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Image guided radiotherapy - IGRT
RÁKOSNÍKOVÁ, Štěpánka
This bachelor thesis deals with the general description of modern irradiation techniques and the verification technique IGRT The picture of the controlled radiation therapy, which was put into operation in the hospital České Budějovice a.s. in the year 2015. It deals with two ways of verification used during irradiation of the prostate in the hospital with 2D Mv-kV and CBCT pictures. Radiation therapy is a young and rapidly growing field in medicine. Presently, there has been a big change in instrumentation used in radiotherapeutic divisions. Today on most of the Czech Republic work places it is a standard to have the option to use IMRT techniques (radiation therapy with modulated intensity). This technique, thanks to intensity modulation across the beam of radiation and dose distribution corresponding with the target volume allows maximal saving of the healthy surrounding tissue. With the use of IMRT technology, which enables to increase doses applied to the volume goal, the requirement for the verification system increased. That is why radiation therapy controlled by pictures IGRT is slowly being introduced, it ensures higher accuracy in the setting of the position of the patient. This verification method shifts present methods irradiation to a higher level and especially in safety and the quality of the execution of the irradiation. This works goal is to obtain information about verification methods used in the hospital České Budějovice a.s., which are verifications through 2D pictures Mv-kV and CBCT (cone beam CT). Further the subject of the research is the observation of corrections of imbalances that are, used after these two verification methods are utilized, related only for diagnosing prostate cancer. This diagnosis was chosen because it belongs to the most occurring cancer of the male population, which has an increased incidence. Another reason for focusing on this cancer are the requirements for accuracy on locating the volume goal which is in the vicinity if a lot of critical structures. Answer to the investigative question "how big are the corrections of imbalances used after the verification of MV-kV pictures and CBCT" was made based on the analysis of the assembled corrections of 54 patients, who were treated in the hospital of České Budějovice with the diagnosis of prostate cancer within the last two years. In the conclusion of this work there are calculations of made verifications based on MV-kV and CBCT pictures in a summarized table. The pictures were recorded only if both methods were used in one day in a fractional regime. The reason was evaluating potential differences of the used corrections based on 2D pictures and CBCT. Next, in the table, there are calculations of significant deviation over 3mm during CBCT verifications and previous verifications according to 2D pictures MV-kV. All these recorded deviations are commented and explained. The goal of this paper is proof of the importance of more accurate verification methods whilst using IMRT irradiation technique. This paper points out on unaffected movements of the inner organs, which are near the irradiated volume, and on the importance of the preparation of the patient before the irradiation and affected focus of the volume goal with an uncooperative patient. The content of this bachelor thesis can provide basic view about current irradiation and verification techniques to students of medical fields. This Information can be used as a subject matter for processing research and professional articles that focus on a similar topic.
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The analysis of effectiveness and undesirable effects of the radical chemoradiotherapy of anal cancer
Vácha, Ondřej ; Vítek, Pavel (advisor) ; Konopásek, Bohuslav (referee)
The subject of presented bachelor thesis is an analysis of efficacy and side effects in chemoradiotherapy of anal canal cancer. High anticancer activity besides severe adverse effects are specific for anal canal cancer. Adverse effect may finally negatively influence even overall survival. The data of 110 patients treated within the last 20 years at the Institute of Radiation Oncology, University Hospital Na Bulovce, Prague were analyzed to determine an impact of radiation delivery technique, chemotherapy and other variables on treatment results. Common chemoradiation regimen of mitomycin + 5-FU and radiation up to 60 Gy was employed. The single-institution data confirm high efficacy of standard treatment in terms of survival and relapse rate. There is a substantial rate of acute and delayed toxicity. Therefore there is a significant reduction of chemotherapy in elderly patients. However the survival and time to relapse data do not significantly differ in elderly patients. The age at diagnosis as a continuous variable does not significantly influence either survival or time to relapse. More advanced radiation delivery technique IMRT brings significantly less side effects compared to classic 2D and 3D conformal radiation therapy. Conclusions: High toxicity of standard chemoradiation for anal canal...
