Análisis de 150 pacientes trasplantados pulmonares por Enfermedad Pulmonar Intersticial Difusa ( EPID )

Les malalties pulmonars intersticials difuses ( MPID) representen la segona indicación de trasplantamente pulmonar (TP) després del enfisema. El treball és un estudi retrospectiu de 150 malalts sotmesos a un TP per MPID entre agost-1990 i gener de 2010. Es tracta de 86 (57%) homes amb una edad mitja de 49 (r: 20-67) anys. Es van fer 104 (69%) trasplantaments unipulmonares ( TUP) i 46 bipulmonars ( TBP). El diagnòstic més freqüent va ser en 94 ( 63%) malalts la Neumonía intersticial Usual. L’objectiu ha estat establir els resultats significatius en quant a supervivència i ganància funcional del grup. La supervivència del TP en malalts amb MPID és comparable als registres internacionals. Un de cada 6 malalts torna a treballar i la realització d’un TUP o un TBP no suposa més ganància funcional.

Caratterizzazione di epid a silicio amorfo per controlli dosimetrici su fasci di fotoni ad alta energia.

Il presente lavoro è stato svolto presso la struttura di Radioterapia del Policlinico S. Orsola - Malpighi e consiste nella caratterizzazione di un sistema di acquisizione per immagini portali (EPID) come dosimetro relativo bidimensionale da usare nei controlli di qualità sui LINAC. L’oggetto di studio è il sistema di acquisizione di immagini portali OPTIVUE 1000ST (Siemens), dispositivo flat panel di silicio amorfo (a-Si) assemblato all’acceleratore lineare Siemens Oncor. La risposta dell’EPID è stata analizzata variando i parametri di consegna della dose, mantenendo fissa la distanza fuoco-rivelatore. Le condizioni di stabilità, ottimali per lavorare, si hanno intorno alle 50 U.M. Dalle curve dei livelli di grigio ottenute risulta evidente che in diverse condizioni d’irraggiamento il sistema risponde con curve di Dose-Risposta differenti, pur restando nello stesso range di dose. Lo studio include verifiche sperimentali effettuate con l’OPTIVUE e usate per espletare alcuni controlli di qualità di tipo geometrico come la coincidenza campo luminoso – campo radiante e la verifica del corretto posizionamento delle lamelle del collimatore multilamellare. Le immagini portali acquisite verranno poi confrontate con quelle ottenute irraggiando tradizionalmente una CR (computed radiography), per la coincidenza e una pellicola radiocromica EBT 3, per l’MLC. I risultati ottenuti mostrano che, per il primo controllo, in entrambi i modi, si è avuta corrispondenza tra campo radiante e campo luminoso; il confronto fra le due metodiche di misura risulta consistente entro i valori di deviazioni standard calcolati, l’OPTIVUE può essere utilizzato efficacemente in tale controllo di qualità. Nel secondo controllo abbiamo ottenuto differenze negli errori di posizionamento delle lamelle individuati dai due sistemi di verifica dell’ordine di grandezza dei limiti di risoluzione spaziale. L’OPTIVUE è in grado di riconoscere errori di posizionamento preesistenti con un’incertezza che ha come limite la dimensione del pixel. Il sistema EPID, quindi, è efficace, affidabile, economico e rapido.

Introduction of a novel dose saving acquisition mode for the PortalVision aS500 EPID to facilitate on-line patient setup verification

In external beam radiotherapy, electronic portal imaging becomes more and more an indispensable tool for the verification of the patient setup. For the safe clinical introduction of high dose conformal radiotherapy like intensity modulated radiation therapy, on-line patient setup verification is a prerequisite to ensure that the planned dosimetric coverage of the tumor volume is actually realized in the patient. Since the direction of setup fields often deviates from the direction of the treatment beams, extra dose is delivered to the patient during the acquisition of these portal images which may reach clinical relevance. The aim of this work was to develop a new acquisition mode for the PortalVision aS500 electronic portal imaging device from Varian Medical Systems that allows one to take portal images with reduced dose while keeping good image quality. The new acquisition mode, called RadMode, selectively enables and disables beam pulses during image acquisition allowing one to stop wasting valuable dose during the initial acquisition of "reset frames." Images of excellent quality can be taken with 1 MU only. This low dose per image facilitates daily setup verification with considerably reduced extra dose.

