Radiotherapy & Oncology RSS feed: Current Issue. Radiotherapy and Oncology publishes papers describing original research as well as review articles. It covers areas of interest relating to radiation oncology. This includes: clinical radiotherapy, combined modality treatment, experimental work in radiobiology, chemobiology, hyperthermia and tumour biology, as well as physical aspects relevant to oncology, particularly in the field of imaging, dosimetry and radiation therapy planning. Papers on more general aspects of interest to the radiation oncologist including chemotherapy, surgery and immunology are also published. Papers are accepted on a worldwide basis. Manuscripts should be sent to the following address: Radiotherapy and Oncology Secretariat, Professor Jens Overgaard, M.D., Danish Cancer Society, Department of Experimental and Clinical Oncology, Aarhus University Hospital, Building 5, Norrebrogade 44, DK 8000 Aarhus C, DENMARK (Tel: +45 89 49 26 29; Fax: +45 86 19 71 09; email: ro@oncology.dk ). A subscription to Radiotherapy and Oncology is included in the membership fee of the European Society for Therapeutic Radiology and Oncology (ESTRO) . Further information can be obtained from the ESTRO Office, Av. E. Mounierlaan, 83/4, B-1200 Brussels, Belgium (Tel: +32 2 775 9340; Fax: +32 2 779 5494; E-mail: info@estro.org ). http://www.thegreenjournal.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. Radiotherapy & Oncology0167-8140963September 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.thegreenjournal.com/article/PIIS0167814010004871/abstract?rss=yesEditorial Board10.1016/S0167-8140(10)00487-1Radiotherapy & Oncology 96, 3 (2010)2010-09-01Radiotherapy & Oncology2010-09-01963S0167-8140(10)X0005-6iiiihttp://www.thegreenjournal.com/article/PIIS0167814010004883/abstract?rss=yesContents10.1016/S0167-8140(10)00488-3Radiotherapy & Oncology 96, 3 (2010)2010-09-01Radiotherapy & Oncology2010-09-01963S0167-8140(10)X0005-6vvhttp://www.thegreenjournal.com/article/PIIS0167814010004226/abstract?rss=yesIn medicine, clinical practice cannot resist fashion: in the year 2000, 9 publications dealt with the “use of PET in radiotherapy planning”; by the end of 2005, 187 articles have been published on this subject, and by the end of June 2010, PubMed indicated 565 hits using the same keywords!PET in radiotherapy planning: Particularly exquisite test or pending and experimental tool?Vincent Gregoire, Arturo Chiti10.1016/j.radonc.2010.07.015Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Editorials275276http://www.thegreenjournal.com/article/PIIS0167814010004482/abstract?rss=yesPersonalized medicine is the new driving force in the modern era of medicine. In oncology, personalized management of a patient’s disease means the application of specific therapeutic strategies that are best suited for an individual patient and for the particular type of tumour, which the therapy is aiming to target. Molecular diagnostics influences cancer management in several ways that aid personalisation and this is why research has now focused on individualizing treatment strategies by incorporating a combination of physiological variables, genetic characteristics and environmental factors together with the traditional tumour characteristics that currently drive clinical decision making.Clinical use of PET-CT data for radiotherapy planning: What are we looking for?Arturo Chiti, Margarita Kirienko, Vincent Grégoire10.1016/j.radonc.2010.07.021Radiotherapy & Oncology 96, 3 (2010)2010-08-20Radiotherapy & Oncology2010-08-20963S0167-8140(10)X0005-6Editorials277279http://www.thegreenjournal.com/article/PIIS0167814010004494/abstract?rss=yesAbstract: During the last decade several different PET radiopharmaceuticals entered into the clinic and positron emission tomography (PET) became an important tool for staging of cancer patients and assessing response to therapy. Meanwhile FDG-PET has also found application in radiation treatment planning. Potential radiopharmaceuticals for radiation treatment planning may also include tracers allowing monitoring of proliferation, amino acid metabolism, hypoxia, lipid metabolism and receptor expression. Here the syntheses of a selection of clinically tested promising tracers are summarized and the different molecular mechanisms for accumulation are discussed which may help to choose the appropriate tracer for planning radiation treatment strategies.PET radiopharmaceuticals in radiation treatment planning – Synthesis and biological characteristicsRoland Haubner10.1016/j.radonc.2010.07.022Radiotherapy & Oncology 96, 3 (2010)2010-08-19Radiotherapy & Oncology2010-08-19963S0167-8140(10)X0005-6Reviews280287http://www.thegreenjournal.com/article/PIIS0167814010004007/abstract?rss=yesAbstract: The positron emission tomography in combination with CT in hybrid, cross-modality imaging systems (PET/CT) gains more and more importance as a part of the treatment-planning procedure in radiotherapy. Positron emission tomography (PET), as a integral part of nuclear medicine imaging and non-invasive imaging technique, offers the visualization and quantification of pre-selected tracer metabolism. In combination with the structural information from CT, this molecular imaging technique has great potential to support and improve the outcome of the treatment-planning procedure prior to radiotherapy. By the choice of the PET-Tracer, a variety of different metabolic processes can be visualized. First and foremost, this is the glucose metabolism of a tissue as well as for instance hypoxia or cell proliferation. This paper comprises the system characteristics of hybrid PET/CT systems. Acquisition and processing protocols are described in general and modifications to cope with the special needs in radiooncology. This starts with the different position of the patient on a special table top, continues with the use of the same fixation material as used for positioning of the patient in radiooncology while simulation and irradiation and leads to special processing protocols that include the delineation of the volumes that are subject to treatment planning and irradiation (PTV, GTV, CTV, etc.). General CT acquisition and processing parameters as well as the use of contrast enhancement of the CT are described. The possible risks and pitfalls the investigator could face during the hybrid-imaging procedure are explained and listed. The interdisciplinary use of different imaging modalities implies a increase of the volume of data created. These data need to be stored and communicated fast, safe and correct. Therefore, the DICOM-Standard provides objects and classes for this purpose (DICOM RT). Furthermore, the standard DICOM objects and classes for nuclear medicine (NM, PT) and computed tomography (CT) are used to communicate the actual image data created by the modalities. Care must be taken for data security, especially when transferring data across the (network-) borders of different hospitals.Overall, the most important precondition for successful integration of functional imaging in RT treatment planning is the goal orientated as well as close and thorough communication between nuclear medicine and radiotherapy departments on all levels of interaction (personnel, imaging protocols, GTV delineation, and selection of the data transfer method).PET/CT (and CT) instrumentation, image reconstruction and data transfer for radiotherapy planningBernhard Sattler, John A. Lee, Markus Lonsdale, Emmanuel Coche10.1016/j.radonc.2010.07.009Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Reviews288297http://www.thegreenjournal.com/article/PIIS0167814010004470/abstract?rss=yesAbstract: PET/CT imaging modalities have been shown to be useful in the diagnosis, staging, and monitoring of malignant diseases. Its inclusion into the treatment planning process is now central to modern radiotherapy practice. However, it is essential to be cognisant of the factors that are necessary in order to ensure that the acquired images are consistent with the requirements for both treatment planning and treatment delivery.Essential parameters required in image acquisition for radiotherapy planning and treatment include consistencies of table tops and the use of laser light for patient set-up. But they also include the accurate definition of the patient’s initial positioning and the use of proper immobilization devices in the radiotherapy department. While determining this optimum set-up, patient psychological factors and limitations that may be due to the subsequent use of PET/CT for planning purposes need to be taken into account. Furthermore, patient set-up data need to be properly recorded and transmitted to the imaging departments. To ensure the consistency of patient set-up, the radiation therapist should ideally be directly involved in informing and positioning the patient on the PET/CT. However, a proper exchange of patient-related information can also be achieved by a close liaison between the two departments and by the use of clear detailed protocols per type of patient set-up and/or per localization of tumour site.Patient setup for PET/CT acquisition in radiotherapy planningMary Coffey, Aude Vaandering10.1016/j.radonc.2010.07.020Radiotherapy & Oncology 96, 3 (2010)2010-08-20Radiotherapy & Oncology2010-08-20963S0167-8140(10)X0005-6Reviews298301http://www.thegreenjournal.com/article/PIIS0167814010003865/abstract?rss=yesAbstract: Positron emission tomography can be used in radiation oncology for the delineation of target volumes in the treatment planning stage. Numerous publications deal with this topic and the scientific community has investigated many methodologies, ranging from simple uptake thresholding to very elaborate probabilistic models. Nevertheless, no consensus seems to emerge. This paper reviews delineation techniques that are popular in the literature. Special attention is paid to threshold-based techniques and the caveats of this methodology are pointed out by formal analysis. Next, a simple model of positron emission tomography is suggested in order to shed some light on the difficulties of target delineation and how they might be eventually overcome. Validation aspects are considered as well. Finally, a few recommendations are gathered in the conclusion.Segmentation of positron emission tomography images: Some recommendations for target delineation in radiation oncologyJohn A. Lee10.1016/j.radonc.2010.07.003Radiotherapy & Oncology 96, 3 (2010)2010-08-13Radiotherapy & Oncology2010-08-13963S0167-8140(10)X0005-6Reviews302307http://www.thegreenjournal.com/article/PIIS0167814010003877/abstract?rss=yesAbstract: Quantitative analysis can be included relatively easily in clinical PET-imaging protocols, but in order to obtain meaningful quantitative results one needs to follow a standardized protocol for image acquisition and data analysis. Important factors to consider are the calibration of the PET scanner, the radiotracer uptake time and the approach for definition of regions of interests. Using such standardized acquisition protocols quantitative parameters of tumor metabolism or receptor status can be derived from tracer kinetic analysis and simplified approaches such as calculation of standardized uptake values (SUVs).Quantitative analysis of PET studiesWolfgang A. Weber10.1016/j.radonc.2010.07.004Radiotherapy & Oncology 96, 3 (2010)2010-07-26Radiotherapy & Oncology2010-07-26963S0167-8140(10)X0005-6Reviews308310http://www.thegreenjournal.com/article/PIIS0167814010004214/abstract?rss=yesAbstract: Purpose: To describe the degradation effects produced by respiratory organ and lesion motion on PET/CT images and to define the role of respiratory gated (RG) 4D-PET/CT techniques to compensate for such effects.Methods: Based on the literature and on our own experience, technical recommendations and clinical indications for the use of RG 4D PET/CT have been outlined.Results: RG 4D-PET/CT techniques require a state of the art PET/CT scanner, a respiratory monitoring system and dedicated acquisition and processing protocols. Patient training is particularly important to obtain a regular breathing pattern. An adequate number of phases has to be selected to balance motion compensation and statistical noise. RG 4D PET/CT motion free images may be clinically useful for tumour tissue characterization, monitoring patient treatment and target definition in radiation therapy planning.Conclusions: RG 4D PET/CT is a valuable tool to improve image quality and quantitative accuracy and to assess and measure organ and lesion motion for radiotherapy planning.Detection and compensation of organ/lesion motion using 4D-PET/CT respiratory gated acquisition techniquesValentino Bettinardi, Maria Picchio, Nadia Di Muzio, Luigi Gianolli, Maria Carla Gilardi, Cristina Messa10.1016/j.radonc.2010.07.014Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Reviews311316http://www.thegreenjournal.com/article/PIIS0167814010004032/abstract?rss=yesAbstract: Positron emission tomography (PET) provides molecular information about the tumor microenvironment in addition to anatomical imaging. Hence, it seems to be highly beneficial to integrate PET data into radiotherapy (RT) treatment planning. Functional PET images can be used in RT planning following different strategies, with different orders of complexity. In a first instance, PET imaging data can be used for better target volume delineation. A second strategy, dose painting by contours (DPBC), consists of creating an additional PET-based target volume which will then be treated with a higher dose level. In contrast, dose painting by numbers (DPBN) aims for a locally varying dose prescription according to the variation of the PET signal. For both dose painting approaches, isotoxicity planning strategies should be applied in order not to compromise