1 Transition from 2D to 3D Brachytherapy in Cervical Cancers: The Vienna Experience Richard Pötter MD BrachyNext, Miami, 2014 Disclosures Richard Pötter, MD, does not have any financial relationships or products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months. The Medical University of Vienna receives financial and equipment support for training and research activities equipment support for training and research activities from Nucletron, an Elekta Company and Varian Medical.
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Transition from 2D to 3D Brachytherapy in Cervical Cancers: The Vienna Experience
Richard Pötter MD
BrachyNext, Miami, 2014
DisclosuresRichard Pötter, MD, does not have any financial relationships or products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
The Medical University of Vienna receives financial and equipment support for training and research activitiesequipment support for training and research activities from Nucletron, an Elekta Company and Varian Medical.
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Driving forces for the evolution from point (A) to 3D/4D image guided adaptive approach
Improvement of local control in advanced diseasepImprovement of cure
Decrease of adverse side effects/improvement in QoL(rectosigmoid, bladder, vagina, bowel, fatigue…)
Not accepting the „mystery“ of point A-based intracavitary brachytherapy
Implementation of 3D/4D Radiotherapy into Gynaecol.
2D Image based brachytherapy (100 years)
Applicator insertionClinical examination
3D/4D drawing
Dose delivery
Standard dose plan
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Vienna 1918 Clinical Evaluation
Drawing DiagramVienna 1918
Radiography
Since ~1983MRI Since 1998
Adler: Strahlentherapie 1918
CT i 1983
Painting
CT since 1983
Image-guided adaptive Brachytherapy
3D/4D imaging
Applicator insertionRepetitive Imaging
diagnosis, EBRT/ChT
3D/4D imaging
Contouring
Repetitive clin exam
+3D/4D drawing
Applicator Reconstruction
3D dose planning
Dose delivery
g
4
EBRTfrom 2D
to 3D
Avoidance of
„geographicalmiss“* posterior field
border * anterior field
border
Gerstner et al. R&O 1999 Zunino et al. IJROBP 1999
Technology Development: Higher conformity through IMRTBetter sparing of OAR (bowel/bladder)Higher chance for geographical miss
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Treatment Planning 2D vs 3D gIn Brachytherapy
Point A (since 1938)
2cm2cm
2cm 2cm
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Point A / target dose
84 Gy
84 Gy
60 Gy
D90 = 65 Gy
Point A / target dose
84 Gy
84 Gy
84 Gy
~ 500 Gy
D90 = 90 Gy
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Standard loading pattern
Optimized loading pattern
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Standard loading pattern
Optimized loading pattern
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Pattern of tumor regression: up to mid parametrium
Kirisits et al. IJROBP 2006
Dimopoulos et IJROBP 2007
The Vienna Applicator
IJROBP 2007
130
140
Median volume = 32 cm3 75 patients
80
90
80
90
100
110
120
HR
-CT
V D
90
sta
nd
ard
Standard
Target dose (Gy)
60 70 80 90 100 110 120
Sig
moi
d do
se
40
50
60
70
85 GyEQD2
50
60
70
0 10 20 30 40 50 60 70 80 90 100 110
Volume HR CTV, cm3
Violation of OAR constraint Tanderup 2007/2010
EQD2=10Gy
Dose constraint
10
140
O ti i d
Median volume = 32 cm3 75 patients
90
80
90
100
110
120
130
R-C
TV
D90
op
tim
ized
Optimised
Target dose (Gy)
60 70 80 90 100 110 120
Sig
moi
d do
se
40
50
60
70
80
85 GyEQD2
50
60
70
0 10 20 30 40 50 60 70 80 90 100 110
Volume HR CTV, cm3
HR
Violation of OAR constraint Application of needles
(Tanderup et al.2007/2010)
EQD2=10Gy
Dose constraint
Imaging And g gTarget Definition
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Stage IIB
At diagnosis
Pathology and TopographyStage IIB
Target Definition
Change of GTV and CTV with time (4D RT)
TumourCervixUterusParametriaOrgans at Risk
Stage IIB
At brachytherapy
Contouring and Dose Volume Assessment
Pathology and Topography
MRI: Initial tumour extension (3D RT)pattern of response (4D RT)