Name: treatment of liver metastases using an internal target volume method for stereotactic body radiotherapy
Uploaded: 2018-05-08T13:30:00.000+00:00
Duration: 8 min 54 s
Description: Watch this Scientific Journal Video about Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy at JoVE.com

这项研究得到台北医科大学医院 (106 tmuh-02) 的支持。

本研究获得台北医科大学联合机构评审委员会批准。
1. SBRT 咨询
<ol><li>通过咨询多学科肿瘤委员会, 评估 SBRT 治疗肝转移瘤患者的资格。 注意: 需要进行局部消融以及手术和其他治疗选择必须由肿瘤委员会评估。我们的选择标准如下: 1) 具有良好表现状态的成年患者 (东方合作肿瘤组 0-1), 2) 通过抗癌药物控制癌症状态, 仅在肝脏 oligometastases, 3) 肝损害数≤3和最大的肿瘤≤6厘米直径, 4) 肝体积 (肝脏不包括总肿瘤) 大于700厘米3, 5), 没有急性肝炎或慢性乙型肝炎在稳定的抗病毒控制。</li>
	<li>讨论 SBRT 及其相关的风险以及 SBRT 与常规放疗之间的差异与患者9,19。</li>
</ol>2. CT 模拟
<ol><li>
把病人放在仰卧位, 头先放在沙发上, 手臂放在头上。
	<ol>
<li>使用系统 (例如, BodyFIX) 来固定病人。将病人放置在一个个性化的, 真空的减压袋中, 用盖子盖住病人。</li>
		<li>应用腹部压缩机 (ac), 并标记交流的深度。 注意: AC 限制患者的呼吸运动;因此, 有些病人可能会在这个过程中产生呼吸困难。应提供通过鼻腔插管补充氧气, 以减轻他们的不适。</li>
		<li>将呼吸跟踪传感器放在胸腔壁上, 并监测呼吸波形。</li>
	</ol>
</li>
	<li>
获得放射治疗计划的 CT 图像。
	<ol>
<li>选择4维 CT 扫描模式, 3 毫米切片厚度。</li>
		<li>进行 surview 扫描 (120 伏, 30 mA), 以获得患者的前后 (AP) 和侧面视图。在屏幕和控制面板上单击"转到"。</li>
		<li>确定 "螺旋扫描" 分页下的 ct 扫描覆盖率, 并在 "肺门扫描" 分页中决定4维 ct 扫描范围。 注: 螺旋扫描的覆盖范围应从肺的顶端延伸到离肝尾缘至少5厘米的距离。肺门扫描的领域, 这是小于螺旋扫描, 应该覆盖肝脏与3-5 厘米延伸从颅和尾部的肝脏。</li>
		<li>监测呼吸波形, 直到它保持稳定3分钟。</li>
		<li>注射100毫升造影剂 (例如, 欧乃派克), 速度为4-5 毫升/秒, 通过18克静脉注射导管进入 antecubital 静脉。</li>
		<li>进行对比螺旋 CT 扫描 (120 kV, 400 mAs/切片), 十五年代后造影注射。</li>
		<li>随后通过点击 "下一个系列" 进行非对比的4维 CT 扫描 (120 伏, 2000 mAs/切片)。</li>
	</ol>
</li>
</ol>3. 放疗治疗计划
<ol><li>
将图像从 CT 模拟和诊断扫描导入计划系统。 注: 诊断图像可能包括正电子发射断层扫描 (pet)/pet-ct, 磁共振图像, 或诊断螺旋 CT 扫描。</li>
	<li>
轮廓转移肿瘤成总肿瘤体积和相邻器官的危险 (桨)。
	<ol>
<li>选择一个器官 (这里, 胃) 和使用刷子, 铅笔,等。在 CT 图像的每个切片中对器官进行轮廓。圈或定义感兴趣的器官。使用 "向上" 和 "向下" 按钮查看每个图像切片。 注: 桨叶包括肺部、胃、十二指肠、脊髓、肝脏、小肠、肋骨和肾脏。</li>
	</ol>
</li>
	<li>
根据动态跟踪图像观察到的器官运动, 对肿瘤的内靶容积 (ITV) 进行轮廓分析。在 ITV 中添加一个5毫米的边距以获得规划目标卷 (PTV)。
	<ol>
<li>选择一个器官 (这里, 胃) 和使用刷子, 铅笔,等。在 CT 图像的每个切片中对器官进行轮廓。圈或定义感兴趣的器官。使用 "向上" 和 "向下" 按钮查看每个图像切片。</li>
	</ol>
</li>
	<li>为相对较大的肿瘤, 在五个馏分中规定辐射剂量为48至三分或 35 PTV。 注: 治疗计划必须考虑因桨而造成的限制;如果桨的辐射剂量在约束范围内 (表 1), 则相对较高的处方剂量是可以接受的。</li>
</ol>4. 治疗分娩
<ol><li>使用每日质量保证确认辐射光束数据, 确保数据在正常范围内。</li>
	<li>使用病人的姓名、出生日期和身份证识别病人。将病人放置在真空袋中, 放置盖板, 并根据 CT 模拟部分所描述的程序固定 AC。</li>
	<li>
获取4D 锥束 CT (总站) 图像, 调整沙发, 使其与在模拟 CT 图像上获得的4维总站图像的目标位置相关联。
	<ol>
<li>选择4D 总站模式并确认安装数据。单击面板上的"转到" 。</li>
	</ol>
</li>
	<li>
4D 总站后, 将获得的4D 总站图像加载到 IGRT 系统中。左上、右下图像均由 CT 模拟作为轮廓和治疗计划。右上角和下左图像来自4D 总站, 每天在每个分数之前执行。
	<ol>
<li>使用软件调整设置。然后, 手动调整沙发上的每个参数。沙发在 X、Y 和 Z 轴上只有3直线运动, 而系统在6中可以调整, 包括旋转、俯仰和滚动。因此, 技术员需要证实调整。</li>
		<li>记录和打印每日调整的参数。 注: 如果肿瘤位置在任何一个六轴上超过5毫米的公差限制, 病人应重新定位。</li>
	</ol>
</li>
	<li>提供放射治疗。确认处理计划和系统配置。单击 "转到" 开始治疗。在整个治疗过程中用实时摄像头监控病人, 以确保病人的安全。</li>
</ol>

