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The human brain as an organ has numerous functions; some of them can be visualized by functional imaging techniques (e.g., functional MRI [fMRI] or positron emission tomography). The localization of the appropriate activity clusters requires sophisticated instrumentation and complex measuring protocol. As the inclusion of the activation pattern in modern self-tailored 3D based radiotherapy has notable advantages, this method is applied frequently. Unfortunately, no standardized method has been published yet for the integration of the fMRI data into the planning process and the detailed description of the individual applications is usually missing. Thirteen patients with brain tumors, receiving fMRI based RT planning were enrolled in this study. The delivered dose maps were exported from the treatment planning system and processed for further statistical analysis. Two parameters were introduced to measure the geometrical distance Hausdorff Distance (HD), and volumetric overlap Dice Similarity Coefficient (DSC) of fMRI corrected and not corrected dose matrices as calculated by 3D planning to characterize similarity and/or dissimilarity of these dose matrices. Statistical analysis of bootstrapped HD and DSC data was performed to determine confidence intervals of these parameters. The calculated confidence intervals for HD and DSC were (5.04, 7.09), (0.79, 0.86), respectively for the 40 Gy and (5.2, 7.85), (0.74, 0.83), respectively for the 60 Gy dose volumes. These data indicate that in the case of HD5.04 and/or DSC0.86, the 40 Gy dose volumes obtained with and without fMRI activation pattern do not show a significant difference (5% significance level). The same conditions for the 60 Gy dose volumes were HD5.2 and/or DSC0.83. At the same time, with HD7.09 and/or DSC0.79 for 40 Gy and HD7.85 and/or DSC0.74 for 60 Gy the impact of fMRI utilization in RT planning is excessive. The fMRI activation clusters can be used in daily RT planning routine to spare activation clusters as critical areas in the brain and avoid their high dose irradiation. Parameters HD (as distance) and DSC (as overlap) can be used to characterize the difference and similarity between the radiotherapy planning target volumes and indicate whether the fMRI delivered activation patterns and consequent fMRI corrected planning volumes are reliable or not.

Abstract: Introduction and aim: In case of imaging modalities using ionizing radiation, radiation exposure of the patients is a vital issue. It is important to survey the various dose-reducing techniques to achieve optimal radiation protection while keeping image quality on an optimal level. Method: We reprocessed 105 patients’ data prospectively between February and April 2017. The determination of the radiation dose was based on the effective dose, calculated by multiplying the dose-length product (DLP) and dose-conversation coefficient. In case of image quality we used signal-to-noise ratio (SNR) based on manual segmentation of region of interest (ROI). For statistical analysis, one sample t-test and Wilcoxon signed rank test were used. Results: Using iterative reconstruction, the effective dose was significantly lower (p0.05). Conclusion: Using iterative reconstruction, it was possible to achieve significant dose reduction. Since the noise content of the images was not significantly higher using the iterative reconstruction compared to the filtered back projection, further dose reduction can be achievable while preserving the optimal quality of the images. Orv Hetil. 2019; 160(35): 1387–1394.

Background: The concept of the use of MRI for image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer was introduced 20 years ago. Here, we report on EMBRACE-I, which aimed to evaluate local tumour control and morbidity after chemoradiotherapy and MRI-based IGABT. Methods: EMBRACE-I was a prospective, observational, multicentre cohort study. Data from patients from 24 centres in Europe, Asia, and North America were prospectively collected. The inclusion criteria were patients older than 18 years, with biopsy-proven squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix, The International Federation of Gynecology and Obstetrics (FIGO) stage IB–IVA disease or FIGO stage IVB disease restricted to paraaortic lymph metastasis below the L1–L2 interspace, suitable for curative treatment. Treatment consisted of chemoradiotherapy (weekly intravenous cisplatin 40 mg/m2, 5–6 cycles, 1 day per cycle, plus 45–50 Gy external-beam radiotherapy delivered in 1·8–2 Gy fractions) followed by MRI-based IGABT. The MRI-based IGABT target volume definition and dose reporting was according to Groupe Européen de Curiethérapie European Society for Radiation Oncology recommendations. IGABT dose prescription was open according to institutional practice. Local control and late morbidity were selected as primary endpoints in all patients available for analysis. The study was registered with ClinicalTrials.gov, NCT00920920. Findings: Patient accrual began on July 30, 2008, and closed on Dec 29, 2015. A total of 1416 patients were registered in the database. After exclusion for not meeting patient selection criteria before treatment, being registered but not entered in the database, meeting the exclusion criteria, and being falsely excluded, data from 1341 patients were available for analysis of disease and data from 1251 patients were available for assessment of morbidity outcome. MRI-based IGABT including dose optimisation was done in 1317 (98·2%) of 1341 patients. Median high-risk clinical target volume was 28 cm3 (IQR 20–40) and median minimal dose to 90% of the clinical target volume (D90%) was 90 Gy (IQR 85–94) equi-effective dose in 2 Gy per fraction. At a median follow-up of 51 months (IQR 20–64), actuarial overall 5-year local control was 92% (95% CI 90–93). Actuarial cumulative 5-year incidence of grade 3–5 morbidity was 6·8% (95% CI 5·4–8·6) for genitourinary events, 8·5% (6·9–10·6) for gastrointestinal events, 5·7% (4·3–7·6) for vaginal events, and 3·2% (2·2–4·5) for fistulae. Interpretation: Chemoradiotherapy and MRI-based IGABT result in effective and stable long-term local control across all stages of locally advanced cervical cancer, with a limited severe morbidity per organ. These results represent a positive breakthrough in the treatment of locally advanced cervical cancer, which might be used as a benchmark for clinical practice and all future studies. Funding: Medical University of Vienna, Aarhus University Hospital, Elekta AB, and Varian Medical Systems.

