この研究は、台北医科大学附属病院 (106TMUH-ネ-02) によって支えられました。

今回台北医学大学共同機関審査委員会の承認が得られました。
1. 肺門相談
<ol><li>学際的な腫瘍ボードで肺門の肝転移の治療のための患者の適格性を評価します。 注: 操作と同様に局所療法の必要性、他の治療オプションは、腫瘍委員会によって評価されなければなりません。当社の選択基準は次のとおり: 抗癌薬や肝、肝病変の数 3) oligometastases のみで良好なパフォーマンス状態 (東部組合オンコロジー 0-1)、2) 制御 1) 成人患者癌状態3、最大腫瘍 ≤6 cm 径、4) 肝容積 (総腫瘍を除く肝) 700 cm3、および 5 を超える) 急性肝炎や慢性肝炎 B 安定した抗ウイルス制御の下でなし。</li>
	<li>肺門、その関連するリスク、肺門と患者9,19と従来の放射線治療との違いについて説明します。</li>
</ol>2. CT シミュレーション
<ol><li>
患者を仰臥位、両手を頭の上のソファの上の先頭に配置します。
	<ol>
<li>患者を固定するのにシステム (例えばBodyFIX) を使用します。パーソナライズされた、真空真空袋に患者を置き、カバー シートで患者をカバーします。</li>
		<li>腹部の圧縮機 (AC) を適用し、AC の深さをマークします。 注意: AC 患者の呼吸運動が制限されます。したがって、いくつかの患者は、この手順の中に呼吸困難を開発するかもしれない。鼻カニューレによる酸素補給は、その不快感を和らげるために提供されなければなりません。</li>
		<li>胸壁上息追跡センサーを設置し、呼吸波形を監視します。</li>
	</ol>
</li>
	<li>
放射線治療治療計画用 CT 画像を取得します。
	<ol>
<li>3 mm スライス厚で 4 D CT スキャン ・ モードを選択します。</li>
		<li>Surview スキャンを実施 (120 kV、30 mA) 前後 (AP) と患者の側のビューを取得します。"Go をクリックして"画面のコントロール パネル。</li>
		<li>「ヘリカル スキャン」の改ページの下で CT スキャンのカバレッジを決定する、"肺ゲーティング スキャン"改ページの下で 4 D CT の走査分野を決定します。 注: ヘリカル スキャンのカバレッジでは肝臓の尾側の国境から、少なくとも 5 cm の距離両方肺の頂点から拡張する必要があります。ヘリカル スキャンよりも小さい場合は、肺のゲーティング スキャン分野肝臓の前葉および後葉の境界から拡張してカバー 3-5 cm の肝ください。</li>
		<li>3 分間そのまままで、呼吸波形を監視します。</li>
		<li>4-5 mL の割合で (例えばOmnipaque)、造影剤 100 mL を注入/s、肘に 18 G 静脈カテーテルを静脈。</li>
		<li>対照的な連続したヘリカル CT スキャンを実施 (120 kV、400 Ma/スライス) 15、造影後 s。</li>
		<li>その後非対照的 4次元 CT スキャンを実施 (120 kV、2,000 Ma/スライス)「次シリーズ」をクリック。</li>
	</ol>
</li>
</ol>3. 放射線治療計画
<ol><li>
CT シミュレーションと診断スキャンから計画システムに画像をインポートします。 注: 診断イメージは、ポジトロン断層法 (PET) を含めることができます/ペット CT や磁気共鳴画像診断 CT スキャンします。</li>
	<li>
総腫瘍体積とリスク (オール) で隣接臓器に輪郭の転移性腫瘍。
	<ol>
<li>器官 (ここで胃) を選択し、ブラシ、鉛筆などを使用します。CT 画像の各スライスの器官を輪郭。サークルまたは関心の器官を定義します。"Up"と"Down"ボタンを使用して、各画像のスライスを表示します。 注: 肺、胃、十二指腸、脊髄、肝臓、小腸、リブ、そして腎臓にオールが含まれます。</li>
	</ol>
</li>
	<li>
臓器運動の動的追跡画像の観察によると腫瘍内部のターゲット ・ ボリューム (ITV) を輪郭します。ターゲット ・ ボリュームの計画 (PTV) を取得する ITV に 5 mm の余白を追加します。
	<ol>
<li>器官 (ここで胃) を選択し、ブラシ、鉛筆などを使用します。CT 画像の各スライスの器官を輪郭。サークルまたは関心の器官を定義します。"Up"と"Down"ボタンを使用して、各画像のスライスを表示します。</li>
	</ol>
</li>
	<li>3 画 48 Gy または比較的大きな腫瘍の PTV を 5 分画で 35 Gy の線量を処方します。 注: 治療計画はオール; により、制約を考慮する必要があります。力漕する放射線量 (表 1) の制約内にある場合、比較的高い処方線量は許容できるかもしれません。</li>
</ol>4. 治療
<ol><li>毎日の品質保証を使用して放射ビーム データを再確認し、データが正常範囲内であることを確認します。</li>
	<li>患者の名前、生年月日、および ID カードを使用して、患者を識別します。真空袋、カバー シートの場所および CT シミュレーション」で説明した手順に従って修正 AC で患者の位置。</li>
	<li>
4 D コーンビーム CT (CBCT) 画像を取得し、シミュレーションの CT 画像を得、4 D CBCT の画像を得られるターゲットの場所を関連付けるためにソファを調整します。
	<ol>
<li>4 D CBCT モードを選択し、セットアップ データを確認します。パネルには、 "Go"をクリックします。</li>
	</ol>
</li>
	<li>
4 D CBCT 後、治療システムに取得した 4 D CBCT 画像を読み込みます。左上と右下の画像は輪郭と治療計画 CT シミュレーションからです。上右と左下の画像は、4 D CBCT は、毎日各分画の前に行われるからです。
	<ol>
<li>ソフトウェアを使用するを設定を調整できます。ソファのそれぞれのパラメーターを手動で調整します。ソファにのみ 3 直線運動は、X、Y、および Z 軸システム調整がある 6、回転を含む、ピッチおよびロールします。したがって、技術者は調整を確証する必要があります。</li>
		<li>記録し、毎日調整のパラメーターを出力します。 注: 腫瘍の位置は、6 軸のいずれかの 5 mm の許容限度を超えてシフト、患者移動します。</li>
	</ol>
</li>
	<li>放射線治療を提供します。治療計画とシステム構成を確認します。治療を開始するをクリックします。全体の治療中に患者の安全性を確保するためリアルタイム カメラを使用して患者を監視します。</li>
</ol>

