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Image-guided radiation therapy (IGRT): practical recommendations of Italian Association of Radiation Oncology (AIRO)

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Abstract

The use of imaging to maximize precision and accuracy throughout the entire process of radiation therapy (RT) delivery has been called “Image-guided RT” (IGRT). RT has long been image guided: in fact, historically, the portal films and later electronic megavoltage images represented an early form of IGRT. A broad range of IGRT modalities is now available and adopted. The target location may be defined for each treatment fraction by several methods by localizing surrogates, including implanted fiducial markers, external surface markers or anatomical features (through planar imaging, fluoroscopy, KV or MV computed tomography, magnetic resonance imaging, ultrasound and X-ray imaging, electromagnetic localization, optical surface imaging, etc.). The aim of the present review is to define practical recommendations for IGRT.

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References

  1. Hartford AC, Palisca MG, Eichler TJ, Beyer DC, Devineni VR, Ibbott GS et al (2009) American society for therapeutic radiology and oncology (ASTRO) and American College of Radiology (ACR) practice parameters for intensity-modulated radiation therapy (IMRT). Int J Radiat Oncol Biol Phys 73(1):9–14

    Article  PubMed  Google Scholar 

  2. American College of Radiology. ACR-ASTRO practice parameter for intensity modulated radiation therapy (IMRT). http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/IMRT.pdf. Accessed 20 July 2016

  3. American College of Radiology. ACR-ASTRO practice parameter for the performance of stereotactic body radiation therapy. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Stereo_body_radiation.pdf. Accessed 20 July 2016

  4. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK (2010) A survey of image-guided radiation therapy use in the United States. Cancer 116(16):3953–3960

    Article  PubMed  PubMed Central  Google Scholar 

  5. van Herk M (2007) Different styles of image-guided radiotherapy. Semin in Radiat Oncol 17(4):258–267

    Article  Google Scholar 

  6. Chang JY, Dong L, Liu K, Starkschall G, Balter P, Mohan R et al (2008) Image-guided radiation therapy for non small cell lung cancer. J Thorac Oncol 3(2):177–186

    Article  PubMed  Google Scholar 

  7. Thorson T, Prosser T (2006) X-ray volume imaging in image-guided radiotherapy. Med Dosim 31(2):126–133

    Article  PubMed  Google Scholar 

  8. Herman MG (2005) Clinical use of electronic portal imaging. Semin in Radiat Oncol 15(3):157–167

    Article  Google Scholar 

  9. Amer AM, Mackay RI, Roberts SA, Hendry JH, Williams PC (2001) The require number of treatment imaging days for an effective offline correction of systematic errors in conformal radiotherapy of prostate cancer: a radiobiological analysis. Radiother Oncol 61(2):143–150

    Article  CAS  PubMed  Google Scholar 

  10. Bortfeld T, van Herk M, Jiang SB (2002) When should systematic patient positioning errors in radiotherapy be corrected? Phys Med Biol 47(23):297–302

    Article  Google Scholar 

  11. de Boer HC, Heijmen BJ (2001) A protocol for the reduction of systematic patient setup errors with minimal portal imaging workload. Int J Radiat Oncol Biol Phys 50(5):1350–1365

    Article  PubMed  Google Scholar 

  12. De Los Santos J, Popple R, Agazaryan N, Bayouth JE, Bissonnette JP, Bucci MK et al (2013) Image guided radiation therapy (IGRT) technologies for radiation therapy localization and delivery. Int J Radiat Oncol Biol Phys 87(1):33–45

    Article  Google Scholar 

  13. Letourneau D, Wong JW, Oldham M, Gulam M, Watt L, Jaffray DA et al (2005) Cone-beam-CT guided radiation therapy: technical implementation. Radiother Oncol 75:279–286

    Article  PubMed  Google Scholar 

  14. McBain CA, Henry AM, Sykes J, Amer A, Marchant T, Moore CM et al (2006) X-ray volumetric imaging in image-guided radiotherapy: the new standard in on-treatment imaging. Int J Radiat Oncol Biol Phys 64:625–634

    Article  PubMed  Google Scholar 

  15. Kan M, Leung L, Wong W, Lam N (2008) Radiation dose from cone beam computed tomography for image-guided radiation therapy. Int J Radiat Oncol Biol Phys 70(1):272–279