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Comparison of doses in the target volume and critical organs for Intensity Modulated Radiation Therapy (IMRT) and proton therapy
STIEBLINGOVÁ, Tereza
The topic of this thesis is a view at the two selected modern irradiation techniques - IMRT (Intensity-Modulated Radiation Therapy) and proton therapy. I compared them at a general level in the theoretical part, and in the practical part I focused on the absorbed doses in selected critical organs in patients with prostate cancer. In the theoretical part I worked with specialized literature and articles from medical journals and also with a number of internet sources. For example I worked with a publication titled Radiační onkologie by Pavel Šlampa or Klinická onkológia a rádioterapia by Ľudovit Jurga. I made a concept based on the obtained information, which is composed of generally related topics, e.g. the position of radiotherapy in the treatment of oncological diseases, characteristics of ionizing radiation, the process of radiation treatment planning etc. After these introductory chapters I focused specifically on photon IMRT technique and proton therapy which are among the most modern methods of contemporary radiation oncology. In the theoretical part I set the description of these selected techniques as a goal, with an emphasis on their advantages and disadvantages. In the practical part I analyzed these two techniques in terms of received minimum, medium and maximum doses in selected critical organs rectum, bladder and both femoral heads using different fractionation schemes. The results were compared with information from the theoretical part. In the practical part, the testing of this hypothesis was set as my goal: During the treatment of prostate cancer with accelerated protons the healthy surrounding tissue and critical organs will receive smaller amount of radiation dose than IMRT technique. Proton Therapy Center (PTC) in Prague provided me with some irradiation plans including CT scans from 20 anonymous patients diagnosed with prostate cancer and treated with protons. Then I worked with these plans in planning program to create a photon IMRT plan for each proton plan and in order to be able compare these two techniques in each patient in different fractionation schemes. When I compared IMRT technique and proton therapy, both in norm-fractionated scheme, moderate doses were lower with protons in all 20 patients in all selected critical organs. The average difference in moderate doses of these techniques in all selected critical organs is 11,022 Gy. Specifically, from the results is further evident, that the bladder and the rectum absorb less minimal and medium dose if proton therapy has been used in any fractional mode (short, long, norm-fractionated scheme) than in the photon IMRT therapy. These results were obtained in all 20 patients. When I compared IMRT technique and proton therapy, both in short scheme or long scheme, in terms of the maximum doses in the bladder and rectum, the values were comparable in the both critical organs. In none of the literature used as a source is a mention of minimal and medium doses on heads of both femurs. But if I compare the median doses proton's therapy with doses IMRT's photon therapy, both in norm-fractionated scheme, the medium doses were lower if proton therapy had been used. The results of minimal doses are contradictory and conclusions are not so unequivocal. The values of the maximum doses of the right and left femoral head were lower in overwhelming majority of 20 patients in proton therapy (in the short and also in long scheme). The average difference in the left head of femur is 3,434 Gy (proton's short scheme vs. photon's short scheme), respectively 6,654 Gy (proton's long scheme vs. photon's long scheme). The average difference in the right head of femur is 5,422 Gy (proton's short scheme vs. photon's short scheme), respectively 9,273 Gy (proton's long scheme vs. photon's long scheme).
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Development of prostate cancer radiotherapy from the 80s to the present day
SUCHANOVÁ, Markéta
Prostate cancer (CaP) remains the most common cancer diagnosed in men. This desease has worldwide increasing incidence. In the Czech Republic incidence has tripled during the last 20 years. The increase of the mortality is much more slower, but CaP is still the third leading cause of cancer-related death in men. CaP treatment management options may include active surveillance, radical prostatectomy, brachytherapy and external beam radiation therapy. The radiotherapy occupies an irreplaceable position. It is used as a curative therapy for clinically localized CaP with a low and intermediate risk. In the case of high risk CaP and locally advanced tumors are often treated with the addition of the hormonal therapy, which enhances tumor control and overall patient's survival. The radiotherapy is also used in some cases as an adjuvant treatment following a radical prostatectomy, as well as a salvage therapy in a biochemical relapse or as a palliative treatment if the cancer progresses. The aim of this study is to provide an overview of the development of CaP radiotherapy from the 80s till the present day. The specific objective of the study is to assess the incidence of the radiation-related complications (RRC) in patients with CaP treated with IMRT and PT. Among the methods of processing this thesis was using secondary data analysis. Practical information were obtained during the visits to the Department of the Radiation Oncology at the Hospital Ceske Budejovice a.s. (NCB) and