organs at risk compared to conventional modern RT treatment.In terms of physical dose painting treatment planning, several factors that may introduce limitations and uncertainties are of major importance. These are the PET voxel size, uncertainties due to image acquisition and reconstruction, a reproducible image registration, inherent biological uncertainties due to biological and chemical tracer characteristics, accurate dose calculation algorithms and radiation delivery techniques able to apply highly modulated dose distributions. Further research is necessary in order to investigate these factors and their influence on dose painting treatment planning and delivery thoroughly.To date, dose painting remains a theoretical concept which needs further validation. Nevertheless, molecular imaging has the potential to significantly improve target volume delineation and might also serve as a basis for treatment alteration in the future.Physical radiotherapy treatment planning based on functional PET/CT dataDaniela Thorwarth, Xavier Geets, Marta Paiusco10.1016/j.radonc.2010.07.012Radiotherapy & Oncology 96, 3 (2010)2010-08-02Radiotherapy & Oncology2010-08-02963S0167-8140(10)X0005-6Reviews317324http://www.thegreenjournal.com/article/PIIS0167814010004615/abstract?rss=yesAbstract: AA-PET (MET-PET and FET-PET) can be used for gross tumour volume (GTV) delineation in brain gliomas and for the differentiation between treatment-related changes (pseudo-progression, pseudo-regression) and residual/recurrent tumour. There are some data showing that MET-PET and (DOTATOC)-PET can be used for GTV delineation in meningiomas and glomus tumours. The role of PET in the visualization of the biological characteristics of the tumours: proliferation (FLT-PET), hypoxia (FMISO-PET) and angiogenesis/peptide expression (RGD-PET) should be investigated in future studies.PET for radiation treatment planning of brain tumoursAnca-L. Grosu, Wolfgang A. Weber10.1016/j.radonc.2010.08.001Radiotherapy & Oncology 96, 3 (2010)2010-08-23Radiotherapy & Oncology2010-08-23963S0167-8140(10)X0005-6Reviews325327http://www.thegreenjournal.com/article/PIIS016781401000424X/abstract?rss=yesAbstract: The potential benefits of positron emission tomography (PET) imaging for the management of head and neck tumours are increasingly being recognized. Integrated PET–CT has found its way into the practice of radiation oncology providing both functional and anatomical tumour information for treatment planning and the implications for clinical practice are currently being investigated. First, it has been demonstrated that 18F-fluorodeoxyglucose (18FDG)-PET can improve the accuracy of gross tumour volume delineation for radiation therapy planning. Next, PET using 18FDG or more specific tracers may facilitate dose escalation to radioresistant tumour subvolumes. Finally, PET can provide tumour characterization prior to and during radiotherapy, facilitating adaptive radiotherapy and other tailored treatment strategies. Although these are promising prospects, unresolved issues remain and these applications are not yet ready for introduction into routine clinical practice.Clinical evidence on PET–CT for radiation therapy planning in head and neck tumoursEsther G.C. Troost, Dominic A.X. Schinagl, Johan Bussink, Wim J.G. Oyen, Johannes H.A.M. Kaanders10.1016/j.radonc.2010.07.017Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Reviews328334http://www.thegreenjournal.com/article/PIIS0167814010003853/abstract?rss=yesAbstract: Especially for non-small cell lung cancer, FDG-PET has in the majority of the patients led to the safe decrease of radiotherapy volumes, enabling radiation-dose escalation and, experimentally, redistribution of radiation doses within the tumor. In limited-disease small cell lung cancer, the role of FDG-PET is emerging.PET scans in radiotherapy planning of lung cancerDirk De Ruysscher, Carl-Martin Kirsch10.1016/j.radonc.2010.07.002Radiotherapy & Oncology 96, 3 (2010)2010-07-26Radiotherapy & Oncology2010-07-26963S0167-8140(10)X0005-6Reviews335338http://www.thegreenjournal.com/article/PIIS0167814010004469/abstract?rss=yesAbstract: A large number of histological and anatomically distinct malignancies originate from the gastro-intestinal (GI) tract. Radiotherapy (RT) plays an increasing role in the multimodal treatment of most of these malignancies. The proximity of different organs at risk such as the kidneys, the spinal cord and the small bowel and the potential toxicity associated with combined treatment modalities make accurate target volume delineation imperative. The ability of positron