超中央肺肿瘤立体定向放疗中如何保护近端支气管树：磁共振引导治疗的经验。

IF 2.7 3区医学 Q3 ONCOLOGY

Clinical and Translational Radiation Oncology Pub Date : 2024-12-07 DOI:10.1016/j.ctro.2024.100899

Sebastian Regnery , Efthimios Katsigiannopulos , Hin Lau , Philipp Hoegen-Saßmannshausen , Fabian Weykamp , Claudia Katharina Renkamp , Carolin Rippke , Fabian Schlüter , Sophia Albert , Jan Meis , Marietta Kirchner , Alexandra Balzer , Nicolaus Andratschke , Matthias Guckenberger , Jürgen Debus , Sebastian Klüter , Juliane Hörner-Rieber

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引用次数: 0

摘要

目的：利用超中心性肺肿瘤（ULT）立体定向磁共振引导在线自适应放疗（SMART）的影像学数据，为ULT立体定向全身放疗（SBRT）的安全非自适应入路发展提供参考。患者和方法：分析基于前瞻性MAGELLAN试验中19例接受SMART （10 × 5.0-5.5 Gy）治疗0.35 T MR-Linac （MRIdian®）的ULT患者。6例患者的4d规划CT数据用于量化近端支气管树（PBT）呼吸运动。每日分数mri用于计算分数间平移（中外侧（ML），前后（AP），上-下（SI））及其对PBT的剂量学影响。在深度吸气屏气（DIBH）和表面引导（AlignRT®）中，计算了假设的非自适应SBRT的规划风险量（PRV）。最后，对N = 10例患者（10 × 5.5 Gy）的非自适应体积调制电弧（VMAT） SBRT进行了有和没有PRV的模拟。结果：PBT显示相应的呼吸运动，尤其是上下方向（中位ML: 2.5 mm, AP: 1.9 mm, SI: 9.2 mm）。此外，观察到适度的分数间平移（平均绝对平移ML: 1.3 mm, AP: 1.3 mm, SI: 1.1 mm），仅分数间变化的PRV边缘估计为2mm。模拟非适应性SBRT导致60%的患者PBT过量（过量剂量中位数VMAT: 2.5，预测MR-linac计划4）。mr引导的在线计划适应（SMART）和基于prv的非适应性VMAT均可预防PBT过量，但SMART的计划目标体积（PTV）覆盖率显著更高（SMART：中位数96% [IQR 95-96]， VMAT：中位数89% [IQR 77-94]， p = 0.014）。结论：在ULT的SBRT过程中，术中呼吸运动和术中平移都可能影响PBT的剂量。SMART保护PBT免受过量使用，同时保持高PTV覆盖率。采用先进的呼吸运动管理和PRV，非自适应SBRT似乎是安全的，但PTV覆盖率较低。

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How to protect the proximal bronchial tree during stereotactic radiotherapy of ultracentral lung tumors: Lessons from MR-guided treatment

Purpose

To use imaging data from stereotactic MR-guided online adaptive radiotherapy (SMART) of ultracentral lung tumors (ULT) for development of a safe non-adaptive approach towards stereotactic body radiotherapy (SBRT) of ULT.

Patients and Methods

Analysis is based on 19 patients with ULT who received SMART (10 × 5.0–5.5 Gy) on a 0.35 T MR-Linac (MRIdian®) in the prospective MAGELLAN trial. 4D-planning CT data of six patients served to quantify proximal bronchial tree (PBT) breathing motion. Daily fraction MRIs are used to calculate interfractional translations (mediolateral (ML), anterior-posterior (AP), superior-inferior (SI)) and their dosimetric consequences for the PBT. A planning risk volume (PRV) is calculated for an assumed non-adaptive SBRT in deep-inspiration breath hold (DIBH) with surface-guidance (AlignRT®). Finally, non-adaptive volumetric modulated arc (VMAT) SBRT is simulated with and without a PRV for N = 10 patients (10 × 5.5 Gy).

Results

The PBT shows relevant breathing motion, especially in superior-inferior direction (median ML: 2.5 mm, AP: 1.9 mm and SI: 9.2 mm). Furthermore, moderate interfractional translations are observed (mean absolute translation ML: 1.3 mm, AP: 1.3 mm, SI: 1.1 mm), with an estimated 2 mm PRV margin for interfractional changes alone. Simulated non-adaptive SBRT leads to PBT overdoses in 60 % of patients (median overdosed fractions VMAT: 2.5, predicted MR-linac plans 4). Both MR-guided online plan adaptation (SMART) and PRV-based non-adaptive VMAT prevent PBT overdoses, but SMART yields significantly higher planning target volume (PTV) coverage (SMART: median 96 % [IQR 95–96], VMAT: median 89 % [IQR 77–94], p = 0.014).

Conclusions

Both intrafractional breathing motion and interfractional translations may impact doses to the PBT during SBRT of ULT. SMART protects the PBT from overdoses while maintaining high PTV coverage. Non-adaptive SBRT appears safe with advanced breathing motion management and PRV, but yields inferior PTV coverage.

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