Programação linear no planejamento do tratamento de câncer por radiocirurgia

Medical Physics has been reaching an important role among several lines in Science, providing means for the improvement of several theories and procedures. Currently, its main application is related with the use of ionizing radiations, specially, in treatment procedures such as Radiotherapy. Radiosurgery is a Radiotherapy technique which consists in administering a single tumoricidal dose of radiation exclusively to the tumorous lesion. It becomes then an interesting alternative to surgical treatment, mainly in cerebral metastases, which are the most frequent cerebral tumors in the central nervous system. The radio neurosurgical team works out a planning for the Radiosurgery treatment, aiming for obtaining an appropriate ideal treatment for each case. For the working out of this treatment planning, Computed Tomography images of the region to be treated are obtained, digitalized and later, fused with nuclear magnetic resonance images. Through these images, critical structures, organs at risk and lesions are localized. After this, calculations are made to determine three-dimensional positions of isocenters, isodose curves, prescribed dose, collimators sizes, position, numbers and respective weight of isocentric conformal fields, and others. The treatment planning is commonly based in desired levels of dose for specific types of tumors and organs at risk concerning the irradiated region. Theses levels of dose are chosen in a way that a high probability of cure may be achieved and meanwhile, that the probability of complications, in whichever organ at risk, may be minimal. Thus, many researches have been carried out, showing that mathematical techniques may help to obtain an optimal planning for the treatment of cerebral metastases. Among the methods of optimization in the study...(Complete abstract click electronic access below)

Integrative Musterbildung kranialer Strukturen

Form und Gestalt kraniofazialer Strukturen sind primär beeinflusst durch die inhärente Integration der unterschiedlichsten Funktionssysteme und externer selektiver Einflüsse. Die Variabilität der Schädel-Morphe ist ein Indikator für solche Einflussfaktoren und damit ein idealer Gegenstand für vergleichende Analysen morphogenetischer Formbildung. Zur Ermittlung morphologisch-adaptiver Trends und Muster wurden sowohl Hypothesen zur morphologischen Differenziertheit als auch zu Korrelationen zwischen modularen Schädelkompartimenten (fazial, neurokranial, basikranial) untersucht. Zusätzlich wurden aus Schichtröntgenaufnahmen (CT) virtuelle Modelle rekonstruiert, welche die Interpretation der statistischen Befunde unterstützen sollten. Zur Berechnung der Gestaltunterschiede wurden mittels eines mechanischen Gelenkarm-Messgerätes (MicroScribe-G2) max. 85 ektokraniale Messpunkte (Landmarks) bzw. dreidimensionale Koordinaten an ca. 520 Schädeln von fünf rezenten Gattungen der Überfamilie Hominoidea (Hylobates, Pongo, Gorilla, Pan und Homo) akquiriert. Aus dem Datensatz wurden geometrische Störfaktoren (Größe, Translation, Rotation) mathematisch eliminiert und die verbleibenden Residuale bzw. ‚Gestalt-Variablen‘ diversen multivariat-statistischen Verfahren unterzogen (Faktoren, Cluster-, Regressions- und Korrelationsanalysen sowie statistische Tests). Die angewandten Methoden erhalten die geometrische Information der Untersuchungsobjekte über alle Analyseschritte hinweg und werden unter der Bezeichnung „Geometric Morphometrics (GMM)“ als aktueller Ansatz der Morphometrie zusammengefasst. Für die unterschiedlichen Fragestellungen wurden spezifische Datensätze generiert. Es konnten diverse morphologische Trends und adaptive Muster mit Hilfe der Synthese statistischer Methoden und computer-basierter Rekonstruktionen aus den generierten Datensätzen ermittelt werden. Außerdem war es möglich, präzise zu rekonstruieren, welche kranialen Strukturen innerhalb der Stichprobe miteinander wechselwirken, einzigartige Variabilitäten repräsentieren oder eher homogen gestaltet sind. Die vorliegenden Befunde lassen erkennen, dass Fazial- und Neurokranium am stärksten miteinander korrelieren, während das Basikranium geringe Abhängigkeiten in Bezug auf Gesichts- oder Hirnschädelveränderungen zeigte. Das Basikranium erweist sich zudem bei den nicht-menschlichen Hominoidea und über alle Analysen hinweg als konservative und evolutiv-persistente Struktur mit dem geringsten Veränderungs-Potential. Juvenile Individuen zeigen eine hohe Affinität zueinander und zu Formen mit einem kleinem Gesichts- und großem Hirnschädel. Während das Kranium des rezenten Menschen primär von Enkephalisation und fazialer Retraktion (Orthognathisierung) dominiert ist und somit eine einzigartige Gestalt aufweist, zeigt sich der Kauapparat als maßgeblich formbildendes Kompartiment bei den nicht-menschlichen Formen. Die Verbindung von GMM mit den interaktiven Möglichkeiten computergenerierter Modelle erwies sich als valides Werkzeug zur Erfassung der aufgeworfenen Fragestellungen. Die Interpretation der Befunde ist durch massive Interkorrelationen der untersuchten Strukturen und der statistisch-mathematischen Prozeduren als hoch komplex zu kennzeichnen. Die Studie präsentiert einen innovativen Ansatz der modernen Morphometrie, welcher für zukünftige Untersuchungen im Bereich der kraniofazialen Gestaltanalyse ausgebaut werden könnte. Dabei verspricht die Verknüpfung mit ‚klassischen’ und modernen Zugängen (z. B. Molekularbiologie) gesteigerte Erkenntnismöglichkeiten für künftige morphometrische Fragestellungen.

