Variations in organ motion may be small (e.g. brain), larger and predictable (e.g. respiration or cardiac pulsation), or unpredictable (e.g. rectal and bladder filling). When treating lung tumours, the displacement of the CTV caused by respiration can be dealt with in several ways: by increasing the CTV-PTV margin eccentrically to include all CTV positions during a respiratory cycle; by using suspended respiration with a technique such as the active breathing control (ABC) device; or by delivery of radiation using gating or respiratory correlated CT scanning and treatment. Protocols for minimising effects on the CTV of variations in bladder and rectal filling are described in relevant chapters. Uncertainties from organ motion can also be reduced by using fiducial markers, and published results are available for lung, prostate and breast tumours. Radio-opaque markers are inserted and imaged at localisation using CT or MRI, and at treatment verification, using portal films, electron...
Using CT data, software generates images from a beam’s eye perspective, which are equivalent to conventional simulator images. External landmarks are used to define an internal isocentre for treatment set-up. The CT simulator provides maximal tumour information as well as full 3D capabilities (unlike the simulator CT facility). It is particularly useful for designing palliative treatments such as for lung and vertebral metastases, as well as for some breast treatments using tangential beams, which can be virtually simulated and then 3D planned. The ability to derive CT scans, and provide target volume definition, margin generation, and simulation all on one workstation, provides a rapid solution.
A CT mode attached to the simulator gantry can be used to produce images with a relatively limited resolution during the simulation process. This provides both external contouring and some normal anatomical data, such as lung and chest wall thickness, for simple inhomogeneity corrections. Images do not give detailed tumour information or accurate CT numbers. These scans are time consuming to obtain, and are therefore usually limited to the central, superior and inferior levels of the target volume.
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