DVH 5161 PDF

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Ten sets of atlas patients were registered to the new patient using deformable image registration DIR and the deformed atlas contours were fused to produce the final auto-segmented brachial plexus contours for the new patient. Finally, because brachial plexopathy is dvu rare, the number of events in our study was low, which complicates our ability to generalize our defined dose limits to a larger population of patients with lung cancer.


This may prove to be problematic for complying with dose constraints to structures like the brachial plexus. Brachial plexus contouring using deformable image registration.

Minor clinical symptoms with no medical intervention required were considered grade 1; moderate symptoms requiring pain medication with good response, grade 2; and severe symptoms, treated with multiple pain medications, including neuropathic drugs or steroid injections, dch some or no improvement in symptoms, grade 3. For these reasons, estimates of smaller point doses may not have been accurate enough to predict the development of plexopathy.

However, with current dvg evaluating 74 Gy, the dose constraints for the brachial plexus need to be revisited, particularly because most of the literature on brachial plexus toxicity comes from studies of head and neck or breast cancer. A Axial CT scan delineating the brachial plexus based on physician consensus green and computer-generated contours red.

We used a multi-atlas segmentation method combined with deformable image registration to delineate the brachial plexuson the original planning CT scans and scoredplexopathy according to the Common Terminology Criteria for Adverse Events v4. Our findings here, focusing specifically on patients treated for lung cancer, indicate that the median dose to the brachial plexus should be kept below 69 Gy, and the maximum dose to 2 cm 3 below 75 Gy,for patients with Dv.


Brachial plexus lesions in patients with cancer: Conclusions For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy. Lung cancer is the leading cause of cancer-related death worldwide, with approximately 1.

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Complication without a cure. Dh two curves were nearly superimposable. Balancing the benefit of local control with the risk of considerable toxicity is a particular challenge for tumorsof the superior sulcus or tumors with supraclavicular adenopathy.

Author information Copyright and License information Disclaimer. The V 10 values volume of brachial plexus volume receiving 10 Gy were Also, changes in arm position can affect the visibility of the brachial plexus and can contribute to inaccuracies in deformable image registration.

Where no foramen was present, only the regions between the scalene muscles were contoured. We developed a computer-assisted image segmentation method which allowed us to rapidly and consistently contour the brachial plexus and establish the dose limits to minimize the risk of brachial plexopathy.

This study was approved by the appropriate dhv review board of MD Anderson. When patients were treated with proton therapy using Varian Eclipse treatment planning, DICOM-RT dose plans were first exported from Eclipse planning system and then converted and imported into Pinnacle planning system for dose calculation.

Most studies since have recommended the maximum dose be kept under 66 Gy. The Mann-Whitney two-sample statistic or Wilcoxon rank-sum test was used to test the distribution of continuous variables according to plexopathy status. We further attempted to address the difficulties in consistently contouring this structure by using deformable image registration.

However, radiation doses of that magnitude often result in local failure, which itself cancause brachial plexopathy. Arya AminiB.

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The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. The contours were drawn jointly by two thoracic radiation oncologists and one thoracic radiologist. Other studies have also noted correlations between receipt of concurrent chemoradiotherapy or use of large radiation doses per fraction [ 1617 ]; these other findings suggest that use of twice-daily fractionation may reduce toxicity and may provide particular benefit in patients with plexopathy prior to treatment.


The underlying mechanismis thought to be due to demyelination leading to axon loss [ 9 ]. The potential benefit of tumor control must be balanced against the risk of dvb side effects on a case-by-case basis. This overall framework is illustrated in Figure 2.

Deformable image registration is a valuable tool, especially for contouring difficult structures like the brachial plexus. As the recommended radiation dose for non-small cell lung cancer NSCLC increases, meeting dose constraints for critical structures 516 the brachial plexus becomes increasingly challenging, particularly evh tumors in the superior sulcus.

The resultant displacement vector fields characterizing the individual registrations were then used to deform the atlas brachial plexus contours to obtain 10 individual segmentations for each patient. To reduce variability in our contouring of the brachial plexus, we followed guidelines based on easily delineated structures such as the sternocleidomastoid and scalene muscles and bony landmarks.

Validation of Deformable Image Registration Auto-segmentation using 516 image registration followed by modification was found to be accurate for the majority of the cases, with only slight modification needed, mostly based on aberrant arm position. Interestingly, we found that doses to 0. Next we plan to validate these dose constraints in an ongoing randomized phase III trial looking at dose escalation for lung cancer. This patient later developed grade 2 toxicity.

Characteristics Value or No. Author manuscript; available in PMC Sep In this retrospective analysis, we compared dose-volume histogram information with the incidence of plexopathy to establish the maximum tolerated dose to the brachial plexus.

Factors assessed in this manner include patient age at treatment, body mass index, smoking pack-years, median dose to the brachial plexus and maximum dose to 0. The median overall dose to the brachial plexus was Radiation-induced brachial plexus neuropathy in breast cancer patients.