New Advanced in Radiotherapy

NEW ADVANCED IN RADIOTHERAPY

FIELDA DJUITA DEPARTEMENT OF RADIOTHERAPY DHARMAIS CANCER CENTER HOSPITALJakarta, 11 November 2009

CURRICULUM VITAEFielda Djuita1977 1989 1990 1993 1997 2002 2004 2005 2005 2005 2006 2007 2008 Medical doctor, University of Indonesia Spesialis Radiologi, University of Indonesia Sub Spesialis Radioterapi, University of Indonesia Training Course in Treatment Planning System of Brachytherapy in Beijing Fellowship in Radiology Imaging, Royal Perth Hospital Australia Study in Technique Radiation in Sentinel Node Procedure of Breast Cancer in Academie Ziekenhuis Groningen. : Fellowship in Radiation Oncology in Toranomon Hospital, Tokyo - Japan : Training Radiotherapy at Sussex Country Hospital Brighton and St.Thomas Hospital London, UK : International Gynecologic Cancer Society Course in Kyoto-Japan : European Society Therapeutic and Oncology. : American Society of Therapeutic Radiation Oncology, Philadelphia. America. : From 2D to 3 D Teaching Courses, St Petersburs , Rusia : IMRT Technique , Milan, Italia. : : : : : :

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The aim of radiotherapy is to kill tumor cells and spare normal tissues In external beam and brachytherapy one inevitably delivers some dose to normal tissueBeam 2 Beam 1 Beam 3 Brachytherapy sources

tumor

patient

Basic Radiotherapy Department 1 Teletherapy Unit (Co-60 or single energy Linac with no MLC, portal imaging or networking) Orthovoltage unit 1 Brachytherapy afterloader (HDR or 2 LDR with full range of applicators) 1 Simulator (or CT Simulator or access to CT) Machine Computerized Treatment Planning System QA and RP physics equipment Film processing equipment Patient immobilization devices and mould room equipment 1 machine/ 500 patients

IAEA Pub 1296

Recommended number of staffRadiation Oncologist chief Radiation Oncology Staff Medical Physicist Dosimetrist or Physics assistant Physics Technologist (Mould rm) Supervisor Rad Therapy Tech Rad Therapy Staff 1 per program 1 additional per 200-250 pts treated annually 1 per 400 patients treated annually 1 per 300 patients treated annually 1 per 600 patients treated annually 1 per center 2 per MV unit up 25 or 4 per MV up to 50 pts a day treated 1 per 500 patients simulated annually As needed 1 per center up to 300 patients

Staff simulation Brachytherapy staff Nurse

IAEA Pub 1296

CANCER PATIENT : RT MACHINE IN INDONESIARATIO NEED FOR RT

WHAT IS NEW ADVANCED ?HOW FAR ADVANCED?

WHAT DO WE REALLY NEED?

WHY DO WE NEED NEW ADVANCED TECHNOLOGIES ?

WHO DOES NEED IT ?

Non-imaging featuresCross Hair stability with collimator, gantry and couch rotation: Mount a metallic pointer on table top and observe its position relative to the cross-hair on the fluoro monitor as the collimator rotates. Repeat for gantry and couch rotation. This should be performed using both focal spot.Laser Alignment

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Non-imaging featuresCollimator , Gantry and Couch Rotation and Isocenter Accuracy Couch vertical, longitudinal and lateral motions

Radiation OncologyRadiation Oncology is a quickly evolving field. A little more than 10 years ago 2D was still common. Image guidance was limited to a set of port films or portal images.

