2010 poznan g guidi adaptive rt rcs sbrt

Adaptive RTRCS (Radiosurgery)

SBRT (Stereotactic Body RT)

G.Guidi, et.alMedical Physics Dpt. & U.O. Radiation Oncology Azienda Ospedaliero - Universitaria di Modena –

Policlinico“Fight” with the doctor...

..with Tomo will be possible?

Doctor

Physicist

Email: [email protected]

Email Private: [email protected]

Phone: +390594225699

mailto:[email protected]

mailto:%[email protected]

diapositiva 2G.Guidi, et.al.

MODENA HUB-SPOKE PROJECT (RADIATION ONCOLOGY HEALTH SERVICES)


TOSHIBA 4D LARGE BORE + VISION RT

4D RADIATION THERAPY …. NEXT VISION(4DRT & 4D TOMOTHERAPY)

TOMOTHERAPY + VISIONRT4D LINAC + ABC (ACTIVE BREATHING COORDINATOR) or OMC System


3D-IGRT HEALTH TECHNOLOGY ASSESSMENTS(13 REGIONAL RADIATION THERAPY CENTERS COLLABORATION)

HTA Report: In Press 2010


….. 1 Month

MADISON, Wis.--(BUSINESS WIRE)--Sept. 10, 2008—

TomoTherapy Incorporated (NASDAQ: TOMO)

“....Thanks to the perfect cooperation and planning between the hospital and TomoTherapy, we took delivery of our TomoTherapy system and just 30 days later

we were already imaging and treating our first patient.“ (S. Cencetti - MO)

FROM TRUCK (WITH TRICK) …. TO CLINICAL USE

30/04/2008


…… preliminary data are consistent with a better tolerance and lower acute toxicity of Tomotherapy treatment compared with other standard treatments using LINAC (3DCRT – IMRT –

RCS - SBRT)

Mesothelioma

H-N

Lymphoma

Pancreas

Prostate

Radiosurgery

Craniospinal

CLINICAL PRACTICE & RESEARCH AREA

Re-Irradiation

Lung

Total Lymphoid Irradiation

Total Body Irradiation

Lung - SBRTBilateral Breast

Multiple Lesions


Type of Plans

Daily Revision of the contouring and weekly re-planning. Enthusiastic results of the treatment, but too much complicated using the current version v.3x. and the DC2/3 cluster

Frequently are performed Adaptive evaluation of the treatment based on the daily MVCT of the patients


Plan Type vs. Treatment Time (s)


Pathology vs. Mean Treatment Time (s)


Pathology vs. Mean Couch Travel


Pathologies Details


Process and Workflow


ADAPTIVE: HAVING A CAPACITY FOR ADAPTATION Adaptive Strategies When How / What Time Consuming Advantages Disadvantages

External Patient Setup Daily

•Immobilization Device (i.e. Thermoplastic Mask)•Surface reposition system (i.e. VisionRT)

Fast

•Reproducibility•Re-Adjustment•Monitoring during treatment (i.e. VisionRT)

•External signal surrogate can not detect the real position of the internal organs•Immobilization device could be inadequate after few fractions

Internal Patient Setup Daily MVCTMVCT Resolution (2,4,6mm)

Images can detect the position of the internal organs and the good pre-delivery preparation of the patients

•Extra doses•Low Tissue Contrast•Local or global matching can change the X,Y,Z shift to apply to the patient

Multimodality Imaging(Fusion)

Daily

Not available with Tomotherapy SW, but possible off line with 3th part SW

HighPET, RMI, US, SPECT, Contrast Exams comparison and evaluationMultimodality evaluation

None

MVCT vs. kVCT•Daily

•Weekly

•Dose Re-Calculation on MVCT•Superimpose the dose delivered on new kVCT acquired (3th part SW)

•Long•Only for few patients•Cluster/Console occupancy

•Understand the current delivery of the plan•Evaluate the volume mismatch or over dosage

•Without 4DCT, PET, RMI images integration and/or contrast exams could be done incorrect assumption (i.e. target shrinkage)•Offline images evaluation could be unacceptable with patient delivery performance (e.g. incorrect Tx)

Translation & Rotation Daily Mutual information algorithmMedium (depend on demand and type of Tx)