<ol><li>Mountain, C. F., McMurtrey, M. J., Hermes, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgery+for+pulmonary+metastasis%3A+a+20-year+experience%5BTitle%5D)+AND+%22Ann+Thorac+Surg%22%5BJournal%5D)">Surgery for pulmonary metastasis: a 20-year experience.</a> Ann Thorac Surg. 38 (4), 323-330 (1984).</li>
<li>Hellman, S., Weichselbaum, R. R. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/7799047">Oligometastases.</a> J Clin Oncol. 13 (1), 8-10 (1995).</li>
<li>Weichselbaum, R. R., Hellman, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Oligometastases+revisited%5BTitle%5D)+AND+%22Na.+Rev+Clin+Oncol%22%5BJournal%5D)">Oligometastases revisited.</a> Na. Rev Clin Oncol. 8 (6), 378-382 (2011).</li>
<li>Comito, T., Clerici, E., Tozzi, A., D'Agostino, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Liver+metastases+and+SBRT%3A+A+new+paradigm%3F%5BTitle%5D)+AND+%22Rep+Pract+Oncol+Radiother%22%5BJournal%5D)">Liver metastases and SBRT: A new paradigm?</a> Rep Pract Oncol Radiother. 20 (6), 464-471 (2015).</li>
<li>Scorsetti, M., Clerici, E., Comito, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Stereotactic+body+radiation+therapy+for+liver+metastases%5BTitle%5D)+AND+%22J+Gastrointest+Oncol%22%5BJournal%5D)">Stereotactic body radiation therapy for liver metastases.</a> J Gastrointest Oncol. 5 (3), 190-197 (2014).</li>
<li>Shady, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+Radiofrequency+Ablation+of+Colorectal+Cancer+Liver+Metastases%3A+Factors+Affecting+Outcomes--A+10-year+Experience+at+a+Single+Center%5BTitle%5D)+AND+%22Radiology%22%5BJournal%5D)">Percutaneous Radiofrequency Ablation of Colorectal Cancer Liver Metastases: Factors Affecting Outcomes--A 10-year Experience at a Single Center.</a> Radiology. 278 (2), 601-611 (2016).</li>
<li>van Hazel, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((SIRFLOX%3A+Randomized+Phase+III+Trial+Comparing+First-Line+mFOLFOX6+%28Plus+or+Minus+Bevacizumab%29+Versus+mFOLFOX6+%28Plus+or+Minus+Bevacizumab%29+Plus+Selective+Internal+Radiation+Therapy+in+Patients+With+Metastatic+Colorectal+Cancer%5BTitle%5D)+AND+%22J+Clin+Oncol%22%5BJournal%5D)">SIRFLOX: Randomized Phase III Trial Comparing First-Line mFOLFOX6 (Plus or Minus Bevacizumab) Versus mFOLFOX6 (Plus or Minus Bevacizumab) Plus Selective Internal Radiation Therapy in Patients With Metastatic Colorectal Cancer.</a> J Clin Oncol. 34 (15), 1723-1731 (2016).</li>
<li>Salama, J. K., Milano, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Radical+irradiation+of+extracranial+oligometastases%5BTitle%5D)+AND+%22J+Clin+Oncol%22%5BJournal%5D)">Radical irradiation of extracranial oligometastases.</a> J Clin Oncol. 32 (26), 2902-2912 (2014).</li>
<li>Rusthoven, K. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Multi-institutional+phase+I%2FII+trial+of+stereotactic+body+radiation+therapy+for+liver+metastases%5BTitle%5D)+AND+%22J+Clin+Oncol%22%5BJournal%5D)">Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases.</a> J Clin Oncol. 27 (10), 1572-1578 (2009).</li>
