Роль сучасних методів візуалізації у плануванні променевої терапії та моніторингу онкогінекологічних хворих (огляд літератури)

The proposed RT planning algorithm begins with the initial and detailed diagnosis of cancer disease. At the same time linear dimensions of tumors subject to conformal remote RT and BT are determined by means of diagnostic ultrasound. For example, for CC and carcinoma of the corpus uteri their size and volume are determined, as well as the size of the lesion and the thickness of the unchanged uterine wall. Elastography data and blood flow characteristics are used to select the BT conditions (type of endostat, its geometry) and indirect assessment of radiochemo-sensitivity Further planning of RT involves conducting an independent topometric study with inserted endostats and contrasting of organs at risk. It was found that the visual pattern obtained at this stage with the help of diagnostic ultrasound is less informative due to the subjective perception of signal in comparison with CT, which really reflects not only the external contours of tumor and organs at risk, but also bone structures, combined (metal and plastic) endostatic devices, and detectors of the direct dosimetry (scintillative or thermoluminescent ones) [47, 54, 55].

The data of various studies allow to state that CT technology is quite in demand for visualization of endostats, dosimeter detectors, and actually the BT planning for all types of tumor processes, while the contact high-energy BT retains its decisive role in sustainable treatment of tumors in the framework of both combined and independent RT impact. At the same time the CT-topometry is repeatedly performed in case of a high-grade tumor resorption (more than 50 %) to correct the type and method of endostat placement and the plan of further BT [51, 53, 56].

The use of MRI and in recent years of PET-CT and PET-MRI provides information that significantly expands the possibilities of individual PT planning, but these visualization methods have certain financial and methodological limitations in the specialized healthcare institutions, as they require the allocation of independent time, availability of MRI-compatible endostats and medical conditions for MRI examination with inserted endostats. Studies have shown that PET-CT has an advantage over CT when planning the RT. More precise planning of irradiation allows minimizing the irradiation of intact tissues, and concentrating the radiation effect directly on tumors. Diagnostic accuracy of PET-MRI is significantly higher in malignant and benign neoplasms. Reduced radiation dose and better detection of lesions, as well as a significant and strong correlation between tumor metabolism and higher cellularity in the foci of CC allows the widespread use of PET-MRI in future in the planning and control of RT sessions [38, 39, 57].

Control of the effectiveness of treatment and monitoring of the RT or complex therapy results, as well as differential diagnosis of radiation complications and disease relapses is the next stage of implementation of diagnostic algorithm. A range of diagnostic methods from ultrasound to PET-CT technologies are used to reliably monitor the state of primary focus, detect recurrence or generalization of cancer process [58, 59].

Currently the BT in cancer healthcare institutions countrywide is mainly represented by its automated variants with remote delivery of the small-sized closed sources of high activity based on Iridium 192 (¹⁹²Ir) or Cobalt 60 (⁶⁰Co) radionuclides in the pre-placed and directly fixed in tumor or its bed intrastats or endostats. Planning is mainly carried out using the 3D-dosimetric planning systems requiring a direct monitoring of the proposed and actual delivered radiation doses by means of in vivo dosimetry. The latter is necessary in order to guarantee the quality of BT and prevent complications that often accompany treatment [53, 60, 61].

Conclusion

Thus, for the planning of conformal RT and BT it is necessary to use contemporary visualization technologies taking into account the integrated computer software for contouring the target tumor and risk organs using MRI, CT, and PET-CT technologies in accordance with requirements for the formation of therapeutic dose distribution in three planes and volume, formulated by radiotherapists and medical physicists, which allows to optimize the task by the volume of irradiation and reduce the dose load on organs at risk. MRI and transanal endoscopic diagnostic ultrasound remains the clinical standard for disease staging. Technological progress has made it possible to expand the quantitative functional assessment using MRI to examine the whole body with accurate determination of cancer stage. The additional detection of metastases in small lymph nodes, in unexpected pelvic and inguinal lymph nodes, as well as the detection of hidden distant metastases is a specific advantage of PET-CT. In addition, PET-CT provides information on biological features of tumors, such as metabolism, hypoxia and proliferation, which can help to identify the radioresistant areas and use them to optimize the treatment plans. Therefore, involvement of MRI and PET-CT in the planning of conformal RT and BT is justified, despite the increase in economic costs of RT, the indications for which should be expanded, especially in the period of emergency situation.

In conclusion, it should be noted that PET-CT is an objective method of examination of patients with locally advanced CC both in the initial planning of multicomponent treatment and in the survey of patients with suspected disease generalization. PET should be included in diagnostic algorithm when examining the CC patients, especially in cases of visualization of parametrial tissue or involvement of regional and distant lymph nodes. In addition, PET is of a great value in the determining of metastatic dissemination, diagnosing of tumor recurrence, choosing of strategy and tactics of treatment arrangements, and evaluating their effectiveness.

Thus, PET-CT is often used for staging, longterm follow-up, treatment planning, and predicting the response to treatment in cancer patients.

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