STEREOTACTIC BODY RADIATION THERAPY STEREOTACTIC BODY RADIATION THERAPY Presented at the Presented at the Annual Meeting of the Annual Meeting of the American College of Medical Physics American College of Medical Physics in Orlando, Florida, May 24, 2005 in Orlando, Florida, May 24, 2005
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STEREOTACTIC BODY RADIATION STEREOTACTIC BODY RADIATION THERAPYTHERAPY
Presented at the Presented at the Annual Meeting of the Annual Meeting of the
American College of Medical Physics American College of Medical Physics in Orlando, Florida, May 24, 2005in Orlando, Florida, May 24, 2005
STEREOTACTIC BODY STEREOTACTIC BODY RADIATION THERAPY(SBRTRADIATION THERAPY(SBRT))
Part 1: Part 1: Overview of SBRT Overview of SBRT (S.H. Benedict, Virginia Commonwealth University)(S.H. Benedict, Virginia Commonwealth University)• AAPM Task Group 101: SBRTAAPM Task Group 101: SBRT• ASTRO GuidelinesASTRO Guidelines
Part 2: Part 2: Treatments of the spine with SBRT Treatments of the spine with SBRT (Paul Medin, Ph.D., UCLA)(Paul Medin, Ph.D., UCLA)
Part 3: Part 3: SBRT in the “Conventional” Clinical SettingSBRT in the “Conventional” Clinical SettingBill Hinson, PhD, Wake Forest UniversityBill Hinson, PhD, Wake Forest University
Part 4:Part 4: KV and MV imaging in SBRTKV and MV imaging in SBRTMichael lovelock, PhD, MSKCCMichael lovelock, PhD, MSKCC
EXTRACRANIAL STEREOTACTICEXTRACRANIAL STEREOTACTICRADIOSURGERY – What’s in a RADIOSURGERY – What’s in a
name?name? ESRT is the use of external beams to treat lesions of the body ESRT is the use of external beams to treat lesions of the body
with “surgical” doses and high precision tumor identification with “surgical” doses and high precision tumor identification and relocalization employing “stereotactic” image guidance or and relocalization employing “stereotactic” image guidance or implanted fiducials.implanted fiducials.
Surgery vs. Ablation vs. Therapy vs. …Surgery vs. Ablation vs. Therapy vs. …
According to the chief CPT code developer it will be called:According to the chief CPT code developer it will be called:
Stereotactic Body RadiotherapyStereotactic Body Radiotherapy
SBRT REQUIRES:SBRT REQUIRES:
Higher confidence in tumor targeting Higher confidence in tumor targeting
Reliable mechanisms for generating focused, sharply Reliable mechanisms for generating focused, sharply delineated dose distributionsdelineated dose distributions
Reliable accurate patient positioning accounting Reliable accurate patient positioning accounting for target motion related to time dependent for target motion related to time dependent organ movementorgan movement
SBRT: why try it?SBRT: why try it?
Highly efficient and extremely potent form of Highly efficient and extremely potent form of radiation treatment applicable to a wide variety of radiation treatment applicable to a wide variety of tumor typestumor types
Safe and effective for patients with medically Safe and effective for patients with medically inoperable primary lung cancerinoperable primary lung cancer Timmerman R, et al. Timmerman R, et al. ChestChest, 2003., 2003.
Ongoing investigations for patients with primary Ongoing investigations for patients with primary liver cancer (hepatocellular carcinoma)liver cancer (hepatocellular carcinoma) Extremely common type of cancer worldwideExtremely common type of cancer worldwide These patients are often unfit for surgeryThese patients are often unfit for surgery
Non-invasive alternative to surgery, RFA, or Non-invasive alternative to surgery, RFA, or cryosurgery for selected patients with cryosurgery for selected patients with “oligometastases”“oligometastases” Especially relevant in era of improving systemic “targeted therapy”Especially relevant in era of improving systemic “targeted therapy”
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
SBRT: what is it?SBRT: what is it?