Population-Based Design of Mandibular Plates Based on Bone Quality and Morphology

In this paper we present a new population-based implant design methodology, which advances the state-of-the-art approaches by combining shape and bone quality information into the design strategy. The method enhances the mechanical stability of the fixation and reduces the intra-operative in-plane bending which might impede the functionality of the locking mechanism. The method is presented for the case of mandibular locking fixation plates, where the mandibular angle and the bone quality at screw locations are taken into account. Using computational anatomy techniques, the method automatically derives, from a set of computed tomography images, the mandibular angle and the bone thickness and intensity values at the path of every screw. An optimisation strategy is then used to optimise the two parameters of plate angle and screw position. Results for the new design are presented along with a comparison with a commercially available mandibular locking fixation plate. A statistically highly significant improvement was observed. Our experiments allowed us to conclude that an angle of 126° and a screw separation of 8mm is a more suitable design than the standard 120° and 9mm.

Population-based design of mandibular fixation plates with bone quality and morphology considerations

In this paper we present a new population-based implant design methodology, which advances the state-of-the-art approaches by combining shape and bone quality information into the design strategy. The method may enhance the mechanical stability of the fixation and reduces the intra-operative in-plane bending which might impede the functionality of the locking mechanism. The computational method is presented for the case of mandibular locking fixation plates, where the mandibular angle and the bone quality at screw locations are taken into account. The method automatically derives the mandibular angle and the bone thickness and intensity values at the path of every screw from a set of computed tomography images. An optimization strategy is then used to optimize the two parameters of plate angle and screw position. The method was applied to two populations of different genders. Results for the new design are presented along with a comparison with a commercially available mandibular locking fixation plate (MODUS(®) TriLock(®) 2.0/2.3/2.5, Medartis AG, Basel, Switzerland). The proposed designs resulted in a statistically significant improvement in the available bone thickness when compared to the standard plate. There is a higher probability that the proposed implants cover areas of thicker cortical bone without compromising the bone mineral density around the screws. The obtained results allowed us to conclude that an angle and screw separation of 129° and 9 mm for females and 121° and 10 mm for males are more suitable designs than the commercially available 120° and 9 mm.

Early changes in biochemical markers of bone formation during teriparatide therapy correlate with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis

Summary Changes of the bone formation marker PINP correlated positively with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis (GIO) who received 18-month treatment with teriparatide, but not with risedronate. These results support the use of PINP as a surrogate marker of bone strength in GIO patients treated with teriparatide. Introduction To investigate the correlations between biochemical markers of bone turnover and vertebral strength estimated by finite element analysis (FEA) in men with GIO. Methods A total of 92 men with GIO were included in an 18-month, randomized, open-label trial of teriparatide (20 μg/day, n = 45) and risedronate (35 mg/week, n = 47). High-resolution quantitative computed tomography images of the 12th thoracic vertebra obtained at baseline, 6 and 18 months were converted into digital nonlinear FE models and subjected to anterior bending, axial compression and torsion. Stiffness and strength were computed for each model and loading mode. Serum biochemical markers of bone formation (amino-terminal-propeptide of type I collagen [PINP]) and bone resorption (type I collagen cross-linked C-telopeptide degradation fragments [CTx]) were measured at baseline, 3 months, 6 months and 18 months. A mixed-model of repeated measures analysed changes from baseline and between-group differences. Spearman correlations assessed the relationship between changes from baseline of bone markers with FEA variables. Results PINP and CTx levels increased in the teriparatide group and decreased in the risedronate group. FEA-derived parameters increased in both groups, but were significantly higher at 18 months in the teriparatide group. Significant positive correlations were found between changes from baseline of PINP at 3, 6 and 18 months with changes in FE strength in the teriparatide-treated group, but not in the risedronate group. Conclusions Positive correlations between changes in a biochemical marker of bone formation and improvement of biomechanical properties support the use of PINP as a surrogate marker of bone strength in teriparatide-treated GIO patients.