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作者没有披露。

呼吸引起的肝畸形和器官运动导致了与辐射传递有关的困难, 以及轮廓 (目标划定) 问题。对器官运动管理技术的改进提高了治疗的准确性和精确度, 这对 SBRT 是至关重要的。目前有几种图像引导技术和呼吸运动管理系统。基准标记植入是目标定位的常用技术。基准标记通常是圆柱形的金籽, 长度为2.5 到5毫米, 直径为0.8 毫米. 在病变附近植入一个基准标记, 使基于 X 射线的图像引导系统能够定位目标。然而, 在 > 30% 的患者中, 使用基准标记 (包括内出血、发热、疼痛、脱位和感染) 的并发症已被报道。患者接受侵入性手术是另一项关注事项12。此外, 空气呼吸协调 (ABC) 和深灵感呼吸保持 (DIBH) 技术经常用于图像引导放疗;这些无创的呼吸控制系统旨在帮助患者屏住呼吸, 从而在放射治疗中使靶固定。尽管在治疗前进行了耐心训练, 但是, 每一个分数的长期治疗时间、呼吸困难和个别的医疗状况限制了 ABC 和 DIBH13、14的使用。
用 AC 进行肺 SBRT 的呼吸相关 ct 和4维 ct 辅助扫描的准确性已被广泛证明15,16。最近的几项研究讨论了这种技术在呼吸相关肝运动中的应用。高桥et al。建议4维 CT 扫描与 AC 实现实质性的呼吸运动管理, 并减少 PTV 边缘 < 5 毫米16。此外, 4 维 CT 积分的肝脏 SBRT 剂量评价已被处理17。Shimohigashi et al。最近报道, 4 d-CT 与 AC 准确地代表肿瘤运动在 SBRT18期间。使用4维 CT 的交流比其他呼吸运动管理技术更有利, 因为该技术是无创的, 并允许自由呼吸。此外, 病人认为这项技术比其他管理技术更方便。医生和治疗师也可能受益于这种技术, 因为它创造了一个方便的工作流程。最近的一些研究报告说, 使用4维 CT 作为一种呼吸管理技术在肝转移 SBRT 期间19,20,21。患者不需要屏住呼吸时, 4 d-CT 与 AC 使用 (不像在病人训练时, DIBH 或 ABC 使用);因此, 4 d-CT 的交流被认为是方便的, 因此通常用于 SBRT 肺和肝脏。然而, 还应强调的是, 在肝脏运动管理中, 4 维 CT 的交流与治疗肺部病变的方法不同。
首先, 虽然规划 ct 扫描的图像质量仍未像 ct 扫描那样高, 但我们仍然建议对比 ct 能够精确地进行肿瘤的轮廓。与肺 SBRT 不同的是, 肺部病变可以很容易地与正常的肺组织区别于肺部 CT 图像。然而, 在 noncontrasted 肝脏图像中, 正常和恶性组织不能很容易区分。第二, 每日4维总站在治疗前对肿瘤部位进行验证, 对于显著提高 intrafractional 准确性至关重要;PTV 边距的3毫米以前被认为是足够的每日4维总站扫描 (尽管我们仍然遵守5毫米的 PTV 保证金标准)18。第三, 慢速 ct 扫描或电影 ct 扫描应在自由呼吸下进行。4维 CT 动态跟踪图像的各个阶段的肿瘤可作为 ITV 的肿瘤运动, 而交流限制器官运动以减少照射量。此外, 应评估肺的辐射剂量。靠近隔膜的肝脏病变可导致肺部辐射剂量增加。放射性肺炎是常见的并发症;然而, i. 级放射性肺炎通常无症状。对整个肺的剂量限制和 CT 扫描不应忽视。
从历史上看, 常规放疗对肝癌的治疗效果极低。然而, 肝脏对辐射剂量的耐受性相对较低, 辐射诱发肝病 (RILD) 可能是致命的。虽然一些研究提出了预防肝细胞癌放疗中 RILD 的预处理评价22, 但使用常规放疗治疗肝脏病变必须谨慎。SBRT 提供改进的肿瘤控制与极小的严重并发症;然而, 只有少数研究报告的风险评估, 以防止 RILD, 同时使用 SBRT 治疗肝转移。此外, 对于接受 SBRT 肝转移瘤患者的资格标准还没有明确定义, 尽管一些研究报告了一些常见的标准4,5。我们的选择标准如下: 1) 具有良好表现状态的成年患者 (东方合作肿瘤组 0-1), 2) 通过抗癌药物控制癌症状态, 仅在肝脏 oligometastases, 3) 肝损害数≤3和最大的肿瘤≤6厘米直径, 4) 肝体积 (肝脏不包括总肿瘤) 大于700厘米3, 5), 没有急性肝炎或慢性乙型肝炎在稳定的抗病毒控制。原癌的组织病理学不需要仅限于结肠、乳房和肺部, 但这些部位是首选。在拟议的议定书中需要进行多学科的肿瘤委员会讨论, 而行动应是第一个选择。其他局部消融疗法可以由肿瘤委员会讨论, 最后的治疗是根据病人的决定。
虽然局部消融包括 SBRT 可以实现局部肿瘤控制和使用 4 d-CT 的 AC 可以促进运动控制, 生存和无进展间隔严重依赖化疗的抗癌作用, 靶向治疗, 或其他系统药物。换言之, 如果没有适当的系统控制, 即使是最合适的局部消融治疗也不会提供任何整体的好处。因此, 回顾全身疗法的效果有助于选择局部消融治疗。此外, oligometastases 控制与无进展生存或整体生存之间的相关性仍需进一步调查。不同的因素, 如 oligometastases 的位置和数量, 原癌的病理组织学, 或治疗-天真的病人, 可能会对结局23产生影响。尽管有上述限制, SBRT, 这是无创的, 并在临床上方便, 作为 4 d-CT 与 AC 呼吸运动管理, 提供了相当大的局部消融作用的肝转移。