StereotacticallyStereotactically localized, ultra-high- localized, ultra-high-dose radiotherapy delivered to discrete dose radiotherapy delivered to discrete tumor nodules in the lung, liver, and tumor nodules in the lung, liver, and other extracranial locations in a other extracranial locations in a hypofractionatedhypofractionated regimen (typically 1-5 regimen (typically 1-5 treatments)treatments)
The goal is complete cancer cell kill The goal is complete cancer cell kill within the treated volumewithin the treated volume
Beginning in January, 2005, SBRT will be Beginning in January, 2005, SBRT will be a category III CPT code for billing a category III CPT code for billing purposespurposes
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
SBRT: who started it?SBRT: who started it?
Answer: Blomgren and Lax, Karolinska Institute, Stockholm, Sweden
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
SBRT: who started it?SBRT: who started it?
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
Conventional vs SBRTConventional vs SBRT
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
Linear Accelerators with Linear Accelerators with features especially suitable features especially suitable
for SBRTfor SBRT
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
SBRT: how much is SBRT: how much is enough?enough?
Fowler JF, Tome WA, Welsh JS. Estimation of the Required Doses in Stereotactic Body Radiation Therapy. In Stereotactic Body Radiation Therapy, Kavanagh BD and Timmerman RD, eds. Lippincott Williams & Wilkins, 2005.
* Slide courtesy of Brian Kavanagh / * Slide courtesy of Brian Kavanagh / University of ColoradoUniversity of Colorado
Fowler JF, Tome WA, Welsh JS. Estimation of the Required Doses in Stereotactic Body Radiation Therapy. In Stereotactic Body Radiation Therapy, Kavanagh BD and Timmerman RD, eds. Lippincott Williams & Wilkins, 2005.
* Slide courtesy of Brian Kavanagh / University of Colorado* Slide courtesy of Brian Kavanagh / University of Colorado
AAPM Task Group 101:AAPM Task Group 101:Stereotactic Body Radiation Stereotactic Body Radiation
TherapyTherapy The AAPM RTC approved the following charges of the task group:The AAPM RTC approved the following charges of the task group:
Charge (1): To review the literature and identify the range of historical Charge (1): To review the literature and identify the range of historical experiences, reported clinical findings and expected outcomesexperiences, reported clinical findings and expected outcomes
Charge (2): To review the relevant commercial products and associated Charge (2): To review the relevant commercial products and associated clinical findings for an assessment of system capabilities, technology clinical findings for an assessment of system capabilities, technology limitations, and patient related expectations and outcomes. limitations, and patient related expectations and outcomes.
Charge (3): Determine required criteria for setting-up and establishing an Charge (3): Determine required criteria for setting-up and establishing an ESRT facility, including protocols, equipment, resources, and QA ESRT facility, including protocols, equipment, resources, and QA procedures.procedures.
Charge (4): Develop consistent documentation for prescribing, reporting, Charge (4): Develop consistent documentation for prescribing, reporting, and recording ESRT treatment delivery.and recording ESRT treatment delivery.
AAPM TG 101: SBRT - Table of AAPM TG 101: SBRT - Table of Contents:Contents:
1. 1. . Clinical Rationale for SBRT . Clinical Rationale for SBRT
2. Review of Clinical History and Current Use of SBRT (Volker Steiber)2. Review of Clinical History and Current Use of SBRT (Volker Steiber)
3. Patient Immobilization, Relocalization, and Verification 3. Patient Immobilization, Relocalization, and Verification
4a. Treatment Planning and Dosimetry 4a. Treatment Planning and Dosimetry
4b. Treatment plan evaluation and dose reporting 4b. Treatment plan evaluation and dose reporting
7. Clinical Implementation of SBRT7. Clinical Implementation of SBRT
8. Future directions8. Future directions
RADIATION THERAPY ONCOLOGY GROUP (RTOG) RADIATION THERAPY ONCOLOGY GROUP (RTOG) 0236:0236:A Phase II Trial of Stereotactic Body Radiation Therapy A Phase II Trial of Stereotactic Body Radiation Therapy (SBRT) in the Treatment of Patients with Medically (SBRT) in the Treatment of Patients with Medically Inoperable Stage I/II Non-Small Cell Lung CancerInoperable Stage I/II Non-Small Cell Lung Cancer
PI: Robert Timmerman, MDPI: Robert Timmerman, MD EligilibityEligilibity
Patients with T1, T2 (≤ 5 cm), T3 (≤ 5 cm), Patients with T1, T2 (≤ 5 cm), T3 (≤ 5 cm), N0, M0 medically inoperable non-small cell N0, M0 medically inoperable non-small cell lung cancer;lung cancer;
Patients with T3 tumors chest wall primary Patients with T3 tumors chest wall primary tumors onlytumors only
No patients with tumors of any T-stage in No patients with tumors of any T-stage in the zone of the proximal bronchial treethe zone of the proximal bronchial tree*. *.