Path Towards More Precise Radiation TherapyIndustry Goal: Precisely Deliver Radiation to Tumors; Avoid Healthy Tissue & Structure Intensity Modulated Radiation Therapy (IMRT) Varies the intensity Varies the intensity of the radiation of the radiation Conforms radiation Conforms radiation to the shape of the to the shape of the tumor tumor Does not account Does not account for changes in for changes in anatomy anatomy

Image Guided Radiation Therapy (IGRT) IMRT requires imaging for precise targeting Image guidance repositions patient for tumor movement Limited by the quality and frequency of images available

Dose Escalation / Hypofractionation Reduces the number of fractions and delivers larger doses of radiation per fraction To date, used to treat only a limited number of tumor types Includes Radiosurgery

Adaptive Radiation Therapy

Maximum precision enabled by daily CT imaging Treatment plan adjusted to changes in patient anatomy and radiation actually delivered Personalized treatments designed to optimize outcomes

External Beam Therapys Evolution

TomoTherapy evolved from CT scanners (newer style slip ring gantries). C-Arms evolved from classic type diagnostic X-Ray machine designs. TomoTherapy is the new paradigm IG-IMRT.

C-Arms 40 Year Evolution

Clinac 4 (1969)

Clinac 6-100 & 600c (1970s - 90s)

Clinac 1800c (1980s 1990s)

Clinac 2300 series (1990s - 2000s)

Modern

RTOG Plan Comparison

Structure Brainstem Spinal Cord Mandible Unspecified tissue Right Parotid

RTOG H-0022 Goal < 54 Gy < 45 Gy < 70 Gy 100% Vol 110% PTV66 Mean Dose < 26 Gy, or 50% Vol < 30 Gy Mean Dose < 26 Gy, or 50% Vol < 30 Gy

IMRT Plan Max 56.97 Gy Max 47 Gy Achieved Achieved

Tomo Plan Max 50 Gy Max 15 Gy (!) Achieved Achieved

60% Vol < 30 Gy

74% Vol < 30 Gy

Left Parotid

Only 1% Vol < 30 Gy

68% Vol < 30 Gy

5 Esophagus (case1)HOT SPOTs

Isodose distributions for Tomotherapy, IMRT, and 3DCRT plans CHEN et al. Helical Tomotherapy For Radiotherapy In Esophageal Cancer: A Preferred Plan With Better Conformal Target Coverage And More Homogeneous Dose Distribution. Medical Dosimetry, Vol. 32, No. 3, pp. 166-171, 2007

Step and shoot IMRT

7 Lung (case1MPM)

Tomotherapy

Higher Dose Regions

Lower Dose Regions

STERZING et al. Evaluating Target Coverage And Normal Tissue Sparing In The Adjuvant Radiotherapy Of Malignant Pleural Mesothelioma: Helical Tomotherapy Compared With Step-and-shoot IMRT. Radiotherapy and Oncology 86 (2008) 251257

Average Treatment TimesTreatments with Imaging: Site Time in Room Treatment Time (beam on) Esophagus 17 min 4 min 35 sec Chest 21 min 6 min 29 sec Head and Neck 13 min 4 min 13 sec Head and Neck 19 min 4 min 36 sec Chest 22 min 4 min 47 sec Head and Neck 17 min 4 min 50 sec Rectum 15 min 4 min 32 sec Liver 17 min 7 min 26 sec Bladder 15 min 4 min 18 sec CT Time Target Length 2min 17 sec 13.8 cm 1min 41 sec 19.6 cm 1min 12.7 cm 4 min 37 sec 13.8 cm 2 min 17 sec 14.2 cm 1 min 23 sec 14.3 cm 1 min 42 sec 13.7 cm 1 min 47 sec 22.3 cm 1 min 47 sec 12.8 cm

Treatments without Imaging: Head and Neck Head and Neck Head and Neck 13 min 12 min 10 min 5 min 11 sec 6 min 5 sec 6 min 0 0 0 16.1 cm 18.3 cm 18.2 cm

Courtesy of Southeast Regional Cancer Center Tallahassee, FL

Helical or TomoDirect?

