CN102686277A - 采用连续的躺椅旋转/移位和同时进行的锥形射束成像的调强电弧治疗 - Google Patents
采用连续的躺椅旋转/移位和同时进行的锥形射束成像的调强电弧治疗 Download PDFInfo
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Abstract
一种放射线治疗系统，该系统包括在物体周围移动并且朝向所述物体引导治疗放射线射束的放射线源、以及在所述物体周围移动并且朝向所述物体引导成像放射线射束的成像源。该系统进一步包括放置物体的工作台，该工作台能够平动和转动。该系统也包括1）第一成像器，该第一成像器用于接收由所述治疗放射线源产生的穿过所述物体的放射线，并且用于由该放射线形成第一成像信息，以及2）第二成像器，该第二成像器用于接收由所述成像源产生的穿过所述物体的放射线，并且用于由该放射线形成第二成像信息，其中所述第一成像信息和所述的第二成像信息同时形成。
Description
在35U.S.C.§119(e)下，申请人要求申请日为2010年1月5日并在上述日期提交的美国临时申请系列号61/335,314的优先权利益，该优先权文件的公开内容通过引用而整体并入本文中。
技术领域
本发明总体上涉及治疗放射线的治疗和传输的系统和方法，并且特别地涉及在治疗放射线的体积调强电弧治疗（VMAT）传输中，用于附加的连续电弧旋转/移位躺椅（C-ARC）的系统和方法，还涉及同时进行kV锥形射束成像以用于实时治疗验证和治疗适应。
背景技术
有多种已知的治疗放射线治疗和传输的系统和方法。其中之一被称为三维适形放射线治疗(3D-CRT)。3D-CRT涉及三维成像、准确的放射线剂量计算、计算机最优化治疗计划，以及计算机控制的治疗传输。特别地，3D-CRT使用计算机和专用的成像技术，例如CT、MR或PET扫描，以显示肿瘤以及周围器官的尺寸、形状和位置。然后治疗放射线射束采用多叶准直仪或定制的场成形挡铅块来精准地裁定肿瘤的尺寸和形状。精确应用治疗放射线射束造成附近的正常组织接收到更少的放射线，从而正常组织能够在治疗放射线治疗期之后更加迅速地痊愈。将更多的正常组织隔离以避免接收治疗放射线，其允许增加实际传输到肿瘤的放射线的量，因此增加了成功治疗肿瘤的机会。在Takahashi,S.所著的出版物“Conformation radiotherapy:rotation techniques as applied to radiographyand radiotherapy of cancer”（Acta Radiol 1965,Suppl.242）中描述了3D-CRT的例子。
另一个治疗放射线的治疗计划和传输的系统和方法被称为调强放射线治疗，或IMRT。IMRT是3D-CRT的特殊形式，该特殊形式允许放射线被调整，因此更加精确地成形以适配于肿瘤。特别地，IMRT涉及将治疗放射线射束分解成许多“细射束（beamlets）”。然后单独地调整每个细射束的强度。当与3D-CRT相比较时，该强度的调整使得靠近肿瘤的健康组织所接收的放射线进一步减少。在Brahme,A.等人所著的出版物“Solution of an integral equation encountered in rotation therapy”（PhysMed Biol Vol.27,No.10,1982,pp.1221-29）中描述了IMRT的例子。
治疗放射线的治疗和传输的第三个系统被称为调强电弧治疗（IMAT）以及后来的体积调强电弧治疗，也被称为VMAT。VMAT解决了IMRT的几个缺点，即，需要更大量的射束引导而增加治疗时间以及使用增加的监测器单元（MU）。通过允许连续的桶架/准直仪旋转、叶运动，以及剂量速率调整以用于治疗计划的最优化，从而使得VMAT解决了这些缺点，其中剂量是在单一桶架弧度高达到360度期间而被传输。VMAT技术与螺旋断层放疗（tomotherapy）的相似之处在于全360度范围内的射束引导可以用于进行优化，但是VMAT技术与IMRT的根本不同之处在于整个剂量体积是以单源旋转方式传输的。在1）Yu,C.X.