<li>Ricardi, U., Badellino, S., Filippi, A. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+applications+of+stereotactic+radiation+therapy+for+oligometastatic+cancer+patients%3A+a+disease-oriented+approach%5BTitle%5D)+AND+%22J+Radiat+Res%22%5BJournal%5D)">Clinical applications of stereotactic radiation therapy for oligometastatic cancer patients: a disease-oriented approach.</a> J Radiat Res. 57 (Suppl 1), i58-i68 (2016).</li>
<li>Wild, A. T., Yamada, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Treatment+Options+in+Oligometastatic+Disease%3A+Stereotactic+Body+Radiation+Therapy+-+Focus+on+Colorectal+Cancer%5BTitle%5D)+AND+%22Visc+Med%22%5BJournal%5D)">Treatment Options in Oligometastatic Disease: Stereotactic Body Radiation Therapy - Focus on Colorectal Cancer.</a> Visc Med. 33 (1), 54-61 (2017).</li>
<li>Gill, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patient-reported+complications+from+fiducial+marker+implantation+for+prostate+image-guided+radiotherapy%5BTitle%5D)+AND+%22Br+J+Radiol%22%5BJournal%5D)">Patient-reported complications from fiducial marker implantation for prostate image-guided radiotherapy.</a> Br J Radiol. 85 (1015), 1011-1017 (2012).</li>
<li>Eldredge-Hindy, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Active+Breathing+Coordinator+Reduces+Radiation+Dose+to+the+Heart+and+Preserves+Local+Control+in+Patients+with+Left+Breast+Cancer%3A+Report+of+a+Prospective+Trial%5BTitle%5D)+AND+%22Pract+Radiat+Oncol%22%5BJournal%5D)">Active Breathing Coordinator Reduces Radiation Dose to the Heart and Preserves Local Control in Patients with Left Breast Cancer: Report of a Prospective Trial.</a> Pract Radiat Oncol. 5 (1), 4-10 (2015).</li>
<li>Swanson, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Six-year+experience+routinely+using+moderate+deep+inspiration+breath-hold+for+the+reduction+of+cardiac+dose+in+left-sided+breast+irradiation+for+patients+with+early-stage+or+locally+advanced+breast+cancer%5BTitle%5D)+AND+%22Am+J+Clin+Oncol%22%5BJournal%5D)">Six-year experience routinely using moderate deep inspiration breath-hold for the reduction of cardiac dose in left-sided breast irradiation for patients with early-stage or locally advanced breast cancer.</a> Am J Clin Oncol. 36 (1), 24-30 (2013).</li>
<li>Sweeney, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Accuracy+and+inter-observer+variability+of+3D+versus+4D+cone-beam+CT+based+image-guidance+in+SBRT+for+lung+tumors%5BTitle%5D)+AND+%22Radiat+Oncol%22%5BJournal%5D)">Accuracy and inter-observer variability of 3D versus 4D cone-beam CT based image-guidance in SBRT for lung tumors.</a> Radiat Oncol. 7, 81(2012).</li>
<li>Takahashi, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Verification+of+Planning+Target+Volume+Settings+in+Volumetric+Modulated+Arc+Therapy+for+Stereotactic+Body+Radiation+Therapy+by+Using+In-Treatment+4-Dimensional+Cone+Beam+Computed+Tomography%5BTitle%5D)+AND+%22Int+J+Radiat+Oncol+Biol+Phys%22%5BJournal%5D)">Verification of Planning Target Volume Settings in Volumetric Modulated Arc Therapy for Stereotactic Body Radiation Therapy by Using In-Treatment 4-Dimensional Cone Beam Computed Tomography.</a> Int J Radiat Oncol Biol Phys. 86 (3), 426-431 (2013).</li>
