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Computed Tomography for

Oncology Care

Page 4

CASE 14:

Clinical Studies of CT with PET

Page 6

CASE 56:

Clinical Studies of CT with

Angiographic Interventions

Page 18

CASE 7:

Clinical Study of CT-guided

Radiation Therapy

Page 22

CASE 8:

Clinical Study of CT

in Therapy Planning

Page 24

Virtual Simulation

Page 26

Contents

SOMATOMSESSIONS

Is sue no.11


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SOMATOM SESSIONS 11

This is the eleventh issue of Siemens SOMATOM Sessions.

We feature CT in oncology care, namely clinical applications

in combination with the other modalities such as Angio-

graphy, Radiation Therapy (RT) and Positron Emission

Tomography (PET).

This issue also presents you with clinical case studies for

each application.

To order copies of the past issue or submit your registration

for receiving future issues, please visit our Web site at:

http://www.siemensmedical.com/somatomsessions

As always, we appreciate your suggestions and comments.

Xiaoyan Chen, M.D., MBA Roselle Anderson

Editor of SOMATOM Sessions Guest editor of this issue

The information in this document contains general descriptions of the tech-

nical options available, which do not always have to be present in individual

cases. The required features should therefore be specified in each individual

case at the time of closing the contract.

The information presented in the case report is for illustration only and is not

intended to be relied upon by the reader for instruction as to the practice of

medicine. Any health care practitioner reading this information is reminded

that they must use their own learning,training and expertise in dealing with

their individual patients.This material does not substitute for that duty and is

not intended by Siemens Medical Solutions Inc., to be used for any purpose

in that regard.

The drugs and doses mentioned herein were specified to the best of our

knowledge.We assume no responsibility whatsoever for the correctness of

this information.Variations may prove necessary for individual patients.

The treating physician bears the sole responsibility for all of the parameters

selected.

From the Editor


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Computed Tomography for Oncology Care Page 4

CASE 1:

Diagnosis of Gastrointestinal

Stromal Tumor with Multiple Metastases Page 6

CASE 2:

Diagnosis of Non-Small Cell Lung Cancer

with Multiple Metastases Page 10

CASE 3:

Therapy Monitoring in the Treatment

of Hepatic Metastasis with Radiofrequency

Ablation Page 14

CASE 4:

Diagnosis of Recurrent

Non-Hodgkins Lymphoma Page 16

CASE 5:

Diagnosis of Hepatocellular

Carcinoma Page 18

CASE 6:

Diagnosis and Interventions of

Bladder Cancer Page 20

CASE 7:

Image Guided Radiation Therapy of Prostate

Cancer Using a Novel Combination of

CT and Linear Accelerator, the PRIMATOM Page 22

CASE 8:

CT imaging in Radiation Therapy Page 24

Virtual Simulation Page 26

Contents


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4

SOMATOM SESSIONS 11

SINCE THE EARLY DAYS of Computed Tomography dat-

ing back to the early 1970s medical engineering has been

pushing the limits of this technology. Today, we boast

shorter scan times than ever before; increased detail reso-

lution; sophisticated image post-processing capabilities;

greater ease of use with the common syngo user interface;

and efficient networking solutions.

Routinely, much of the focus of clinical work with CT has

been for the visualization and staging of malignancy. In

fact, it is estimated today that over 50% of all examinations

are performed to help the physician either confirm the

presence or absence of lesions like tumors. Other applica-

tions such as low-dose CT exams for the early visualization

of pulmonary nodules and CT-guided interventions are also

performed clinically. The merging of CT and PET technolo-

gies brings oncology imaging to unprecedented levels,

helping to reduce the PET examination times and providing

functional images with morphological landmarks. And as

advanced techniques such as Intensity Modulated Radia-

tion Therapy (IMRT) become more widespread in the ther-

apy arena, CT is gaining presence as the modality of choicefor simulation of radiation treatments. In the following

brief overview, we would like to introduce you to some of

the clinical applications of CT as a crucial modality in the

continuum of oncology care.

biograph CT + PET

The biograph system combines two technologies Com-

puted Tomography and Positron Emission Tomography

(PET) [Fig. 1]. It provides both anatomical and functional

information by image acquisition and fusion from both

modalities. Please refer to cases 14 for clinical examples.

Computed Tomography for Oncology Care

[ 1 ] biograph system


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5

Miyabi CT + Angiography

The Miyabi system combines two modalities a CT scanner

with sliding gantry and an Angiography system

[Fig. 2]. It can be used to aid the physician in the visualiza-

tion of lesions like tumors and also for performing safe and

effective interventional treatments. Please refer to cases

5 & 6 for clinical examples.