所著的“Intensity-modulated arc therapy with dynamic multileaf collimation:analternative to tomotherapy”（Phys Med Biol Vol.40,1995,pp.1435-1449）、2）Yu,C.X.,等人所著的“Clinical implementation of intensity-modulated arctherapy”（Int J Radiat Oncol Biol Phys Vol.53,2002,pp.453-463）以及3)Otto,K.所著的“Volumetric modulated arc therapy:IMRT in a single gantryarc”（Med Phys Vol.35,2008,pp.310-317）中描述了VMAT的例子。
VMAT部分地涉及使用多叶准直仪（MLC）的叶运动以及剂量速率调整以调节射束输出强度。另外，通过旋转线性加速器的桶架和准直仪使其穿过一个或多个完整或部分的电弧（持续在其上面进行治疗放射线），VMAT传输已调整的射束强度输出，从而减少治疗时间。在桶架旋转期间，可以动态地改变大量的参数，例如：i）MLC孔隙形状，ii）注量输出速率（“剂量速率”），iii）桶架旋转速度以及iv）MLC的定向。能够改变参数i）-iv）使得VMAT减少大量电弧的使用需求，在更短时间内传输了更少的监测器单元（MU），同时提供了与IMRT相当的剂量测定。虽然VMAT能够利用上述四个有效的可变的参数的优势，但是其必须同时考虑线性加速器和MLC的物理限制——例如最大的桶架速度、最大的叶的速度、MLC的导向限制和注量输出速率的有效的细分。
在治疗传输期间，在无需动态地控制所有的机器参数，特别是机器和患者之间的定向的条件下，目前的VMAT技术受限于某些治疗位置。在治疗乳房癌的情况下，相比于改良的宽切线，已经显示出应用于治疗左侧乳房癌的VMAT（采用内部乳核放射）造成肺的体积增大，心脏和对侧乳房接收到低剂量（5Gy）的放射。通过定义，由于VMAT的配置的原因，用于乳房放射的VMAT含有朝向心脏、肺和对侧乳房引导的射束。
VMAT系统的另一个劣势在于其不与kV成像同时整合。因此，这种VMAT系统不能够实时的治疗验证。
发明内容
本发明一个方面涉及放射线治疗系统，该放射线治疗系统包括放射线源和成像源，该放射线源在物体周围移动并且朝向该物体引导治疗放射线射束，该成像源在物体周围移动并且朝向物体引导成像放射线射束。该系统进一步包括工作台，物体放置在该工作台上，该工作台能够平动和转动。该系统还包括1）第一成像器，该第一成像器用于接收由治疗放射线源产生的穿过物体的放射线，并且用于由所述放射线形成第一成像信息，和2）第二成像器，该第二成像器用于接收由成像源产生的穿过物体的放射线，并且用于由该放射线形成第二成像信息，其中第一成像信息和第二成像信息同时形成。该系统附加地包括与放射线源、工作台、第一成像器和第二成像器相通信的计算机，其中该计算机基于第一成像信息和第二成像信息，以实时方式控制手术台的运动和放射线源的以下参数中的一个或多个：放射线源运动和注量输出速率。
本发明第二个方面涉及提供放射线的方法，该方法包括：朝向物体引导治疗放射线射束并且朝向该物体引导成像放射线射束。该方法包括：将物体放置在在工作台上，该工作台能够平动和转动。该方法还包括：基于穿过物体的治疗放射线射束形成第一成像信息，并且基于穿过物体的成像放射线射束形成第二成像信息，其中第一成像信息和第二成像信息同时形成。该方法进一步包括：基于第一成像信息和第二成像信息，以实时方式同时控制工作台的移动和治疗放射线射束的以下参数中的一个或多个：治疗放射线射束运动和注量输出速率。
本发明的一个或多个方面提供了指定更少的监测器单元以及使用更少的控制点的优势。
本发明的一个或多个方面减少了毒性和次发性恶性肿瘤的风险。
附图说明
图1示出了根据本发明的放射线治疗系统的实施方式，该放射线治疗系统能够进行C-ARC治疗。
图2示出了可行过程的流程图，该可行过程的流程图用于操作根据本发明的图1的放射线治疗系统。
图3示意性地示出了用于根据本发明的kV/MV同时成像的系统。
