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ThomasBortfeld·RupertSchmidt-Ullrich·WilfriedDeNeve·DavidE.Wazer(Eds.)
Image-Guided IMRT
Thomas Bortfeld · Rupert Schmidt-Ullrich
Wilfried De Neve · David E. Wazer (Eds.)
Image-Guided IMRT
With 124 Figures, 96 in Color and 44 Tables
123
Thomas Bortfeld
Dept. of Radiation Oncology
Massachusetts General Hospital
30 Fruit Street
Boston, MA 02114
USA
Rupert Schmidt-Ullrich
Dept. of Radiation Oncology
Virginia Commonwealth University
401 College Street
Richmond, VA 23298–0058
USA
Wilfried De Neve
Dept. of Radiotherapy
Ghent University Hospital
De Pintelaan 185
9000 Ghent
Belgium
David E. Wazer
Dept. of Radiation Oncology
Tufts University
750 Washington Street
Boston, MA 02111
USA
Library of Congress Control Number 2005925670
ISBN-10 3-540-20511-X Springer Berlin Heidelberg 2006
ISBN-13 978-3-540-20511-1 Springer Berlin Heidelberg 2006
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfilms or in any other way and storage in data banks. Duplication of this publication
or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965,
in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are
liable for prosecution under the German Copyright Law.
Springer-Verlag is a part of Springer Science+Business Media
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© Springer-Verlag Berlin Heidelberg 2006
Printed in Germany
The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the relevant protective laws
and regulations and therefore free for general use.
Product liability: the publishers cannot guarantee the accuracy of any information about dosage and
application contained in this book. In every individual case the user must check such information by
consulting the relevant literature.
Editor: Dr. Ute Heilmann
Desk Editor: Meike Stoeck
Production and Typesetting: LE-T
E
X Jelonek, Schmidt & Vöckler GbR, Leipzig
Cover: Frido Steinen-Broo, EStudio Calamar, Spain
Printing and binding: Stürtz, Würzburg
Printed on acid-free paper
21/3150/YL 543210
Preface
Intensity-modulated radiotherapy (IMRT) has widened
the horizons of radiation therapy due to its ability to
conform radiation dose distributions to complex tumor
target volumes while sparing nearby critical structures
as much as physically possible. IMRT has also led to
paradigm shifts in all elements of the chain of radio-
therapy, from treatment prescription over treatment
planning (“inverse” planning) to treatment delivery and
verification. Although IMRT and inverse planning have
the potential to streamline and simplify radiotherapy, at
the current stage of the development IMRT is still signif-
icantly more involved than conventional radiotherapy.
This book is meant to help the reader understand
the concepts and components of IMRT, to give a topi-
cal overview of advanced image-guided and biologically
guided approaches, and to provide useful hints on how
to master IMRT in clinical practice. Reading this text
alone is not sufficient to start a clinical IMRT program.
The book will rather provide up-to-date theoretical and
practical information about IMRT that should be con-
sulted in addition to other sources that are listed as
references. We highlight not only the strengths of IMRT
but discuss also the weaknesses, limitations, and unique
challenges such as the prolonged treatment times and
increased leakage radiation. All this, we hope, will be
useful for clinicians and physicists who are interested in
exploring the potential of IMRT, as well as a reference
for those who already apply IMRT in clinical practice.
Thebookhasbeenwrittenbyaninternationalgroup
of authors with an international readership in mind.
Some IMRT aspects, such as quality assurance, have
different flavors in different countries, because of na-
tional regulations and reimbursement issues. We tried
to take this into account by covering the American and
the European perspectives on quality assurance in two
separate chapters. This also emphasizes the importance
of the topic. The authors of all chapters are distinguished
experts in their field and we are grateful that they de-
voted some of their precious time to the writing of their
chapters.
The material has been organized into three major
parts: (I) Foundations, (II) Advanced Image-Guided and
Biologically Guided Techniques, and (III) Clinical Ap-
plications. Part I lays the foundation for state-of-the-art
IMRT. As for image guidance (part II), it has been said
that radiotherapy, and in particular IMRT, has always
been image-guided and that the current hype about im-
ageguidanceisnotjustified.Whilethereissometruth
to this statement, there have been recent developments
in image-guided IMRT that deserve separate coverage.
The developments with the biggest potential impact are
probably the inclusion of functional imaging informa-
tion into target segmentationanddoseprescription, and
the advancement of adaptive “4D” radiotherapy tech-
niques, which incorporate temporal changes into the
treatment scheme. These developments, which are cur-
rently being pursued at only a few centers, will most
likely find their way into broader clinical application in
the near future.
The Clinical Applications section (III) reviews the
use of IMRT for individual anatomic sites and com-
mon clinical applications. Each chapter is presented in
a similar format: Clinical problem – Potential benefits
of IMRT – Unique challenges – Target and organ-at-
risk definition – Planning – Delivery issues – Clinical
studies and trials – Future directions. We have drawn
upon experienced practitioners of IMRT to summarize
the current literature as well as provide their personal
insights as to how they approach the specifics of treat-
ment planning and delivery including required imaging,
anatomic segmentation, normal tissue dose-volume re-
lationships, and target dose. The section is designed to
provide detailed and practical information to the clin-
ician and medical physicist as they implement IMRT
under a broad set of clinical circumstances.
In closing, we must make special mention of our
coeditor, Rupert K.A. Schmidt-Ullrich. Dr. Schmidt-
Ullrich was one of the early pioneers in the development
of IMRT and has fostered within his department at
the Virginia Commonwealth University one of the most
distinguished research programs in the world. His over-
ridingpassioninrecentyearswastoproduceatextbook
for IMRT that would be broadly recognized for its com-
prehensiveness, quality, and readability. The effort, as
reflected in these pages, is a testament to his vision, in-
sight, and commitment to excellence. Sadly, Rupert will
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