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OR, odds ratio; CI, confidence interval. 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 51661 for all 90 patients.
This was corrected withminor modifications for each individual to ensure consistency.
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Also, the borders of fvh brachial plexus, unlike those of other organs can be difficult to define. Bar graphs representing the percent risk for brachial plexopathy according to a cutoff median dose of 69 Gy to the entire brachial plexus panel A and a 75 Gy dose cutoff to 2 cm 3 of the brachial plexus panel B. Also, changes in arm position can affect the visibility of the brachial plexus and can contribute to inaccuracies in deformable image registration.
P values of 0. 5611
Interestingly, we found that doses to 0. See other articles in PMC that cite the published article. The Mann-Whitney two-sample statistic or Wilcoxon rank-sum test was used to test the distribution of continuous variables according to plexopathy status. Brachial plexus lesions in patients with cancer: Author information Copyright and License information Disclaimer. The inferior and lateral borders of the plexus terminated with the subclavian vascular bundle Fig.
Preliminary report by the Radiation Therapy Oncology Group. 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.
The maximum 55161 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. We 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.
Journal of Clinical Oncology. The planned tumor volume PTV received 74 Gy. dvg
Development and validation of a standardized method for contouring the brachial plexus: In this study we found that plexopathy before treatment was also associated with greater risk of toxicity after treatment. Atlas of human anatomy.
The median overall dose to the brachial plexus was It is well known that peripheral nerves are sensitive to recurrent episodes of trauma, whether from tumor invasion or from surgical intervention [ 915 ]; multiple traumas might be expected to reduce the threshold for development of symptoms.
Patients with brachial plexopathy before treatment due to tumor invasion or surgical intervention were considered to have plexopathy after radiation treatment only if the plexopathy had cleared and then returned without evidence of new tumor impingement. 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.
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.
To reduce variability in our contouring of the brachial plexus, we followed guidelines based on easily delineated structures such as the sternocleidomastoid and scalene muscles and bony landmarks. The median dose to the tumor was 70 Gy range The median maximum doses to 0. Significant effect of adjuvant chemotherapy on survival in locally advanced non-small-cell lung carcinoma. Gender, concurrent chemoradiation, and the presence of diabetes were not associated dgh risk of brachial plexopathy Table 2.
Additional inclusion criteria were having at least 4 months of follow-up and having had either photon or proton dvj with 3D conformal or intensity-modulated radiation treatment planning, with or without concurrent chemotherapy. Open in a separate window. 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.
Most studies since have recommended the maximum dose be kept under 66 Gy. Dbh refer to the text for details. Finally, the Simultaneous Truth and Performance Level Estimation STAPLE algorithm [ 14 ] was used to combine these 10 individual segmentations to produce a single fused contour, which was considered the best statistical estimation of dbh true segmentation from multiple measurements.
Dose-volume histogram data showing the median radiation dose of 10 patients manually contoured forming the training set dotted dvg compared to the automatically generate plexus contours using deformable image registration, prior to modification. The resultant displacement vector fields characterizing the individual registrations were then used to deform the atlas brachial plexus contours to obtain 10 individual segmentations for each patient.
Abstract Purpose As the recommended radiation dose for non-small cell lung cancer NSCLC increases, meeting dose constraints for critical structures like the brachial plexus becomes 561 challenging, particularly for tumors in the superior sulcus.
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A Axial CT scan delineating the brachial plexus based on physician consensus green and computer-generated contours red. This overall framework is illustrated in Figure 2. The Pinnacle planning system was used to calculate the dose to the brachial plexus using the original treatment plan. Radiation-induced brachial plexopathy can be quite debilitating and is difficult to treat [ rvh ].
Treatment plans from those patients were de-archived from the tape backup system and restored into a research Pinnacle planning system Philips Healthcare. The median time to symptom onset was 6.
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Deformable image registration is a valuable tool, especially for contouring difficult structures like the brachial plexus. The contours were drawn jointly by two thoracic radiation oncologists and one thoracic radiologist. 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.
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. 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.
However, radiation doses of that magnitude often result in local failure, which itself cancause brachial plexopathy. Patients were retrospectively identified by searching an institutional database of patients treated with radiation for lung cancer at MD Anderson Cancer Center between March and September The purpose of this study was to identify a threshold radiation dose at which plexopathy becomes evident when that radiation is delivered using modern-day techniques to tumors in the superior sulcus, upper mediastinum, or supraclavicular regions.