Effect of Decompressive Craniectomy on Perihematomal Edema in Patients with Intracerebral Hemorrhage.

BACKGROUND Perihematomal edema contributes to secondary brain injury in the course of intracerebral hemorrhage. The effect of decompressive surgery on perihematomal edema after intracerebral hemorrhage is unknown. This study analyzed the course of PHE in patients who were or were not treated with decompressive craniectomy. METHODS More than 100 computed tomography images from our published cohort of 25 patients were evaluated retrospectively at two university hospitals in Switzerland. Computed tomography scans covered the time from admission until day 100. Eleven patients were treated by decompressive craniectomy and 14 were treated conservatively. Absolute edema and hematoma volumes were assessed using 3-dimensional volumetric measurements. Relative edema volumes were calculated based on maximal hematoma volume. RESULTS Absolute perihematomal edema increased from 42.9 ml to 125.6 ml (192.8%) after 21 days in the decompressive craniectomy group, versus 50.4 ml to 67.2 ml (33.3%) in the control group (Δ at day 21 = 58.4 ml, p = 0.031). Peak edema developed on days 25 and 35 in patients with decompressive craniectomy and controls respectively, and it took about 60 days for the edema to decline to baseline in both groups. Eight patients (73%) in the decompressive craniectomy group and 6 patients (43%) in the control group had a good outcome (modified Rankin Scale score 0 to 4) at 6 months (P = 0.23). CONCLUSIONS Decompressive craniectomy is associated with a significant increase in perihematomal edema compared to patients who have been treated conservatively. Perihematomal edema itself lasts about 60 days if it is not treated, but decompressive craniectomy ameliorates the mass effect exerted by the intracerebral hemorrhage plus the perihematomal edema, as reflected by the reduced midline shift.

Avaliação das inclinações dentárias obtidas no tratamento ortodôntico com bráquetes autoligados utilizando tomografia computadorizada

O objetivo deste trabalho foi analisar a expressão dos torques dentários em pacientes tratados com aparelhos ortodônticos fixos com bráquetes autoligados, utilizando tomografias computadorizadas. Para este estudo, foi selecionada uma amostra clínica de 10 pacientes, seguindo como critérios de inclusão, indivíduos que apresentavam dentição permanente e todos os dentes presentes, com apinhamento superior ou igual a 4 mm, tratados sem extração. Todos os pacientes foram tratados na clínica da pós-graduação em Ortodontia da Universidade Metodista de São Paulo, utilizando-se bráquetes autoligados Damon 2 ORMCO na prescrição padrão. Foram realizadas medições das inclinações dos dentes anteriores, de canino a canino, superiores e inferiores, realizadas por meio de imagens tomográficas obtidas em um tomógrafo computadorizado volumétrico NewTom, em seu modelo DVT-9000 (NIM Verona - Itália), obtidas em dois tempos: antes do início do tratamento ortodôntico (denominado de T1) e depois do tratamento ortodôntico, após a inserção do último fio de nivelamento, de calibre 0,019 x 0,025 de aço inoxidável(denominado de T2). Para auxílio destas mensurações, foi utilizado o software QR-DVT 9000 e após análise dos resultados foram aplicados testes estatíscos (testes "t" pareado e Dalberg) e observou-se que as inclinações dos dentes do segmento anterior aumentaram, principalmente, nos caninos e incisivos laterais superiores, incisivos centrais e laterais inferiores. Os dentes apresentaram valores de inclinação diferentes da prescrição, tanto no início quanto no final do tratamento, denotando a incapacidade do fio 0,019 x 0,025 de aço inoxidável em reproduzir os torques indicados na prescrição padrão utilizada neste presente estudo.(AU)

Avaliação das inclinações dentárias obtidas no tratamento ortodôntico com bráquetes autoligados utilizando tomografia computadorizada