传统上, 转移被认为是癌症的末期阶段, 与预后和生存率差有关。但是, 山et al。在1984年报告说, 根据他们20年的经验, 完整的手术切除肺转移导致一个相对较高的存活率, 如果主要肿瘤部位是在系统控制的时候, 手术1。赫尔曼和 Weichselbaum 在1995年首次提出 oligometastases, 一个中间阶段之间的局部病变和系统性疾病与 polymetastases, 这可以治愈使用额外的局部治疗2,3。在过去的几十年中, 早期发现转移, 新的手术方法治疗 oligometastases (后) 和有效的化疗改善了预后的转移。肝脏是实体肿瘤最常见的转移器官之一, 肝 oligometastases 的手术切除可以改善生存。局部消融方法, 包括射频消融, radioembolization 和放疗, 为治疗肝转移已建议一些无法手术的病人, 以实现必要的局部肿瘤控制3,4,5,6,7. 在过去几年中, 一些前瞻性和回顾性的研究报告通过立体定向体放疗 (SBRT), 也称为立体定向消融放疗, 对肝转移瘤进行有效的局部肿瘤控制, 可耐受毒性4,5,8,9。
在病人定位和固定化方法方面已经有了改进;图像采集、整合和转移到放疗系统;呼吸运动管理;高剂量输出和快速辐射输送;以及从靶病变到周围正常组织的陡峭剂量梯度。由于这些进展, SBRT 实现高度精确和精确的放射治疗与极小的严重毒性10,11。呼吸运动管理是 SBRT 的基础, 特别是对肝脏和肺部病变。一种无创、临床方便的呼吸管理技术将极大地提高 SBRT 作为治疗方案的普及程度。本文详细介绍了肝转移的 SBRT 协议, 使用四维计算机断层扫描 (4 d-CT) 与腹部压缩机 (AC) 的图像引导帮助和肝脏运动管理。