PRIMATOM CT +PRIMUS Linear Accelerator

The PRIMATOM system combines two modalities a CT

scanner with Sliding Gantry and a Radiation Therapy

delivery system [Fig. 3]. It is used for accurate verification

of tumor location prior to treatment delivery, as well as for

precise simulation on the therapy table. Please refer to case

7 for a clinical example.

In the pages that follow, we offer a glimpse of how

Siemens SOMATOM CT scanners are being used in

diverse applications and configurations in the oncology

arena today. We invite you to join us for an interesting

read.

[ 2 ] MIYABI system [ 3 ] PRIMATOM system


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6

SOMATOM SESSIONS 11

PATIENT HISTORY

A 48-year-old male patient had been diagnosed with

hepatic metastases of an unknown primary tumor. Biopsy

of the hepatic lesions revealed metastases from a gastro-

intestinal stromal tumor. CT imaging of the abdomen as

well as endoscopy of the stomach and the colon had not

been able to define the primary lesion. A dual-modality

PET-CT examination was scheduled for further evaluation.

DIAGNOSIS

Examinations with a combined PET/ CT scanner, the bio-

graph, revealed a hypodense 2.5x2.5 cm lesion at the

lesser curvature of the stomach [Fig.1] with pathologically

increased tracer uptake (SUV 9.1). Adjacent to the gastric

lesion a pathologically enlarged lymph node (1.5 cm on CT)

was found to present with increased FDG utilization. Fur-

thermore, multiple hepatic metastases with pathologically

increased glucose metabolism (SUV 9.9) were verified

[Fig. 1 and 2]. On thoracic imaging bilateral pulmonarylesions of up to 0.7 cm in size were found, but no increased

tracer uptake was demonstrated [Fig. 3].

Diagnosis: Gastrointestinal stromal tumor of the stomachs

lesser curvature with local lymph node metastasis as well

as multiple hepatic and pulmonary metastases.

EXAMINATION PROTOCOLS

Case1: Diagnosis of Gastrointestinal Stromal Tumorwith Multiple Metastases

CT examination

Scanned body regions Thorax, abdomen, pelvis

Arm positioning Raised above head

mAs 140

kV 120

Slice width 5 mm

Table feed/rotation 8 mm

Pitch 1.6

Rotation time 800 msIncrement 2.5 mm

Scanning direction Craniocaudal

Oral contrast material 1000 ml barium(1.5 g/ 100 ml)

i.v. contrast material 1.80 ml at 3 ml/s

2.60 ml at 2 ml/ s

PET examination

Tracer 350 MBq FDG

Scanned body regions Thorax, abdomen, pelvis

Arm positioning Raised above headNumber of bed positions 5

Scan time/bed position 5 minutes

Reconstruction algorithms Iterative (FORE and AWOSEM),

2 iterations and 8 subsets;

Data filtered (FWHM 3.2 mm)Data scatter corrected

Reconstructed slice width 5 mm

Scanning direction Caudocranial


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[ 1 ] Axial images of the primary tumor (arrow) at the

lesser curvature of the stomach on CT (A), fused PET/ CT

(B), and PET images (C) with adjacent lymph node

metastasis and hepatic metastases.

7

A B

C


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8

SOMATOM SESSIONS 11

[ 2 ] Coronal view of CT (A), fused PET/CT (B), and PET

images (C) of the primary tumor and hepatic metastases.Evaluation of the PET images alone may have led to

misinterpretation of the primary tumor as just another

hepatic metastasis.

A B

C


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9

CASE 1: Clinical studies of CT with PET

COMMENTS

Dual-modality PET/CT was able to define a lesion at the

lesser curvature of the stomach as the primary tumor.

The diagnosis was verified on biopsy. Initially, the tumor of

the lesser curvature had not been visualized by CT orendoscopy. CT was negative because the hypodense lesion

may have been mistaken for parts of a bowel loop.

Endoscopy was negative because the tumor originated

from the outer parts of the gastric wall and was there-

fore not visible from inside the stomach. Compared to CT

alone, PET/ CT was able to define the primary tumor. Com-

pared to PET alone, the area of focal tracer uptake in the

epigastrium could accurately be attributed to a lesion at

the stomachs lesser curvature and an adjacent lymph

node. On plain PET imaging the primary tumor with the

adjacent lymph node metastasis would, probably, have

been mistaken for just another hepatic metastasis [see

Fig. 2]. Considering the pulmonary lesions another benefit

of combined PET/ CT over PET imaging becomes obvious.Small pulmonary lesions may not demonstrate tracer

uptake as PET images are acquired in shallow breathing

which leads to smearing in visualization of FDG uptake.