    Article  CAS  PubMed  Google Scholar 

  16. Hyer DE, Serago CF, Kim S, Li JG, Hintenlang DE (2010) An organ and effective dose study of XVI and OBI cone-beam CT system. J Appl Clin Med Phys 11(2):3183

    PubMed  Google Scholar 

  17. http://www.natcansat.nhs.uk/dlhandler.ashx?d=pubs&f=National%20Radiotherapy%20Implementation%20Group%20Report%20IGRT%20Final.pdf. Accessed 20 July 2016

  18. Alongi F, Fiorentino A, Mancosu P, Navarria P, Giaj Levra N, Mazzola R, Scorsetti M (2016) Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach. Expert Rev Anticancer Ther 16(7):731–740

    Article  CAS  PubMed  Google Scholar 

  19. Clemente S, Chiumento C, Fiorentino A, Simeon V, Cozzolino M, Oliviero C et al (2013) Is ExacTrac X-ray system an alternative to CBCT for positioning patients with head and neck cancers? Med Phys 40(11):111725

    Article  PubMed  Google Scholar 

  20. Zeidan AO, Langen KM, Meeks SL, Manon RR, Wagner TH, Willoughby TR et al (2007) Evaluation of image-guidance protocols in the treatment of head and neck cancers. Int J Radiat Oncol Biol Phys 67(3):670–677

    Article  PubMed  Google Scholar 

  21. Fiorentino A, Caivano R, Metallo V, Chiumento C, Cozzolino M, Califano G et al (2012) Parotid gland volumetric changes during intensity-modulated radiotherapy in head and neck cancer. Br J Radiol 85(1018):1415–1419

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Barker J, Garden AS, Ang KK, O’Daniel JC, Wang H, Court LE et al (2004) Quantification of volumetric and geometric changes occurring during fractionated radiotherapy for head-and-neck cancer using an integrated CT/linear accelerator system. Int J Radiat Oncol Biol Phys 59(4):960–970

    Article  PubMed  Google Scholar 

  23. Motegi K, Kohno R, Ueda T, Shibuya T, Ariji T, Kawashima M et al (2014) Evaluating positional accuracy using megavoltage cone-beam computed tomography for IMRT with head-and neck cancer. J Radiat Res 55(3):568–574

    Article  PubMed  PubMed Central  Google Scholar 

  24. van Kranen S, van Beek S, Rasch C, van Herk M, Sonke JJ (2009) Setup uncertainties of anatomical sub-regions in head-and-neck cancer patients after offline CBCT guidance. Int J Radiat Oncol Biol Phys 73(5):1566–1573

    Article  PubMed  Google Scholar 

  25. Lai YL, Yang SN, Liang JA, Wang YC, Yu CY, Su CH et al (2014) Impact of body-mass factor on setup displacement in patients with head and neck cancer treated with radiotherapy using daily on-line image guidance. Radiat Oncol 9:19

    Article  PubMed  PubMed Central  Google Scholar 

  26. Fiorentino A, Cozzolino M, Caivano R, Pedicini P, Chiumento C, Oliviero C et al (2013) Cone-beam computed tomography dose monitoring during intensity-modulated radiotherapy in head and neck cancer: parotid glands. Clin Transl Oncol 15(5):412–415

    Article  CAS  PubMed  Google Scholar 

  27. Fiorentino A, Cozzolino M, Caivano R, Pedicini P, Oliviero C, Chiumento C et al (2014) Head and neck intensity modulated radiotherapy parotid glands: time of re-planning. Radiol Med 119(3):201–207

    Article  PubMed  Google Scholar 

  28. Mazzola R, Ricchetti F, Fiorentino A, Fersino S, Giaj Levra N, Naccarato S et al (2014) Dose-volume-related dysphagia after constrictor muscles definition in head and neck cancer intensity-modulated radiation treatment. Br J Radiol 87(1044):20140543

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Den RB, Doemer A, Kubicek G, Bednarz G, Galvin JM, Keane WM et al (2010) Daily image guidance with cone-beam computed tomography for head-and-neck cancer intensity-modulated radiotherapy: a prospective study. Int J Radiat Oncol Biol Phys 76(5):1353–1359