The aim of the study was to evaluate the predictive value of pretreatment positron emission tomography (PET) standardized uptake value (SUVmax), standardized uptake value corrected for lean body mass (SULpeak) value, metabolic tumour volume (MTV) and total lesion glycolysis (TLG) parameters of the primary tumour assessed with PET/computed tomography (CT) in the clinical out-come in patients diagnosed with histopathologically confirmed head and neck squamous cell carcinoma.Retrospective evaluation was performed using PET/CT image datasets of 52 histologically proven head and neck cancer patients in 4 weeks' prior receiving definitive chemo-radiotherapy (CRT). Positron emission tomography /CT was performed before the CRT and 12 weeks after it for response evaluation. Image data was used for target volume delineation and for specify SUVmax, SULpeak, MTV and TLG parameters of the primary tumour. According to the results of the therapeutic response evaluation two patient subgroups were created in relation to the presence or absence of viable tumour. Metabolic data from pre-treatment PET/CT and therapeutic response were correlated using Kruskal-Wallis test.After completion of the CRT in 24/52 (46%) cases viable residual tumour was detected on restaging PET/CT, while in 28/52 (54%) patients showed complete remission. For the therapeutic success prediction assessment, we could not find any significant correlation with pre-treatment SUVmax and SULpeak values (P0.44, P0.33). Total lesion glycolysis provided nearly significant difference (P=0.052) and MTV had shown significant difference (P=0.001) between the two patient subgroups statistically.Simple metabolic data (SUVmax and SULpeak) from pretreatment fluorine-18-fluorodeoxyglucose (

Background and purpose Radiotherapy plays important role in the complex oncological treatment of glioblastoma multiforme (GBM). The modern 3D radiotherapy treatments are based on cross-sectional CT and MR information, however more attention is being paid to functional hybrid imaging describing the biological and functional morphology of tumor lesions. 18F-DOPA is an amino acid tracer with high specificity and sensitivity, which may play an important role in the precise definition of target volume in the irradiation process of GBM patients. Our study presents the first experiences with 18F-DOPA based PET/CT/MR 3D irradiation planning process. Methods In Hungary the 18F-DOPA radiotracer has been available for clinical use since September 2017. Between September 2017 and January 2018, at the Somogy County Kaposi Mor Teaching Hospital Dr. Jozsef Baka Diagnostic, Radiation Oncology, Research and Teaching Center 3 histologically verified glioblastoma multiforme patients received 18F-DOPA based 3D irradiation treatment. In the contouring process the native planning CT scanes were fused with the PET/MR series (T1 contrast enhanced, T2 and 18F-DOPA sequences). We defined 18F-DOPA uptake volume (BTV-F-DOPA), the T1 contrast enhanced MRI volume (GTV-T1CE), and the volume of the area covered by oedema on the T2 weighted MRI scan (CTV-oedema) in all patients. We also registered the BTV-F-DOPA volumes not covered by the conventional MR based target volumes. Results Examining the 3 cases, the average volume of 18F-DOPA tumor was 22.7 cm3 (range 15.3-30.9; SD = 7.82). The average GTV T1 CE was found to be 8.7 cm3 (range 3.8-13.2; SD = 4.70). The mean CTV oedema volume was 40.3 cm3 (range 27.7-57.7; SD = 15.36). A non-overlapping target volume difference (BTV-F-DOPA not covered by CTV oedema area) was 4.5 cm3 (range 1-10.3; SD = 5.05) for PTV definition. Conclusion Based on our results the tumor area defined by the amino acid tracer is not fully identical with the MRI defined T2 oedema CTV. 18F-DOPA defined BTV can modify the definiton of the PTV, and the radiotherapy treatment.

Abstract: Introduction and aim: The aim of our study was to investigate changes in clinical staging N (lymph node) and M (distant metastasis) in patients who receive PET/CT-based 3D radiotherapy within complex oncological treatment, and compare to conventional cross-sectional imaging staging technique. We also investigated the presence of PET/CT-detected second tumors and the effect of PET/CT on therapeutic decisions. Method: From the 1st of January 2015 to the 30th of November 2016, 192 patients (n = 192) were treated with PET/CT-based radiation (109 head, 44 lung, 28 rectum and 11 cervical localization) in the Oncoradiology Institute of the Health Center of the University of Kaposvár. All patients received conventional cross-sectional and PET/CT imaging in accordance with the valid investigation protocol. The average time interval between the two cross-sectional investigations was 5.2 weeks. Clinical N and M staging was performed on the basis of the classification of the American Joint Committee on Cancer (AJCC) and the Union of International Cancer Control (UICC). Results: By analyzing the clinical stages N and M separately, based on the results of the PET/CT studies, the N stage was changed in 77 cases and the M stage changed in 31 cases. Overall, the PET/CT study resulted in higher clinical stages in 68 (35.4%) patients and lower clinical stages in 14 (7.3%) patients. The treatment plan was changed in 9% of the patients (n = 18) (definitive versus palliative treatment) and the extension of radiotherapy treatment target volume (PTV) was indicated in 20% of the patients (n = 39) due to the change in clinical lymph node status. PET/CT also detected secondary tumors in 15 (8%) patients. Conclusion: Based on our results, the addition of PET/CT to conventional cross-sectional staging imaging permits a more accurate clinical classification of N and M stages and significantly influences therapeutic decisions. PET/CT imaging also provides a great help in detecting occult second tumors. The results of our Institute harmonize with the international data available in the literature. Orv Hetil. 2018; 159(39): 1593–1601.

Abstract: Hungary’s first and still only multimodality PET/MR device is operating in the Health Center of Kaposvár University. The aim of our review article is to present the current Hungarian PET/MR imaging application opportunities, our available initial experiences with this novel multimodality imaging technique in malignant and non-malignant diseases and further potential targeted clinical fields of use are also addressed. Orv Hetil. 2018; 159(34): 1375–1384.