Dosimetric properties of an amorphous silicon EPID for verification of modulated electron radiotherapy

Purpose: To investigate the dosimetric properties of an electronic portal imaging device (EPID) for electron beam detection and to evaluate its potential for quality assurance (QA) of modulated electron radiotherapy (MERT). Methods: A commercially available EPID was used to detect electron beams shaped by a photon multileaf collimator (MLC) at a source-surface distance of 70 cm. The fundamental dosimetric properties such as reproducibility, dose linearity, field size response, energy response, and saturation were investigated for electron beams. A new method to acquire the flood-field for the EPID calibration was tested. For validation purpose, profiles of open fields and various MLC fields (square and irregular) were measured with a diode in water and compared to the EPID measurements. Finally, in order to use the EPID for QA of MERT delivery, a method was developed to reconstruct EPID two-dimensional (2D) dose distributions in a water-equivalent depth of 1.5 cm. Comparisons were performed with film measurement for static and dynamic monoenergy fields as well as for multienergy fields composed by several segments of different electron energies. Results: The advantageous EPID dosimetric properties already known for photons as reproducibility, linearity with dose, and dose rate were found to be identical for electron detection. The flood-field calibration method was proven to be effective and the EPID was capable to accurately reproduce the dose measured in water at 1.0 cm depth for 6 MeV, 1.3 cm for 9 MeV, and 1.5 cm for 12, 15, and 18 MeV. The deviations between the output factors measured with EPID and in water at these depths were within ±1.2% for all the energies with a mean deviation of 0.1%. The average gamma pass rate (criteria: 1.5%, 1.5 mm) for profile comparison between EPID and measurements in water was better than 99% for all the energies considered in this study. When comparing the reconstructed EPID 2D dose distributions at 1.5 cm depth to film measurements, the gamma pass rate (criteria: 2%, 2 mm) was better than 97% for all the tested cases. Conclusions: This study demonstrates the high potential of the EPID for electron dosimetry, and in particular, confirms the possibility to use it as an efficient verification tool for MERT delivery.

Verification of intensity modulated stereotactic radiotherapy using Monte Carlo calculations and EPID dosimetry

The purpose of this work was to develop a comprehensive IMSRT QA procedure that examined, using EPID dosimetry and Monte Carlo (MC) calculations, each step in the treatment planning and delivery process. These steps included verification of the field shaping, treatment planning system (RTPS) dose calculations, and patient dose delivery. Verification of each step in the treatment process is assumed to result in correct dose delivery to the patient. ^ The accelerator MC model was verified against commissioning data for field sizes from 0.8 × 0.8 cm 2 to 10 × 10 cm 2. Depth doses were within 2% local percent difference (LPD) in low gradient regions and 1 mm distance to agreement (DTA) in high gradient regions. Lateral profiles were within 2% LPD in low gradient regions and 1 mm DTA in high gradient regions. Calculated output factors were within 1% of measurement for field sizes ≥1 × 1 cm2. ^ The measured and calculated pretreatment EPID dose patterns were compared using criteria of 5% LPD, 1 mm DTA, or 2% of central axis pixel value with ≥95% of compared points required to pass for successful verification. Pretreatment field verification resulted in 97% percent of the points passing. ^ The RTPS and Monte Carlo phantom dose calculations were compared using 5% LPD, 2 mm DTA, or 2% of the maximum dose with ≥95% of compared points required passing for successful verification. RTPS calculation verification resulted in 97% percent of the points passing. ^ The measured and calculated EPID exit dose patterns were compared using criteria of 5% LPD, 1 mm DTA, or 2% of central axis pixel value with ≥95% of compared points required to pass for successful verification. Exit dose verification resulted in 97% percent of the points passing. ^ Each of the processes above verified an individual step in the treatment planning and delivery process. The combination of these verification steps ensures accurate treatment delivery to the patient. This work shows that Monte Carlo calculations and EPID dosimetry can be used to quantitatively verify IMSRT treatments resulting in improved patient care and, potentially, improved clinical outcome. ^

Desvios de posicionamento: uma condicionante da precisão em radioterapia

Barreiras para a precisão em radioterapia: delimitação de volumes, erros de posicionamento, movimento dos órgãos. Revolução imagiológica na monitorização do tratamento: radiografia, EPID, CONE-BEAM CT. Objectivo do estudo: quantificar desvios de posicionamento em doentes com patologias de cabeça e pescoço e próstata nos tratamentos de Radioterapia.