O objetivo deste trabalho foi analisar a expressão dos torques dentários em pacientes tratados com aparelhos ortodônticos fixos com bráquetes autoligados, utilizando tomografias computadorizadas. Para este estudo, foi selecionada uma amostra clínica de 10 pacientes, seguindo como critérios de inclusão, indivíduos que apresentavam dentição permanente e todos os dentes presentes, com apinhamento superior ou igual a 4 mm, tratados sem extração. Todos os pacientes foram tratados na clínica da pós-graduação em Ortodontia da Universidade Metodista de São Paulo, utilizando-se bráquetes autoligados Damon 2 ORMCO na prescrição padrão. Foram realizadas medições das inclinações dos dentes anteriores, de canino a canino, superiores e inferiores, realizadas por meio de imagens tomográficas obtidas em um tomógrafo computadorizado volumétrico NewTom, em seu modelo DVT-9000 (NIM Verona - Itália), obtidas em dois tempos: antes do início do tratamento ortodôntico (denominado de T1) e depois do tratamento ortodôntico, após a inserção do último fio de nivelamento, de calibre 0,019 x 0,025 de aço inoxidável(denominado de T2). Para auxílio destas mensurações, foi utilizado o software QR-DVT 9000 e após análise dos resultados foram aplicados testes estatíscos (testes "t" pareado e Dalberg) e observou-se que as inclinações dos dentes do segmento anterior aumentaram, principalmente, nos caninos e incisivos laterais superiores, incisivos centrais e laterais inferiores. Os dentes apresentaram valores de inclinação diferentes da prescrição, tanto no início quanto no final do tratamento, denotando a incapacidade do fio 0,019 x 0,025 de aço inoxidável em reproduzir os torques indicados na prescrição padrão utilizada neste presente estudo.(AU)

Determinação do contorno pulmonar orientado em sequências temporais de imagens de RM pela transformada de Hough.

O estudo do movimento pulmonar é assunto de grande interesse na área médica. A observação direta do mesmo é inviável, uma vez que o pulmão colapsa quando a caixa torácica é aberta. Dentre os meios de observação indireta, escolheu-se o imageamento por ressonância magnética em respiração livre e sem uso de nenhum gás para melhorar o contraste ou qualquer informação de sincronismo. Esta escolha propõe diversos desafios, como: a superar a alta variação na qualidade das imagens, que é baixa, em geral, e a suscetibilidade a artefatos, entre outras limitações a serem superadas. Imagens de Tomografia Computadorizada apresentam melhor qualidade e menor tempo de aquisição, mas expõem o paciente a níveis consideráveis de radiação ionizante. É apresentada uma metodologia para segmentação do pulmão, produzindo um conjunto de pontos coordenados. Isto é feito através do processamento temporal da sequência de imagens de RM. Este processamento consiste nas seguintes etapas: geração de imagens temporais (2DSTI), transformada de Hough modificada, algoritmo de contornos ativos e geração de silhueta. A partir de um dado ponto, denominado centro de rotação, são geradas diversas imagens temporais com orientações variadas. É proposta uma formulação modificada da transformada de Hough para determinar curvas parametrizadas que sejam síncronas ao movimento diafragmático, chamados movimentos respiratórios. Também são utilizadas máscaras para delimitar o domínio de aplicação da transformada de Hough. São obtidos movimentos respiratórios que são suavizados pelo algoritmo de contornos ativos e, assim, permitem a geração de contornos para cada quadro pertencente a sequência e, portanto, de uma silhueta do pulmão para cada sequência.

Automatic measurement of vertebral rotation in idiopathic scoliosis

Study Design. Development of an automatic measurement algorithm and comparison with manual measurement methods. Objectives. To develop a new computer-based method for automatic measurement of vertebral rotation in idiopathic scoliosis from computed tomography images and to compare the automatic method with two manual measurement techniques. Summary of Background Data. Techniques have been developed for vertebral rotation measurement in idiopathic scoliosis using plain radiographs, computed tomography, or magnetic resonance images. All of these techniques require manual selection of landmark points and are therefore subject to interobserver and intraobserver error. Methods. We developed a new method for automatic measurement of vertebral rotation in idiopathic scoliosis using a symmetry ratio algorithm. The automatic method provided values comparable with Aaro and Ho's manual measurement methods for a set of 19 transverse computed tomography slices through apical vertebrae, and with Aaro's method for a set of 204 reformatted computed tomography images through vertebral endplates. Results. Confidence intervals (95%) for intraobserver and interobserver variability using manual methods were in the range 5.5 to 7.2. The mean (+/- SD) difference between automatic and manual rotation measurements for the 19 apical images was -0.5 degrees +/- 3.3 degrees for Aaro's method and 0.7 degrees +/- 3.4 degrees for Ho's method. The mean (+/- SD) difference between automatic and manual rotation measurements for the 204 endplate images was 0.25 degrees +/- 3.8 degrees. Conclusions. The symmetry ratio algorithm allows automatic measurement of vertebral rotation in idiopathic scoliosis without intraobserver or interobserver error due to landmark point selection.

