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The underlying mechanismis thought to be due to demyelination leading to axon loss [ 9 ]. National Center for Biotechnology InformationU. 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. 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.

Dose escalation introduces challenges with regard to meeting dose constraints for proximal critical structures such as the brachial plexus. Tolerance of normal tissue to therapeutic irradiation.

Dose-volume histogram data showing the median radiation dose of 10 patients manually contoured forming ddvh training set dotted line compared to the automatically generate plexus contours using deformable image registration, prior to modification.

Finally, because brachial plexopathy is relatively rare, the number of events in our study was low, which complicates our ability to generalize our defined dose limits to a larger population of patients with lung cancer.

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Next we plan to validate these dose constraints in an ongoing randomized phase III trial looking at dose escalation for lung cancer. These 10 images were then incorporated in the deformable registry program.

For these reasons, estimates of smaller point doses may not have been accurate enough to predict the development of plexopathy. The contours created by the image registration provided a good approximate location of the brachial plexus. In this retrospective analysis, we compared dose-volume histogram dvn with the incidence of plexopathy to establish the maximum tolerated dose to the brachial plexus.

Also, the borders of the brachial plexus, unlike those of other organs can be difficult to define.


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The V 10 values volume of brachial plexus volume receiving 10 Gy were 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. The contours were drawn jointly by two thoracic radiation oncologists and one thoracic radiologist. 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.

Where no foramen was present, only the regions between the scalene muscles were contoured. This may prove to be problematic for complying with dose constraints to structures like the brachial plexus.

Significant effect of adjuvant chemotherapy on survival in locally advanced non-small-cell lung carcinoma. Other significant risk factors were having plexopathy before treatment OR 4. The Pinnacle planning system was used to calculate the dose to the brachial plexus using the original treatment plan. The authors declare no conflicts of interest regarding the work presented here. 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.

We identified C5 through T1 roots, which served as the medial borders of the brachial plexus; the plexus was contoured from medial to lateral using the scalene muscles as landmarks[ 11 ]. 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.

Balancing the benefit of local control with the risk of considerable toxicity is a particular challenge for tumorsof the superior sulcus or tumors with supraclavicular adenopathy. 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.

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 increasingly challenging, particularly for tumors in the superior sulcus. Development and validation of a standardized method for contouring the brachial plexus: The superior border of the plexus was initiated between the neural foramina at C4-C5 where the nerve was traced as it exited the foramina.

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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.

Open in a separate window. A prospective randomized study of various irradiation doses and fractionation schedules in the treatment of inoperable non-oat-cell carcinoma of the lung.

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Preliminary report 1561 the Radiation Therapy Oncology Group. B Digitally-reconstructed radiographs DRR showing manual contours green and computer-generated contours red. This work was made possible through the generosity of the family of M. Arya AminiB. There were minimal differences in DVHs between the auto-segmented contours and the modified contours. Brachial plexopathy was documented according to the Common Terminology Criteria for Adverse Events v4. This was corrected withminor modifications for each individual to ensure consistency.

At a median dvu time of The planned tumor volume PTV received 74 Gy. OR, odds ratio; CI, confidence interval.

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. Radiation-induced brachial plexopathy can be quite debilitating and is difficult to treat [ 7 ].

When patients were treated with proton therapy using Varian Eclipse treatment planning, DICOM-RT dose plans were first exported from Eclipse planning system and then converted and imported into Pinnacle planning system for dose calculation.

Brachial plexopathy can present with a wide range of symptoms, often irreversibly, including numbness, pain, parasthesias, and motor impairment [ 8 ]. Gender, concurrent chemoradiation, and the presence of diabetes were not associated with risk of brachial plexopathy Table 2. Several explanations 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 surrounding organs; tumor motion, change in tumor size, and variations in patient anatomy and positioning during treatment would all be further sources of inaccuracy.