图4A-4D分别示出了在桶架90°、135°、180°和270°的位置上，采用射束方向观视（BEV）成像的数字重建放射成像术（DRR）的参考图，其用于立体定位放射手术（SRS）的治疗；
图5A-5D分别示出了在桶架90°、135°、180°和270°的位置上，用于立体定位放射手术治疗的kV和MV射野图像；
图6A示出了用于根据本发明的乳房肿瘤治疗的可行射束布置的外部视图；
图6B-6C示出了用于已知的乳房肿瘤治疗计划的射束布置的外部视图；
图7A示出了用于图6A乳房肿瘤治疗的射束布置的内部视图；
图7B-7C分别示出了用于图6B-6C的乳房肿瘤治疗的射束布置的内部视图；
图8A示出了当与根据本发明的治疗计划相比时，各种已知治疗计划的同侧乳房体积/剂量%的曲线图；
图8B示出了当与根据本发明的治疗计划相比时，各种已知治疗计划的同侧肺体积/剂量%的曲线图；
图9A示出了用于根据本发明的乳房肿瘤治疗计划的典型轴向剂量分布；并且
图9B示出了用于VMAT治疗计划的典型轴向剂量分布。
具体实施方式
如图1所示出，此处示出了可包括成像系统（例如锥形射束计算机层析成像系统102）和治疗放射线源（例如医用线性源或医用线性加速器104）的放射线治疗系统100。计算机层析成像系统102包括x射线源106以及安装在桶架110上的平板成像器108。计算机层析成像系统102的细节在美国专利号6,842,502和7,471,765中有所描述，其全部公开内容通过引用而并入本文中。当然，可以在不脱离本发明的精神下使用其他类型的成像系统，例如C型臂支撑锥形射束系统以及质子成像系统。
将系统102改造到现有的或者新的放射线治疗系统112上，该放射线治疗系统112包括独立的放射线治疗源，例如医用线性源104，其在一定的功率级下运行从而允许治疗物体（例如人类患者）中的目标体积。医用线性源104产生x射线或者粒子（例如光子、质子或电子）的射束，所述的x射线或粒子具有的能量在4MeV至25MeV的范围内。事实上，可以在不脱离本发明精神下将医用线性源104替换为用于患者医疗的其他放射线源。放射线治疗系统112进一步包括多叶准直仪（MLC）113，该多叶准直仪113可作为一个单元移动，并且包括多个叶，这些叶是能够移动的以便限定孔隙，治疗射束穿过该孔隙而到患者身上。放射线治疗系统112还可以包括成像器（未示出），该成像器与医用线性源104对准，而患者介于成像器与医用线性源之间。
设置了计算机控制的治疗工作台114以用于支撑患者并且用于帮助治疗放射线射束的应用。工作台114被计算机控制，例如图1中示意性地示出的计算机116。工作台114允许患者在x、y和z方向上平动以及绕着在x、y和z轴旋转。此外，优选由射线透过材料建造治疗工作台114从而不会明显干扰计算机层析成像的结果。工作台114可以具有许多形式，例如在美国专利号6,842,502和7,471,765以及美国专利申请公开号US2010-0119032A1中公开的形式，其全部公开内容通过引用而并入本文中。
图1的系统100由计算机116控制，从而执行根据本发明的C-ARC治疗放射线治疗的计划。特别地，C-ARC（类似VMAT）涉及将已调整的射束孔隙与剂量速率和旋转传输相结合。与VMAT不同，C-ARC引入传输旋转的可替换形式。特别地，工作台或者躺椅114通过平动和/或转动来控制向感兴趣的区域传输的治疗放射线。注意到工作台114可以在图1中示出的x、y和z中的一个或多个方向上平动。另外，工作台114可以绕x、y和z中的一个或多个方向旋转。在工作台114旋转期间，对于特定的治疗位置（例如脑），桶架10的环118也可以同时旋转。