Abstract: Introduction: Image-guided intensity-modulated radiation therapy is essential for oncology treatment of head-and-neck cancer patients. Aim: MV-kV and CBCT modalities were compared in case of IGRT treatment for head-and-neck cancer patients. Setup error, setup margin (SM), imaging and evaluation times and imaging doses were analyzed. Method: Eight patients’ elective treatment was evaluated, 66 orthogonal MV-kV images and 66 CBCT series were acquired. Setup error measurement was based on bony manual image registration in three translational directions. Normality test and F-test were performed followed by the comparison with independent-samples T-test (p

Glioblastoma multiforme (GBM) is the most common malignant primary anomaly of central nervous system. The GBM infiltrates the nearly sturctures from the initial tumor and its metastatic attribution is well known. The aim of our single-centered retrospective study was to introduce the importance of postoperative medical imaging confirmation of total tumor resection for patient with GBM combined concomitant and adjuvant chemoradiotherapy on a 10 year long patient follow up.From January 2006 to April 2015 we registered 59 patients with newly diagnosed GBM at the University of Kaposvár Health Center Institute of Diagnostic Imaging and Radiation Oncology. The histological diagnosis was confirmed by a proficient neuropathologist (World Health Organisation WHO; grade IV astrocytoma). According to histological status if the ECOG performance status of patients allowed it the mutidisciplinary oncoteam recommended adjuvant chemoradiotherapy all features strictly by Stupp protocol. (60 Gy dose on the gross tumor volume and 2-3 cm margin for the clinical target volume with parallel 75 mg/m2 TMZ. Four weeks after monotherapial phase patients had to recieve 6 cycles of TMZ first cycle with 150 mg/m2 up to 200 mg/m2). The irradiation was carried out by a conformal three dimensional planning system.59 patients with the median age of 63 (range 17-84) year. Our sample counted 34 male patients and 25 woman patients. 14 patients underwent gross total tumor resection while, 39 patients underwent partial resection and the rest from our sample 6 patients passed through biopsy. Statistical analysis showed a lengthier survival among males than females, with a median survival of 13 months for males and females, the OS of 26.209 for males, meanwhile 15.625 for females. However, the difference is not considerable (log-rank p=0.203). Our study found that the estimated survival of patients at least 50 years old is significantly shorter at a median survival of 12 months (log rank p=0.027) than that of patients below 50 years of age at a median survival of 23 months. The longest estimated median survival was calculated with patients of ECOG '0' condition (16 months). However, no significant difference was found in the estimated survival of patients of different ECOG conditions (log-rank p=0.146). Based on the extent of surgery, complete resection resulted in the longest average survival of 36.4 months, followed by 21.5 months among patients with biopsy, and 15.8 months among patients with partial resection. Different surgical procedures, however, did not result in significant differences in survival (log-rank p=0.059). The overal survival of patients who had complete resection confirmed by MRI compared with the overal survival of patients with residual tumor confirmed by MRI as well we can estimate that there is significant difference between these two groups (p=0,004).Despite complex and intense treatment, recurrence is inevitable and causes relatively rapid death. In our analysis complete resection, as defined from the neurosurgeon's report and postoperative MRI, resulted in an independently significant improvement in OS. Our results are the evidences that the treatment of patients with glioblastoma multiforme in Hungary is at least on the same level as any other developed European countries.A glioblastoma multiforme (GBM) a központi idegrendszer leggyakoribb, nagy agresszivitású, rosszindulatú primer daganata. Az intézetünkben kezelt beteg-anyagon, 10 éves nyomon követésen alapuló retrospektív vizsgálat célja a kezelési eredmények leírásán kívül a posztoperatív képalkotás kiemelt jelentőségének bemutatása volt, különös tekintettel az MRI által igazolt komplett sebészi reszekció túlélésre gyakorolt hatására.Vizsgálatuk során a Kaposvári Egyetem Egészségügyi Központ Diagnosztikai és Onkoradiológiai Intézetében 2006. januártól 2015. áprilisig 59 újonnan felfedezett, szövettanilag igazolt (World Health Organization WHO, IV. Astrocytoma) GBM-es beteg adatait dolgoztuk fel. Minden beteg, akinek ECOG-státusza ezt lehetővé tette, a multidiszciplináris onkológiai bizottság döntése alapján adjuváns kemoradioterápiában részesült Stupp-protokoll szerint. Minden esetben a kezelés előtt, majd azt követően hat héttel, és háromhavonta ismételve kontrasztanyagos koponya-MR-vizsgálat történt. A betegek 60 Gy összdózisú, 3D alapú, konformális sugárkezelést kaptak konkomittáló 75 mg/m2 temozolomid (TMZ) medikációval. A radiokemoterápiás fázis után négy héttel a monoterápiás TMZ-fázis kezdődött el. Az első ciklus 150 mg/m2, majd a továbbiakban 200 mg/m2 öt napon keresztül, 28 napos ciklusokban, összesen hat ciklust tervezve.Az 59 beteg átlagéletkora 63 év (17-84 éves) volt. A vizsgálatban 34 férfi és 25 nőbeteg vett részt. 14 beteg esetében teljes tumorreszekció, 39 betegnél rész-leges reszekció, míg hat beteg esetén biopszia történt. A statisztikai elemzés szerint a férfiaknál a túlélés hosszabb volt, mint a nőknél, a férfiak és a nők medián túlélése 13 hónap volt, ugyanakkor a teljes túlélés (OS) a férfiaknál 26,209, a női betegek esetében 15,625 hónap volt (log-rank, p=0,203). Vizsgálatunk szerint az 50 év feletti betegek becsült túlélése szignifikánsan rövidebb volt 12 hónapos medián túléléssel (log rank p=0,027), mint az 50 évnél fiatalabb betegeknél, 23 hónapos medián túléléssel. A leghosszabb becsült átlagos túlélés az ECOG „0” állapotú (16 hónap) betegeknél adódott. Ugyanakkor nem találtunk szignifikáns különbséget a különböző ECOG-státuszú betegek (log-rank p=0,146) becsült túlélésében. A műtéti ellátás alapján, a posztoperatív szakban MRI-vel igazolt komplett reszekcióban részesült betegek átlagtúlélése volt a leghosszabb (36,4 hónap), melyet a biopsziában részesült betegek túlélése követett 21,5 hónappal. Az MRI-vel igazolt részleges reszekcióban részesült betegek átlagtúlélése 15,8 hónap volt.A komplex ellátás ellenére a GBM kiújulása gyakori, a betegek túlélése továbbra is szerény. Vizsgálatunkból megállapítható, hogy a műtét utáni MR-vizsgálattal igazolt komplett reszekció esetében számíthatunk csak hosszú távú túlélésre. Eredményeink azt bizonyítják, hogy a komplex neuroonkológiai ellátásban részesülő betegek ellátása Magyarországon hasonló szinten van, mint bármely más fejlett európai országban.