<table><tbody><tr><td>CT scan</td><td>Philips</td><td>Brilliance&amp;nbsp;Big Bore&amp;nbsp;16 Slice&amp;nbsp;CT, 7387</td><td>Acquire CT images for contouring and planning</td></tr><tr><td>CT contrast</td><td>GE Healthcare</td><td>Omnipaque 350 mg L/mL</td><td>Enhence lesion in CT images</td></tr><tr><td>Linear accelerator</td><td>Elekta</td><td>Synergy</td><td>Deliver radiotherapy</td></tr><tr><td>Palnning system</td><td>Pinnacle</td><td>Pinnacle 9.8</td><td>Implement radiotherapy planning</td></tr><tr><td>Immobilization: BlueBag BodyFix</td><td>Elekta</td><td>900 mm x 2325 mm, P10104840</td><td>Immobilize the patient</td></tr><tr><td>Immobilization: BodyFix Cover sheet</td><td>Elekta</td><td>2700 mm x 1400 mm, P10102-304</td><td>Immobilize the patient</td></tr><tr><td>Immobilization: BodyFix abdominal compressor</td><td>Elekta</td><td>diaphragm control, P10102-149</td><td>Restrict breath motion and organ/lesion motion</td></tr><tr><td>Immobilization: vacuum pump</td><td>Elekta</td><td>vacuum pump, p2 120V, P10102-110</td><td>Shape body bag and cover sheet according to the patient</td></tr></tbody></table>

treatment of liver metastases using an internal target volume method for stereotactic body radiotherapy

由于有效的化疗和 oligometastatic 手术, 在过去数十年中, 转移性癌症患者的预后有所改善。对于无法手术的病人, 局部消融治疗, 如立体定向体放射治疗 (SBRT), 可以提供有效的局部肿瘤控制和最小的毒性。由于它的高精度和准确性, SBRT 提供了更高的辐射剂量每分数, 是更有效的, 并针对较小的辐射量比常规放疗。此外, 利用 SBRT 实现了靶向病灶向周围正常组织的陡峭剂量梯度;因此, SBRT 提供更有效的肿瘤控制, 并表现出较少的副作用比常规放疗。使用 SBRT 是普遍的治疗颅内病变 (称为立体定向放射外科);然而, 它现在也被用于治疗脊柱和肾上腺转移。由于在图像引导辅助和呼吸运动管理方面的进步, 一些研究已经研究了使用 SBRT 治疗肺或肝肿瘤, 这是作为一个病人呼吸移动。这些研究的结果表明, SBRT 有利控制肿瘤的运动性病变。
四维计算机断层扫描 (4 维 ct) 与腹部压缩机 (AC) 是临床上方便有效的呼吸运动管理。因为这种方法是无创的, 并允许自由呼吸, 它的使用减少并发症。此外, 病人认为这种方法很方便。此外, 它被认为比其他方法的呼吸运动管理的医生和治疗师。应用4维 CT 和 AC 治疗肺部病变也得到了广泛的研究, 该技术正在获得接受治疗肝损害。然而, 使用4维 CT 的交流治疗肝脏病变的协议与治疗肺部病变的方法不同。在本文中, 我们描述了一个新的协议 SBRT 4 维 CT 和交流治疗肝转移。

SBRT 可以通过强调制放疗 (IMRT) (与6辐射束) 或容积式电弧放疗 (VMAT) (连续剂量传递和龙门旋转) 来覆盖所有目标的单一治疗, 因为单一的手术可能<img alt="image" src="/files/ftp_upload/57050/57050imgv2.jpg">不能达到切除所有肿瘤的效果。有代表性的 SBRT 治疗计划表明, 手术不可行时两种肝转移瘤的放疗计划成功。两个转移肿瘤的长度为 3cm (从段4到段 8) 和4.3 厘米 (段 8), 其体积分别为13厘米3和22厘米3。所规定的剂量为5个分数的 50, 而光束被定向以避免桨 (图 1A-c)。复杂的处理计划包括四部分光束弧, 即180°到 50°, 260°到 50°, 335° 35°, 50°到 180° (图 1D)。剂量容积直方图显示了肿瘤的覆盖范围, 100% 的 PTVs 的体积由 > 95% 所规定的剂量;桨的辐射剂量在约束范围内 (图 2)。
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always"><tbody>
<tr>
<td></td>
			<td>3分数</td>
			<td>5分数</td>
		</tr>
<tr>
<td>覆盖</td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>PTV</td>
			<td colspan="2">D105% < 15%</td>
		</tr>
<tr>
<td></td>
			<td colspan="2">V100% ≥95%</td>
		</tr>
<tr>
<td>桨</td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>正常肝脏容量12
</td>
			<td>> 700 厘米3 at < 15</td>
			<td>平均 < 15</td>
		</tr>
<tr>
<td>胃、十二指肠、小肠</td>
			<td>D 3 厘米3 at < 21</td>
			<td>D 0.5 厘米3 at < 32</td>
		</tr>
<tr>
<td>两个肾脏</td>
			<td>V 15 < 35%</td>
			<td>平均 < 12Gy</td>
		</tr>
<tr>
<td>脊髓</td>
			<td>D 1 厘米3 at < 18</td>
			<td>D 0.5 厘米3 at < 28</td>
		</tr>
<tr>
<td>心</td>
			<td>D 1 厘米3 at < 30</td>
			<td>V 32 < 15 cm3</td>
		</tr>
<tr>
<td>两肺</td>
			<td>V 12.4 到 < 1000 cm3
</td>
			<td>V 11.4 到 < 1000 cm3
</td>
		</tr>
<tr>
<td>肋</td>
			<td>D 30 厘米3 at < 30</td>
			<td>零</td>
		</tr>
</tbody></table>表 1: 建议的风险器官剂量限制 (桨).PTV: 计划目标量。桨: 有危险的器官。1总肝脏体积-累计总肿瘤体积。2建议正常肝脏容积为 > 700 厘米3。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57050/57050fig1.jpg"> 图 1:剂量分布 (-c) 和波束方向 (D)。紫色和淡蓝色线条指示计划目标卷, 而黄色和粉红色的线条分别表示50和 30 (-c)。<a href="/files/ftp_upload/57050/57050fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57050/57050fig2.jpg"> 图 2:剂量-体积直方图.规划目标卷 (PTV) 1 和 PTV2 是彩色的紫色和浅蓝色。危险器官包括正常肝脏 (橙色), 肋骨 (淡粉色), 心脏 (黄色), 左肺 (荧光绿色), 右肺 (粉红色) 和脊髓 (蓝色)。<a href="/files/ftp_upload/57050/57050fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy at JoVE.com

Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy

立体定向体放疗 (SBRT) 需要严格的准确性和精确度, 以提供高辐射剂量每分数到小的治疗量, 以改善肿瘤控制和同时减少毒性。在此, 我们提出了一个无创和临床方便的呼吸运动管理协议 SBRT 肝转移。

内靶容积法治疗肝转移瘤的立体定向体放疗

The prognosis of patients with metastatic cancers has improved in the past decades due to effective chemotherapy and oligometastatic surgery. For ...

treatment-liver-metastases-using-an-internal-target-volume-method-for

Universidad San Sebastian

Research

JoVE Journal

Medicine

14.1K 次观看.  Taipei Medical University Hospital. 立体定向体放疗 (SBRT) 需要严格的准确性和精确度, 以提供高辐射剂量每分数到小的治疗量, 以改善肿瘤控制和同时减少毒性。在此, 我们提出了一个无创和临床方便的呼吸运动管理协议 SBRT 肝转移。

视频: Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy

PET and MRI Guided Irradiation of a Glioblastoma Rat Model Using a Micro-irradiator

For decades, small animal radiation research was mostly performed using fairly crude experimental setups applying simple single-beam techniques without the ability to target a specific or well-delineated tumor volume. The delivery of radiation was achieved using fixed radiation sources or linear accelerators producing megavoltage (MV) X-rays. These devices are unable to achieve sub-millimeter precision required for small animals. Furthermore, the high doses delivered to healthy surrounding tissue hamper response assessment. To increase the translation between small animal studies and humans, our goal was to mimic the treatment of human glioblastoma in a rat model. To enable a more accurate irradiation in a preclinical setting, recently, precision image-guided small animal radiation research platforms were developed. Similar to human planning systems, treatment planning on these micro-irradiators is based on computed tomography (CT). However, low soft-tissue contrast on CT makes it very challenging to localize targets in certain tissues, such as the brain. Therefore, incorporating magnetic resonance imaging (MRI), which has excellent soft-tissue contrast compared to CT, would enable a more precise delineation of the target for irradiation. In the last decade also biological imaging techniques, such as positron emission tomography (PET) gained interest for radiation therapy treatment guidance. PET enables the visualization of e.g., glucose consumption, amino-acid transport, or hypoxia, present in the tumor. Targeting those highly proliferative or radio-resistant parts of the tumor with a higher dose could give a survival benefit. This hypothesis led to the introduction of the biological tumor volume (BTV), besides the conventional gross target volume (GTV), clinical target volume (CTV), and planned target volume (PTV).
At the preclinical imaging lab of Ghent University, a micro-irradiator, a small animal PET, and a 7 T small animal MRI are available. The goal was to incorporate MRI-guided irradiation and PET-guided sub-volume boosting in a glioblastoma rat model.

In the past, small animal irradiation was usually performed without the ability to target a well-delineated tumor volume. The goal was to mimic the treatment of human glioblastoma in rats. Using a small animal irradiation platform, we performed MRI-guided 3D conformal irradiation with PET-based sub-volume boosting in a preclinical setting.

PET 与 MRI 引导下微器对大鼠胶质瘤模型的照射

For decades, small animal radiation research was mostly performed using fairly crude experimental setups applying simple single-beam techniques without ...