当工作台114正在移动的时候，MLC113的孔隙形状和定向能够发生动态变化。另外，可以改变注量输出速率（“剂量速率”）和桶架旋转速度以及随后的放射线源104的旋转速度。通过计算机116进行对工作台运动、桶架运动、注量输出速率、MLC定向和MLC的形状的控制。用于控制计算机116的软件可以类似于VMAT中使用的软件，其中C-ARC的软件使得产生临床可接受的剂量测定同时避免工作台114、桶架110和其附属物与患者之间的任何碰撞。考虑到上述的系统100，相对于图2的流程图在此描述了系统100的可行操作过程。特别地，示意性地显示了过程200，其涉及首先形成患者某区域的计算机层析成像或者其他三维计划成像，已知该患者某区域包括感兴趣的物体（例如肿瘤），以用于按照过程210进行治疗。可以现场外执行计划成像或者就地通过使用计算机层析成像系统102进行计划成像。然后，将肿瘤一般区域图像的三维信息输入到计算机116或者其他计算机中，以按照过程220计算虚拟的三维放射线治疗计划，以用于改变工作台运动、桶架运动、注量输出速率、MLC定向和MLC的形状，从而将所需的治疗剂量应用于肿瘤上同时减少健康组织的剂量。
在计算了虚拟计划之后，现在可以根据计划用放射线来治疗患者。尽管这么说，但是应该记住当肿瘤按照过程210成像时，虚拟计划假定肿瘤会位于相同的空间位置。当按照过程230将患者置于工作台114时，肿瘤的空间位置可以按照过程240进行微调，从而当按照过程210以两个方式中的一个对肿瘤成像时使得该空间位置相同。对空间位置进行微调的一个方法是使得技术员对患者进行复位直到其视觉观察到在患者身上的皮肤标记与按照过程210采集的图像处于相同位置。微调的第二个方法是使用计算机层析成像系统102采集肿瘤的三维图像并且调整患者的位置，从而在微调图像中示出的肿瘤将会被复位而与按照过程210所测定的肿瘤的位置相一致。一旦患者已经按照过程240复位，然后过程220的虚拟计划可以应用于按照过程250的肿瘤。
注意到，除了之前提到的微调方法，使用C-ARC的计划的治疗可以如美国专利号6,842,502和7,471,765中描述的那样以实时方式进行，其中在放射线治疗期间进行肿瘤的实时成像并且通过计算机116来使用肿瘤的实时图像，以控制工作台运动、桶架运动、注量输出速率、MLC定向和MLC的形状。
在图3中示意性地示出上述实时C-ARC治疗的例子。特别地，将kV锥形射束引导穿过工作台114上的患者，并且在平板成像器108上产生三维实时图像。此外，基于源104（未示出）发射的治疗放射线，也同时使用MV射野成像器120以产生患者的实时二维图像，该源104设置为与成像器120相反。在治疗放射线的传输期间，通过kV锥形射束投影成像以及MV射野成像两者的该同时实时成像可以通过采用射束患者定向中的VMAT及C-ARC的旋转特征的优势来进行。MV射野成像和kV锥形射束投影成像的投影图像能够分别对于2D和3D验证图像进行，以在治疗放射线治疗期间实时地监测患者/身体的位置运动/改变。
图5A-5D中示出了在不同的桶架旋转位置处的由上述kV锥形射束和MV成像器形成的kV和MV射野图像的例子，其中正在治疗脊椎区域。采用射束方向观视的相应的参考数字重建放射成像术在图4A-4D中示出。（其代表着射束方向和孔隙内的物体）
与其它的已知的治疗计划进行比较，采用上述的C-ARC治疗计划显示了本发明的优势。在通过加速部分乳房放射（APBI）在治疗乳房中的肿瘤的情况下，桶架110保持固定在一定切线角度，同时工作台114旋转穿过一个中间电弧和一个侧面电弧，其中相对于患者乳房的定向而限定中间电弧和侧面电弧。
当之前已经通过3D-CRT计划治疗了讨论中的乳房时，3D-CRT计划的射束布置可以用于引导C-ARC的计划，因为该射束布置被认为是已经提供了临床可接受的剂量测定，同时避免了工作台、桶架和患者之间的任何碰撞。来自3D-CRT计划中的工作台位置被取做采用作为工作台电弧的界限。类似地，每个电弧的桶架位置被选择为与3D-CRT计划中的桶架位置一样。通过沿着电弧的10°间隔而定位的控制点来完成最优化和剂量计算。该乳房治疗保留了采用3D-CRT治疗的APBI的标准切线射束布置的益处。C-ARC是VMAT在乳房放射治疗领域中的创新的自然延伸，其中标准切线射束的几何构型使得目标之外的剂量最小化。这在图6A和7A中进行了显示，其中使用C-ARC的放射线射束绝大部分被导引到乳房并且极少的放射线影响到了健康器官，例如心脏和肺。相对照而言，如图6B-6C和7B-7C所示，当利用IMRT和VMAT来应用APBI时，APBI能导致射束被导引到健康组织。
