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Weekly response assessment of involved lymph nodes to radiotherapy using
diffusion-weighted MRI in oropharynx squamous cell carcinoma
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Patients with cancers of oropharynx have a favorable prognosis and are an
ideal candidate for adaptive therapy. A replan to improve coverage or
escalate/de-escalate dose based on morphological information alone may not be
adequate as the grossly involved lymph nodes (LNs) of a subset of these patients
tend to become cystic and often do not regress. Functional adaptation may be a
better approach when considering replanning for these patients. The purpose of
this study was to evaluate the weekly trends in treatment related
morphological and physiological changes for these LNs using diffusion-weighted
(DW-MRI) and evaluate its implications for adaptive replanning.
Ten patients with histologically proven oropharynx HNSCC undergoing concurrent
chemoradiation were analyzed in this study. MR imaging protocol
included axial T1w, T2w, and DW-MRI using a 3 T Philips MR scanner. The patients
were scanned weekly in radiation treatment planning position using a 16 element
phased-array anterior coil and a 44 element posterior coil. A total of 65 DWI and
T2w scans were analyzed. DWI was performed using an optimized single-shot
echo planar imaging sequence (TR/TE = 5000/65 ms, slice thickness = 5 mm;
slices = 28; b values = 0 and 800 s/mm2).
Quantification of the DW-MRI images was performed by calculating the apparent
diffusion coefficient (ADC). T2w and DWI scans were imported
into the Eclipse treatment planning system and gross tumor volumes (GTVs)
corresponding to grossly involved LNs were contoured on each axial slice by
physician experts. An attempt was made to remove any cystic or necrotic components
so that the ADC analysis was of viable tumor only. A
pixel-by-pixel fit of signal intensities within the GTVs was performed assuming
monoexponential behavior. From each GTV histogram mean, median, standard
deviation, skewness, and kurtosis were calculated. Absolute and percent change in
weekly ADC histogram parameters and percent change in T2w GTV were also
For all nodes, an immediate change in ADC was observed during first 2–3 weeks
after which ADC values either continued to increase or plateaued. A few nodal
volumes had a slightly decreased ADC value during later weeks. Percent increase in
median ADC from weeks 1 to 6 with respect to baseline was 14%, 25%, 41%, 42%, 45%,
and 58%. The corresponding change in median T2 volumes was 8%, 10%, 16%, 22%, 40%,
and 42%, respectively. The ADC distribution of the viable tumors was initially
highly kurtotic; however, the kurtosis decreased as treatment progressed.
The ADC distribution also showed a higher degree of skewness in the first 2 weeks,
progressively becoming less skewed as treatment progressed so as to slowly approach a
more symmetric distribution.
Physiological changes in LNs represented by changes in ADC evaluated using DW-MRI
are evident sooner than the morphological changes calculated from T2w
The decisions for adaptive replanning may need to be individualized and should be
based primarily on tumor functional information. The authors’ data also suggest
that for many patients, week 3 maybe the optimal time to intervene and replan.
Larger studies are needed to confirm their findings.
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