Desvio de posicionamento em radioterapia para patologias de cabeça e pescoço e próstata: revisão de literatura

Introdução – Numa era em que os tratamentos de Radioterapia Externa (RTE) exigem cada vez mais precisão, a utilização de imagem médica permitirá medir, quantificar e avaliar o impacto do erro provocado pela execução do tratamento ou pelos movimentos dos órgãos. Objetivo – Analisar os dados existentes na literatura acerca de desvios de posicionamento (DP) em patologias de cabeça e pescoço (CP) e próstata, medidos com Cone Beam Computed Tomography (CBCT) ou Electronic Portal Image Device (EPID). Metodologia – Para esta revisão da literatura foram pesquisados artigos recorrendo às bases de dados MEDLINE/PubMed e b-on. Foram incluídos artigos que reportassem DP em patologias CP e próstata medidos através de CBCT e EPID. Seguidamente foram aplicados critérios de validação, que permitiram a seleção dos estudos. Resultados – Após a análise de 35 artigos foram incluídos 13 estudos e validados 9 estudos. Para tumores CP, a média (μ) dos DP encontra-se entre 0,0 e 1,2mm, com um desvio padrão (σ) máximo de 1,3mm. Para patologias de próstata observa-se μDP compreendido entre 0,0 e 7,1mm, com σ máximo de 7,5mm. Discussão/Conclusão – Os DP em patologias CP são atribuídos, maioritariamente, aos efeitos secundários da RTE, como mucosite e dor, que afetam a deglutição e conduzem ao emagrecimento, contribuindo para a instabilidade da posição do doente durante o tratamento, aumentando as incertezas de posicionamento. Os movimentos da próstata devem-se principalmente às variações de preenchimento vesical, retal e gás intestinal. O desconhecimento dos DP afeta negativamente a precisão da RTE. É importante detetá-los e quantificá-los para calcular margens adequadas e a magnitude dos erros, aumentando a precisão da administração de RTE, incluindo o aumento da segurança do doente. - ABSTRACT - Background and Purpose – In an era where precision is an increasing necessity in external radiotherapy (RT), modern medical imaging techniques provide means for measuring, quantifying and evaluating the impact of treatment execution and movement error. The aim of this paper is to review the current literature on the quantification of setup deviations (SD) in patients with head and neck (H&N) or prostate tumors, using Cone Beam Computed Tomography (CBCT) or Electronic Portal Image Device (EPID). Methods – According to the study protocol, MEDLINE/PubMed and b-on databases were searched for trials, which were analyzed using selection criteria based on the quality of the articles. Results – After assessment of 35 papers, 13 studies were included in this analysis and nine were authenticated (6 for prostate and 3 for H&N tumors). The SD in the treatment of H&N cancer patients is in the interval of 0.1 to 1.2mm, whereas in prostate cancer this interval is 0.0 to 7.1mm. Discussion – The reproducibility of patient positioning is the biggest barrier for higher precision in RT, which is affected by geometrical uncertainty, positioning errors and inter or intra-fraction organ movement. There are random and systematic errors associated to patient positioning, introduced since the treatment planning phase or through physiological organ movement. Conclusion – The H&N SD are mostly assigned to the Radiotherapy adverse effects, like mucositis and pain, which affect swallowing and decrease secretions, contributing for the instability of patient positioning during RT treatment and increasing positioning uncertainties. Prostate motion is mainly related to the variation in bladder and rectal filling. Ignoring SD affects negatively the accuracy of RT. Therefore, detection and quantification of SD is crucial in order to calculate appropriate margins, the magnitude of error and to improve accuracy in RTE and patient safety.