Absztrakt

The aim of our study was to investigate changes in clinical staging N (lymph node) and M (distant metastasis) in patients who receive PET/CT-based 3D radiotherapy within complex oncological treatment, and compare to conventional cross-sectional imaging staging technique. We also investigated the presence of PET/CT-detected second tumors and the effect of PET/CT on therapeutic decisions.From the 1st of January 2015 to the 30th of November 2016, 192 patients (n = 192) were treated with PET/CT-based radiation (109 head, 44 lung, 28 rectum and 11 cervical localization) in the Oncoradiology Institute of the Health Center of the University of Kaposvár. All patients received conventional cross-sectional and PET/CT imaging in accordance with the valid investigation protocol. The average time interval between the two cross-sectional investigations was 5.2 weeks. Clinical N and M staging was performed on the basis of the classification of the American Joint Committee on Cancer (AJCC) and the Union of International Cancer Control (UICC).By analyzing the clinical stages N and M separately, based on the results of the PET/CT studies, the N stage was changed in 77 cases and the M stage changed in 31 cases. Overall, the PET/CT study resulted in higher clinical stages in 68 (35.4%) patients and lower clinical stages in 14 (7.3%) patients. The treatment plan was changed in 9% of the patients (n = 18) (definitive versus palliative treatment) and the extension of radiotherapy treatment target volume (PTV) was indicated in 20% of the patients (n = 39) due to the change in clinical lymph node status. PET/CT also detected secondary tumors in 15 (8%) patients.Based on our results, the addition of PET/CT to conventional cross-sectional staging imaging permits a more accurate clinical classification of N and M stages and significantly influences therapeutic decisions. PET/CT imaging also provides a great help in detecting occult second tumors. The results of our Institute harmonize with the international data available in the literature. Orv Hetil. 2018; 159(39): 1593-1601.Absztrakt: Bevezetés és célkitűzés: Jelen kutatásunk célja a komplex onkológiai ellátás keretében PET/CT alapú 3D-sugárkezelésben részesült betegek klinikai staging N és M változásainak vizsgálata volt a konvencionális keresztmetszeti képalkotó staging információkhoz viszonyítva. Vizsgáltuk a PET/CT detektálta második tumorok jelenlétét, illetve a többletinformációk terápiás döntésekre gyakorolt hatását is. Módszer: 2015. 01. 01. és 2016. 11. 30. között a Kaposvári Egyetem Egészségügyi Központjának Onkoradiológiai Intézetében, onkológiai indikáció szerint 192, PET/CT alapú besugárzástervezésre került beteg anyagát dolgoztuk fel retrospektív módon. Minden beteg hagyományos keresztmetszeti, valamint tervezési PET/CT vizsgálatban részesült. A betegek klinikai N- és M-staging-besorolását az American Joint Committee on Cancer (AJCC) és a Union of International Cancer Control (UICC) rendszere alapján végeztük el. Eredmények: Az N- és M-stádiumokat külön elemezve azt tapasztaltuk, hogy a PET/CT alapján a kiindulási képalkotón alapuló N-stádium 77 esetben, az M-stádium pedig 31 esetben változott meg. Összességében a PET/CT vizsgálat 68 betegnél eredményezte a magasabb klinikai stádiumba sorolást, és 14 esetben alacsonyabb klinikai stádium került megállapításra. A kezelési tervben a betegek 9%-ánál történt változás, és az esetek 20%-ában az N-status változása a sugárkezelés kezelési céltérfogatának kiterjesztését vonta maga után. 15 betegnél addig fel nem ismert másodlagos tumor került leírásra. Következtetés: Eredményeink alapján elmondhatjuk, hogy a konvencionális keresztmetszeti staging képalkotásnak az indikált lokalizációkban PET/CT-vel történő kiegészítése pontosabb klinikai N- és M-stádium-besorolást tesz lehetővé, és jelentős mértékben képes befolyásolni a terápiás döntéseket. A PET/CT adta információ ugyancsak komoly segítséget nyújt az okkult második tumorok felismerésében. Intézetünk eredményei harmonizálnak az irodalomban fellelhető nemzetközi adatokkal. Orv Hetil. 2018; 159(39): 1593–1601.

Our aim was to present our treatment and verification protocols of linear accelerator-based lung and abdominal stereotactic ablative radiotherapy (SABR). During our treatments both the volumetric imaging (3D/4D CBCT/CT) and triggered kV intrafractional tumor motion control could be combined allowing a full control on the whole workflow. The most optimal kV directions from which the tumor is well detectable were defined. Tumor movements measured on cine MRI in treatment position correlated well with the ones on 4D CBCT, thus cine MRI is considered an excellent device to pre-select the appropriate image/treatment verification SABR protocol. In abdominal targets implanted markers and cine MRI are preferred due to limited image quality of CBCT with the current version. In selected lung SABR cases (≥8mm motion) the dose delivery of organs at risk (lungs - GTV, chest wall) could be reduced compared to free breathing conditions, however, the treatment time is at least two-folds higher.Célunk a lineáris gyorsítón végzett tüdõ- és hasi sztereotaxiás ablatív radioterápia (SABR) kezelési és verifikációs protokolljainak bemutatása. Kezeléseink során mind a térfogati képalkotás (3D/4D cone beam CT/CT), mind a kezelés alatti kilovoltos tumormozgás-ellenõrzés kombinálható, melyek a sugárterápiás munkafolyamat valamennyi fázisának ellenõrzését lehetõvé teszik. A legoptimálisabb kV-os képi akvizíciók irányát – melybõl a tumor vetülete jól kivehetõ – definiáltuk. A mozgáselemzéseket kiegészítendõ, kezelési pozícióban végzett folytonos, ún. „cine” MRI-n mért tumorelmozdulások jól korrelálnak a 4D CBCT-n mértekkel, mely így kiváló eszköz az SABR kezelési-verifikációs technika megválasztásában. A hasi céltérfogatoknál a jelenlegi 3D térfogati képalkotás korlátozott képminõsége miatt markerkövetést és ugyancsak cine MRI-t preferálunk. Szelektált tüdõ-SABR esetekben (≥8 mm mozgás) légzéskapuzással a rizikószervek dózisterhelése (tüdõk – GTV, mellkasfal, máj) csökkenthetõ, de minimálisan kétszer hosszabb kezelési idõt igényel, mint a szabadlégzéses technika.