the Proton Therapy Center Czech s.r.o. (PTC). During these visits was observed the radiotherapeutic treatment of the patients with CaP and valuable information were obtained through interviews with Mrs.Vančurová, MD and Mr. Vítek, MD., Ph.D., MBA This study analysed the incidence of the acute and late RRC in patients with CaP treated in these facilities. The acute and late side effects was assessed for GU and GI toxicity using RTOG / EORTC score. The specific problems were measured with the CTCAE v.4.0 scale. The overall incidence of the RRC was subjected to the statistical hypothesis testing using a two-sample unpaired t-test. The examined sample consisted of the 30 patients with CaP irradiated at NCB and the 30 patients from PTC with low, intermediate and high risk CaP. It was found that for the patients from NCB the rectum mean dose was 40,7 Gy and the mean dose of bladder was 39,4 Gy. For the patients treated at PTC the mean dose to the rectum was 13,2 Gy and to the bladder 11.1 Gy. This is related to the incidence of the RRC. Acute GU and GI toxicities Grade 2+ occurred in 33 % and 23,3 % of the patients treated in NCB. With a median follow-up of 22 months there was late GU toxicity Grade 2+ in 13,3 %. Late GI toxicity Grade 2+ occurred in 26,7 %, which exceeds incidence of the RRC described in the literature. Incidence of late GI toxicity Grade 3 and 4 was also increased, it appeared in 10 % (3 patients). Furthermore in one case cancer reoccurred and metastasized one and half year after the radiotherapy. In PTC no acute or late Grade 3+ toxicities were observed. Acute GU and GI toxicities Grade 2 occurred in 13,3 % and 6,7 %. After median follow-up of 21,5 months there was incidence of late GI toxicity Grade 2 3,3 %, late GU toxicity appeared only Grade 1 in 13,3 %. There was found statistically significant difference in occurrence of RRC in patients treated in NCB and PTC. The hypothesis that PT reduces the incidence of the radiation side-effects compared to the IMRT technique in the patients with the prostate cancer was confirmed. The prostate can move greatly during the day. It is recommended using CBCT, which is part of new linear accelerators at NCB, to check the position of the prostate before each irradiation. This study provides an overview of the treatment of CaP and may serve to increase of awareness of the RRC. The main contribution can be seen in the comparison of a standard approach with a promising alternative.
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Using the IGRT and IMRT methods to treat prostate gland carcinoma and their side effects
KŘIVSKÁ, Klára
Prostatic carcinoma is a disease with a continuously increasing number of newly diagnosed cases all over the world. According to the commonly available statistic data it is the most frequent tumour disease of men. As far as oncological causes of death are concerned, it occupies the second place, after lung cancer. The situation in the Czech Republic corresponds to this trend. The incidence in this country has almost tripled in the last two decades. On the other hand, the number of deaths due to prostatic carcinoma decreases and it is approximately one third lower now. This very significant difference is given especially by the possibility of examination for the prostate-specific antigen (PSA) within the framework of preventive medical check-ups at general practitioners or at other specialists. The modern treatment of prostatic carcinoma, whether it concerns radical (curative) treatment or support (palliative) treatment, also has had an indisputable positive effect. According to the data obtained from the statistics managed by the National Cancer Registry from 2009, the number of newly diagnosed prostatic carcinomas in the Czech Republic reached 119.3 cases per 100,000 men. The death rate was 28.5 cases per 100,000 men. In conversion to absolute numbers from 2009 it means that 6154 men were diagnosed with a prostatic carcinoma and 1472 men died of it. Great success of modern treatment is confirmed also by a percentage expression of survival of patients after the end of treatment. In the time period of the last thirty years, the overall five-year survival for men with a prostatic carcinoma has increased from 68% to the current almost 100%. This means that an overwhelming majority of patients still live after five years from the diagnosis of their disease. Treatment of prostatic carcinoma has included the conform radiotherapy since the time of its introduction. The pioneers of this therapy are Japanese scientists Umegaki and Takahashi, who invented, in the 1960s, the first rotational conform radiation technology. It is more often associated with introduction of computer tomography (CT) into ordinary clinical practice. It was only in 1983 when a 3D planning system was presented, which then facilitated further development of tumour-conform radiotherapy. It was established that the doses from conventional techniques (e.g. a box) are not sufficient for the patients, do not lead to recovery and, quite on the contrary, they even increase the risk and major development of side effects. The advanced method of intensity-modulated radiation therapy (IMRT), which started to be applied in practice in the 1990s, achieved much better results. Besides a change in the beam shape it enables a change in the beam intensity as well. This can be achieved in cooperation with a multi-leaf collimator (MLC) which changes the shape of its lamellas dynamically and thus it modifies and transfers its beam. Method IMRT better and more accurately shaped beam and thereby more saving to surrounding healthy tissue