科研

癌症研究

Evaluation of the Feasibility, Safety, and Accuracy of an Intraoperative High-intensity Focused Ultrasound Device for Treating Liver Metastases

Today, the only potentially curative option in patients with colorectal liver metastases is surgery. However, liver resection is feasible in less than 20% of patients. Surgery has been widely used in association with radiofrequency, cryotherapy, or microwaves to expand the number of treatments performed with a curative intent. Nevertheless, several limitations have been documented when using these techniques (i.e., a traumatic puncture of the parenchyma, a limited size of lesions, and an inability to monitor the treatment in real-time).High-intensity focused ultrasound (HIFU) technology can achieve precise ablations of biological tissues without incisions or radiation. Current HIFU devices are based on an extracorporeal approach with limited access to the liver. We have developed a HIFU device designed for intraoperative use. The use of a toroidal transducer enables an ablation rate (10 cm3&#183;min-1) higher than any other treatment and is independent of perfusion.
The feasibility, safety, and accuracy of intraoperative HIFU ablation were evaluated during an ablate-and-resect prospective study. This clinical phase I and IIa study was performed in patients undergoing hepatectomy for liver metastases. The HIFU treatment was performed on healthy tissue scheduled for resection.Liver metastases measuring less than 20 mm will be targeted during phase IIb (currently ongoing). This set-up allows the real-time evaluation of HIFU ablation while protecting participating patients from any adverse effects related to this new technique.
Fifteen patients were included in phase I&#8211;IIa and 30 HIFU ablations were safely created within 40 s and with a precision of 1&#8211;2 mm. The average dimensions of the HIFU ablations were 27.5 x 21.0 mm2, corresponding to a volume of approximately 7.5 cm3. The aim of the ongoing phase IIb is to ablate metastases of less than 20 mm in diameter with a 5 mm margin.

Here, we present an ablate-and-resect prospective study to evaluate the feasibility, safety, and accuracy of intraoperative high-intensity focused ultrasound ablation in patients undergoing hepatectomy for liver metastases.

术中高强度聚焦超声装置治疗肝转移的可行性、安全性和准确性评价

Today, the only potentially curative option in patients with colorectal liver metastases is surgery. However, liver resection is feasible in less than 20% ...

Stereotactic Radiosurgery for Gynecologic Cancer

Stereotactic body radiotherapy (SBRT) distinguishes itself by necessitating more rigid patient immobilization, accounting for respiratory motion, intricate treatment planning, on-board imaging, and reduced number of ablative radiation doses to cancer targets usually refractory to chemotherapy and conventional radiation. Steep SBRT radiation dose drop-off permits narrow 'pencil beam' treatment fields to be used for ablative radiation treatment condensed into 1 to 3 treatments.
Treating physicians must appreciate that SBRT comes at a bigger danger of normal tissue injury and chance of geographic tumor miss. Both must be tackled by immobilization of cancer targets and by high-precision treatment delivery. Cancer target immobilization has been achieved through use of indexed customized Styrofoam casts, evacuated bean bags, or body-fix molds with patient-independent abdominal compression.1-3 Intrafraction motion of cancer targets due to breathing now can be reduced by patient-responsive breath hold techniques,4 patient mouthpiece active breathing coordination,5 respiration-correlated computed tomography,6 or image-guided tracking of fiducials implanted within and around a moving tumor.7-9 The Cyberknife system (Accuray [Sunnyvale, CA]) utilizes a radiation linear accelerator mounted on a industrial robotic arm that accurately follows patient respiratory motion by a camera-tracked set of light-emitting diodes (LED) impregnated on a vest fitted to a patient.10 Substantial reductions in radiation therapy margins can be achieved by motion tracking, ultimately rendering a smaller planning target volumes that are irradiated with submillimeter accuracy.11-13
Cancer targets treated by SBRT are irradiated by converging, tightly collimated beams. Resultant radiation dose to cancer target volume histograms have a more pronounced radiation "shoulder" indicating high percentage target coverage and a small high-dose radiation "tail." Thus, increased target conformality comes at the expense of decreased dose uniformity in the SBRT cancer target. This may have implications for both subsequent tumor control in the SBRT target and normal tissue tolerance of organs at-risk. Due to the sharp dose falloff in SBRT, the possibility of occult disease escaping ablative radiation dose occurs when cancer targets are not fully recognized and inadequate SBRT dose margins are applied. Clinical target volume (CTV) expansion by 0.5 cm, resulting in a larger planning target volume (PTV), is associated with increased target control without undue normal tissue injury.7,8 Further reduction in the probability of geographic miss may be achieved by incorporation of 2-[18F]fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET).8 Use of 18F-FDG PET/CT in SBRT treatment planning is only the beginning of attempts to discover new imaging target molecular signatures for gynecologic cancers.

Stereotactic body radiotherapy (SBRT) involves image-guided, ablative radiation delivered to cancer targets refractory to chemotherapy or to conventional radiation treatment. The robotic-armed Cyberknife SBRT system, using sophisticated target localization, delivers hypofractionated radiation doses capable of sterilizing cancer targets. This article will consider new therapeutic roles of SBRT for gynecological cancers.

