Wednesday, December 18, 2013

Radiotherapy planning for glioblastoma based on a tumor growth model: Improving target volume delineation

Jan Unkelbach, Bjoern H. Menze, Ender Konukoglu, Florian Dittmann, Matthieu Le, Nicholas Ayache, Helen A. Shih

Glioblastoma di ffer from many other tumors in the sense that they grow in filtratively into the brain tissue instead of forming a solid tumor mass with a de fined boundary. Only the part of the tumor with high tumor cell density can be localized through imaging directly. In contrast, brain tissue infi ltrated by tumor cells at low density appears normal on current imaging modalities. In current clinical practice, a uniform margin, typically two centimeters, is applied to account for microscopic spread of disease that is not directly assessable through imaging. The current treatment planning procedure can potentially be improved by accounting for the anisotropy of tumor growth, which arises from di fferent factors: Anatomical barriers such as the falx cerebri represent boundaries for migrating tumor cells. In addition, tumor cells primarily spread in white matter and in lfiltrate gray matter at lower rate. We investigate the use of a phenomenological tumor growth model for treatment planning. The model is based on the Fisher-Kolmogorov equation, which formalizes these growth characteristics and estimates the spatial distribution of tumor cells in normal appearing regions of the brain. The target volume for radiotherapy planning can be defi ned as an isoline of the simulated tumor cell density. This paper analyzes the model with respect to implications for target volume de finition and identifi es its most critical components. A retrospective study involving 10 glioblastoma patients treated at our institution has been performed.

To illustrate the main fi ndings of the study, a detailed case study is presented for a glioblastoma located close to the falx. In this situation, the falx represents a boundary for migrating tumor cells, whereas the corpus callosum provides a route for the tumor to spread to the contralateral hemisphere. We further discuss the sensitivity of the model with respect to the input parameters. Correct segmentation of the brain appears to be the most crucial model input. We conclude that the tumor growth model provides a method to account for anisotropic growth patterns of glioma, and may therefore provide a tool to make target delineation more objective and automated.