Image Guided Proces

homas BortfeldDept. of Radiation OncologyMassachusettsGeneral Hospital30 Fruit St reetBoston, MA 02114USARupert Schmidt-UllrichDept. of Radiation OncologyVirginia Commonwealth University401 College StreetRichmond, VA 23298–0058USAWilfriedDe Nev eDept. of RadiotherapyGhent University HospitalDe Pintelaan 1859000GhentBelgiumD avid E. WazerDept. of Radiation OncologyTufts University750 Washington StreetBos ton, MA 02111USA Library of Congress Control Number2005925670ISBN-10 3-540-20511-XSpringer Berlin Heidelberg2006ISBN-13 978-3-540-20511-1Springer Berlin Heidelberg2006This work is subject to copyright. All rights are reserved, whether the whole or part of t he material isconcerned, speci cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,reproduction on micro lms or in any oth er way and storage in data banks. Duplication of this publicationor parts thereo f is permitted only under the provisions of the German Copyright Law of Septembe r 9, 1965,in its current version, and permission for use must always be obtained from Springer-Verlag. Violations areliable for prosecution under the German Cop yright Law.Springer-Verlag is a part of Springer Science+Business Mediaspringero nline.com©Springer-Verlag Berlin Heidelberg2006Printed in GermanyTheuseofgeneralde scriptivenames,registerednames,trademarks,etc.inthispublicationdoesnot imply,eve n in the absence of a speci c statement, that such names are exempt from the relev ant protective lawsandregulations and therefore free forgeneral use.Product liab ility: the publishers cannot guarantee the accuracy of any information about dos age andapplication contained in this book. In every individual case the user mus t check such information byconsulting the relevant literature.Editor: Dr. Ute He ilmannDeskEditor: Meike StoeckProduction andTypesetting:LE-TEXJelonek, Schmidt & Vöckler GbR, LeipzigCover: FridoSteinen-Broo, EStudio Calamar, SpainPrinting and binding: Stürtz, WürzburgPrintedon acid-free paper 21/3150/YL 5 4 3 2 1 0 Preface Intensity-modulated radiotherapy (IMRT) has widenedthe horizons of radiation the rapy due to its ability toconform radiation dose distributionsto complex tumorta rget volumes while sparing nearby critical structuresas much as physically possi ble. IMRT has also led toparadigm shifts in all elements of the chain of radio-t herapy, from treatment prescription over treatmentplanning(“inverse”planning)totreat mentdeliveryandveri cation. Although IMRT and inverse planning havethepotentialtos treamlineandsimplifyradiotherapy,atthecurrentstageofthedevelopmentIMRTisstillsig nif-icantly more involved than conventional radiotherapy.This book is meant to h elp the reader understandthe concepts and components of IMRT, to give a topi-cal overviewofadvancedimage-guidedandbiologically guided approaches, and to provide useful hints on how to master IMRT in clinical practice. Reading this textalone is not suf cient to start a clinical IMRT program.The book will rather provide upto-date theoretical andpractical information about IMRT that should be con-sulte d in addition to other sources that are listed asreferences. We highlight not on ly the strengths of IMRTbutdiscussalsotheweaknesses,limitations,anduniquechallen ges such as the prolonged treatment times andincreased leakage radiation. All th is, we hope, will beusefulforcliniciansandphysicistswhoareinterestedinexploring the potential of IMRT, as well as a referencefor those who already apply IMRT in clinical practice.Thebookhasbeenwrittenbyaninternationalgroupof authors with an international readership in mind.Some IMRT aspects, such as quality assurance, havedifferent avors in different countries, because of na-tional regulations and reimbursement issues. We triedto take this into account by covering the American andthe European perspectives on quality assurance in twoseparate chapters. This also emphasizes the importanceofthetopic.Theauthorsofallchaptersaredistinguishe dexperts in their eld and we are grateful that they de-voted some of their precio us time to the writing of theirchapters.The material has been organized into thr ee majorparts:(I)Foundations,(II)AdvancedImage-GuidedandBiologically Guided Tech niques, and (III) Clinical Ap-plications.Part I lays the foundation for state-of -the-artIMRT. As for image guidance (part II), it has been saidthat radiotherapy , and in particular IMRT, has alwaysbeen image-guided and that the current hype about im-age guidance is not justi ed. While there is some truthto this statement, there have been recent developmentsin image-guided IMRT that deserve separate c

overage.The developments with the biggest potential impact areprobably the inclu sion of functional imaging informa-tionintotargetsegmentationanddoseprescription ,andthe advancement of adaptive “4D” radiotherapy tech-niques, which incorporate tem poral changes into thetreatment scheme. These developments, which are cur-rently being pursued at only a few centers, will mostlikely nd their way into broader c linical application inthe near future.The Clinical Applications section (III) re views theuse of IMRT for individual anatomic sites and com-mon clinical applicat ions. Each chapter is presented ina similar format: Clinical problem – Potential b ene tsof IMRT – Unique challenges – Target and organ-at-risk de nition – Planning – Delivery issues – Clinicalstudies and trials – Future directions. We have drawnupon experien ced practitioners of IMRT to summarizethe current literature as well as provide their personalinsights as to how they approach the speci cs of treat-mentplanninga nddeliveryincludingrequiredimaging,anatomic segmentation, normal tissue dose-vol ume re-lationships, and target dose. The section is designed toprovide detailed and practical information to the clin-ician and medical physicist as they implem ent IMRTunder a broad set of clinical circumstances.In closing, we must make spe cial mention of ourcoeditor, Rupert K.A. Schmidt-Ullrich. Dr. Schmidt-Ullrichwas oneoftheearlypioneersinthedevelopmentof IMRT and has fostered within his departm ent atthe Virginia Commonwealth University one of the mostdistinguishedresearchp rogramsintheworld.Hisover-ridingpassioninrecentyearswastoproduceatextbookfor IMR T that would be broadly recognized for its com-prehensiveness, quality, and read ability. The effort, asre ected in these pages, is a testament to his vision, in-s ight, and commitment to excellence. Sadly, Rupert will