The integration of CT accurately demonstrated pulmonary

metastases and, therefore, increased diagnostic yield over

PET alone.

[ 3 ] Pulmonary metastasis without signs of FDG uptake.

PET image (C) was acquired in shallow breathing.(A) shows axial view of CT image and (B) shows fused

PET/CT image.

A B

C


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10

SOMATOM SESSIONS 11

PATIENT HISTORY

45-year-old male patient with histologically proven non-

small cell lung cancer (NSCLC) in the apex of the left upper

pulmonary lobe. CT imaging of the thorax had revealed

mediastinal lesions suspected of lymph node metastases

as well as pulmonary lesions of up to 2.5 cm in diameter in

the right lung. PET/ CT imaging was carried out for tumor

staging.

EXPLANATION FORSPLIT PROTOCOL

To improve image quality by minimizing artefacts from the

arms in the field of view, combined PET/ CT was acquired in

two steps in this patient. First a PET/ CT of the thorax, ab-

domen and pelvis was carried out followed by another PET/

CT covering the head and neck. Between examinations the

patients arms were repositioned to be outside the field of

view.

DIAGNOSIS

The primary tumor in the left apex of the lung was clearly

visible on FDG-PET/CT as a region of inhomogeneous

contrast enhancement on CT with pathologically increased

tracer uptake on PET [SUV 8.0; Fig. 1]. In addition focal FDG

uptake could be demonstrated in mediastinal lymph nodes

[Fig. 2] as well as in the pulmonary lesions on the right side

[Fig. 3]. An area of focal tracer uptake was, furthermore,

demonstrated in projection on the pelvis. This hot spot

could be accurately attributed to the right pubic bone. Thecorresponding CT images revealed only mild sclerosis of

the bone without typical signs of osseous destruction

[Fig.4]. Diagnosis: NSCLC of the left pulmonary apex with

mediastinal lymph node metastases, pulmonary metas-

tases and a right pubic bone metastasis.

Case 2: Diagnosis of Non-Small Cell Lung Cancerwith Multiple Metastases


CT examination

Scanned body regions Head, neck, thorax,

abdomen, pelvis

Arm positioning Split protocol:

1. Beside trunk for head

and neck2. Raised above head for thorax

to pelvis

mAs 140

kV 120Slice width 5 mm


Pitch 1.6

Rotation time 800 ms

Increment 2,5 mm


Oral contrast material 1000 ml barium

(1,5 g/100 ml)

i.v. contrast material Head /neck: 70 ml at 2 ml /s

Thorax pelvis: 50 ml at

3 ml/s; 50 ml at 2 ml/s

PET examination

Tracer 350 MBq FDG


abdomen, pelvis

Arm positioning Split protocol:1. Beside trunk for head

and neck

2. Raised above head for thorax

to pelvis

Number of bed positions 7


Reconstruction algorithms Iterative (FORE and AWOSEM)

2 iterations and 8 subsetsData filtered (FWHM 3.2 mm);

Data scatter corrected


Scanning direction Caudocranial in both

examinations


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[ 1] Partially necrotic non-small cell lung cancer

of the left pulmonary apex as demonstrated on CT (A),

fused (B), and PET (C) images.

[ 2 ] CT (A), PET/CT (B), and PET (C) images of an

infracarinal lymph node metastasis from NSCLC.

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A

B

C

A

B

C


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[ 3 ] Right pulmonary metastasis from NSCLC.

Only mild FDG uptake is mainly attributed to smearing

due to respiratory motion.

Also note a mediastinal lymph node metastasis.

[ 4 ] Bone metastasis in the right pubic bone.

CT (A) demonstrated only mild sclerosis while PET (C)

shows pathologically increased focal tracer uptake.

On fused images focal tracer uptake can be accurately

attributed to the lesion in question.

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SOMATOM SESSIONS 11

A

B

C

A

B

C


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COMMENTS

Dual-modality PET/CT is a useful tool for tumor staging.

The application of a whole-body protocol (head to upper

thigh) is required to ensure visualization of distant meta-

stases. In this case, the bone metastasis would have beenmissed if scanning had been limited to the thorax. The ben-

efit of the combined approach over CT alone is demon-

strated by the visualization of the bone metastasis which is

characterized by only mild sclerosis on conventional CT

imaging. The acquisition of a fully diagnostic CT compo-

nent is, however, of importance, as there are tumors that

do not show increased glucose metabolism, or metastases

from a tumor may express FDG-uptake characteristics dif-

ferent from the primary lesion. A fully diagnostic, contrast-

enhanced CT can be of great value in these cases.