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The results of radiotherapy of head and neck tumors. Comparison of conformal radiotherapy and IMRT
HLAVÁČOVÁ, Veronika
Malignant tumors of the head and neck are globally around 5 % of all malignant tumors. To the group of tumors of the head and neck falls oral cavity, pharynx, larynx, nasal cavity, paranasal sinuses, and salivary glands. The main treatment modalities are included surgical treatment, radiotherapy, chemotherapy and biotherapy. The first aim of this thesis was to compare the results of radiotherapy of tumors of the head and neck in a hospital in Ceske Budejovice with specialised literature.The second objective was to compare conformal and IMRT techniques within the meaning of recurrences.Data collection was conducted in patients diagnosed with tumor of the oral cavity and pharynx during years 2004 to 2010. When comparing treatment results with data from the first scientific literature with the results monitored group agree on decreasing tendency on five-year survival with increasing degree of the stadium. When comparing five-year survival rate for tumors of the oral cavity with the reference group of patients with data from the other specialised literature, correspondence does not exist.In this case, the hypothesis can not be confirmed. In the second set hypothesis it was assumed that the lower incidence of relapses occur after irradiation by the technique IMRT. Although the hypothesis was confirmed,although the gap between the technology 3D-CRT and IMRT for recurrences is tiny, only tenths.A crucial factor influencing survival is the time of diagnosis. Improving this fact could be achieved by appropriate preventive programs, which are targeted primarily at risk group of people.
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The Results of Radiotherapy in Tumors of the Vocal Cords
HRDLIČKA, Vojtěch
Malignant tumors of vocal cords are the less common, but not rare carcinomas. My thesis contains information on results of radiotherapy in tumors of the vocal cords in terms of recurrence and five-year survival rates for early stage disease. It's also included statistics containing information about rescue total laryngectomy, radiation techniques and within hypothesis are compared results of radiotherapy of IMRT and CRT techniques. Also compared are doses delivered to the target volume. The aim is then compare results with literature and assess whether the indicated dosage affects the efficacy of curative radiotherapy. This work is supported by quantitative statistical survey in the range of 106 patients. Data was obtained for South Bohemian Region, in the archive of the Oncology Department in the Hospital České Budějovice, a.s. in the range of 2000 2009. In the total group of 91 curative irradiated patients was found 57,54 % preponderance representation of T1 tumors and 21,69 % of T2 tumors. Five-year survival of patients with stage T1 corresponds to 90,16 % and 69,57 % of T2 stage. Rescue laryngectomy was performed a total of 12 with an average extension of life of patients by 5 years. A dose used for IMRT and conformal technique was found to be lower than literature recommends.
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Radiotherapy of prostate tumours through the IMRT technique and its toxicity
VRÁNOVÁ, Jana
Abstract Radiotherapy of prostate tumours through the IMRT technique and its toxicity In today´s modern world, prostate carcinoma is one of the most frequent malignant diseases suffered by men. Most ill persons who suffer from this disease are men between 50 and 70 years, and their number is increasing more and more. My work deals with occurrence of late complications after radiation of patients with prostate carcinoma through the IMRT technique in Nemocnice České Budějovice, a.s.. I assessed the number of late complications in the area of gastrointestinal and genito-urinary tract, degree of damage, and period of latency in dependence on a technique and amount of radiation. I observed whether the number of late complications is comparable with data in professional literature, or whether it considerably differs from these results. Method for preparation of an expert study being quantitative research. I obtained data from the files of the Department of Oncology of Nemocnice České Budějovice, a.s., in 2007-2010. From the group of 243 patients, there were 211 patients appropriate for statistical processing of my research who were exposed to radiation through the IMRT technique due to prostate carcinoma diagnosed in 2007 - 2010. There were complications with 114 of them (54.03%). In the area of gastrointestinal tract, the 1st degree of late toxicity was with 47 patients (88.68%), 2nd degree with 4 patients (7.56%) and 3rd degree with 2 patients (3.77%). Median value of the period of latency is 13.86 months. Undesirable effects were shown in 3 months at the earliest, in 39 months at the latest. In the area of genito-urinary tract, the 1st degree of toxicity was with 39 patients (82.98%), 2nd degree with 8 patients (17.02%), and 3rd degree did not occur at all. Median value of the period of latency is 10.3 months. First, there occurred symptoms of late toxicity in 2 months, in 30 months at the latest. Upon comparison of all the results which I found out during my research done, I arrived at the conclusion that in Nemocnice České Budějovice, a.s., the occurrence of late toxicity of the second and third degree is slightly smaller in the area of gastrointestinal tract, while in the area of genito-urinary tract late complications of the second and third degree occur more often.