Anatomia foliar de pedra-hume-caá (Myrcia sphaerocarpa, Myrcia guianensis, Eugenia punicifolia - Myrtaceae)

As folhas de Myrcia multiflora (Lam.) DC, Myrcia guianensis (Aubl.) Urb. e Eugenia punicifolia (H. B. K.) DC. são anatômica c morfologicamentc descritas. As espécies revelaram diversos elementos histológicos universais para a família, bem como peculiares das mesmas e importantes para orientar a diagnose desses vegetais e para o reconhecimento de fraudes, que ocorrem através de substituições intencionais ou não. Entre os elementos histológicos característicos, destacam-se: ornamentações de cutícula foliar, tipos de estômatos, tipos de contornos celulares das células epidérmicas em vista facial, tipo e abundância relativa de inclusões celulares inorgânicas.

Supervivencia y factores pronósticos en una serie de 317 pacientes con esclerodermia

La esclerosis sistèmica és una malaltia del teixit conectiu que té una gran variabilitat a la seva expressió y evolució clíniques. El càlcul de la supervivència dels malalts no ofereix resultats uniformes als diferents estudis realitzats. En aquest treball estudiem la supervivència i factors de risc associats al pronòstic a 317 pacients espanyols amb ES controlats en un únic hospital universitari. Tal i com mostra aquest estudi la supervivència a l´esclerodermia ha aumentat a la última dècada, essent la principal causa de mort a l´actualitat l´afecció pulmonar. Segons aquest treball, són factors de risc associats a una major mortalitat: l´afecció pulmonar, la forma difusa, la crisis renal esclerodèrmica i l´edat superior als 60 anys al moment del inici de la malaltia.

Enfermedad pulmonar intersticial en Esclerosis Sistémica: diferencia en la presentación clínica y evolución clínica y evolución entre pacientes con anticuerpos Scl-70 frente PM-Scl

La esclerosis sistémica (ES) es una enfermedad autoinmune multisistémica que afecta de forma variable a diferentes órganos. En el pulmón produce la enfermedad pulmonar intersticial difusa (EPID), cuyo pronóstico difiere según el autoanticuerpo asociado. Se estudiaron las características clínicas y espirométricas de 63 pacientes diagnosticados de ES y EPID, con positividad para anti-Scl-70 o anti-PM-Scl. En el grupo anti-Scl-70 se documentó mayor prevalencia de úlceras digitales y afección gastrointestinal, con mayor pérdida de capacidad vital forzada (CVF) al final del seguimiento y mayor proporción de patrón restrictivo grave. El grupo anti-PM-Scl presentó mayor miopatía inflamatoria y mejor evolución espirométrica.

Análisis in vivo de la vasculopatía arterial pulmonar mediante ultrasonido intravascular (IVUS) en pacientes con insuficiencia respiratoria crónica evaluados para trasplante pulmonar

El objetivo del estudio es evaluar el remodelado estructural y funcional de las arterias pulmonares asociado a insuficiencia respiratoria crónica severa, mediante ecografía intravascular (IVUS). Se incluyeron 80 pacientes en estudio pretrasplante pulmonar a los que se les realizó cateterismo cardiaco derecho e IVUS de una arteria pulmonar de mediano calibre. A través del IVUS se determinó el módulo elástico, pulsatilidad y porcentaje de fibrosis arterial. La insuficiencia respiratoria crónica se asoció a una vasculopatía arterial pulmonar severa, independientemente de la presencia de hipertensión pulmonar. Los pacientes con EPOC (enfermedad pulmonar obstructiva crónica) presentaban un mayor grado de fibrosis arterial, mientras que los pacientes con EPID (enfermedad pulmonar intersticial difusa) presentaban mayor rigidez arterial.

GENIUS, ??plagio o creatividad? : aportes para una discusi??n sobre las pr??cticas pedag??gicas

El t??tulo aparece en espa??ol y, a continuaci??n, el t??tulo traducido al ingl??s: ???GENIUS, Plagiarism or Creativity? A Contribution toward a Discussion about Teaching Practices'

Daily organ tracking in intensity-modulated radiotherapy of prostate cancer using an electronic portal imaging device with a dose saving acquisition mode