Hungary's first and still only multimodality PET/MR device is operating in the Health Center of Kaposvár University. The aim of our review article is to present the current Hungarian PET/MR imaging application opportunities, our available initial experiences with this novel multimodality imaging technique in malignant and non-malignant diseases and further potential targeted clinical fields of use are also addressed. Orv Hetil. 2018; 159(34): 1375-1384.Absztrakt: Hazánkban az első és eddig egyetlen centrumként a Kaposvári Egyetem Egészségügyi Központjában üzemel multimodalitású PET/MR képalkotó berendezés. Összefoglaló közleményünk célja bemutatni a PET/MR képalkotás hazai klinikai alkalmazásának lehetőségeit, a tumoros és nem malignus kórképek diagnosztikájában szerzett kezdeti tapasztalatainkat, illetve az új hibrid képalkotó technológia további, jövőbeli alkalmazási területeinek ismertetése. Orv Hetil. 2018; 159(34): 1375–1384.

The revolutionary role of modern cross-sectional imaging, the improved target definition in CT/MRI image guided brachytherapy, the precise topography for applicator and anatomy contribute to a better knowledge and management of tumors and critical organs. Further developments and functional imaging is expected to lead to a broad use of patient tailored therapy in the field of interventional radiation oncology. Orv. Hetil., 2015, 156(17), 706–710.

Existing evidence shows that biochemical control rates are improved if the delivered dose to the prostate gland is increased [1]. Brachytherapy (BT) proved to be an effective and safe way for dose ...

Aim: In the complex therapy of head neck cancers modern 3D based radiotherapy plays an important role. The parotid sparing effect of intensity modulated radiotherapy is proven, but in many patients the conventional 3D based techniques are still being used. Since 2006 the “Conpas” technique has been routinely used in our institution for the treatment of locally advanced head neck tumor patients. The aim of our study was to analyze the dosimetry, survival and side effect profile of this 3D based treatment modality. Patient and Methods: Between 01.07.2006 and 31.11.2008 a total of 83 patients were treated using this technique. An elective dose of 50,4 Gy was prescribed to the primary tumor and the bilateral neck node regions, followed by a simple two field boost to the primary tumor region (up to 70Gy). We retrospectively analyzed the following factors related to this method: dosimetry profile (PTV and OR doses, focusing on parotid gland doses), clinical responses, local and distant progression free survival profile, acute and late side effects. Results: The mean dose of primary tumors was 71.98 Gy, the elective region dose of 50.4 Gy was achieved in all cases. Following the treatment in 37 patients complete clinical response in 25 cases partial response in 5 cases stable disease and in 16 cases progressive disease was registered. The mean overall survival was 30,06 months, the mean disease free survival was 25,82 months. When reporting the superficial lobe volumes in “lower” tumor locations good mean parotid doses were achieved (25.3 Gy and 23.4 Gy). Comparing the acute side effect profiles in the “upper” localized group higher rate of Grade III xerostomia (21% vs. 2%, p?0.05) and dermatitis (27% vs. 6%, p?0.05) were observed compared to “lower” localization group. In the “upper” localized group the late xerostomia (grade 2-3) rate was also higher (8% vs. 0%, p?0.05). Conclusion: Based on our experience Conpas technique is feasible technique for treatment of advanced head neck cancer patients. Our clinical outcome, dosimetry and follow up results show that this technique should be used successfully in patients with ”lower” localized primer tumor sites. High attention should be addressed when reporting parotid doses.

PurposeThis study analyzed functioning and symptom scores for longitudinal quality of life (QoL) from patients with locally advanced cervical cancer who underwent definitive chemoradiation therapy with image guided adaptive brachytherapy in the EMBRACE study.Methods and MaterialsIn total, 744 patients at a median follow-up of 21 months were included. QoL was prospectively assessed using European Organization for Research and Treatment of Cancer Quality of Life core module 30 (EORTC QLQ-C30) and EORTC cervical cancer module 24 (CX24) questionnaires at baseline, then every 3 months during the first year, every 6 months in the second and third years, and finally yearly thereafter in patients with no evidence of disease. Outcomes were evaluated over time and compared to those from an age-matched female reference population.ResultsGeneral QoL and emotional and social functioning were impaired at baseline but improved during the first 6 months after treatment, to reach a level comparable to that of the reference population, whereas cognitive functioning remained impaired. Both social and role functioning showed the lowest scores at baseline but which increased after treatment to reach a plateau at 6 months and then declined slightly at 3 and 4 years. The overall symptom experience was elevated at baseline and decreased to a level within the range of that of the reference population. Similarly, tumor-related symptoms (eg, pain, appetite loss, and constipation), which were present before treatment, decreased substantially at the first follow-up after treatment. Several treatment-related symptoms developed either immediately after and persisted over time (diarrhea, menopausal symptoms, peripheral neuropathy, and sexual functioning problems) or developed gradually after treatment (lymphedema and dyspnea).ConclusionsThis longitudinal prospective QoL analysis showed that patients' general QoL and functioning were impaired before treatment compared to those of reference data. Several tumor-related symptoms resolved after treatment, and functioning and general QoL returned to that of the level of the reference population, indicating a transient impact of diagnosis and treatment. However, several treatment-related symptoms and problems did develop and persist, either immediately or gradually after treatment.

