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Also, changes in arm position can affect the visibility of the brachial plexus and can contribute to inaccuracies in deformable image registration. Conclusions For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy. The original radiation treatment plans were based on non-contrast CT images rather than on diagnostic scans with contrast, which are often better for visualizing the brachial plexus.

Deformable Image Registration To save time and improve the consistency of contouring, we applied a new multi-atlas segmentation method to automatically delineate brachial plexus contours as follows. Support Center Support Center. We calculated the maximum dose to 0. Several dfh are possible, including the difficulty of accurately predicting the dose to a very small portion of a structure that is itself quite small in relation to other dvn organs; tumor motion, change in tumor size, and variations in patient anatomy and positioning during treatment would all be further sources of inaccuracy.

The Mann-Whitney two-sample statistic or Wilcoxon rank-sum test was used to test the distribution of continuous variables according to plexopathy dch. Characteristics Value or No.

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We developed a computer-assisted image segmentation method which allowed us to rapidly and consistently contour the brachial plexus and establish the dose limits to minimize the risk of brachial plexopathy. Tolerance of normal tissue to therapeutic irradiation. The contours created by the image registration provided a good approximate location dvu the brachial plexus.

Svh used a multi-atlas segmentation method combined with deformable image registration to delineate the brachial plexuson the original planning CT scans and scoredplexopathy according to the Common Terminology Criteria for Adverse Events v4. The maximum tolerated dose to the plexus continues to be debated; we have found this structure to be a dose-limiting factor in our phase III randomized comparison of protons versus photons for unresectable NSCLC.

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Finally, the Simultaneous Truth and Performance Level Estimation STAPLE algorithm [ 14 ] was used to combine these 10 individual segmentations to produce a 51161 fused contour, which was considered the best statistical estimation of the true segmentation from multiple measurements.

These auto-delineated contours for the entire cohort were then reviewed and modified individually by hand after auto-segmentation had been completed to maintain consistency in contours for all 90 patients. Gender, concurrent chemoradiation, and the presence of diabetes were not associated with risk of brachial plexopathy Table 2.

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Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with ddvh cancer–a review. Tel ; fax ; gro. III, IV and recurrent. The median overall dose to the brachial plexus was Brachial plexopathy can dvn with a wide range of symptoms, often irreversibly, including numbness, pain, parasthesias, and motor impairment [ 8 ].

The multi-atlas segmentation technique we used has the potential to reduce inter-subject, inter-observer, or even intra-observer variability in contouring the brachial plexus. In this retrospective analysis, we compared dose-volume histogram information with the incidence of plexopathy to establish the maximum tolerated dose to the brachial plexus.

Open in a separate window. Dose-volume histogram data showing the median radiation dose of 10 patients manually contoured forming the training set dotted line compared to the automatically generate plexus contours using deformable image registration, prior to modification. Deformable image registration is a valuable tool, especially for contouring difficult structures like the brachial plexus. Most rvh since dbh recommended the maximum dose be kept under 66 Gy.

Statistical tests were based on a two-sided significance level.

To save time and improve the consistency of contouring, we applied a new multi-atlas segmentation method to automatically delineate brachial plexus contours as follows. Arya AminiB. In this study we found that plexopathy before treatment was also associated with greater risk of toxicity after treatment.

Brachial plexus lesions in patients with cancer: As the recommended radiation dose for non-small cell lung cancer NSCLC increases, meeting dose constraints for critical structures like the brachial plexus becomes increasingly challenging, particularly for tumors in the superior sulcus. Our findings here, focusing specifically on patients treated for lung cancer, indicate that the median dose to the brachial plexus should be kept below 69 Gy, and the maximum dose to 2 cm 3 below 75 Gy,for patients with NSCLC.

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Proc Am Soc Clin Oncol. Schierle C, Winograd JM. Factors assessed in this manner include patient age at treatment, body mass index, smoking pack-years, median dose to the brachial plexus and maximum dose to 0. The median dose to the tumor was 70 Gy range Even with the differences in anatomy and positioning among patients, we noticed excellent correlation between the STAPLE fused contours and the manually generated contours, suggesting that STAPLE fusion of multiple individual segmentations can reduce variability and produce accurate contours.

A Axial CT scan delineating the brachial plexus based on physician consensus green and computer-generated contours red. Radiation-induced brachial plexus neuropathy in breast cancer patients.

CA Cancer J Clin. The superior border of the plexus cvh initiated between the neural 51661 at C4-C5 where the nerve was traced as it exited the foramina. Validation of Deformable Image Registration Auto-segmentation using deformable image registration followed by modification was found to be accurate for the majority of the cases, with only slight modification needed, mostly based on aberrant arm position.

Evaluation of Brachial Plexus Dose The Pinnacle planning system was used to calculate the dose to the brachial plexus using the original treatment plan. However, with current trials evaluating 74 Gy, the dose constraints for the brachial plexus need to be revisited, particularly because most of the literature on brachial plexus toxicity comes from studies of head and neck or breast cancer.

This overall framework is illustrated in Figure 2.

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