[ 5 ] biograph system

13

CASE 2: Diagnosis of Non-Small Cell Lung Cancer with Multiple Metastases


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SOMATOM SESSIONS 11

PATIENT HISTORY

66-year-old male patient with recurrent hepatic metastasis

from colorectal carcinoma in segment 4 of the liver.

The patient had undergone resection of the rectum and

resection of a solitary hepatic metastasis in segment

4 one year prior. Radiofrequency ablation was carried out

for treatment of metastatic recurrence. A combined

PET/CT examination was scheduled before and after

radiofrequency ablation to determine the therapeutic

effectiveness.

DIAGNOSIS AND FOLLOW-UP

Dual-modality PET/CT imaging revealed an ill-defined

hypodense lesion in the area of prior resection in segment

4 of the liver [Fig. 1A]. Fused images demonstrated patho-

logically increased tracer uptake of the lesion as a sign of

metastatic recurrence [Fig. 1B and C]. Radiofrequency

ablation was carried out featuring an ablative device with

3 cm distal tip exposure (Cool-Tip, Radionics, Burlington,MA, USA) over a time period of 20 minutes. No compli-

cations occurred. In the 4 weeks following radiofrequency

treatment the patient had another PET/ CT scan to deter-

mine the effectiveness of the RF-ablation procedure. Figure

2A demonstrates the thermo-induced hepatic necrosis on

plain CT imaging. Fused images showed a small area of

decreased glucose metabolism in the necrotic region

[Fig. 2B and C]. There is no increased FDG uptake visible in

the periphery of the necrotic lesion. Complete necrosis of

the metastasis was demonstrated by PET/ CT.

COMMENTS

Follow-up examinations to evaluate the effectiveness of

tumor therapy are frequently compromised by the inability

to differentiate viable tumor areas from therapy-induced

necrosis on CT imaging. As demonstrated in this case, com-

bined PET/ CT can accurately evaluate metabolism in liver

tissue adjacent to the necrotic area to exclude residual or

recurrent viable tumor.

Case 3: Therapy Monitoring in the Treatmentof Hepatic Metastasis with Radiofrequency Ablation


CT examination

Scanned body regions Liver


mAs 140

kV 120

Slice width 5 mm


Pitch 1.6

Rotation time 800 msIncrement 2.5 mm


Oral contrast material none

i.v. contrast material 100 ml at 3 ml/ sDelay 70 seconds

PET examination

Tracer 350 MBq FDG

Scanned body regions Liver




Reconstruction algorithms Iterative (FORE and

AWOSEM); 2 iterations and

8 subsets; Data filtered

(FWHM 3.2 mm)Data scatter corrected


Scanning direction Caudocranial


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[ 1 ] CT (A), fused PET/CT (B), and PET (C) images of

recurrent hepatic metastasis from colorectal carcinoma

one year after resection. Images prior to radiofrequency

ablation.

[ 2 ] Successful treatment of recurrent hepatic metastasis

by radiofrequency ablation.

PET/ CT demonstrated tumor-free margins of the

ablated area 4 weeks post-intervention.

15

A

B

C

A

B

C


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SOMATOM SESSIONS 11

PATIENT HISTORY

51-year-old male patient who had undergone multiple

cycles of chemotherapy for non-Hodgkins lymphoma with

mediastinal, pulmonary, and cerebral involvement. A PET /

CT staging examination was carried out 6 months after ter-

mination of therapy. The patient had been disease-free

over the past 6 months.

DIAGNOSIS

Combined PET/ CT imaging revealed focal FDG (SUV 4.3)

uptake in the left axilla [Fig. 1 and 2] which could be accu-

rately co-registered with a lymph node. The lymph node

was determined to be 1.3 cm in size on CT imaging. From

PET/ CT findings recurrence of non-Hodgkins lymphoma

was diagnosed and diagnosis was verified histologically

after lymph node excision.

COMMENTSBy demonstrating focal tracer uptake within a lymph node,

combined PET/ CT improves differential diagnosis of benign

and malignant diseases. FDG-PET/ CT will play an important

role in tumor follow-up with emphasis on early diagnosis of

tumor recurrence.

Case 4: Diagnosis of RecurrentNon-Hodgkins Lymphoma


CT examination

Scanned body regions Head, neck, thorax, abdomen,

pelvis

Arm positioning Beside trunk

mAs 140

kV 120

Slice width 5 mm


Pitch 1.6Rotation time 800 ms

Increment 2.5 mm


Oral contrast material none

i.v. contrast material 1.80 ml at 3 ml/s

2.60 ml at 2 ml/ s

PET examination

Tracer 350 MBq FDG


abdomen, pelvis

Arm positioning Beside trunk



Reconstruction algorithms Iterative (FORE and

AWOSEM); 2 iterations and

8 subsets; Data filtered(FWHM 3.2 mm)

Data scatter corrected


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[ 1 ] Coronal CT (A), fused PET/ CT (B), and PET (C) images of a patient with recurrence of

non-Hodgkins lymphoma in the left axilla.

