by Feldkamp, the 2D
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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

projections are reconstructed into a 3D volume analogous to the CT planning dataset. MVCT Megavoltage Computed Tomography is a medical imaging technique that uses the Megavoltage range of Xrays to create an image of bony structures or surrogate structures within the body. The original rational for MVCT was spurred by the need for accurate density estimates for treatment planning. Both patient and target structure localization were secondary uses. A test unit using a single linear detector, consisting of 75 cadmium tunstate crystals, was mounted on the linear accelerator gantry. The test results indicated a spatial resolution of .5m, and a contrast resolution of 5% using this method. While another approach could involve integrating the system directly into the MLA, it would limit the number of revolutions to a number prohibitive to regular use. Optical Tracking The use of a camera to relay positional information of objects within its inherent coordinate system by means of a subset of the electromagnetic spectrum of wavelengths spanning ultra-violet, visible, and infrared light. Optical navigation has been in use for the last 10 years within image guided surgery (neurosurgery, ENT, and orthopaedic) and has increased in prevalence within radiotherapy to provide real-time feedback through visual cues on graphical user interfaces (GUIs). For the latter, a method of calibration is used to align the cameras native coordinate system with that of the isocentric reference frame of the radiation treatment
RAD 462 Image Guided Radiotherapy 10

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

delivery room. Optically tracked tools are then used to identify the positions of patient reference set-up points and these are compared to their location within the planning CT coordinate system. A computation based on least-squares methodology is performed using these two sets of coordinates to determine a treatment couch translation that will result in the alignment of the patients planned isocenter with that of the treatment room. These tools can also be used for intrafraction monitoring of patient position by placing an optically tracked tool on a region of interest to either initiate radiation delivery (i.e. gating regimes) or action (i.e. repositioning).

Clinical application of IGRT Most cancers will benefit from treatments that are more accurate and precise. Tumors of the prostate, brain and head and neck region are treated using IGRT to ensure that delicate tissues such as the rectum, urethra, spinal cord and salivary glands remain away from the higher dose of radiation that is delivered to the tumor. At North Shore Radiation Therapy, IGRT is used in with other advanced technologies such as Stereotactic Radiosurgery, Respiratory Gating and IMRT (Intensity Modulated Radiation Therapy).

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Image Guided Radiotherapy

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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

Tumors of the brain, head and neck region fare well when treated using IGRT because the technology ensures that the delicate tissues, such as the spinal cord and salivary glands remain away from the high dose region. IGRT can ensure that the head and neck position is so precise that doses to the spinal cord and vital organs can be significantly reduced or eliminated. Lung and breast cancers will benefit from IGRT and other technologies such as Respiratory Gating and IMRT by taking breathing motion into consideration, and decreasing radiation doses to the lungs and heart. It has been shown that unnecessary radiation to these organs can create significant problems after treatment, such as secondary cancers.

PROSTATE When treating prostate cancer with IGRT, we see significant benefits. As the bladder fills and empties, the prostate moves, sometimes significantly. This means that the prostate will be in different positions for each day of radiation treatment. So before the treatment, IGRT is given to ensure a more precise delivery of radiation. Before the treatments begin, the urologist will implant small fiducial markers into the prostate utilizing a simple procedure to direct the radiation oncologist to
RAD 462 Image Guided Radiotherapy 12

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

the exact location of the prostate. During the treatment, state-of-the-art imaging will be used to locate these markers every day and the treatment machine will be realigned to ensure that the prostate is exactly where it should be during your treatment (See fig.1).
Pre-IMRT IMRT
Dose Sculpting

IMRT + IGRT
Dose Sculpting + Targeting

Improved Outcomes Reduced Side Effects

High Dose

Figure 1. an example of the benefits of IMRT/IGRT in prostate cancer treatment.

CONCLUSION

IGRT or Image Guided Radiation Therapy is the most advanced technology to track cancer and normal tissues and spare normal tissues. . This is very useful since tumors can move between treatments due to differences in organ filling or movements while breathing. These advances allowed radiation oncologists to better see and target tumors, which have resulted in better treatment outcomes, more organ preservation and fewer side effects.
RAD 462 Image Guided Radiotherapy 13

IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

IGRT decreases radiation dose to normal tissue, decreases side effects and improves outcomes. CT, MRI, PET, US, and x-ray imaging may be used for IGRT. At the beginning of each radiation therapy session, the patient is carefully positioned guided by the marks on the skin defining the treatment area. Devices may be used to help the patient maintain the proper position. Images are then taken using imaging equipment that is built into the radiation delivery machine or mounted in the treatment room. The physician then reviews the images and compares them to the images taken during simulation. The patient may be repositioned and additional imaging may be performed. After any necessary adjustments are made to the treatment plan and patient positioning, radiation therapy is then delivered. The image-guidance process may add up to five minutes to each radiation therapy session.

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Image Guided Radiotherapy

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IGRT article

[IMAGE GUIDED RADIOTEARPY (IGRT) ]

The references

 http://www.cancerradiation.com/index.php/external-beam-radiationtherapy-treatments/what-is-igrt

 http://en.wikipedia.org/wiki/Imageguided_radiation_therapy  http://www.radiologyinfo.org/en/info.cfm?pg=IGR T  http://www.northerncalprostatecare.com/index.php? option=com_content&view=article&id=24&Itemid =3  http://advancedradiationcenters.com/?p=whatisigrt

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Image Guided Radiotherapy

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