SBRT dose: 20 Gy x 3 fractionsSBRT dose: 20 Gy x 3 fractions
RADIATION THERAPY ONCOLOGY GROUP (RTOG) RADIATION THERAPY ONCOLOGY GROUP (RTOG) 0236:0236:Dosimetry specificationsDosimetry specifications
““Zone of the proximal Zone of the proximal bronchial tree” (figure)bronchial tree” (figure)
Dose “isotropicity” Dose “isotropicity” limitation requiring limitation requiring falloff of approx 50% falloff of approx 50% within 2 cm of PTVwithin 2 cm of PTV
3. Planning3. Planning: : Small field dosimetry considerationsSmall field dosimetry considerations
4. Repositioning4. Repositioning: : High precision High precision patientpatient set-up: set-up: Fiducial systems, IR/LED Active and Passive markers, US, Video Fiducial systems, IR/LED Active and Passive markers, US, Video
5. Relocalization5. Relocalization: : Identify Identify tumortumor location in the treatment field: location in the treatment field: * MV/ KV Xray, Implanted markers and/or set-up fiducials* MV/ KV Xray, Implanted markers and/or set-up fiducials* Motion tracking and gating systems* Motion tracking and gating systems* Real-time tumor tracking systems with implanted markers* Real-time tumor tracking systems with implanted markers
Clinical Implementation of Clinical Implementation of ESRT – ESRT –
““These techniques are unusual in These techniques are unusual in the high technology realm of the high technology realm of radiation treatment in that they radiation treatment in that they require more specialized require more specialized training training of physicians and physicists rather of physicians and physicists rather than specialized than specialized equipmentequipment.” .”
* Timmerman et al, * Timmerman et al, Technology in Technology in Cancer Research and TreatmentCancer Research and Treatment – – 20032003
SUMMARY: Technical elements of QASUMMARY: Technical elements of QA
The physicist should be responsible for all The physicist should be responsible for all technical QA procedures: technical QA procedures:
• • Imaging equipment Imaging equipment • • Localization and simulation equipmentLocalization and simulation equipment• • Treatment planning and evaluation systemTreatment planning and evaluation system• • Treatment delivery equipmentTreatment delivery equipment• • Treatment verification equipmentTreatment verification equipment
SUMMARY: Clinical elements of SBRT SUMMARY: Clinical elements of SBRT
QAQA A physician A physician andand physicist should carry out all clinical QA physicist should carry out all clinical QA
procedures:procedures:
• • Consistent target volume and organs–at–risk delineation Consistent target volume and organs–at–risk delineation • • Quantitative assessment of target and organ motion during Quantitative assessment of target and organ motion during
imaging and treatmentimaging and treatment • • Quantitative assessment of setup variation during imaging Quantitative assessment of setup variation during imaging
and treatmentand treatment • • Patient–specific QAPatient–specific QA
NEED TO ESTABLISH TERMINOLOGY NEED TO ESTABLISH TERMINOLOGY AND REPORTING CONVENTIONSAND REPORTING CONVENTIONS Prescription considerations: GTV, margins, dose Prescription considerations: GTV, margins, dose
inhomogeneity/uniformity inhomogeneity/uniformity Biological evaluations: EUD, NTCP, etcBiological evaluations: EUD, NTCP, etc Dose and Fractionation strategy: (1 to 5 fractions, QOD, Dose and Fractionation strategy: (1 to 5 fractions, QOD,