    Article  PubMed  Google Scholar 

  30. Chen AM, Farwell DG, Lu Q, Donald PJ, Perks J, Purdy JA (2011) Evaluation of the planning target volume in the treatment of head and neck cancer with intensity-modulated radiotherapy: what is the appropriate expansion margin in the setting of daily image guidance? Int J Radiat Oncol Biol Phys 81(4):943–949

    Article  PubMed  Google Scholar 

  31. Artignan X, Rastkhah M, Balosso J, Fourneret P, Gilliot O, Bolla M (2006) Quantification des mouvements prostatique lors de l’irradiation prostatique. Cancer Radiother 10:381–387

    Article  CAS  PubMed  Google Scholar 

  32. Melancon AD, O’Daniel J, Zhang L, Kudchadker RJ, Kuban DA, Lee AK (2007) Is a 3 mm intrafractional margin sufficient for daily image-guided intensity-modulated radiation therapy of prostate cancer? Radiother Oncol 85(2):251–259

    Article  PubMed  PubMed Central  Google Scholar 

  33. Dudouet P, Boutry C, Mounie G, Thouveny F, Redon A (2009) Système d’imagerie par tomographie conique de basse énergie (KV) de Varian: experience de Montauban. Cancer Radiother 13(5):375–383

    Article  CAS  PubMed  Google Scholar 

  34. Palombarini M, Mengoli S, Fantazzino P, Cadioli C, Degli Espositi C, Frezza GP (2012) Analysis of inter-fraction setup errors and organ motion by daily kilovoltage cone beam computed tomography in intensity modulated radiotherapy of prostate cancer. Radiat Oncol 7:56

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kupelian PA, Langen KM, Willoughby TR, Zeidan OA, Meeks SL (2008) Image-guided radiotherapy for localized prostate cancer: treating a moving target. Seminar Radiat Oncol 18(1):58–66

    Article  Google Scholar 

  36. Reggiori G, Mancosu P, Tozzi A, Cantone MC, Castiglioni S, Lattuada P et al (2010) Cone beam CT pre- and post-daily treatment for assessing geometrical and dosimetric intrafraction variability during radiotherapy of prostate cancer. J Appl Clin Med Phys 12(1):3371

    PubMed  Google Scholar 

  37. De Ridder M, Tournel K, Van Nieuwenhove Y, Engels B, Hoorens A, Everaert H et al (2008) Phase II study of preoperative helical tomotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 70(3):728–734

    Article  PubMed  Google Scholar 

  38. Alongi F, Fersino S, Mazzola R, Fiorentino A, Giaj-Levra N, Ricchetti F et al (2016) Radiation dose intensification in pre-operative chemo-radiotherapy for locally advanced rectal cancer. Clin Transl Oncol. doi:10.1007/s12094-016-1522-0

  39. Anal Carcinoma (2016). NCCN clinical practice guideline in oncology. https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/anal.pdf. Accessed 20 July 2016

  40. Rectal Cancer (2016) NCCN clinical practice guideline in oncology. https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. Accessed 20 July 2016

  41. Creutyberg CL, Van Putten WL, Koper PC, Lybsen JJ, Warlam-Rodenhuis CC, De Winter KA et al (2000) For the PORTC (post operative radiation therapy in endometrial carcinoma) study group. surgery and postoperative radiotherapy versus surgery alone for patients with stage 1 endometrial carcinoma. multicentre randomized trial. Lancet 355(9213):1404–1411

    Article  Google Scholar 

  42. Mundt AJ, Lujan AE, Rotmensch J, Waggoner SE, Yamada SD, Fleming G et al (2002) Intensity-modulated whole pelvic radiotherapy in women with gynecologic malignancies. Int J Radiat Oncol Biol Phys 52(5):1330–1337

    Article  PubMed  Google Scholar 

  43. Tyagi N, Lewis JH, Yashar CM, Vo D, Jiang SB, Mundt AJ, Mell LK (2011) Daily online cone beam computed tomography to assess interfractional motion in patients with intact cervical cancer. Int J Radiat Oncol Biol Phys 80:273–278

    Article  PubMed  Google Scholar 

  44. Chan P, Dinniwell R, Haider MA, Cho YB, Jaffray D, Lockwood G et al (2008) Inter- and intra-fractional tumor and organ movement in patients with cervical cancer undergoing radiotherapy: a cinematic-MRI point-of-interest study. Int J Radiat Oncol Biol Phys 70(5):1507–1515