emission tomography (PET) imaging to visualize a so-called ‘biological target volume’ (BTV) may be helpful in this respect. Currently the most widely used tracer for diagnosis, staging, restaging and response assessment is [18F]Fluoro-deoxyglucose (FDG). Promising preliminary results in esophageal, pancreatic and anorectal cancers and colorectal liver metastasis suggest that FDG-PET might provide us with additional information useful in target volume delineation. Poor image resolution and a low sensitivity for lymph node detection currently obstructs its widespread implementation. Moreover, validation in large prospective trials and the pathological validation of the correct tumor volume is still lacking. In hepatocellular carcinoma (HCC) and gastric adenocarcinoma there is currently little evidence for the use of FDG-PET in target delineation. However more extensive research is warranted before the true value of FDG-PET in these sites can be assessed. Also other tracers are constantly being developed and investigated. Up to now however none of these tracers has found its way into the daily practice of target volume delineation.Clinical evidence on PET-CT for radiation therapy planning in gastro-intestinal tumorsMaarten Lambrecht, Karin Haustermans10.1016/j.radonc.2010.07.019Radiotherapy & Oncology 96, 3 (2010)2010-08-20Radiotherapy & Oncology2010-08-20963S0167-8140(10)X0005-6Reviews339346http://www.thegreenjournal.com/article/PIIS0167814010004238/abstract?rss=yesAbstract: The present chapter is focused on the role of positron emission tomography/computed tomography (PET/CT) and [11C]-labelled Choline ([11C]Choline) for the management of prostate cancer patients for radiation therapy planning.Although still a matter of debate, PET/CT with [11C]Choline is not routinely recommended for selecting patients for prostate cancer primary radiation treatment. However, due to its high accuracy in detecting and localizing recurrences when a biochemical failure occurs, [11C]Choline PET/CT may play a role in the re-staging phase to distinguish patients with local versus distant relapse, thus influencing patient management (curative versus palliative therapy).Limited data are currently available on the role of [11C]Choline PET/CT in target volume selection and delineation. According to available literature, [11C]Choline PET/CT is not clinically recommendable to plan target volume both for primary prostate treatment and for local recurrence. Nevertheless, promising data suggested a potential role of [11C]Choline PET/CT as an image guide tool for the irradiation of prostate cancer relapse.Clinical evidence on PET/CT for radiation therapy planning in prostate cancerMaria Picchio, Elisabetta Giovannini, Cinzia Crivellaro, Luigi Gianolli, Nadia di Muzio, Cristina Messa10.1016/j.radonc.2010.07.016Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Reviews347350http://www.thegreenjournal.com/article/PIIS0167814010004019/abstract?rss=yesAbstract: PET–CT plays an increasing role in the diagnosis and treatment of gynaecological cancers. In cervix cancer, whilst MRI remains the best imaging technique for initial primary tumor staging, PET–CT has been showed to be a highly sensitive method to determine lymph node status, except in patients with early-stage cervical cancer where PET–CT cannot replace surgical exploration of pelvic lymph nodes. In patients with advanced cervical cancer, PET–CT has the potential of showing lymph node metastasis not only within the pelvis, but also outside the pelvis, more particularly in the para-aortic area. PET–CT has also been described as a useful tool in 3-D-based adaptative brachytherapy. In endometrial cancer, the issues are different, as the recent decade has seen a therapeutic decrease in early-stage disease, especially in postoperative radiation therapy, whilst more advanced disease have been approached with more aggressive treatments, integrating chemotherapy and external beam radiotherapy. Lymph node status is also an important issue and PET-Scan may replace lymph node surgical procedure particularly in obese patients.Clinical evidence on PET–CT for radiation therapy planning in cervix and endometrial cancersChristine Haie-Meder, Renaud Mazeron, Nicolas Magné10.1016/j.radonc.2010.07.010Radiotherapy & Oncology 96, 3 (2010)2010-08-16Radiotherapy & Oncology2010-08-16963S0167-8140(10)X0005-6Reviews351355http://www.thegreenjournal.com/article/PIIS0167814010004901/abstract?rss=yesImportant ESTRO dates10.1016/S0167-8140(10)00490-1Radiotherapy & Oncology 96, 3 (2010)2010-09-01Radiotherapy & Oncology2010-09-01963S0167-8140(10)X0005-6II