妇科肿瘤的立体定向放射外科

Stereotactic body radiotherapy (SBRT) distinguishes itself by necessitating more rigid patient immobilization, accounting for respiratory motion, ...

医学

小鼠的引导肿瘤接种和多模式成像

A Dorsal Skinfold Window Chamber Tumor Mouse Model for Combined Intravital Microscopy and Magnetic Resonance Imaging in Translational Cancer Research

Preclinical intravital imaging such as microscopy and optical coherence tomography have proven to be valuable tools in cancer research for visualizing the tumor microenvironment and its response to therapy. These imaging modalities have micron-scale resolution but have limited use in the clinic due to their shallow penetration depth into tissue. More clinically applicable imaging modalities such as CT, MRI, and PET have much greater penetration depth but have comparatively lower spatial resolution (mm scale). 
To translate preclinical intravital imaging findings into the clinic, new methods must be developed to bridge this micro-to-macro resolution gap. Here we describe a dorsal skinfold window chamber tumor mouse model designed to enable preclinical intravital and clinically applicable (CT and MR) imaging in the same animal, and the image analysis platform that links these two disparate visualization methods. Importantly, the described window chamber approach enables the different imaging modalities to be co-registered in 3D using fiducial markers on the window chamber for direct spatial concordance. This model can be used for validation of existing clinical imaging methods, as well as for the development of new ones through direct correlation with "ground truth" high-resolution intravital findings. 
Finally, the tumor response to various treatments-chemotherapy, radiotherapy, photodynamic therapy-can be monitored longitudinally with this methodology using preclinical and clinically applicable imaging modalities. The dorsal skinfold window chamber tumor mouse model and imaging platforms described here can thus be used in a variety of cancer research studies, for example, in translating preclinical intravital microscopy findings to more clinically applicable imaging modalities such as CT or MRI.

作者聚焦:整合高分辨率活体成像和 MRI 以增强立体定向放射治疗计划

Translation of Intravital microscopy findings is challenged by its shallow depth penetration into tissue. Here we describe a dorsal window chamber mouse model that enables co-registration of intravital microscopy and clinically applicable imaging modalities (e.g., CT, MRI) for direct spatial correlation, potentially streamlining clinical translation of intravital microscopy findings.

背侧皮褶窗室肿瘤小鼠模型在转化癌症研究中用于联合活体显微镜和磁共振成像

Preclinical intravital imaging such as microscopy and optical coherence tomography have proven to be valuable tools in cancer research for visualizing the ...

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

隔离肝脏灌注作为治疗葡萄膜黑色素瘤肝转移

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

Clinical Factors Influencing the Radiation Dose of Circulating Immune Cells during Radiotherapy for Small Cell Lung Cancer

Small cell lung cancer (SCLC) has garnered significant attention due to its high malignancy, propensity for distant metastasis, and poor prognosis. Radiotherapy remains the cornerstone of treatment for limited-stage small cell lung cancer (LS-SCLC). However, outcomes with radiotherapy alone or in combination with chemotherapy remain suboptimal. Radiotherapy can induce lymphopenia by directly irradiating hematopoietic organs or destroying mature circulating lymphocytes, leading to immunosuppression and consequently diminishing therapeutic efficacy. The estimated dose of radiation to immune cells (EDRIC) model integrates factors such as hemodynamics, lymphocyte radiosensitivity, and proliferation capacity. This study employs the EDRIC model with enhancements to calculate the circulating immune cell radiation dose. By utilizing the EDRIC methodology, the study explores the correlation between EDRIC and tumor target size, average lung dose, average heart dose, clinical features, and peripheral blood lymphocytopenia during radiotherapy for LS-SCLC, aiming to inform personalized patient treatment strategies.
This study analyzed data from 64 LS-SCLC patients who met the inclusion criteria at the General Hospital of Ningxia Medical University from January 2023 to January 2024, all of whom received radical thoracic conventional fractionated radiotherapy. Lymphocyte counts were recorded at the following points: before radiotherapy, at the lowest observed value during radiotherapy, at the end of radiotherapy, and one-month post-radiotherapy. Dosimetric data, including average lung, heart, and body doses, were extracted from the treatment planning system, and the circulating EDRIC was calculated using this model. The relationship between EDRIC values and therapeutic outcomes was analyzed. In LS-SCLC, the EDRIC model effectively predicts lymphocyte count reduction, correlating with planning target volume (PTV; cm3), TNM stage, and the percentage of target lesion shrinkage. Post-radiotherapy, there was a significant decrease in peripheral blood lymphocyte counts, with greater EDRIC values indicating more pronounced lymphocyte reduction.

Here, we present a protocol to evaluate the effects of radiation therapy on immune system lymphocytes in small cell lung cancer.

Small cell lung cancer (SCLC) has garnered significant attention due to its high malignancy, propensity for distant metastasis, and poor prognosis. ...