在以下的比较中，其涉及之前通过3D-CRT采用APBI治疗的患者，并且为每个患者生成三个附加且连续的计划：1）C-ARC计划；2）IMRT计划，以及3）VMAT计划。用于评估的DVH参数大部分都取自用于乳房治疗的NSABP-B39/RTOG 0413协议的正常组织限制，并且这些DVH参数列在下表1中：
表1.NSABP B-39/RTOG 0413协议的正常组织剂量限制以及用于3D-CRT、IMRT、C-ARC和VMAT计划的计划比较参数、平均值和范围
上述表1列出了C-ARC、IMRT和VMAT计划的正常组织剂量的平均值，所有的平均值与初始3D-CRT计划相比较。所有的三个治疗计划形式明显地减少了同侧乳房组织V50%的体积，该值平均减少了7.8%（见图8A）。如所示的那样，所有的三个计划明显地减少了同侧肺V30%，但仅有C-ARC和IMRT计划对于V5Gy而进行了减少（见图8B）。在对侧肺V5%中没有明显的减少。4个VMAT计划在对侧乳房内不可避免地产生很高的Dmax，其超过NSABP B-39/RTOG 0413协议（表1）中规划的3D-CRT计划和正常组织剂量限制。IMRT和C-ARC的计划均未产生这种违反现象。与3D-CRT相比，C-ARC、IMRT和VMAT计划都明显地减少了监测器单元的数量，其中C-ARC计划规定了MU的最低平均数量（平均减少：IMRT 136MU，p=0.013，VMAT 281MU，p<0.001，C-ARC339MU，p<0.001）。
还比较了C-ARC和VMAT计划。这两个计划形式产生的接收了50%和100%规定剂量的同侧乳房以及接收了30%的规定剂量的同侧肺的体积减少是相当的。但是VMAT计划造成明显增大的接收5Gy的同侧肺体积（10.4%与7.8%，p=.008）以及明显增大的接收192.5cGy的心脏体积（7.7%与5.5%，p=.021）。图9A-9B分别显示了C-ARC和VMAT典型的轴向剂量的分布。同样地，与VMAT计划相比，C-ARC的计划规定了明显更少的监测器单元的数量（p=.011）。出现了更低的Dmax传输至对侧乳房的C-ARC计划的不显著趋势（p=0.05）。
除了减少同侧乳房的剂量，C-ARC的计划还降低了至肺和心脏的剂量。由于C-ARC和IMRT缺乏面向患者（en face）的几何构型，C-ARC和IMRT最大地减少了V5Gy测定的同侧肺放射。C-ARC和IMRT的计划也明显降低了心脏的低剂量放射。
由于缺少楔形物，与3D-CRT的计划相比，C-ARC、IMRT和VMAT的计划都减少了所规定的监测器单元的数量，其中C-ARC的计划减少的最大。C-ARC的计划也使用最少数量的控制点，因此使得放射线的泄漏最小化。
如图1所示出，C-ARC的计划明显地减少了同侧乳房的放射而没有增加肺、心脏和对侧乳房的剂量。VMAT的计划也能够减少同侧乳房的放射线剂量，但是其通常的代价是增加了其他地方的剂量。
VMAT、C-ARC的自然延伸将会允许采用改良的正形性（conformality）、减少监测器单元传输以及期望的更短的治疗时间来进行治疗。从治疗计划者和操作员的角度上看，C-ARC的复杂性并没有明显高于现有电弧治疗的复杂性。为了采用该创新，必须将躺椅旋转控制与剂量速率和多叶准直仪的运动相联接。还需要小幅修改VMAT的计划软件从而并入躺椅电弧。
在APBI C-ARC治疗的情况中，桶架110固定而工作台114移动。存在C-ARC治疗能够涉及工作台114和桶架110同时移动的例子。采用局部脑放射线治疗的情形是这样一个例子。工作台114和桶架110的移动允许应用于健康区域的治疗放射线的量，该健康区域涉及视交叉神经、视神经和脑干。确实，当与IMRT相比，C-ARC治疗减少了应用于视交叉神经、视神经和脑干的平均剂量和最大剂量（当于IMRT相比）。
从上述描述中，本领域技术人员能够轻易地确定本发明的基本特征，并且在不脱离从本发明的精神和范围内的情况下，本领域技术人员也能对本发明进行各种改变和/或修改，从而使得本发明适应不同的用途和环境。
Claims (12)
1.一种放射线治疗系统，其包括：
放射线源，该放射线源在物体周围移动并且朝向所述物体引导治疗放射线射束；
成像源，该成像源在所述物体周围移动并且朝向所述物体引导成像放射线射束；