50.4 Gy 1.8 Gy/fxradiation time: 12.5 minCase from University of Heidelberg, Department of Radiation Oncology

50 Gy 2.0 Gy/fx 5 Beams radiation time: 3.3 minTomoTherapy Planning Study

Quality Depends on Number of Beams

mm

mm

mm

1 Beam 17 Beams

5 Beams 25 Beams

11 Beams 51 Beams

mm

mm

mm

COMPARISON DOSE DISTRIBUTION BETWEEN TWO MODALITY RapidArc Delivery TomoTherapy Comparison

Extreme Lack of HomogeneityBut reported 2 minute beam on time (Modulation takes time)

High degree of homogeneity and rectal avoidance3.6 minutes beam on time

THE CHOICE IS DEPENT OF OUR NEEDAbility to trade speed for quality Field width 5 cm Mod. Factor 1.2 Field width 2.5 cm Mod. Factor 2.4

Better cord sparingTreat time 2.1 mins Treat time 6.4 mins

More conformal target dose

More uniform nodal dose

SPINE PLAN COMPARISON BETWEEN ..

CyberKnife 80% isodose = 16 Gy

TomoTherapy 95% volume = 20 Gy

65 minute beam time plus 80 direction changes plus collimator change

40 minute delivery time

Repeat 4D cone beam CT

Shows respiration, tumor shrinkage and baseline position variation, J.J. Sonke

Planning Technique ComparisonMean Relative Reduction Versus Standard 3D

All plans based on 63.0 Gy in 35 fractions 3D conformal plan based on CTV from free-breathing CT scan + 0.5 cm (setup) + respiratory motion (maximum of 1.0 cm for motion) Mean tumor respiratory motion (SI) = 0.7 cm (range: 0.3-1.3 cm)

Harsolia et al. Int J Radiat Oncol Biol Phys 63S:A50; 2005

Image volume of Cone-Beam Electronic Portal

Coordinator or ABC Respiration

BREAST CANCER - ABCFree Breathing Scan Deep Inspiration ScanTum Bed or Tum Bed or

Heart Border

Heart Border

Normal Respiration

Deep Inspiration

TRANSVERSE VIEW BETWEEN NORMAL INSPIRATION & DEEP INSPIRATION115% 110% 105% 100% 95% 90%

Wedges

IMRT

ELECTRONIC PORTAL IMAGING

MEDIAL FIELD Sequential Images ( 4weeks)

Prostate

9 beam IMRT (72 segments) 79.2 Gy to Prostate + SV

IMRT - Solid VMAT - Dashed

Femoral

VolumeRectumNormal

PTV

Bladder

Dose (cGy)

ProstateIMRT80 73 60 50 40 30 20 10 5 Gy

VMAT

717 MU, 12 minutes

501 MU, 2 minutes

Hypofractionated Lung8 Beam, 8 Seg IMRT60 55 50 45 35 25 15 5 Gy

VMAT

2200 MU, 14 minutes

2020 MU, 6.5 minutes

Spine SRS10 Beam, 45 Seg IMRT 2 arc VMAT

22 19 16 13 10 7 5 Gy

10998 MU

7482 MU

Head/NeckIMRT75 70 66 56 45 35 25 15 10 Gy

VMAT vs. 7 beam IMRT (80 segments) VMAT

925 MU

325 MU

TREATMENT PLANNING WITH BIOLOGIC FUNCTION

CONCLUSION ADVANCED TECHNOLOGIES: MOVING TARGET OLD DOSE/VOLUME GUIDELINES:VALID IN IMRT ERA ? IMRT MOVES DOSE AROUND, NOT MAGIC ! ! ! NEW APPROACHES ARE USUALLY COMPLEX OPPORTUNITIES FOR ERROR / INJURY THINK ABOUT BIOLOGIC FUNCTION CHALLENGING/ EXCITING TIMES LOCAL FAILURE: COMPLICATION

CONCLUSION COMPARISON RATIO BETWEEN PATIENT: RT MACHINE IS HIGH FOR MEDICAL SERVICES IN INDONESIA WE NEED A LOT OF MACHINE WITH MEDIOCARE TECHNOLOGIES FOR CANCER CENTRE OR EDUCATION WE NEED HIGH TECHNOLOGY MACHINE

Everyone thinks of changing the world, but no one thinks of changing himself on her self.(Leo Tolstoy, The Kingdom of God is within you)

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