<li>Yeo, U. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+dosimetric+misrepresentations+from+3D+conventional+planning+of+liver+SBRT+using+4D+deformable+dose+integration%5BTitle%5D)+AND+%22J+Appl+Clin+Med+Phys%22%5BJournal%5D)">Evaluation of dosimetric misrepresentations from 3D conventional planning of liver SBRT using 4D deformable dose integration.</a> J Appl Clin Med Phys. 15 (6), 4978(2014).</li>
<li>Shinmohigashi, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Tumor+motion+changes+in+stereotactic+body+radiotherapy+for+liver+tumors%3A+an+evaluation+based+on+four-dimensional+cone-beam+computed+tomography+and+fiducial+markers%5BTitle%5D)+AND+%22Radiat+Oncol%22%5BJournal%5D)">Tumor motion changes in stereotactic body radiotherapy for liver tumors: an evaluation based on four-dimensional cone-beam computed tomography and fiducial markers.</a> Radiat Oncol. 12, 61(2017).</li>
<li>Goodman, B. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+safety+and+efficacy+of+stereotactic+body+radiation+therapy+for+hepatic+oligometastases%5BTitle%5D)+AND+%22Pract+Radiat+Oncol%22%5BJournal%5D)">Long-term safety and efficacy of stereotactic body radiation therapy for hepatic oligometastases.</a> Pract Radiat Oncol. 6 (2), 86-95 (2016).</li>
<li>Scorsetti, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Is+stereotactic+body+radiation+therapy+an+attractive+option+for+unresectable+liver+metastases%3F+A+preliminary+report+from+a+phase+2+trial%5BTitle%5D)+AND+%22Int+J+Radiat+Oncol+Biol+Phys%22%5BJournal%5D)">Is stereotactic body radiation therapy an attractive option for unresectable liver metastases? A preliminary report from a phase 2 trial.</a> Int J Radiat Oncol Biol Phys. 86 (2), 336-342 (2013).</li>
<li>Andratschke, N. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Stereotactic+radiation+therapy+for+liver+metastases%3A+factors+affecting+local+control+and+survival%5BTitle%5D)+AND+%22Radiat+Oncol%22%5BJournal%5D)">Stereotactic radiation therapy for liver metastases: factors affecting local control and survival.</a> Radiat Oncol. 10, 69(2015).</li>
<li>Huang, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+parameters+for+predicting+radiation-induced+liver+disease+after+intrahepatic+reirradiation+for+hepatocellular+carcinoma%5BTitle%5D)+AND+%22Radiat+Oncol%22%5BJournal%5D)">Clinical parameters for predicting radiation-induced liver disease after intrahepatic reirradiation for hepatocellular carcinoma.</a> Radiat Oncol. 11 (89), (2016).</li>
<li>Huang, F., Wu, G., Yang, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Oligometastasis+and+oligo-recurrence%3A+more+than+a+mirage%5BTitle%5D)+AND+%22Radiat+Oncol%22%5BJournal%5D)">Oligometastasis and oligo-recurrence: more than a mirage.</a> Radiat Oncol. 31 (9), 230(2014).</li>
</ol>