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Importace of verification treatment irradiaton position of IMRT prostate
KŘÍŽOVÁ, Marcela
Prostate cancer is the most frequent oncological disease in men. Based on the disease phase and extent, patiens with prostate carcinoma diagnosis are treated with number of different therapies including radical prostatectomy, hormone therapy, chemotherapy, brachytherapy, conventional radiotherapy, conformal radiotherapy and combination of these. This Bachelor Thesis deals with prostate carcinoma treatment using a special conformal radiotherapy method - IMRT (Intensity Modulated Radiotherapy). The first section describes the disease charakter from the clinical point of view and the disease diagnosis, followed by treatment modalities. The main part examines and describes IMRT, treatment planning and resultes from statistic evaluation of irradiation position deviations. IMRT technique allows escalation of the irradiation dose while protecting critical structures. In this way the patient can be irradiated with a total dose of 80 grays (Gy). Patients are irradiated in a linear accelerator. Modulation of the radiation beam using multileaf collimator allows irradiation of different segments of target volume with different doses, so that overal homogenity of the irradiation treatment is achieved through nonhomogenous distribution of the dose. Escalation of the irradiation dose is in a close relationship with the irradiaion position and isocentre position kontrol, so that the treatment quality is guaranteed preventing damane to surrounding healthy tissue. Fixing the patient in irradiation position as well as reproductibility of the position is of essentials importance. The isocentre in irradiation position is verified efore every fraction. Verification portal images are acquired using EPID (Electonic Portal Image Device) Portal Vision LC 250 and then compared with reference verification images acquired by CT when planning the treatment. Portal images are made up of two fields of 12x12 cm size under 0 and 90 or 270 degrees. Deviations are recorded in craniocaudal, mediolateral and anterior-posterior axes, and if they exceed 3mm, the irradiation position is corrected on the irradiation table. In this Thesis, deviations in a group of 30 patients were evaluated using the Aria-Offline Review programme which is an accesory to the treatment planning system. In one third of the statistical group of patient, deviations identified using on offline review were compared with deviations identified by start efore each fraction. Dutiny statistical processing, deviations were recorded within ranges 0-3 mm, 3,1-5 mm and over 5mm. 69% of acceptable deviations were recorded within the 0-3 mm range in the craniocaudal axis, 71% in the mediolateral axis and 67% in the anterior-posterior axis. Based on a complete analysis and evaluation of the deviations we can conclude that verification of the irradiation position in treatment of prostate carcinoma using IMRT is essentials to guarantee the irradiation treatment quality. We have also verified that deviations between 0 and 3 mm are acceptable and in no way impair the treatment quality.
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The Importance of Verification Images during IMRT in the Area of Head and Neck.
MYSLÍKOVÁ, Petra
Tumours of the head and neck are the fifth most common cancers in the Czech Republic. Despite easily available medical examination and observable symptoms most patients come for treatment with various types of tumours in advanced phases which lowers their chance of being cured. The technique of IMRT has recently become the most often used curative method for the tumours of the head and neck, enabling better treatment of healthy tissues and critical organs in this area. The thesis is divided into the theoretical and practical part. In the first part, the areas of head and neck and the types of cancers found in these areas are analysed. The chapters concern symptoms, aetiology, diagnostics, prognosis and, of course, their treatment. Further, the common course of planning has been included and at the end of this part the history and presence of verification images is mentioned. The second part of this thesis includes objectives and a hypothesis. The objective of the thesis is to explore and evaluate portal verification images of target volume in tumours of the head and neck and compare these images with referential verification images as well as to state deviations in irradiation position and to prove the significance of verification images in the area of head and neck. This part also includes chapters describing methodology (with resources), and the course planning process in a patient using IMRT technology. Further, it includes the research result of the a collection of 50 patients with the tumours of the head and neck who were irradiated by IMRT technology and whose verification images of target volume were evaluated. The predicted objectives were fulfilled and the hypothesis was disproved. Verification portal images are made in oncology department once a week. I would suggest making verification portal images with a fixation mask at least twice a week in order to achieve better accuracy and control of the irradiation position.
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