[ 2 ] Accurate co-registration of CT and PET images (B)

demonstrates FDG uptake in a lymph node suspected for

recurrence of non-Hodgkins lymphoma.

17

A B

C

A B C


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[ 1 ] Angiography performed through the common

hepatic artery.

[ 2 ] Angiography performed superselectively through the

right hepatic artery.

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SOMATOM SESSIONS 11

PATIENT HISTORY

A 65-year-old male patient had a history of chronic hepati-

tis C. Hypoechoic lesion was visualized in the right lobe of

the liver by ultrasonography. Serum PIVKA-II level was

elevated, which is well known as a tumor marker of hepa-

tocellular carcinoma (HCC). Dynamic arterial phase CT

scan showed high attenuation area in the liver (segment

eight/ tumor size: 3.5 x 3 cm).

DIAGNOSIS

Angiography was performed for preoperative examination

[Fig. 1 and 2]. In addition to hepatic angiography, the pa-

tient underwent CT during arterioportography (CTAP) and

CT during hepatic arteriography (CTA) using the Angio-CT

system MIYABI [Fig. 3]. The tumor was manifested as a

solitary perfusion defect of portal venous flow on CTAP and

no other portal perfusion defect was seen in the liver. On

CTA,the tumor was depicted as a hypervascular lesion. Par-

tial hepatic lobectomy was performed and histologicalexamination of the tumor showed moderately differenti-

ated HCC.

COMMENTS

CT during arteriography with the Angio-CT system

MIYABI provides useful information about tumor visuali-

zation and drug distribution. In this case, such information

helps to determine surgery plan. Patients with severe liver

dysfunction may not tolerate an operation or transcatheter

arterial chemoembolization (TACE) covering a wide area.To reduce damage of normal liver tissue, superselective

TACE is necessary. MIYABI enables us to identify whether

drug infusion area contains whole area of the tumor with

minimal surrounding liver tissue.

The Angio-CT system MIYABI is useful not only for diag-

nosing tumor but also for performing safe and effective

interventional treatments.

According to our experience, syngo viewer is very useful

for the comparison of images between different phases

[Fig. 3]. It is very easy to identify even very small lesions.

The stack mode is ideal for ICT image viewing.

Case 5: Diagnosis of Hepatocellular Carcinoma


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[ 4 ] Image comparison between different phases with

syngo viewer in Stack mode simultaneous image

scrolling within different segments an easy, useful andideal way of ICT image viewing.

LU: plain CT

RU: CTAP (portal venous phase, through superior

mesenteric artery)

LL: CTA (early arterial phase, through hepatic artery)

RL: CTA (later arterial phase, through hepatic artery)

19


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[ 4 ] Axial CT image revealed a tumor arising in the

bladder wall.

[ 1 ] Angio-CT system, MIYABI

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SOMATOM SESSIONS 11

PATIENT HISTORY

An 83-year-old male patient presented with hematuria.

Computed Tomography (CT) revealed a tumor arising in

the bladder wall [Fig. 4]. Left hydroureter was seen due to

tumor invasion. Transurethral partial resection of the blad-

der tumor was performed and the histopathological diag-

nosis was transitional cell carcinoma.

INTERVENTIONAL TREATMENTTranscatheter arterial chemoembolization was performed.

The contralateral internal iliac artery was catheterized with

a 4-F cobra type catheter [Fig. 2]. Using a coaxial tech-

nique, a microcatheter was introduced into bladder artery

superselectively [Fig. 3]. Then, CT images during super-

selective bladder arteriography were acquired with the

Angio-CT system MIYABI, and the tumor included in

the enhanced areas was confirmed [Fig. 5]. CDDP (50 mg/

body) was infused through this feeding artery, which was

subsequently embolized with gelatine sponge.

COMMENTS

The advantages of this treatment are its abilities to expose

tumor to a highly concentrated anticancer agent and to

avoid unexpected normal tissue damages. Because

patients with bladder cancer are generally elderly and

usually have severe arteriosclerosis, and because many

arterial variants exist around the bladder, superselective

bladder arteriography is technically difficult. In such cases,

the Angio-CT system MIYABI helps us to determine

the final position of the catheter tip for safe and effective

treatment.