著者の開示があります。

呼吸誘発肝変形とオルガン運動 (ターゲット描写) の輪郭の問題と同様、放射の配達と関連付けられた難しさに貢献します。臓器運動管理使用する技術の改善は、治療精度と肺門に不可欠な高精度の改善につながっています。いくつかの画像誘導技術や呼吸運動管理システムは現在利用します。画像マーカ注入は、ターゲットのローカリゼーションのための一般的な手法です。画像マーカは円...

従来、転移癌の末期である、予後と生存率と関連付けられる。ただし、山ら。1984 年に、彼らの 20 年の経験によると肺転移巣の完全な外科的切除の結果比較的高い生存率で原発腫瘍部位が全身管理時手術1の場合を報告しました。ヘルマン、および 1995 最初提案 oligometastases、局所病変と polymetastases は、追加のローカル治療2,3を使用して治すことができると全身疾患との間の中間段階でキタサト。過去十年にわたって転移、oligometastases (転移) および有効な化学療法の治療のため外科的手法の早期発見は転移患者の予後を改善しています。固形腫瘍に対する最も一般的な転移臓器である肝臓と肝 oligometastases の外科的切除は、生存率を改善することができます。焼灼法、ラジオ波焼灼術、radioembolization、肝転移を治療するための放射線療法などが必要な局所腫瘍制御3,4を達成するためにいくつかの手術不能の患者に推奨されてきた,5,6,7します過去数年間、いくつかの前向きと後ろ向き研究が許容と、定位のアブレーション放射線治療としても知られている体幹部定位放射線治療 (中枢) を介して肝転移の効果的な局所腫瘍制御を報告している。毒性4,5,8,9。
患者のポジショニングと固定化の方法で強化されています画像の取得、統合、および放射線治療システムへの転送呼吸運動の管理;高用量の出力と高速放射配信;周囲の正常組織にターゲット病変から急な線量のグラデーション。これらの前進のため中枢は最小限の深刻な毒性10,11の高精密、高精度放射線治療を実現します。呼吸運動管理、肺門、肝・肺の病変に対して特に重要です。非侵襲的で臨床的に便利なが呼吸管理手法は実質的に治療のオプションとして肺門の人気を増加させます。ここでは、画像誘導支援と肝運動管理のため腹部の圧縮機 (AC) と四次元 ct (4 D-) を使用する肝転移に対する肺門プロトコルについて詳しく説明します。