工作台，所述物体放置于所述工作台上，所述工作台能够平动和转动；
第一成像器，该第一成像器用于接收由所述治疗放射线源产生的穿过所述物体的放射线，并且用于由该放射线形成第一成像信息；
第二成像器，该第二成像器用于接收由所述成像源产生的穿过所述物体的放射线，并且用于由该放射线形成第二成像信息，其中所述第一成像信息和所述第二成像信息同时形成；以及
计算机，该计算机与所述放射线源、所述工作台、所述第一成像器和所述第二成像器相通信，其中所述计算机基于所述第一成像信息和所述第二成像信息以实时方式同时控制所述工作台的运动和所述放射线源的以下参数中的一个或多个：放射线源运动以及注量输出速率。
2.根据权利要求1所述的系统，其进一步包括多叶准直仪，该多叶准直仪包括多个可移动的叶，所述可移动的叶限定了孔隙，所述射束从所述放射线源穿过该孔隙而被引导到所述物体；并且其中所述计算机基于所述第一成像信息和所述第二成像信息以实时方式来控制多叶准直仪的导向和所述孔隙的形状。
3.根据权利要求2所述的系统，其中所述治疗放射线射束包括光子，并且所述成像放射线射束包括kV x-射线。
4.根据权利要求2所述的系统，其中所述治疗放射线射束包括粒子，并且所述成像放射线射束包括kV x-射线。
5.根据权利要求4所述的系统，其中所述粒子选自电子和质子。
6.根据权利要求1所述的系统，其中所述物体是肿瘤。
7.一种提供放射线的方法，该方法包括：
朝向物体引导治疗放射线射束；
朝向所述物体引导成像放射线射束；
将物体放置于工作台之上，该工作台能够平动和转动；
基于穿过所述物体的所述治疗放射线射束，形成所述物体的第一成像信息；
基于穿过所述物体的所述成像放射线射束，形成所述物体的第二成像信息，其中所述第一成像信息和所述第二成像信息同时形成；并且
基于所述第一成像信息和所述第二成像信息，以实时方式同时控制所述工作台的移动和所述治疗放射线射束的以下参数中的一个或多个：治疗放射线射束运动以及注量输出速率。
8.根据权利要求7所述的方法，其中所述的同时控制进一步包括：控制所述治疗放射线射束的参数形态。
9.根据权利要求7所述的方法，其中所述治疗放射线射束包括光子，所述成像放射线射束包括kV x-射线。
10.根据权利要求7所述的系统，其中所述治疗放射线射束包括粒子，并且所述成像放射线射束包括kV x-射线。
11.根据权利要求10所述的系统，其中所述粒子选自电子和质子。
12.根据权利要求7所述的系统，其中所述物体是肿瘤。
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| CN111821583A (zh) * | 2019-04-22 | 2020-10-27 | 苏州雷泰医疗科技有限公司 | 加速器治疗装置及治疗方法 |
| WO2020215664A1 (zh) * | 2019-04-22 | 2020-10-29 | 苏州雷泰医疗科技有限公司 | 放射治疗装置及放射治疗方法 |
Also Published As
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| BR112012016558A2 (pt) | 2016-04-26 |
| WO2011084878A1 (en) | 2011-07-14 |
| EP2521592A1 (en) | 2012-11-14 |
| US20140100408A1 (en) | 2014-04-10 |
| JP2013516278A (ja) | 2013-05-13 |
| EP2521592A4 (en) | 2013-12-18 |
| US20120020449A1 (en) | 2012-01-26 |
| US9320917B2 (en) | 2016-04-26 |
| US8670523B2 (en) | 2014-03-11 |
| CN102686277B (zh) | 2016-10-12 |
| CA2785995A1 (en) | 2011-07-14 |
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