Case 6: Diagnosis and Interventionsof Bladder Cancer


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[ 2 ] Contralateral internal iliac artery was catheterized

with a 4-F cobra type catheter. Image shows the feeding

artery of the tumor (arrow).

[ 3 ] Using a coaxial technique, a microcatheter was

introduced into bladder artery superselectively.

Image shows the feeding artery of the tumor (arrow).

[ 5 ] CT images acquired during superselective bladder arteriography confirmed the tumor was

included in the enhanced areas.

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[ 1 ] The PRIMATOM installation at Morristown Memorial

Hospital, Morristown, New Jersey, USA.

22

SOMATOM SESSIONS 11

The PRIMATOM system is a unique combination of a

Siemens PRIMUS linear accelerator and Siemens

SOMATOM CT* technologies. Using the PRIMATOM,

daily CT localization can be performed prior to each

radiation treatment, thus reducing significantly the

extrinsic and intrinsic uncertainties that are associated

with patient set up and organ motion, respectively. We

illustrate this principle in the radiation treatment of a

very common cancer in men, prostate cancer.

PATIENT HISTORY

A 73-year-old white male with prostate cancer was

referred to radiation therapy. The patient consented to the

use of the PRIMATOM because of the extreme precision of

the radiation beams. The imaging property of the

PRIMATOM directs the radiation beams to the target

(prostate) while sparing radiation dose to the adjacentnormal tissues.


For PRIMATOM treatment of the prostate, the patient is set

up on the treatment couch, with radio-opaque markers

placed over skin marks that delineate the central axis

planes. The treatment couch is rotated 180 degrees for PRI-

MATOM CT scanning. The patient is scanned by way of a

SOMATOM Plus 4 with Sliding Gantry, a movable CT scan-

ner on a pair of horizontal rails. The exact position of theprostate and rectum are identified and localized. These

positions are then compared to the original simulated posi-

tions. Daily variations of the prostate gland and rectum

outlines from the original contour determine the daily

movement of the prostate gland in the anterior-posterior,

left-right, and cephalic-caudal directions. Similar variations

of the rectum determine the daily anterior-posterior move-

ment of the rectum. Deriving a new isocenter and then

shifting the treatment isocenter to this new position

enable corrections of these daily movements of the

prostate and rectum. The treatment table is then rotated

180 degrees back to the treatment position. Treatment on

the PRIMUS follows this position verification.

DIAGNOSIS AND COMMENTThe PRIMATOM provides a platform for extreme precision

in the radiation treatment of cancer. Here, the prostate

is used as an example of such treatment, but the principle

applies to cancers in any parts of the body. Image Guided

Radiation Therapy using the PRIMATOM allows no misses

and thus, can lead to delivery of higher doses to the tumor

while minimizing unwanted radiation to the adjacent nor-

mal tissues. With ever better imaging technologies such as

PET/ CT or other radiological advances, the PRIMATOM

could provide a platform for even more precise radiation

treatments.

Case 7: Image Guided Radiation Therapy ofProstate Cancer Using a Novel Combination of CT andLinear Accelerator, the PRIMATOM


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[ 3 ] Variation of radiation dose to the target with respect

to set up and organ movements. In a hypothetical case,if the allowed margin of set up and organ movement is

5 mm, then a 10 mm movement of the prostate gland

would lead to insufficient dose to the prostate target (red

line). The green line assumes that there is no movement.

[ 2 ] Daily movement of the prostate over 5 consecutive

treatment days. The prostate is outlined in red, while the

rectum is outlined in green. As can be seen in the figures,

the prostate and rectum are dynamic structures that take

on different positions with respect to the bony landmarks.

Treatment Planning Day 1

Day 2 Day 3

Day 4 Day 5

* The PRIMATOM solution is available with the following models of

SOMATOM CT scanners (with Sliding Gantry option): SOMATOM Balance,

SOMATOM Emotion, SOMATOM Emotion Duo, SOMATOM Sensation 4

and refurbished SOMATOM Plus 4.

An existing PRIMUS, PRIMART or MEVATRON linear accelerator room

can be upgraded with a SOMATOM CT Sliding Gantry for the

PRIMATOM solution. Contact your Siemens therapy representative

for more information.

23

120

100

80

60

40

20

040 50 60 70 80 90 100 110

% Dose Level

% Volume

0 mm

10 mm

CTV Dose coverage for 5 mm margin of PTV with prostate

movement 10 mm relative to original field


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24

SOMATOM SESSIONS 11

PATIENT HISTORY

A 22-year-old male patient with cystic fibrosis had under-

gone bilateral lung transplantation. Although receiving

anti-rejection drug therapy, his lung function was deterio-

rating and he developed bronchiolitis obliterans

syndrome1. Chronic lung allograft rejection resulting in

sustained decline in lung function is the most common

cause of late death after lung transplantation. It was

decided to treat him with Total Nodal Irradiation (TNI) to try

to stabilise his condition2.