<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

効果的な化学療法と oligometastatic の手術による過去数十年で転移癌患者の予後が上がった。手術不能患者の体幹部定位放射線治療 (中枢) などの焼灼療法は、最小毒性を効果的な局所制御を提供できます。高精度、精度のため中枢は分数あたりより高い線量を提供より効果的で、ターゲット小さい照射ボリュームは、従来の放射線治療よりも。さらに、周囲の正常組織にターゲット病変から急な線量のグラデーションは肺門; を使用により実現してしたがって、中枢より効果的な腫瘍制御を提供し、従来の放射線治療よりも副作用が少ないを展示します。肺門の使用は (定位放射線治療として知られている); 頭蓋内の病変を治療するため流行しています。ただし、それは今も使用脊髄、副腎転移を治療するため。画像誘導案内、呼吸管理の進歩のためいくつかの研究は、患者呼吸移動肺や肝臓の腫瘍を治療するための中枢の使用を検討しました。これらの研究結果は、中枢が好意的腫瘍病変を移動する場合を制御することを示唆しています。
四次元 ct (4 D-) 腹部の圧縮機 (AC) とは臨床的に効果的な呼吸運動の管理に便利です。このメソッドは非侵襲的な無料呼吸をことができます、ので、その使用は、合併症を減らします。さらに、患者はこの方法を便利な検討します。また、医師とセラピストの呼吸運動の管理の他の方法よりも効率的と見なされます。肺の病変を治療するため ac 4 D CT の使用はまた広く調査したとテクニックは肝病変の治療のための受諾を得ています。ただし、4 D CT AC を用いた肝病変を治療するためのプロトコルは、肺の病変を治療するために使用されるものとは異なる。この記事で中枢の 4 D CT と治療の肝転移に対する AC と新しいプロトコルについて述べる。

強度変調放射線治療 (IMRT) による肺門を実装できます (と<img alt="image" src="/files/ftp_upload/57050/57050imgv2.jpg">6 放射線ビーム) または体積アーク放射線療法 (VMAT) (連続的な線量配信とガントリー回転) とシングルの手術がありますので、単一の治療ですべてのターゲットをカバーするにはすべての腫瘍の除去を達成できません。代表的な中枢治療計画成功した放射線療法手術?...

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

体幹部定位放射線治療 (中枢) は、腫瘍制御を改善し、同時に毒性を減らす小さな治療ボリュームに分数あたり高線量を提供するため厳密な正確さと精度を必要とします。ここで、肝転移に対する肺門の非侵襲的で臨床的に便利な呼吸運動管理プロトコルを提案します。

体幹部定位放射線照射のため内部のターゲット ボリュームによる肝転移の治療

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

Research

JoVE Journal

Medicine

14.2K ビュー.  Taipei Medical University Hospital. 体幹部定位放射線治療 (中枢) は、腫瘍制御を改善し、同時に毒性を減らす小さな治療ボリュームに分数あたり高線量を提供するため厳密な正確さと精度を必要とします。ここで、肝転移に対する肺門の非侵襲的で臨床的に便利な呼吸運動管理プロトコルを提案します。

ビデオ: 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 や MRI 誘導照射ラットの神経膠芽腫モデルのマイクロ照射器を使用して

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

がん研究

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.