The purpose of our study was to examine the potential benefits of integrating functional MRI (fMRI) information into the 3D-based planning process for central nervous system (CNS) malignancies. Between 01.01.2008 and 01.12.2009, ten patients with astrocytoma (both low and high-grade histological type) were enrolled in this study. Before the planning process, conventional CT planning, postoperative MR, and individual functional MRI examinations were conducted. For the functional MRI examination four types of conventional stimuli were applied: acoustic, visual, somatosensory, and numeric. To examine the potential benefits of using fMRI-based information, three different types of theoretical planning were applied and compared: 3D conformal plan without fMRI information, 3D conformal plan with fMRI information, and IMRT plan with fMRI information. DVH analysis and the NTCP model were used for plan comparison. When comparing planning methods, distance-related subgroups were generated and studied. By using the additional fMRI information, a significantly higher sparing effect can be achieved on these ORs (both with conventional 3D-based planning and IMRT). In cases when the OR-PTV distance is less than 1 cm, IMRT seems to be a significantly better choice than conventional 3D-based techniques. IMRT also has an additional sparing effect on the optic tract and brainstem, especially for locations close to the midline. Our results demonstrated that using fMRI information in conventional 3D-based treatment planning has the potential benefit of significant dose reduction for the critical organs, with no compromise in PTV coverage even when using conventional 3D planning. fMRI can be widely used in low-grade cases (long life expectancy, lower acute and late toxicity) and also in cases with high-grade astrocytomas or distant metastases (higher dose to PTV with better sparing of risk organs). In cases when the OR-PTV distance is less than 1 cm, IMRT should be the choice of treatment for a higher sparing effect on functional active areas. Longer imaging and clinical follow up are needed to confirm the real sparing effect on these functional areas.

The purpose of our study was to examine the integration of functional MRI (fMRI) information into 3D based planning process of the central nervous system (CNS) malignancies. Between 01.01.2008 and 01.12.2008 four patients with astrocytoma were enrolled to this study. Before the planning process conventional planning CT, postoperative MR and individual functional MRI examinations were delivered. For the functional MRI examination the following four types of stimulus were applied: acoustic, visual, somatosensory and numeral. Three different theoretical planning situations were applied and compared: 3D conformal plan without fMRI information, 3D conformal plan with fMRI information and IMRT plan with fMRI information. For plan comparison DVH analysis, and NTCP model were used. fMRI based OR definition resulted in 4 additional OR's in the contouring process. As these cases demonstrate, an average of 50% dose reduction was achieved in OR, OR2 and OR3 with IMRT and fMRI based 3D planning, especially in case of midline localization and big tumor extent. IMRT provides additional sparing effect in the optic tract and brainstem, especially for localizations close to the midline. Our results demonstrated that using fMRI information in conventional 3D based treatment planning potentially benefits significant dose reduction in critical organs, with no compromise in PTV coverage. fMRI can be widely used even in low grade cases (long life expectancies, lower acute and late toxicity in radiotherapy) and in cases with high grade astrocytomas or metastases (higher dose to PTV with better risk organ sparing in radiotherapy).

Background and purpose: Tumor motion is a very important factor in the radiotherapy of lung cancer. Uncertainty resulting from tumor movement must be considered in 3D therapy planning especially in case of IMRT or stereotactic therapy. The aim of our dynamic MR based study was to detect tumor movements in upper and mid lobe lung tumors. Patient and methods: Twenty-four patients with newly diagnosed stage II-IV lung cancer were enrolled into the study. According to tumor localization in the right S1–S3 segments 9, in the right S4–S6 segments 2, in the left S1–S3 segments 9 and in the left S4–S6 segments 4 lesions were detected. In normal treatment position individual dynamic MR examinations were performed in axial, sagittal and coronal planes (100 slices/30 sec). For tumor motion analysis E-RAD PAC's software was used. Results: Movements of the tumor under normal breathing conditions were registered in the three main directions. The mean antero-posterior deviation was 0,109 cm (range: 0,063 cm–0,204 cm), the mean medio-lateral deviation was 0,114 cm (range: 0,06 cm– 0,244 cm). The greatest deviation was measured in cranio–caudal direction (mean: 0,27 cm, range: 0,079 cm– 0,815 cm). The mean direction independent deviation was 0,18 cm (range: 0,09 cm– 0,48 cm). Conclusion: Dynamic MR is a sensitive and well tolerated method for tumor motion monitoring in high precision 3D therapy planning of lung cancer patients. Our results demonstrate that tumors located in the upper and mid lobes have moderate breath synchronous movements. The greatest deviation occur in cranio–caudal direction.

Several methods have been developed to reduce tumor motions and patient movements during radiotherapy of lung cancer. In this study, a multislice CT-based analysis was performed to examine the effect of a thermoplastic patient immobilization system on the chest wall and tumor motions. Ten patients with stage II–IV lung cancer were enrolled into the study. According to tumor localization, five patients had peripheral, and five patients central lung cancer (T2–T4). In total, six series of measurements were made with a multislice CT scanner, both with and without mask fixation, in normal breathing, at maximal tidal volume inhalation, and at maximal tidal volume exhalation. Movements of chest wall, diaphragm and tumor, with and without mask, under different breathing conditions were registered. With the use of the immobilization system, no significant difference was found in diaphragmatic movements (mean deviation of diaphragm: 41.7–40.5 mm to the right, and 40.5–36.8 mm to the left side) and in tumor motions (mean deviation of tumor: 15.3–12.4 mm in craniocaudal, and 11.5–8.8 mm in posterolateral direction, mean medial deviation: 4.6–4.1 mm, mean lateral deviation: 7.2–5 mm). Significant differences were observed concerning tumor motions in anteroposterior direction (mean: 8.9–6.3 mm) and transverse chest movements in anteroposterior direction. Besides the advantage of optimal patient positioning, the movements of the bony chest wall can be considerably reduced by using the immobilization system. However, this fixation system has limitations concerning its suitability for minimizing tumor motions.

The revolutionary role of modern cross-sectional imaging, the improved target definition in CT/MRI image guided brachytherapy, the precise topography for applicator and anatomy contribute to a better knowledge and management of tumors and critical organs. Further developments and functional imaging is expected to lead to a broad use of patient tailored therapy in the field of interventional radiation oncology.