The patient is positioned supine and is scanned from

the level of the external auditory meatus to the level of the

greater trochanter. Landmarks are tattooed on the

patient to correlate with the scanned images. The images

from the CT scan are transferred to the planning station

(EXOMIO) and 3 separate fields are planned. These are

splenic/para aortic field, mantle field and pelvic/inguinal

field. Specific gaps are calculated between the fields to

avoid areas of overlap in underlying tissues.

Treatment consists of parallel opposed fields given

twice weekly with a mid plane dose of 0.8 Gy to a total

of 8 Gy. The blood count is monitored throughout the

treatment4.

According to our experience, the SOMATOM Emotion Duo

has the following advantages for radiotherapy planning:

3 Speed

Prior to the use of the Emotion Duo, patients for TNI

were planned on the Simulator and this imaging procedure

would take at least one hour. However, using the

SOMATOM Emotion Duo, the patient was on the CT couch

for less than 10 minutes.The scan was 862 mm in length and this was covered in

less than one minute, due to the sub-second rotation time.

This is a big advantage over single slice spiral scanning,

where such a scan would take between 2 3 minutes.

This short examination time also reduces the artefacts

produced from breathing and movement. The patient was

allowed to breathe gently throughout the scan in order to

reproduce the treatment conditions.

Multislice sub-second CT, as used in the SOMATOM

Emotion Duo, allows scanning of longer ranges without

compromise in slice thickness and therefore image

resolution. This is due to the SureView concept, wherebythe slice you select is the slice you get, independent of

pitch. This enables a longer range to be planned using an

increased feed per rotation with no compromise in the slice

thickness that is reconstructed.

Case 8: CT Imaging in Radiotherapy Planning

Scanner Emotion Duo

Scan area Head/Chest/Abdo/Pelvis

Scan length 862 mm

Scan time 58.4 s

Scan direction Craniocaudal

kV 130

Effective mAs 79 mAs (+CARE Dose)

Rotation time 0.8 s

Slice collimation 4 mm

Slice width 5 mm


Pitch 3

Reconstruction increment 5 mm

Kernel B 40 s

CTDIw 8.5 mGy

Comments

CTNI is used for transplant rejection in patients whodemonstrate severe or repetitive immunologic response

despite anti-rejection drug therapy. This could lead to fatal

loss of graft. The aim of TNI is to reduce the incidence of

recurrent rejection and decrease the amount of circling

lymphocytes3. The treatment fields include most of the

bodys lymphatic tissue. Supra diaphragmatically these are

the cervical, axillary, supraclavicular, mediastinal and pul-

monary hilar lymph node groups and the thymus gland.

Sub diaphragmatically these are the para aortic, iliac,

inguinal and femoral lymph node groups and the spleen.


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[ 2] (A) Axial head, top of the range (B) Axillary level

(C) Splenic level (D) Femoral level, bottom of range

[ 1 ] Coronal MPR

25

3 Accuracy

The use of the CT images for planning also enables the

spleen to be visualised with greater accuracy than onthe simulated radiographs, thus allowing more precise

planning of this treatment field. The ability of multislice CT

to acquire 5 mm slices throughout the volume produces

high quality digital radiographs on the planning system,

again allowing precise placement of the treatment fields.

3 Workflow

The syngo platform allows the user to automatically trans-

fer images to the planning station as they are recon-

structed, which saves valuable time in a busy department.

REFERENCES1 Tamm M. et al; Bronchiolitis Obliterans Syndrome following heart lung

transplantation Transplant International 1996; 9 Supplement 1: S. 299302.

2 Diamond D.A. et al Efficacy of total lymphoid irradiation for chronic

allograft rejection following bilateral lung tranplantation Int. Journal

Radiation Oncology-Biology-Physics 1998 July 1; 41(4): S. 795 800.

3 Wolden S. et al; Long term results of total lymphoid irradiation

in the treatment of cardiac allograft rejection Int. Journal Radiation

Oncology-Biology-Physics 1997; Vol 39 (5): S. 935 960.

4 Yang F. E. et al: Analysis of weekly complete blood counts in patients

receiving standard fractionated partial body radiation therapy Int. Journal

Radiation Oncology-Biology-Physics 1995, Oct 15; 33 (3): S. 617 620.