婦人科癌に対する定位放射線

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

医学

Modeling Brain Metastasis by Internal Carotid Artery Injection of Cancer Cells

Brain metastasis is a cause of severe morbidity and mortality in cancer patients. Critical aspects of metastatic diseases, such as the complex neural microenvironment and stromal cell interaction, cannot be entirely replicated with in vitro assays; thus, animal models are critical for investigating and understanding the effects of therapeutic intervention. However, most brain tumor xenografting methods do not produce brain metastases consistently in terms of the time frame and tumor burden. Brain metastasis models generated by intracardiac injection of cancer cells can result in unintended extracranial tumor burden and lead to non-brain metastatic morbidity and mortality. Although intracranial injection of cancer cells can limit extracranial tumor formation, it has several caveats, such as the injected cells frequently form a singular tumor mass at the injection site, high leptomeningeal involvement, and damage to brain vasculature during needle penetration. This protocol describes a mouse model of brain metastasis generated by internal carotid artery injection. This method produces intracranial tumors consistently without the involvement of other organs, enabling the evaluation of therapeutic agents for brain metastasis.

Brain metastasis is a cause of severe morbidity and mortality in cancer patients. Most brain metastasis mouse models are complicated by systemic metastases confounding analysis of mortality and therapeutic intervention outcomes. Presented here is a protocol for internal carotid injection of cancer cells that produces consistent intracranial tumors with minimal systemic tumors.

がん細胞の内頸動脈注射による脳転移のモデル化

Brain metastasis is a cause of severe morbidity and mortality in cancer patients. Critical aspects of metastatic diseases, such as the complex neural ...

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.

ブドウ膜黒色腫の肝転移の治療として単離した肝灌流

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.

小細胞肺がんの放射線療法における循環免疫細胞の放射線量に影響を与える臨床的要因

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.

定位アブレーションボディ放射線治療のための動的肺腫瘍の追跡

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.

小動物モデルにおける外部ビーム放射線を用いた多能性幹細胞由来の奇形の対象となる、選択的な治療

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

Proton Therapy Delivery and Its Clinical Application in Select Solid Tumor Malignancies

Radiation therapy is a frequently used modality for the treatment of solid cancers. Although the mechanisms of cell kill are similar for all forms of radiation, the in vivo properties of photon and proton beams differ greatly and maybe exploited to optimize clinical outcomes. In particular, proton particles lose energy in a predictable manner as they pass through the body. This property is used clinically to control the depth at which the proton beam is terminated, and to limit radiation dose beyond the target region. This strategy can allow for substantial reductions in radiation dose to normal tissues located just beyond a tumor target. However, the degradation of proton energy in the body remains highly sensitive to tissue density. As a consequence, any changes in tissue density during the course of treatment may significantly alter proton dosimetry. Such changes may occur through alterations in body weight, respiration, or bowel filling/gas, and may result in unfavorable dose deposition. In this manuscript, we provide a detailed method for the delivery of proton therapy using both passive scatter and pencil beam scanning techniques for prostate cancer. Although the described procedure directly pertains to prostate cancer patients, the method may be adapted and applied for the treatment of virtually all solid tumors. Our aim is to equip readers with a better understanding of proton therapy delivery and outcomes in order to facilitate the appropriate integration of this modality during cancer therapy.

The fundamentals of radiation planning and delivery for proton therapy using prostate cancer as a model are presented. The application of these principles to other selected disease sites highlights how proton radiotherapy may enhance clinical outcomes for cancer patients.

プロトン療法配信と選択固体腫瘍悪性腫瘍の臨床応用

Radiation therapy is a frequently used modality for the treatment of solid cancers. Although the mechanisms of cell kill are similar for all forms of ...

<meta charset="utf8"></head><body>肝細胞癌におけるブリッジング療法としてのY-90 TAREおよびPD-1阻害

Y-90 Radioembolization and PD-1 Inhibitor as Neoadjuvant Treatment in Hepatocellular Carcinoma

