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HODGKIN’S DISEASE
CASE STUDY
BILLY W. LOO JR, MD, PHD, RICHARD T. HOPPE, MD, FACR
547
548 / Intensity-Modulated Radiation Therapy
Target and Tissue Delineation the T8 to L3 levels), and vertebrae (T8 to S3). Representative
slices from the treatment planning CT scan are shown in
All target and normal tissue segmentation was performed
Figure 24.1-1.
manually using an AcQSim VoxelQ workstation (Philips
Medical Systems). In the abdomen, the grossly involved
nodal mass was contoured as the gross tumor volume Treatment Planning
(GTV). To define the clinical target volume (CTV), a uni- For the conventional treatment plan, an internal margin
form 1 cm expansion was created around the GTV. This for organ motion (eg, from breathing) was not considered
volume was modified to prevent expansion into adjacent for most structures of interest. However, for quality assur-
normal structures; expansion into surrounding fat and ance, we perform an additional fluoroscopic simulation
muscle was allowed. Consequently, in the vicinity of the with blocks in place prior to treatment. At that time, we
kidneys, where the GTV abutted the critical structures, also verify that there is an adequate margin on the left
there was little to no expansion. The spleen and remainder hemidiaphragm at natural end-expiration to ensure cov-
of the para-aortic and common iliac nodal chains were erage of the spleen superiorly throughout the respiratory
included as contiguous sites of potential microscopic dis- cycle. In this case, there was essentially no planning target
ease. Because unenlarged lymphatic structures cannot be volume (PTV) expansion in the vicinity of the kidneys, and
visualized reliably by CT, we used the corresponding vas- the block edges projected very close to the edges of the seg-
cular structures (ie, aorta, inferior vena cava, and iliac ves- mented GTV. This can be seen in Figure 24.1-2, the ante-
sels) as surrogate anatomic landmarks. In this case, the rior port of the conventional treatment field.
presence of residual contrast from the previous lymphan- Given the presumably greater sensitivity of IMRT treat-
giogram also aided target definition. The following nor- ments to organ motion, basing the PTV expansion on a
mal tissues were delineated and included in the IMRT measurement of organ motion would be desirable. This
optimization process: left and right lungs, left and right could be accomplished by acquiring CT scans at natural
kidneys, liver, stomach, bowel, spinal cord (contoured from end-inspiration and end-expiration. In the case presented
FIGURE 24.1-1. Sections from the treatment planning computed tomography scan, with targets
and anatomic structures segmented. CTV = clinical target volume; GTV = gross tumor volume. (To
view a color version of this image, please refer to the CD-ROM.)
Hodgkin’s Disease: Case Study / 549
Dose-volume histograms of target structures and nor- short-term toxicities such as nausea, diarrhea, and marrow
mal tissues comparing the conventional plan with the IMRT suppression; intermediate-term symptoms such as
plan are shown in Figures 24.1-3 to 24.1-6. The corre- L’hermitte’s sign; and late complications such as bowel
sponding isodose curves for selected slices are shown in obstruction. Whether such improved clinical end points
Figure 24.1-7. These demonstrate that compared with the are realized remains to be borne out by clinical studies.
conventional treatment plan, IMRT results in improved
target coverage and kidney sparing simultaneously. In prin-
ciple, this should result in improved probability of dis- Treatment Delivery and Quality
ease control and decreased risk of late kidney dysfunction. Assurance
In addition, there is better exclusion of the spinal cord, ver-
The conventional treatment consisted of five fields (anteri-
tebrae, stomach, bowel, and liver from the high-dose regions.
or, posterior open, posterior with wedge, right anterior
The reduction in normal tissue irradiated may decrease
oblique, left posterior oblique), requiring 2,989 monitor
100
100
90
90
80 GTV
CTV 80
Cumulative Frequency
70 Spleen
Cumulative Frequency
70
60 R Kidney
L Kidney 60
50 Spinal Cord
Conv 50
40 IMRT Vertebrae
40 Conv
30 IMRT
30
20
20
10
10
0
0 5 10 15 20 25 30 35 0
Dose (Gy) 0 5 10 15 20 25 30 35
Dose (Gy)
FIGURE 24.1-3. Dose-volume histograms of conventional versus inten- FIGURE 24.1-4. Intensity-modulated radiation therapy (IMRT) results
sity-modulated radiation therapy (IMRT) treatment plans. IMRT results in substantially lower doses to the spinal cord and vertebrae. (To view
in both improved target coverage and kidney sparing. (To view a color a color version of this image, please refer to the CD-ROM.)
version of this image, please refer to the CD-ROM.)