A C

B D


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[ 1 ] Marking of Isocenter-Coordinates for Laser System

26

SOMATOM SESSIONS 11

RADIATION TREATMENT PLANNING (RTP) has tradition-

ally been performed with the help of conventional X-ray

simulation systems, providing beam geometry thatmatches that of the linear accelerator. The radiographs

are then used by physicists or dosimetrists to establish the

margins of the area to be treated, and prescribe the radia-

tion dose.

Although this technique is still in widespread use today,

Virtual Simulation using CT or in some cases MR images

offers detail, software image manipulation and recon-

struction, and substantial increase in patient throughput

not known on conventional simulators. For example, CT

imaging offers virtual fluoroscopy and 3D Beam Design,

supporting more complex radiation treatments.

Accurate virtual simulation begins with the acquisition of

thin-slice, high-resolution images. Choose from Siemens

SOMATOM family of CT scanners, covering the spectrum of

workflow needs and techniques. Through the DICOM inter-

face, Siemens CT image sets are compatible with the treat-

ment planning systems of RTP vendors such as ADAC,

NOMOS, CMS and MEDINTEC.

Siemens syngo-based Virtual Simulation* uses Siemens

imaging expertise, advanced data processing, and the

Virtual Simulation


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syngo software platform to provide a comprehensive

oncology workflow solution. The application is designed to

accurately model all structures, radiation beams and linear

accelerator parameters and to produce high-quality Digi-tal Reconstructed Radiographs (DRRs), Multiplanar Refor-

mats (MPRs), Maximum Intensity Projections (MIPs) and

Surface Shaded Displays (SSDs). A full suite of automatic/

manual contour and edit tools enables streamlined con-

touring of image data with real-time display while inter-

active 3D capabilities enable viewing of and navigation

through the generated structures. syngo brings fast pro-

cessing, image fusion, innovative filming tools, DICOM-RT

compliance, and any easy-to-use interface common to all

Siemens medical imaging modalities.

[ 2 ] PET/ CT tumor visualization

* The information about this product is being provided for planning

purposes. The product is pending 510(k) review, and is not yet commercially

available.


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[ 4 ] Tissue definition

[ 3] Planning target definition

[ 5 ] Beam placement, Rooms-Eye-View


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THIS ISSUES AUTHORS

Computed Tomography for

Oncology Care

Virtual Simulation

Roselle Anderson

Marketing Communications

Siemens Medical Solutions USA, Inc.

Oncology Care Systems

4040 Nelson Avenue

Concord, CA 94520

USA

Case 1 4

Gerald Antoch, M.D.

Joerg F. Debatin, M.D., MBA

Department of Diagnostic and

Interventional Radiology

University Hospital Essen

Hufelandstrasse 55

45122 Essen

Germany

Andreas Bockisch, M.D., PhDDepartment of Nuclear Medicine

University Hospital Essen

Hufelandstrasse 55

45122 Essen

Germany

Case 56

Nakajima Takahito, M.D.

Keigo Endo, M.D.

Jun Aoki, M.D.

Gunma University Hospital

Shouwa Town, 3-39-15

Maebashi City

Gunma Prefecture,

371-8511, Japan

Case 7

James R. Wong1, Lisa Grimm1,

Reva Oren1, Allan Scher1,

Chester Wilson1, Ian Altas1,

Albert Fung1, Peter Schiff3,

Michal Chow1 and Minoru Uematsu2

1 Department of Radiation Oncology,

Morristown Memorial Hospital/Atlantic Health

System, NJ, USA;2

National Defense Medical College, Namiki,Tokorozawa, Japan;

3 Department of Radiation Oncology,

The New York Presbyterian Hospital, NY, USA

Case 8

Susan Dixon, Damien Parr

CT Scanning Dept.

Northern Centre for Cancer Treatment

Newcastle General Hospital

Newcastle-upon-Tyne NE4 6BE

UK

Sue Taylor

CT Applications Specialist

Siemens Medical SolutionsUK

IMPRESSUM

Published by

CT Marketing

Siemens AG

Medical Solutions

Siemensstrasse 1

91301 Forchheim, Germany

International Distribution

Xiaoyan Chen, M.D., MBA

CT Concepts

Siemens AG, Medical Solutions

Siemensstrasse 1


Phone +49-9191-18-9652

Fax +49-9191-18-9996

eMail [email protected]

Anil Gupta

CT Marketing

Siemens AG, Medical Solutions

Siemensstrasse 1


Phone +49-9191-18-8121

Fax +49-9191-18-9998


Stefan Schaller, Ph.D.

CT Concepts

Siemensstrasse 1


Phone +49-9191-18-8160

Fax +49-9191-18-9996


SOMATOM SESSIONS 11


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SOMATOM SESSIONS 11

somatom sessions 11

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