This study showcases a comprehensive treatment protocol for high-risk hepatocellular carcinoma (HCC) patients, focusing on the combined use of Y-90 transarterial radioembolization (TARE) and Programmed Cell Death-1 (PD-1) inhibitors as neoadjuvant therapy. Highlighted through a case report, it offers a step-by-step reference for similar therapeutic interventions. A retrospective analysis was conducted on a patient who underwent hepatectomy following Y-90 TARE and PD-1 inhibitor treatment. Key demographic and clinical details were recorded at admission to guide therapy selection. Y-90 TARE suitability and dosage calculation were based on Technetium-99m (Tc-99m) macroaggregated albumin (MAA) perfusion mapping tests. Lesion coverage by Y-90 microspheres was confirmed through single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging, and adverse reactions and follow-up outcomes were meticulously documented. The patient, with a 7.2 cm HCC in the right hepatic lobe (T1bN0M0, BCLC A, CNLC Ib) and an initial alpha-fetoprotein (AFP) level of 66,840 ng/mL, opted for Y-90 TARE due to high recurrence risk and initial surgery refusal. The therapy's parameters, including the lung shunting fraction (LSF) and non-tumor ratio (TNR), were within therapeutic limits. A total of 1.36 GBq Y-90 was administered. At 1 month post-therapy, the tumor shrank to 6 cm with partial necrosis, and AFP levels dropped to 21,155 ng/mL, remaining stable for 3 months. After 3 months, PD-1 inhibitor treatment led to further tumor reduction to 4 cm and AFP decrease to 1.84 ng/mL. The patient then underwent hepatectomy; histopathology confirmed complete tumor necrosis. At 12 months post-surgery, no tumor recurrence or metastasis was observed in follow-up sessions. This protocol demonstrates the effective combination of Y-90 TARE and PD-1 inhibitor as a bridging strategy to surgery for HCC patients at high recurrence risk, providing a practical guide for implementing this approach.

<meta charset="utf8"></head><body>肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

This study illustrates the methodological potential of combining Yttrium-90 Trans-Arterial Radioembolization (Y-90 TARE) with an anti-PD-1 monoclonal antibody as an effective neoadjuvant strategy leading to hepatectomy in hepatocellular carcinoma (HCC) patients with a high initial recurrence risk. It emphasizes the safety, feasibility, and step-by-step procedural guidance of this approach.

肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

This study showcases a comprehensive treatment protocol for high-risk hepatocellular carcinoma (HCC) patients, focusing on the combined use of Y-90 ...

体幹部定位放射線照射のため内部のターゲットボリュームによる肝転移の治療

要約

さらに動画を探す

PET や MRI 誘導照射ラットの神経膠芽腫モデルのマイクロ照射器を使用して

婦人科癌に対する定位放射線

がん細胞の内頸動脈注射による脳転移のモデル化

ブドウ膜黒色腫の肝転移の治療として単離した肝灌流

小細胞肺がんの放射線療法における循環免疫細胞の放射線量に影響を与える臨床的要因

定位アブレーションボディ放射線治療のための動的肺腫瘍の追跡

小動物モデルにおける外部ビーム放射線を用いた多能性幹細胞由来の奇形の対象となる、選択的な治療

プロトン療法配信と選択固体腫瘍悪性腫瘍の臨床応用

肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

体幹部定位放射線照射のため内部のターゲット ボリュームによる肝転移の治療

要約

さらに動画を探す

PET や MRI 誘導照射ラットの神経膠芽腫モデルのマイクロ照射器を使用して

婦人科癌に対する定位放射線

がん細胞の内頸動脈注射による脳転移のモデル化

ブドウ膜黒色腫の肝転移の治療として単離した肝灌流

小細胞肺がんの放射線療法における循環免疫細胞の放射線量に影響を与える臨床的要因

定位アブレーションボディ放射線治療のための動的肺腫瘍の追跡

小動物モデルにおける外部ビーム放射線を用いた多能性幹細胞由来の奇形の対象となる、選択的な治療

プロトン療法配信と選択固体腫瘍悪性腫瘍の臨床応用

肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

肝細胞癌におけるネオアジュバント治療としてのY-90放射線塞栓術とPD-1阻害剤

体幹部定位放射線照射のため内部のターゲットボリュームによる肝転移の治療