Background: The aim of this study was to analyze the use of magnetic resonance imaging (MRI) as a modern medical imaging technique in radiotherapy with special emphasis on the integration of MRI and a novel technique in brachytherapy to optimize treatment outcome in cervical cancer. Methods: In addition to the CT based shrinking volume conformal teletherapy in 31 patients with locally advanced cervical cancer, MRI examination with a special adjustable applicator at the treatment site was performed for the brachytherapy planning. To avoid excessive doses to the healthy structures during complex cervical radiotherapy isodose curves were calculated upon the information of the MR image and dose distribution was evaluated. Results: The consecutive application of CT and MRI limited the possibility for overdosage of the critical organs and undertreatment of the advanced tumor spread in all cases. The overall response rate for the complex treatment was 74.2% with complete regression in 25.8% of the cases. Based on the exact information of the three dimensional digital data radiation doses could be optimized without increasing the possibility of acute complications rate. Conclusion: The introduction of 3D treatment planning for teletherapy pelvic and boost irradiation of cervical carcinoma as well as for the brachytherapy part of the complex treatment is to be recommended. .

Absztrakt Az inguinofemoralis sérvek korszerű kezelésében hazánkban is egyre nagyobb teret nyernek a hálóbeültetéses eljárások. Az implantátumok laparoscoposan vagy hagyományosan Lichtenstein szerint helyezhetők a műtéti területre. A szerzők femoralis sérvek esetén a tradicionális eljárás módosításával kívánták csökkenteni a sérvrecidíva esélyét. A háló medialis, szélesebb részét a Cooper-szalag alatti praeperitonealis térbe csúsztatták, a Lotheissen-varratokat a háló szélétől másfél centiméterre helyezték el. Így a háló és a szövetek közötti tapadás miatt a varratok esetleges kiszakadása esetén is csökken a sérv visszatérésének esélye.

The aim of our pilot study was to demonstrate the feasibility and dosimetric quality of MR-guided HDR prostate brachytherapy in a low-field 0.35T open MRI scanner and to present our initial clinical experiences. 16 patients with intermediate- to high-risk localized prostate cancer were treated with 46-60 Gy of external beam radiotherapy preceded and/or followed by an 8 Gy MR-guided HDR boost. For interventions an MR compatible custom-made system, coaxial needles and plastic catheters were used. Template reconstruction, trajectory planning, image guidance, contouring and treatment planning were exclusively based on MR images. For treatment planning, dose-point- and anatomy-based inverse planning optimization was used. Image quality was found to be good to excellent in almost all cases. The mean catheter placement accuracy modeled by Rayleigh distribution was 2.9 mm with a sigma value of 2.3 mm. The mean and standard deviation (SD) of the dosimetric results for the target volume were the following: V100: 94.2 ± 4.3%, V150: 43.9 ± 6.8%, V200: 18.5 ± 5.9%. The mean D(0.1), D(1) and D1 values for the intraprostatic urethra were 117.6 ± 12.5%, 98.5 ± 19.9% and 122.3 ± 16.4%, respectively. Regarding the rectal wall the mean D(0.1), D(1) and D(2) values were 77.3 ± 7.2%, 64.8 ± 7.5%, and 53.2 ± 9.1%, respectively. The mean maximum dose for the inner rectal surface was 53.5 ± 9.2%. No RTOG Grade 3 or worse acute toxicities were observed. Our method seems to be a promising approach for performing feasible, accurate and high-quality MR-guided HDR prostate brachytherapy. To determine the long term side effects and outcome higher number of patients, additional follow-up is needed.

In the treatment of early stage breast cancer, breast conserving surgery (BCS) followed by whole breast irradiation (WBI) is the standard treatment. The impact of the tumor bed boost following WBI is well-defined, but there are various delivery methods. In this study we demonstrate our 4 year experience with the 3-D conformal boost technique. Between January 2004 and June 2005, 77 early stage (Stage I-II) breast cancer patients were treated in our institute with whole breast irradiation (WBI, 50.4 Gy in 28 fractions) after breast conserving surgery. Following WBI, 3-D conformal photon boost was delivered (10-16 Gy in five to eight fractions) for all patients. The clinical outcome was retrospectively recorded in terms of survival and local control. The side effect profile (fibrosis, fat necrosis and cosmetic outcome) was also recorded and studied. In our patient group the mean follow up time was 46.8 months (median: 52, range: 17-71, SD: 14.4) The 4-year probability of local tumor control was 96% (crude rate: 74/77-96.1%), the 4-year probability of overall survival was 96% (crude rate: 74/77-96.1%) in this patient group. In case of the distant metastasis free survival the probability was 89, 5% (crude rate: 70/77-90, 1%). Probability of disease specific survival was 98% (crude rate: 76/77-98. 7%). Local relapse occurred in three cases (3.9%). In ten cases (12.9%) asymptomatic grade I-II breast fibrosis, in eight cases (10.4%) asymptomatic breast fat necrosis were registered. For 14 patients (18.2%) asymptomatic lung fibrosis was recorded on the control CT scans. In term of the relapse free survival, the close resection margin and the nodal positivity resulted in significant difference in favor of the clear resection margin group and the node negative group. In this study the 3-D conformal photon boost resulted in good local control and side effect profile. The presence of tumor bed clips resulted in significantly lower boost PTV volumes, but no correlation was found between the irradiated boost volume and the breast fibrosis. In the relapse free survival analysis, nodal negativity and clear margin status resulted in significantly better RFS.

Magnetic resonance imaging (MRI) provides superior visualization of the prostate, its substructure, surrounding tissues, and, most important, focal lesions or cancer. The purpose of our canine study was to demonstrate the feasibility of a low-field (0.35 T) transperineal system that enables precise MR image guidance of prostate interventions. The canines were placed in the right lateral decubitus position. Template reconstruction, trajectory planning, contouring were based on T2-weighted FSE images. For image guidance and target confirmation, fast gradient spoiled-echo (FSPGR) sequence was used. MR compatible coaxial needles were manually inserted through the perineum to the base of the prostate. After satisfactory position was confirmed, brachytherapy catheters were placed through the coaxial needles. The mean deviation of the needle displacements was 2.9 mm with a median value of 2.7 mm. 97% of the errors were less than 4.0 mm. The needle placement accuracy was modelled by the Rayleigh distribution with a sigma value of 2.3 mm. Visual confirmation of needle placements was demonstrated on pathology tissue slices. The time needed for each step was: anaesthesia - 15 min, setup and positioning - 15 min, initial imaging - 15 min, template registration, projection - 15 min, contouring, trajectory planning, insertion of 12 needles - 60 min Based on our canine experiences our method seems to be a promising approach for performing feasible, accurate, reliable and high-quality prostate MR guidance within a reasonable time span.