    Article  PubMed  Google Scholar 

  45. Rockne H, Guy CJ, Charles BS (2015) Whole pelvic intensity-modulated radiotherapy for gynecological malignancies: a review of the literature. Crit Rev Oncol/Hematol 94(3):371–379

    Article  Google Scholar 

  46. Haripotepornkul NH, Sameer K, Scanderbeg ND, Saenz C, Yashar CM (2011) Evaluation of intra- and inter-fraction movement of the cervix during intensity modulated radiation therapy. Radiother Oncol 98:347–351

    Article  PubMed  Google Scholar 

  47. Georg P, Georg D, Hillbrand M, Kirisits C, Poetter R (2006) Factors influencing bowel sparing in intensity modulated whole pelvic radiotherapy for gynecological malignancies. Radiother Oncol 80:19–26

    Article  PubMed  Google Scholar 

  48. van de Bunt L, Jürgenliemk-Schulz IM, de Kort GAP, Roesink JM, Tersteeg RJ, van der Heide UA (2008) Motion and deformation of the target volumes during IMRT for cervical cancer: what margins do we need? Radiother Oncol 88:233–240

    Article  PubMed  Google Scholar 

  49. Bondar ML, Hoogeman MS, Mens JW, Quint S, Ahmad R, Dhawtal G, Heijmen BJ (2012) Individualized non adaptive and online adaptive IMRT strategies for cervical cancer patients based on pretreatment acquired variable bladder filling CT-scans. Int J Radiat Oncol Biol Phys 83:1617–1623

    Article  CAS  PubMed  Google Scholar 

  50. Mazzola R, Ricchetti F, Fiorentino A, Levra NG, Fersino S, Di Paola G, et al (2016) Weekly cisplatin and volumetric-modulated arc therapy with simultaneous integrated boost for radical treatment of advanced cervical cancer in elderly patients: feasibility and clinical preliminary results. Technol Cancer Res Treat. doi10.1177/1533034616655055

  51. Collen C, Engels B, Duchateau M, Toumel K, De Ridder M, Bral S et al (2010) Volumetric imaging by megavoltage computed tomography for assessment of internal organ motion during radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 77:1590–1595

    Article  PubMed  Google Scholar 

  52. Liu H, Balter P, Tutt T, Choi B, Zhang J, Wang C et al (2007) Assessing respiration-induced tumor motion and internal target volume using 4D-CT for radiation therapy of lung cancer. J Radiat Oncol Biol Phys 68(2):531–540

    Article  Google Scholar 

  53. Bissonnette JP, Purdie T, Higgins J, Li W, Bezjak A (2009) Cone-Beam Computed Tomographic image guidance for lung cancer radiation therapy. J Radiat Oncol Biol Phys 7(3):927–934

    Article  Google Scholar 

  54. Yeung AR, Jonathan L, Wenyin S, Heather N, Morris CG, Sanjiv S et al (2010) Optimal image guidance scenario with cone-beam computed tomography in conventionally fractionated radiotherapy for lung tumors. Am J Clin Oncol 33(3):276–280

    PubMed  Google Scholar 

  55. Higgins J, Bezjak A, Hope A, Panzarella T, Li W, Cho JBC et al (2011) Effect of image-guidance frequency on geometric accuracy and setup margin in radiotherapy for locally advanced lung cancer. J Radiat Oncol Biol Phys 80(5):1330–1337

    Article  Google Scholar 

  56. Yamada Y, Lovelock DM, Bilsky MH (2007) A review of image-guided intensity-modulated radiotherapy for spinal tumors. Neurosur 61(2):226–235 (discussion 235)

    Article  Google Scholar 

  57. Guckenberger M, Goebel J, Wilbert J, Baier K, Richter A, Sweeney RA et al (2009) Clinical outcome of dose-escalated image-guided radiotherapy for spinal metastases. J Radiat Oncol Biol Phys 75(3):828–835

    Article  Google Scholar 

  58. Guckenberger M, Meyer J, Wilbert J, Baier K, Bratengeier K, Vordermark D et al (2007) Precision required for dose-escalated treatment of spinal metastases and implications for image-guided radiation therapy (IGRT). Radiother Oncol 84(1):56–63