14
100
Stomach
12
Cumulative Irradiated Volume (L)
90 Bowel
80 Liver
Conv 10
Cumulative Frequency
20
2
10
0 0
0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35
Dose (Gy) Dose (Gy)
FIGURE 24.1-5. With intensity-modulated radiation therapy (IMRT), a FIGURE 24.1-6. Intensity-modulated radiation therapy (IMRT) results in
smaller volume of abdominal organs receives higher doses (above a reduction in the volume of all nontarget tissues receiving higher doses
10–17 Gy), whereas a larger volume receives lower doses. (To view a (> 10 Gy) at the cost of an increase in the volume receiving lower doses.
color version of this image, please refer to the CD-ROM.) (To view a color version of this image, please refer to the CD-ROM.)
Hodgkin’s Disease: Case Study / 551
FIGURE 24.1-7. Isodose curves of conventional versus intensity-modulated radiation therapy (IMRT) treatment plans demonstrate improved dose
conformity with IMRT. (To view a color version of this image, please refer to the CD-ROM.)
units over the entire treatment course to deliver 25.5 Gy to dose. On the other hand, the total-body dose from internal
the reference point in the target. The IMRT treatment plan scatter from the irradiated tissues is slightly lower with IMRT
above would comprise eight fields (five beam angles, with owing to the smaller volume of tissue receiving the high-
three fields split in two, as described above), with 808 seg- est doses. Within the irradiated field, IMRT results in a small-
ments requiring 17,425 monitor units over the treatment er volume of nontarget tissues receiving higher doses (above
course to deliver 25.5 Gy to the 69.5% isodose line, which 10 Gy) at the cost of a larger volume receiving lower doses
encompasses 90% of the GTV. The 5.8 times greater num- (see Figure 24.1-6). However, there are insufficient data to
ber of monitor units required by IMRT in this case would predict whether these dosimetric results would result in a
result in similarly increased leakage radiation from the head greater or lesser risk of radiation-induced secondary malig-
of the linear accelerator, contributing to a higher total-body nancies with IMRT compared with conventional RT, and
552 / Intensity-Modulated Radiation Therapy
well-designed clinical trials are needed to evaluate this impor- al and IMRT planning was compared in three patients (two
tant question in this highly curable patient population. adults with bulky mediastinal disease and a child with bulky
Of note, improvements in IMRT planning and delivery para-aortic disease). Compared to conventional planning,
have the potential to greatly improve its efficiency and treating the periphery of the GTV using IMRT resulted in
decrease the excess radiation to nontarget tissues. an effective dose escalation to most of the GTV due to the
Optimizing the choice of beam angles may result in inherent heterogeneity of GTV coverage with IMRT.
improved dose conformity. Additionally, fewer beam angles Coverage of the CTV was improved, particularly in the
may achieve the same degree of conformity, which could supraclavicular region. As shown above in the case of bulky
result in a smaller volume of tissue irradiated even to lower para-aortic disease, IMRT planning resulted in better GTV
doses.2 Direct optimization of the beam apertures as coverage as well as sparing of the kidneys.
opposed to the beamlet intensities can reduce the treat-
ment complexity and thereby the required number of mon-
itor units substantially (potentially by over 70%) without References
compromising dose conformity.3,4 Both of these improve- 1. Langen KM, Jones DT. Organ motion and its management. Int
ments could significantly reduce the total-body doses from J Radiat Oncol Biol Phys 2001;50:265–78.
IMRT without diminishing its dosimetric advantages over 2. Pugachev A, Xing L. Pseudo beam’s-eye-view as applied to
conventional treatment. beam orientation selection in intensity-modulated radiation
therapy. Int J Radiat Oncol Biol Phys 2001;51:1361–70.
3. Shepard DM, Earl MA, Li XA, et al. Direct aper ture
Clinical Outcome optimization: a turnkey solution for step-and-shoot
IMRT. Med Phys 2002;29:1007–18.
At nearly 2 years follow-up after completing treatment with 4. Cotrutz C, Xing L. Segment-based dose optimization using a
conventional RT, the patient had no clinical or radiographic genetic algorithm. Phys Med Biol 2003;48:2987–98.
evidence of disease recurrence and no symptoms referable 5. Loo BW Jr, Crooks SM, Xing L, et al. A dosimetric comparison
to late treatment-related toxicity. of conventional and intensity modulated radiation therapies
Our dosimetric planning study of IMRT in Hodgkin’s for the treatment of Hodgkin’s disease. Int J Radiat Oncol
disease was presented earlier.5 In that review, convention- Biol Phys 2002;54(suppl 2):323.