The purpose of this study was to investigate the effects of biophysical factors on the diffusion and the relaxation time T2 independently. Certain properties of the extracellular and the intracellular space may change radically in pathological conditions resulting in water diffusion changes. A tissue model consisting of red blood cells was studied. The extra- and intracellular spaces were modified osmotically and by suspending medium concentration. Diffusion measurements were evaluated with regard to the effective medium theory. Neither the nature of the protein in the extracellular space nor an increased level of intracellular hydration caused a significant net water diffusion change in the cell suspension. The relaxation time T2 exhibited very little dependence on the extracellular volume fraction or the concentration or the nature of the protein in the extracellular space. An increased level of intracellular hydration resulted in systematically larger T2 values. It seems probable that increases in extracellular protein concentrations or in the extent of intracellular hydration do not play a significant role in the diffusion changes detected in pathological conditions. T2 appears to depend on the level of hydration or the total water content but is seemingly less dependent of the concentration and the nature of the extracellular protein in our model solutions.

In the treatment of early stage breast cancer breast conserving surgery (BCS) followed by whole breast irradiation (WBI) is a standard method. The impact of the tumor bed boost following WBI is well-defined, but there are various delivery methods. In this study the electron and the photon boost techniques were compared. For 78 early stage breast cancer patients both CT based 3D conformal photon boost and electron boost plans were created. For dosimetric comparison coverage index (CI), external volume index (EI) and conformality index (COIN) were studied. Lung volume receiving a dose of 2 Gy was also reviewed. Seventy-eight patients with 156 plans were compared. The mean tumor bed volume was measured as 61.39 cm3 the mean tumor bed-skin distance was 3.13 cm. In the case of CI and COIN significant differences were found in favor of the photon boost. In the comparison of EI no significant difference was detected between the two techniques. The mean lung volume receiving 2 Gy were 42.3 and 168.35 cm3, for photons and electrons respectively. In the adjuvant treatment of early stage breast cancer WBI followed by conformal photon boost showed to be superior to electron boost in focus of the COIN and CI.

The aim of our study was to detect the possible uncertainties arising from tumor movements in the daily routine treatment planning, in extreme breathing conditions. Ten patients with lung cancer were enrolled into the study. According to tumor location, five patients had peripheral and five had central tumor. After the normal planning CT scan, two more scans were made with the same CT parameters in maximal exhalation and in maximal inhalation. For planning, the normal breathing scans were used with the fusion of the maximal inhalation and maximal exhalation scans. After the fusion in all breathing phases the gross tumor volumes were contoured (GTV1, GTV2, GTV3). Around the GTV1 (normal breathing phase GTV) 3 planning target volumes (PTV) were generated with the margin of 0.5 cm, 1.5 cm and 2.5 cm (PTV1, PTV2, PTV3). Individual plans were generated to all PTVs. All GTV volumes were registered. In all cases volume deviations were registered in different breathing phases (min: 1.5%, max: 35.6%). For GTV coverage comparison the coverage index (CI) was used. In case of extreme breathing conditions, using 0.5 cm margin was sufficient to reach good coverage for central tumors. For peripheral tumors 1.5 cm margin had to be used for the acceptable coverage (CI: 0.85-1.00). In our study, extreme breathing conditions were analyzed. According to our results, CT scans used in the daily routine do not exactly represent the tumor midposition and the true tumor volume. Due to breathing synchronous tumor movements, 0.5 cm margin must be used for planning in central location. In peripheral tumors wider margin should be used.

BACKGROUND Biodegradable stent coatings provide a potential for local drug delivery at the time of vascular injury, while possible tissue toxicity is avoided through constant degradation, leaving behind a bare metal stent. DESIGN Serial three-dimensional (3D) intravascular ultrasonographic results on bare Megaflex stents and biodegradable polymer-coated Megaflex stents (Hyper stents) (Eurocor, Bonn, Germany) were compared 1 and 4 weeks after intracoronary implantation in pigs. METHODS Under general anaesthesia, the left anterior descending and circumflex coronary arteries of domestic pigs were stented with Megaflex and Hyper stents, using right femoral artery access. Control coronary angiography and intravascular ultrasonography (IVUS) were performed 1 and 4 weeks after stent implantation using left femoral artery access and right carotid artery access. After recording of angiographic and IVUS data, the pigs were allowed to recover. RESULTS The 1- and 4-week IVUS follow-ups revealed less neointima formation with Hyper stents than with Megaflex stents: 1-week intimal volume, 11.8+/-0.93 compared with 15.02+/-4.18 mm3, P=0.065; intimal area, 0.81+/-0.06 compared with 1.1+/-0.16 mm2, P =0.003; maximal intimal thickness, 0.12+/-0.01 compared with 0.14+/-0.02 mm, P =0.049; 4-week intimal volume, 12.4+/-1.77 compared with 27.32+/-12.79 mm3, P =0.016; intimal area, 0.82+/-0.12 compared with 1.95+/-0.65 mm2, P=0.003; and maximal intimal thickness, 0.13+/-0.04 compared with 0.30+/-0.10 mm, P=0.003. CONCLUSIONS Implantation of biodegradable polymer-coated (Hyper) stents results in significantly less neointima formation 1 and 4 weeks after intracoronary implantation than with bare Megaflex stents. Taking advantage of the good collateralization of femoral and carotid arteries of pigs, the use of different arterial accesses allows serial angiographic and 3D IVUS measurements on neointimal development without sacrificing the animals.