•Faster if there are no critical structures•Adequate with big volume•Few different algorithm to evaluate soft tissue and bone tissue

•Anatomical global matching can provide abnormal shift of the patients due to the large volume of pixel used by the algorithm (i.e. cord failure position)•Anatomical local matching could lead to unexpected results on the dose distributions (i.e. Lung or liver dose distribution)

Re-ContouringDaily

Weekly

All the structureOnly the PTVOnly few structures (OARs)

Very highAdaptive evaluationEvaluate the real volume and condition

•For RS and SBRT misjudgments could do if used without considering some aspects (e.g. Shrinkage of the volume should be done using 4D tools and multimodality images

Re-Planning on MVCT/kVCT

Dailyweekly

•KvCt or MVCT•With/Without Re-Contouring•With/Without Deformations

High

•Evaluation of the daily delivery•Excellent evaluation tools in case of critical cases to monitoring and planning the strategy and follow-up o the Tx

No deformable considerationNo automatic toolsDose evaluation on MVCT density Table could create some misjudgments

SW/HW Compensation Daily

•Multimodality images•Deformable registration•Dynamic Jaws/MLC•Robotic Couch

Very High

•Excellent tools for evaluation and adaptive treatment•New era of RT techniques•Evaluation of the motion and shrinkage

At the moment not available, but possible very soon or with 3th part SW


How can Adapt? Multiple Workflow and end-points

Organ

Motion

Motion

Artifact

Patient setup

(+MVCT)

Target

Shrinkage

Organ

Change

Imaging/Multimodality

evaluations

Setup

mismatch

Immobilization device

Changed/Inadequate

Option 1


Users & Time Variable

1.kVCT2.MVCT3.kVCT+MVCT4.New kVCT

a.Dailyb.Weeklyc.Cycled.Others

Organ

Motion

Motion

Artifact

Patient setup

(+MVCT)

Re-Contouring

Target

Shrinkage

Organ

Change


evaluations

Setup

mismatch


Changed/Inadequate

How can Adapt? Multiple Workflow and end-points Option 2

MVCTkVCT

No Re-Contouring

Re-Contouring





Organ

Motion

Motion

Artifact

Patient setup

(+MVCT)

Target

Shrinkage

Re-Planning

Organ

Change


evaluations

Setup

mismatch


Changed/Inadequate


Absolute Effects

Differential Effects





Organ

Motion

Motion

Artifact

Patient setup

(+MVCT)

Re-Contouring

Target

Shrinkage

Re-Planning

Organ

Change


evaluations

Setup

mismatch


Changed/Inadequate






Organ

Motion

Motion

Artifact

SW & HW

Compensation

Patient setup

(+MVCT)

Re-Contouring

HW

compensation

Dynamic

Jaws

Couch

Compensation

Re-Planning

Target

Shrinkage

Re-Planning

Organ

Change


evaluations

Setup

mismatch


Changed/Inadequate

Functional & Biological

Approach

Theragnostic

Nanotechnology

Genetics, Etc….




1.kVCT2.MVCT3.kVCT+MVCT

4.New kVCT


Re PositioningPatient setup

(+MVCT)

Dose

Accumulation

Dose

Summation

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle





4.New kVCT


Re PositioningRe-ContouringPatient setup

(+MVCT)

Dose

Accumulation

Dose

Summation

No Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle





4.New kVCT



(+MVCT)

Dose

Accumulation

Dose

Summation

No Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle





4.New kVCT



(+MVCT)

Dose

Accumulation

Re-Planning

Dose

Summation

No Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle




Adequate

Fractionation

Change with

New fractionation





4.New kVCT


Re PositioningRe-Contouring

Contour

Deformation

Patient setup

(+MVCT)

Dose

Accumulation

Dose

Summation

Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle


K.Ruchala – Tomotherapy Inc.




4.New kVCT



Contour

Deformation

Patient setup

(+MVCT)

Dose

Accumulation

Dose

Summation

Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle

Dose

Deformation


K.Ruchala – Tomotherapy Inc.