    Article  PubMed  Google Scholar 

  59. Stoiber EM, Lechsel G, Giske K, Muenter MW, Hoess A, Bendl R et al (2009) Quantitative assessment of image-guided radiotherapy for paraspinal tumors. J Radiat Oncol Biol Phys 75(3):933–940

    Article  Google Scholar 

  60. Alongi F, Di Muzio N, Scorsetti M (2010) Reirradiation: hopes and concerns of the radiation oncologist. Tumori 96(5):792–793

    PubMed  Google Scholar 

  61. Jeong S, Yoo EJ, Kim JY, Han CW, Kim KJ, Kay CS (2013) Re-irradiation of unresectable recurrent head and neck cancer: using helical tomotherapy as image-guided intensity-modulated radiotherapy. Radiat Oncol J 31:206

    Article  PubMed  PubMed Central  Google Scholar 

  62. Gröger C, Hautman MG, Loeschel R, Repp N, Kölbl O, Dobler B (2013) Re-irradiation of spinal column metastases by IMRT: impact of setup errors on the dose distribution. Radiat Oncol 8:269

    Article  PubMed  PubMed Central  Google Scholar 

  63. Dewas S, Bibault JE, Mirabel X, Nickers P, Castelain B, Lacornerie T et al (2011) Robotic Image-guided reirradiation of lateral pelvic recurrences: preliminary results. Radiat Oncol 6:77

    Article  PubMed  PubMed Central  Google Scholar 

  64. Friedman DL, Whitton J, Leisenring W, Mertens AC, Hammond S, Stovall M et al (2010) Subsequent neoplasms in 5-year survivors of childhood cancer: the childhood cancer survivor study. J National Cancer Inst 102(14):1083–1095

    Article  Google Scholar 

  65. Hess CB, Thompson HM, Benedict SH, Seibert JA, Wong K, Vaughan AT et al (2016) Exposure risks among children undergoing radiation therapy: considerations in the era of image guided radiation therapy. J Radiat Oncol Biol Phys 94(5):978–992

    Article  Google Scholar 

  66. Alongi F, Di Muzio N (2009) Image-guided radiation therapy: a new era for the radiation oncologist? Int J Clin Oncol 14(6):568–569

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Elvio G. Russi, AIRO President, Stefano Maria Magrini, AIRO President-Elect, Claudio Arboscello, Marco Gatti, Alessia Guarneri, Pietro Gabriele, Elisabetta Garibaldi, Anna Merlotti, Andrea Ballarè, Renato Chiarlone, Giuseppina Gambaro, Filippo Grillo Ruggieri, Marco Krengli, Maria Rosa La Porta, Gregorio Moro, Fernando Munoz, Umberto Ricardi, Paolo Rovea, Tindaro Scolaro, Maria Tessa, and Alessandro Urgesi.

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Authors and Affiliations

  1. Radiation Oncology Department, S. S. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (TO), Italy

    Paola Franzone & Liana Todisco

  2. Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, via Don Sempreboni 5, 37034, Negrar (VR), Italy

    Alba Fiorentino & Filippo Alongi

  3. Radiation Oncology Department, University of Genova, Genoa, Italy

    Salvina Barra & Renzo Corvò

  4. Radiation Oncology Department, ASL TO 4, Ivrea, Italy

    Domenico Cante

  5. Radiation Oncology Department, University of Novara, Vercelli, Italy

    Laura Masini

  6. Medical Phisycs, S. S. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (TO), Italy

    Elena Cazzulo

  7. Radiation Oncology Department, IRCC, Candiolo, Italy

    Pietro Gabriele & Elisabetta Garibaldi

  8. Radiation Oncology Department, S.Croce e Carle Hospital, Cuneo, Italy

    Anna Merlotti

  9. Radiation Oncology Department, Ospedale Mauriziano, Turin, Italy

    Maria Grazia Ruo Redda

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  1. Paola Franzone
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Franzone, P., Fiorentino, A., Barra, S. et al. Image-guided radiation therapy (IGRT): practical recommendations of Italian Association of Radiation Oncology (AIRO). Radiol med 121, 958–965 (2016). https://doi.org/10.1007/s11547-016-0674-x

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