BACKGROUND AND PURPOSE: Daily use of conventional electronic portal imaging devices (EPID) for organ tracking is limited due to the relatively high dose required for high quality image acquisition. We studied the use of a novel dose saving acquisition mode (RadMode) allowing to take images with one monitor unit per image in prostate cancer patients undergoing intensity-modulated radiotherapy (IMRT) and tracking of implanted fiducial gold markers. PATIENTS AND METHODS: Twenty five patients underwent implantation of three fiducial gold markers prior to the planning CT. Before each treatment of a course of 37 fractions, orthogonal localization images from the antero-posterior and from the lateral direction were acquired. Portal images of both the setup procedure and the five IMRT treatment beams were analyzed. RESULTS: On average, four localization images were needed for a correct patient setup, resulting in four monitor units extra dose per fraction. The mean extra dose delivered to the patient was thereby increased by 1.2%. The procedure was precise enough to reduce the mean displacements prior to treatment to < o =0.3 mm. CONCLUSIONS: The use of a new dose saving acquisition mode enables to perform daily EPID-based prostate tracking with a cumulative extra dose of below 1 Gy. This concept is efficiently used in IMRT-treated patients, where separation of setup beams from treatment beams is mandatory.

Theoretical considerations to the verification of dynamic multileaf collimated fields with a SLIC-type portal image detector

The verification possibilities of dynamically collimated treatment beams with a scanning liquid ionization chamber electronic portal image device (SLIC-EPID) are investigated. The ion concentration in the liquid of a SLIC-EPID and therefore the read-out signal is determined by two parameters of a differential equation describing the creation and recombination of the ions. Due to the form of this equation, the portal image detector describes a nonlinear dynamic system with memory. In this work, the parameters of the differential equation were experimentally determined for the particular chamber in use and for an incident open 6 MV photon beam. The mathematical description of the ion concentration was then used to predict portal images of intensity-modulated photon beams produced by a dynamic delivery technique, the sliding window approach. Due to the nature of the differential equation, a mathematical condition for 'reliable leaf motion verification' in the sliding window technique can be formulated. It is shown that the time constants for both formation and decay of the equilibrium concentration in the chamber is in the order of seconds. In order to guarantee reliable leaf motion verification, these time constants impose a constraint on the rapidity of the image-read out for a given maximum leaf speed. For a leaf speed of 2 cm s(-1), a minimum image acquisition frequency of about 2 Hz is required. Current SLIC-EPID systems are usually too slow since they need about a second to acquire a portal image. However, if the condition is fulfilled, the memory property of the system can be used to reconstruct the leaf motion. It is shown that a simple edge detecting algorithm can be employed to determine the leaf positions. The method is also very robust against image noise.

Calibration of a portal imaging device for high-precision dosimetry: a Monte Carlo study

Today electronic portal imaging devices (EPID's) are used primarily to verify patient positioning. They have, however, also the potential as 2D-dosimeters and could be used as such for transit dosimetry or dose reconstruction. It has been proven that such devices, especially liquid filled ionization chambers, have a stable dose response relationship which can be described in terms of the physical properties of the EPID and the pulsed linac radiation. For absolute dosimetry however, an accurate method of calibration to an absolute dose is needed. In this work, we concentrate on calibration against dose in a homogeneous water phantom. Using a Monte Carlo model of the detector we calculated dose spread kernels in units of absolute dose per incident energy fluence and compared them to calculated dose spread kernels in water at different depths. The energy of the incident pencil beams varied between 0.5 and 18 MeV. At the depth of dose maximum in water for a 6 MV beam (1.5 cm) and for a 18 MV beam (3.0 cm) we observed large absolute differences between water and detector dose above an incident energy of 4 MeV but only small relative differences in the most frequent energy range of the beam energy spectra. It is shown that for a 6 MV beam the absolute reference dose measured at 1.5 cm water depth differs from the absolute detector dose by 3.8%. At depth 1.2 cm in water, however, the relative dose differences are almost constant between 2 and 6 MeV. The effects of changes in the energy spectrum of the beam on the dose responses in water and in the detector are also investigated. We show that differences larger than 2% can occur for different beam qualities of the incident photon beam behind water slabs of different thicknesses. It is therefore concluded that for high-precision dosimetry such effects have to be taken into account. Nevertheless, the precise information about the dose response of the detector provided in this Monte Carlo study forms the basis of extracting directly the basic radiometric quantities photon fluence and photon energy fluence from the detector's signal using a deconvolution algorithm. The results are therefore promising for future application in absolute transit dosimetry and absolute dose reconstruction.