title: Re-Irradiation of Hepatocellular Carcinoma: Clinical Applicability of Deformable Image Registration.
abstract: OBJECTIVE
  This study aimed to evaluate whether the deformable image registration (DIR) method is clinically applicable to the safe delivery of re-irradiation in hepatocellular carcinoma (HCC).
  
  
  METHODS
  Between August 2010 and March 2012, 12 eligible HCC patients received re-irradiation using helical tomotherapy. The median total prescribed radiation doses at first irradiation and re-irradiation were 50 Gy (range, 36-60 Gy) and 50 Gy (range, 36-58.42 Gy), respectively. Most re-irradiation therapies (11 of 12) were administered to previously irradiated or marginal areas. Dose summation results were reproduced using DIR by rigid and deformable registration methods, and doses of organs-at-risk (OARs) were evaluated. Treatment outcomes were also assessed.
  
  
  RESULTS
  Thirty-six dose summation indices were obtained for three OARs (bowel, duodenum, and stomach doses in each patient). There was no statistical difference between the two different types of DIR methods (rigid and deformable) in terms of calculated summation ΣD (0.1 cc, 1 cc, 2 cc, and max) in each OAR. The median total mean remaining liver doses (M(RLD)) in rigid- and deformable-type registration were not statistically different for all cohorts (p=0.248), although a large difference in M(RLD) was observed when there was a significant difference in spatial liver volume change between radiation intervals. One duodenal ulcer perforation developed 20 months after re-irradiation.
  
  
  CONCLUSIONS
  Although current dose summation algorithms and uncertainties do not warrant accurate dosimetric results, OARs-based DIR dose summation can be usefully utilized in the re-irradiation of HCC. Appropriate cohort selection, watchful interpretation, and selective use of DIR methods are crucial to enhance the radio-therapeutic ratio.
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Dong Soo
authors.initials: DS
authors.lastname: Lee
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Joong Yeol
authors.initials: JY
authors.lastname: Woo
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Jun Won
authors.initials: JW
authors.lastname: Kim
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea. jsseong@yuhs.ac.
authors.forename: Jinsil
authors.initials: J
authors.lastname: Seong
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D006528:Carcinoma, Hepatocellular / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D058958:Organs at Risk / Q000528:radiation effects*; D011829:Radiation Dosage; D011874:Radiometry / Q000379:methods*; D011878:Radiotherapy / Q000379:methods; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D050397:Radiotherapy, Intensity-Modulated; D000069475:Re-Irradiation; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome
keywords: Deformable image registration; hepatocellular carcinoma; radiotherapy; re-irradiation