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未来基于磁共振引导直线加速器的立体定向心律失常放射性消融治疗中实时心肺运动管理的首次实验探索。

First experimental exploration of real-time cardiorespiratory motion management for future stereotactic arrhythmia radioablation treatments on the MR-linac.

机构信息

Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.

Elekta AB, Kungstensgatan 18, 113 57 Stockholm, Sweden.

出版信息

Phys Med Biol. 2022 Mar 9;67(6). doi: 10.1088/1361-6560/ac5717.

Abstract

Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive treatment for refractory ventricular tachycardia (VT). The VT isthmus is subject to both respiratory and cardiac motion. Rapid cardiac motion presents a unique challenge. In this study, we provide first experimental evidence for real-time cardiorespiratory motion-mitigated MRI-guided STAR on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) aimed at simultaneously compensating cardiac and respiratory motions.A real-time cardiorespiratory motion-mitigated radiotherapy workflow was developed on the Unity MR-linac in research mode. A 15-beam intensity-modulated radiation therapy treatment plan (1 × 25 Gy) was created in Monaco v.5.40.01 (Elekta AB) for the Quasar MRIphantom (ModusQA, London, ON). A film dosimetry insert was moved by combining either artificial (cos, 70 bpm, 10 mm peak-to-peak) or subject-derived (59 average bpm, 15.3 mm peak-to-peak) cardiac motion with respiratory (sin, 12 bpm, 20 mm peak-to-peak) motion. A balanced 2D cine MRI sequence (13 Hz, field-of-view = 400 × 207 mm, resolution = 3 × 3 × 15 mm) was developed to estimate cardiorespiratory motion. Cardiorespiratory motion was estimated by rigid registration and then deconvoluted into cardiac and respiratory components. For beam gating, the cardiac component was used, whereas the respiratory component was used for MLC-tracking. In-silico dose accumulation experiments were performed on three patient data sets to simulate the dosimetric effect of cardiac motion on VT targets.Experimentally, a duty cycle of 57% was achieved when simultaneously applying respiratory MLC-tracking and cardiac gating. Using film, excellent agreement was observed compared to a static reference delivery, resulting in a 1%/1 mm gamma pass rate of 99%. The end-to-end gating latency was 126 ms on the Unity MR-linac. Simulations showed that cardiac motion decreased the target's D98% dose between 0.1 and 1.3 Gy, with gating providing effective mitigation.Real-time MRI-guided cardiorespiratory motion management greatly reduces motion-induced dosimetric uncertainty and warrants further research and development for potential future use in STAR.

摘要

立体定向心律失常放射消融术(STAR)是一种治疗难治性室性心动过速(VT)的新型非侵入性治疗方法。VT 峡部受呼吸和心脏运动的影响。快速的心脏运动带来了独特的挑战。在这项研究中,我们提供了第一个关于在 1.5T Unity MR-linac(Elekta AB,斯德哥尔摩,瑞典)上进行实时呼吸-心脏运动缓解 MRI 引导的 STAR 的实验证据,旨在同时补偿心脏和呼吸运动。在 Unity MR-linac 上以研究模式开发了一种实时呼吸-心脏运动缓解的放射治疗工作流程。在 Monaco v.5.40.01(Elekta AB)中为 Quasar MRIphantom(ModusQA,伦敦,安大略省)创建了 15 束强度调制放射治疗计划(1×25 Gy)。通过将人工(cos,70 bpm,10 毫米峰峰值)或源自患者的(59 平均 bpm,15.3 毫米峰峰值)心脏运动与呼吸(sin,12 bpm,20 毫米峰峰值)运动相结合,移动了胶片剂量测定插件。开发了一种平衡的 2D 电影 MRI 序列(13 Hz,视野= 400×207 mm,分辨率= 3×3×15 mm)来估计呼吸-心脏运动。通过刚性配准估计呼吸-心脏运动,然后将其解卷积为心脏和呼吸分量。对于束门控,使用心脏分量,而对于 MLC 跟踪,使用呼吸分量。在三个患者数据集上进行了计算机模拟剂量积累实验,以模拟心脏运动对 VT 靶区的剂量学影响。实验中,当同时应用呼吸 MLC 跟踪和心脏门控时,实现了 57%的占空比。使用胶片,与静态参考递送相比,观察到极好的一致性,导致 1%/1 mm 伽马通过率为 99%。Unity MR-linac 的端到端门控延迟为 126 ms。模拟表明,心脏运动使靶区的 D98%剂量降低了 0.1 至 1.3 Gy,门控提供了有效的缓解。实时 MRI 引导的呼吸-心脏运动管理大大降低了运动引起的剂量不确定性,并为未来在 STAR 中的潜在应用提供了进一步的研究和开发。

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