Dynamic Lung Tumor Tracking for Stereotactic Ablative Body Radiation Therapy

Physicians considering stereotactic ablative body radiation therapy (SBRT) for the treatment of extracranial cancer targets must be aware of the sizeable risks for normal tissue injury and the hazards of physical tumor miss. A first-of-its-kind SBRT platform achieves high-precision ablative radiation treatment through a combination of versatile real-time imaging solutions and sophisticated tumor tracking capabilities. It uses dual-diagnostic kV x-ray units for stereoscopic open-loop feedback of cancer target intrafraction movement occurring as a consequence of respiratory motions and heartbeat. Image-guided feedback drives a gimbaled radiation accelerator (maximum 15 x 15 cm field size) capable of real-time &#177;4 cm pan-and-tilt action. Robot-driven &#177;60&#176; pivots of an integrated &#177;185&#176; rotational gantry allow for coplanar and non-coplanar accelerator beam set-up angles, ultimately permitting unique treatment degrees of freedom. State-of-the-art software aids real-time six dimensional positioning, ensuring irradiation of cancer targets with sub-millimeter accuracy (0.4 mm at isocenter). Use of these features enables treating physicians to steer radiation dose to cancer tumor targets while simultaneously reducing radiation dose to normal tissues. By adding respiration correlated computed tomography (CT) and 2-[18F] fluoro-2-deoxy-&#7429;-glucose (18F-FDG) positron emission tomography (PET) images into the planning system for enhanced tumor target contouring, the likelihood of physical tumor miss becomes substantially less1. In this article, we describe new radiation plans for the treatment of moving lung tumors.

Stereotactic ablative body radiation therapy (SBRT) involves the precise delivery of high-dose radiation to cancer tumor targets. A novel SBRT platform offers a first-of-its-kind gimbaled radiation accelerator mounted within a pivoting O-ring gantry capable of dynamic image-guided tumor tracking. Here, we describe dynamic tumor tracking for lung targets.

动态肺肿瘤跟踪烧蚀立体定向放射身体治疗

Physicians considering stereotactic ablative body radiation therapy (SBRT) for the treatment of extracranial cancer targets must be aware of the sizeable ...

Targeted and Selective Treatment of Pluripotent Stem Cell-derived Teratomas Using External Beam Radiation in a Small-animal Model

The growing number of victims of &#34;stem cell tourism,&#34; the unregulated transplantation of stem cells worldwide, has raised concerns about the safety of stem cell transplantation. Although the transplantation of differentiated rather than undifferentiated cells is common practice, teratomas can still arise from the presence of residual undifferentiated stem cells at the time of transplant or from spontaneous mutations in differentiated cells. Because stem cell therapies are often delivered into anatomically sensitive sites, even small tumors can be clinically devastating, resulting in blindness, paralysis, cognitive abnormalities, and cardiovascular dysfunction. Surgical access to these sites may also be limited, leaving patients with few therapeutic options. Controlling stem cell misbehavior is, therefore, critical for the clinical translation of stem cell therapy.
External beam radiation offers an effective means of delivering targeted therapy to decrease the teratoma burden while minimizing injury to surrounding organs. Additionally, this method avoids genetic manipulation or viral transduction of stem cells-which are associated with additional clinical safety and efficacy concerns. Here, we describe a protocol to create pluripotent stem cell-derived teratomas in mice and to apply external beam radiation therapy to selectively ablate these tumors in vivo.

Research on treatment strategies for pluripotent stem cell-derived teratomas is important for the clinical translation of stem cell therapy. Here, we describe a protocol to, first, generate stem cell-derived teratomas in mice and, then, to selectively target and treat these tumors in vivo using a small-animal irradiator.

利用外束辐射对小型动物模型的多能干细胞衍生畸胎瘤进行靶向选择性治疗

The growing number of victims of &#34;stem cell tourism,&#34; the unregulated transplantation of stem cells worldwide, has raised concerns about the ...

内靶容积法治疗肝转移瘤的立体定向体放疗

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此视频中的章节

PET 与 MRI 引导下微器对大鼠胶质瘤模型的照射

术中高强度聚焦超声装置治疗肝转移的可行性、安全性和准确性评价

妇科肿瘤的立体定向放射外科

背侧皮褶窗室肿瘤小鼠模型在转化癌症研究中用于联合活体显微镜和磁共振成像

背侧皮褶窗室肿瘤小鼠模型在转化癌症研究中用于联合活体显微镜和磁共振成像

背侧皮褶窗室肿瘤小鼠模型在转化癌症研究中用于联合活体显微镜和磁共振成像

隔离肝脏灌注作为治疗葡萄膜黑色素瘤肝转移

Clinical Factors Influencing the Radiation Dose of Circulating Immune Cells during Radiotherapy for Small Cell Lung Cancer

动态肺肿瘤跟踪烧蚀立体定向放射身体治疗

利用外束辐射对小型动物模型的多能干细胞衍生畸胎瘤进行靶向选择性治疗