Avaliação das inclinações dentárias obtidas no tratamento ortodôntico com bráquetes autoligados utilizando tomografia computadorizada

O objetivo deste trabalho foi analisar a expressão dos torques dentários em pacientes tratados com aparelhos ortodônticos fixos com bráquetes autoligados, utilizando tomografias computadorizadas. Para este estudo, foi selecionada uma amostra clínica de 10 pacientes, seguindo como critérios de inclusão, indivíduos que apresentavam dentição permanente e todos os dentes presentes, com apinhamento superior ou igual a 4 mm, tratados sem extração. Todos os pacientes foram tratados na clínica da pós-graduação em Ortodontia da Universidade Metodista de São Paulo, utilizando-se bráquetes autoligados Damon 2 ORMCO na prescrição padrão. Foram realizadas medições das inclinações dos dentes anteriores, de canino a canino, superiores e inferiores, realizadas por meio de imagens tomográficas obtidas em um tomógrafo computadorizado volumétrico NewTom, em seu modelo DVT-9000 (NIM Verona - Itália), obtidas em dois tempos: antes do início do tratamento ortodôntico (denominado de T1) e depois do tratamento ortodôntico, após a inserção do último fio de nivelamento, de calibre 0,019 x 0,025 de aço inoxidável(denominado de T2). Para auxílio destas mensurações, foi utilizado o software QR-DVT 9000 e após análise dos resultados foram aplicados testes estatíscos (testes "t" pareado e Dalberg) e observou-se que as inclinações dos dentes do segmento anterior aumentaram, principalmente, nos caninos e incisivos laterais superiores, incisivos centrais e laterais inferiores. Os dentes apresentaram valores de inclinação diferentes da prescrição, tanto no início quanto no final do tratamento, denotando a incapacidade do fio 0,019 x 0,025 de aço inoxidável em reproduzir os torques indicados na prescrição padrão utilizada neste presente estudo.(AU)

Computed Ultrasound Tomography in Echo mode (CUTE) of speed of sound for diagnosis and for aberration correction in pulse-echo sonography

Sound speed as a diagnostic marker for various diseases of human tissue has been of interest for a while. Up to now, mostly transmission ultrasound computed tomography (UCT) was able to detect spatially resolved sound speed, and its promise as a diagnostic tool has been demonstrated. However, UCT is limited to acoustically transparent samples such as the breast. We present a novel technique where spatially resolved detection of sound speed can be achieved using conventional pulse-echo equipment in reflection mode. For this purpose, pulse-echo images are acquired under various transmit beam directions and a two-dimensional map of the sound speed is reconstructed from the changing phase of local echoes using a direct reconstruction method. Phantom results demonstrate that a high spatial resolution (1 mm) and contrast (0.5 % of average sound speed) can be achieved suitable for diagnostic purposes. In comparison to previous reflection-mode based methods, CUTE works also in a situation with only diffuse echoes, and its direct reconstruction algorithm enables real-time application. This makes it suitable as an addition to conventional clinical ultrasound where it has the potential to benefit diagnosis in a multimodal approach. In addition, knowledge of the spatial distribution of sound speed allows full aberration correction and thus improved spatial resolution and contrast of conventional B-mode ultrasound. © (2014) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE). Downloading of the abstract is permitted for personal use only.

Accurately simulating the production of radiotherapy portal images using non-zero beam angles

In this study, the delivery and portal imaging of one square-field and one conformal radiotherapy treatment was simulated using the Monte Carlo codes BEAMnrc and DOSXYZnrc. The treatment fields were delivered to a humanoid phantom from different angles by a 6 MV photon beam linear accelerator, with an amorphous-silicon electronic portal imaging device (a-Si EPID) used to provide images of the phantom generated by each field. The virtual phantom preparation code CTCombine was used to combine a computed-tomography-derived model of the irradiated phantom with a simple, rectilinear model of the a-Si EPID, at each beam angle used in the treatment. Comparison of the resulting experimental and simulated a-Si EPID images showed good agreement, within \[gamma](3%, 3 mm), indicating that this method may be useful in providing accurate Monte Carlo predictions of clinical a-Si EPID images, for use in the verification of complex radiotherapy treatments.

The appearance and effects of metallic implants in CT images

Contemporary 3D radiotherapy treatment planning relies upon the use of 3D electron density maps derived from computed tomography (CT) scans of patient anatomy, to evaluate the effects of that anatomy on radiation dose distributions. Production of these electron density maps requires that the CT numbers (Hounsfield units) that quantify the attenuation of the x-ray beam by the patient’s anatomy must be reliably converted into electron densities, using a stable calibration relationship. This study investigates the fidelity of electron density assignment in the presence of metallic prostheses and implants.