Implementation of hypoxia imaging into treatment planning and delivery

Purpose: To review the current status of implementation of functional hypoxia imaging in radiotherapy (RT) planning and treatment delivery.

Methods: Before biological imaging techniques such as positron emission tomography (PET) or magnetic resonance (MR) can be used for individual RT adaptation, three main requirements have to be fulfilled. First, tissue parameters have to be derived from the imaging data that correlate with individual therapy outcome. Then, the spatial and temporal stability of hypoxia PET images needs to be established. Finally, the dose painting (DP) concepts have to be practically feasible to be used as a basis for clinical trials.

Results: A number of recent clinical studies could show the correlation of hypoxia PET imaging with different tracers and RT outcome. Most of the studies revealed a correlation between mean or maximum values and parameters assessed from the PET avid volume and treatment success, only few investigations used quantitative imaging. Multiparametric imaging seems to be very valuable. Recently, the spatial and temporal stability of hypoxia PET attracted attention. Temporal changes in the distribution of functional tumour properties were reported. Furthermore, technical feasibility of DP by contours (DPC) as well as DP by numbers (DPBN) was shown by several investigators. The challenge is now to design clinical studies in order to prove the impact of DP treatments on individual therapy success.

Conclusion: A patient-specific adaptation of RT based on functional hypoxia imaging with PET is possible and promising. Conceptual feasibility could be shown for DPBN whereas to date, only DPC seems to be plausible and feasible in a clinical context.