J Korean Med Sci.  2015 Oct;30(10):1522-1530. 10.3346/jkms.2015.30.10.1522.

Dosimetric Effects of Magnetic Resonance Imaging-assisted Radiotherapy Planning: Dose Optimization for Target Volumes at High Risk and Analytic Radiobiological Dose Evaluation

• Park JY
• Suh TS
• Lee JW
• Ahn KJ
• Park HJ
• Choe BY
• Hong S

• KMID: 2344189
• DOI: http://doi.org/10.3346/jkms.2015.30.10.1522

Abstract

Based on the assumption that apparent diffusion coefficients (ADCs) define high-risk clinical target volume (aCTVHR) in high-grade glioma in a cellularity-dependent manner, the dosimetric effects of aCTVHR-targeted dose optimization were evaluated in two intensity-modulated radiation therapy (IMRT) plans. Diffusion-weighted magnetic resonance (MR) images and ADC maps were analyzed qualitatively and quantitatively to determine aCTVHR in a high-grade glioma with high cellularity. After confirming tumor malignancy using the average and minimum ADCs and ADC ratios, the aCTVHR with double- or triple-restricted water diffusion was defined on computed tomography images through image registration. Doses to the aCTVHR and CTV defined on T1-weighted MR images were optimized using a simultaneous integrated boost technique. The dosimetric benefits for CTVs and organs at risk (OARs) were compared using dose volume histograms and various biophysical indices in an ADC map-based IMRT (IMRTADC) plan and a conventional IMRT (IMRTconv) plan. The IMRTADC plan improved dose conformity up to 15 times, compared to the IMRTconv plan. It reduced the equivalent uniform doses in the visual system and brain stem by more than 10% and 16%, respectively. The ADC-based target differentiation and dose optimization may facilitate conformal dose distribution to the aCTVHR and OAR sparing in an IMRT plan.

Keyword

Diffusion Magnetic Resonance Imaging; Glioma; Radiotherapy, Intensity-Modulated; Radiotherapy Planning, Computer-Assisted

MeSH Terms

Contrast Media
Gadolinium
Glioma/*radiotherapy
Humans
Magnetic Resonance Imaging/*methods
*Radiotherapy Dosage
Radiotherapy Planning, Computer-Assisted/*methods
Radiotherapy, Intensity-Modulated/*methods
Tumor Burden
Contrast Media
Gadolinium

Figure

• 

  Fig. 1 Overall procedures used in the conventional intensity-modulated radiation therapy (IMRTconv) and an apparent diffusion coefficient (ADC) map-based IMRT (IMRTADC) plans. The left flow chart connected with black lines describes the general and common procedures to create two IMRT plans. The blue dashed line corresponds to the IMRTconv plan. Additionally required procedures for the IMRTADC were presented with orange line.

• 

  Fig. 2 The delineated target volumes in the intensity-modulated radiation therapy plan. The ADC-based high-risk clinical target volume (aCTVHR), contrast enhanced T1 image-based gross tumor volume (tGTV) and CTV (tCTV). The aCTVHR is defined on ADC maps by applying the ADC criteria for high-grade glioma to extract the high-risk residual target volume. The tCTV is defined by adding a 2-cm margin to the tGTV.

• 

  Fig. 3 Multi-modal and post-processed images used to determine the high-risk tumor volume in a high-grade glioma. (A) Computed tomography image. (B) Contrast enhanced-T1 weighted image. (C) Diffusion-weighted (DW) image (b=1,000 s/mm2). (D) ADC map. (E) DW ratio map with normalized average diffusion values of the contralateral normal brain tissues. The red and orange regions represent double- and triple-restricted water diffusion, respectively. (F) Extracted malignant residual tumor volumes on ADC maps with quantitative analysis for suspicious high-risk lesions.

• 

  Fig. 4 Comparison of the dose distributions in the IMRTconv plan and IMRTADC plan. (A) Dose distribution in the IMRTADC plan. Prescribed doses of 59.4 Gy and 50.4 Gy were optimized to the aCTVHR and relative complement volume of aCTVHR in tCTV (sCTV), respectively, using the simultaneous integrated boost technique. (B) Dose distribution in the IMRTconv plan. A dose of 59.4 Gy was prescribed to the tCTV.

• 

  Fig. 5 Comparison of the dose volume histograms (DVHs) in the IMRTconv and the IMRTADC plans. (A) Differential DVHs for the residual clinical target volumes at high risk on the ADC maps. Horizontal axis: doses normalized to the prescribed dose (59.4 Gy). (B) Cumulative DVHs for organs at risk.

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