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Repeat CT-scan assessment of lymph node motion in locally advanced cervical cancer patients

Wiederholte CT-Untersuchungen von Lymphknotenbewegungen bei Patientinnen mit lokal fortgeschrittenem Zervixkarzinom

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Abstract

Purpose

In cervical cancer patients the nodal clinical target volume (CTV, defined using the major pelvic blood vessels and enlarged lymph nodes) is assumed to move synchronously with the bony anatomy. The aim of this study was to verify this assumption by investigating the motion of the major pelvic blood vessels and enlarged lymph nodes visible in CT scans.

Methods and materials

For 13 patients treated in prone position, four variable bladder-filling CT scans per patient, acquired at planning and after 40 Gy, were selected from an available dataset of 9–10 CT scans. The bladder, rectum, and the nodal-vessels structure containing the iliac vessels and all visible enlarged nodes were delineated in each selected CT scan. Two online patient setup correction protocols were simulated. The first corrected bony anatomy translations and the second corrected translations and rotations. The efficacy of each correction was calculated as the overlap between the nodal-vessels structure in the reference and repeat CT scans. The motion magnitude between delineated structures was quantified using nonrigid registration.

Results

Translational corrections resulted in an average overlap of 58 ± 13% and in a range of motion between 9.9 and 27.3 mm. Translational and rotational corrections significantly improved the overlap (64 ± 13%, p value = 0.007) and moderately reduced the range of motion to 7.6–23.8 mm (p value = 0.03). Bladder filling changes significantly correlated with the nodal-vessels motion (p < 0.001).

Conclusion

The motion of the nodal-vessels was large, nonrigid, patient-specific, and only moderately synchronous with the bony anatomy. This study highlights the need for caution when reducing the CTV-to-PTV (PTV planning target volume) margin of the nodal CTV for highly conformal radiation techniques.

Zusammenfassung

Ziel

Bei Zervixkarzinompatientinnen wird davon ausgegangen, dass das nodale klinische Zielvolumen (CTV, definiert anhand der großen Blutgefäße des Beckens und vergrößerter Lymphknoten) sich synchron mit der knöchernen Anatomie bewegt. Ziel der vorliegenden Studie war es, diese Annahme zu verifizieren, indem die in der Computertomographie (CT) sichtbare Bewegung der großen Blutgefäße des Beckens und der vergrößerten Lymphknoten untersucht wurde.

Material und Methoden

Für 13 Patientinnen mit Therapie in Bauchlage wurden aus einer verfügbaren Datenmenge von 9–10 CT-Aufnahmen 4 CT-Aufnahmen pro Patientin mit unterschiedlicher Blasenfüllung ausgewählt, die bei der Planung und nach 40 Gy erstellt worden waren. Blase, Rektum und die Lymphgefäßstrukturen mit den Iliakalgefäßen und allen sichtbaren vergrößerten Lymphknoten wurden auf jeder ausgewählten CT-Aufnahme skizziert. Es wurden 2 Online-Korrekturdurchgänge der Patientenlagerung simuliert. Im ersten Durchgang wurden Verschiebungen der knöchernen Anatomie korrigiert und im zweiten Durchgang Verschiebungen und Rotationen. Die Wirksamkeit der einzelnen Korrekturen wurde als Überlappung der Strukturen der Lymphgefäße in den Referenz- und Wiederholungsaufnahmen berechnet. Das Ausmaß der Bewegung zwischen den skizzierten Strukturen wurde mittels nichtrigider Registrierung quantifiziert.

Ergebnisse

Die Verschiebungskorrektur führte zu einer durchschnittlichen Überlappung von 58 ± 13% und zu einer Bewegungsspanne von 9,9–27,3 mm. Verschiebungs- und Rotationskorrektur führten zu einer signifikanten Verbesserung der Überlappung (64 ± 13%, p-Wert: 0,007) und einer mäßigen Verminderung der Bewegungsspanne auf 7,6–23,8 mm (p-Wert: 0,03). Änderungen der Blasenfüllung korrelierten signifikant mit der Bewegung der Lymphgefäße (p < 0,001).

Schlussfolgerung

Die Bewegung der Lymphgefäße war groß, nichtrigide, patientenspezifisch und nur mäßig synchron mit der knöchernen Anatomie. Diese Studie betont, dass Vorsicht notwendig ist, wenn der CTV-PTV-Saum (PTV: Planungszielvolumen) des nodalen CTV für hoch konformale Bestrahlungsverfahren vermindert wird.

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Compliance with ethical guidelines

Acknowledgements

This work was supported by the Dutch Cancer Society; grant number ECMR 2007–3777.

Conflict of interest.

L. Bondar, L. Velema, J.W. Mens, E. Zwijnenburg, B. Heijmen, and M. Hoogeman state that there are no conflicts of interest.

All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Authors and Affiliations

  1. Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, P.O. Box 5201, 3008 AE, Rotterdam, The Netherlands

    Luiza Bondar Ph.D., Laura Velema M.D., Jan Willem Mens M.D., Ben Heijmen Ph.D. & Mischa Hoogeman Ph.D.

  2. Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands

    Ellen Zwijnenburg M.D.

Authors
  1. Luiza Bondar Ph.D.
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  2. Laura Velema M.D.
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  3. Jan Willem Mens M.D.
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  4. Ellen Zwijnenburg M.D.
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  5. Ben Heijmen Ph.D.
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  6. Mischa Hoogeman Ph.D.
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Correspondence to Luiza Bondar Ph.D..

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Bondar, L., Velema, L., Mens, J. et al. Repeat CT-scan assessment of lymph node motion in locally advanced cervical cancer patients. Strahlenther Onkol 190, 1104–1110 (2014). https://doi.org/10.1007/s00066-014-0720-3

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  • DOI: https://doi.org/10.1007/s00066-014-0720-3

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