4.New kVCT



Contour

Deformation

Patient setup

(+MVCT)

Dose

Accumulation

Re-Planning

Dose

Summation

Deformation

No Deformation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle

Dose

Deformation




Adequate

Fractionation

Change with

New fractionation



How can Adapt? Multiple Workflow and end-points







Organ

Motion


Contour

Deformation

Motion

Artifact

SW & HW

Compensation

Patient setup

(+MVCT)

Dose

Accumulation

Re-Contouring

HW

compensation

Dynamic

Jaws

Couch

Compensation

Re-Planning

Re-Planning

Dose

Summation

Deformation

No Deformation

Adequate

Fractionation

Change with

New fractionation

OARsTargets

1. Target

2. OARs

3. Target+OARs

4. Body

5. Specific Area

Dose Delivered

•Daily

•Weekly

•Cycle

Dose

Deformation

Target

Shrinkage

Biological Approach

Re-Planning

Organ

Change


evaluations

Setup

mismatch


Changed/Inadequate



Users & Time Variable Functional & Biological

Approach

Theragnostic

Nanotechnology

Genetics, Etc….


Question?

…and if some cancer cell it will not be treated due to the margin reduction or geographical missing or to the overestimation or underestimation of the dose delivery and to some “pioneer” adaptive strategies or clinical supposing without formal demonstrations by trials?

Believe or not Believe on Adaptive RT?

TOMOTHERAPY


WHAT SHOULD THE MARGIN BE?

Courtesy of Marcel van Herk – ESTRO IGRT Course 2009


1 -3 “

Easy” Le

sions

35 -50 m

in

(Room

Tim

e occ

upation)

3 “Com

plex” Le

sions

20-25 m

in

(Room

Tim

e Occ

upation)

MANAGEMENT AND OPTIMIZATIONHOW CAN I SAVE TIME …… (RADIOSURGERY)

Equivalence???

2 Radiosurgery using Tomotherapy =50 minutes = 1 Radiosurgery using LINAC + MicroMLC

2 Radiosurgery using Tomotherapy means 50 minutes of free slot at the LINAC available for 3DCRT = 4 Patients?

6 Patients (2 RS+4 pts. 3DCRT) treated at the center with 1 Tomotherapy + 1 LINAC vs. 2 RS treated with 2 LINACs using the same room occupation time


Debate RCS - (LINAC+microMLC vs. Tomotherapy)

LINAC + micro MLC Tomotherapy

Setup * Head Frame (Invasive) + Localization system Thermoplastic mask for RCS

Images (CT/PET/RMI)

•Head Frame and localization system compatibility sometime not available for PET/RMI or have some limitation with small CT bore •Some image artifacts due to the invasive head frame and screws

None limitation with thermoplastic mask

4DCT / fMRI studiesWith some head frame could not be possible dur to the long time of images acquisition (patient comfort)

Possible with thermoplastic mask

Collision (Patient and Equipments)

•With no coplanar beam could be possible some limitation especially with more 3 lesions•Some beam interference issues with Localization system•Many limitations in case of Arc techniques

None

IGRT•Complicated with Micro MLC + EPID•Possible with kV Cone Beam

•Available with MVCT•MVCT resolution imitated for some OARs (e.g. Chiasm, Lens)

Planning

LINAC limitation:•Dose Rate (MU/min) – Frequently must be splitted the arc due to the maximum MU deliverable•Gantry angle•Couch angles•MLC dimension and beams eye view•MLC velocity•Small field dose profiles and Output factor•Algorithm of calculation

•No limitation for RCS also with high dose per fraction•Some limitation due to the resample of the images to 256x256•The problem could be resolved changing the cluster resolution to 512x512)•Possible some volume error calculation (e.g. Lens)

Multiple Lesions

•Multiple isocenter•Multiple setup•Multiple plans•Intersection of doses in case of multiple lesion, frequently is a limitation for the total dose deliverable to the targets•Tunnel of dose

Single scan setup•Single delivery plan•None – Each lesions could be treated at specific doses prescribed by the doctors•Integral low doses due the rotation

Dose Algorithm Usually is a pencil beam or an evolution depend by the TPS Collapsed cone independently by the techniques

Adaptive calculation (post treatment) NOT Available Available

Time of treatment > 50min <25 min

*it is possible to reduce the issue introduced by the head frame and localization systems, but must be consider also the decrease of accuracy in case of RCS


Cord: 10 Gy < 0,03 %

RADIOSURGERY RE-TREATMENT (16-24Gy / Fx @ 95% of the Volume)(PREVIOUS WBRT 30 Gy / 10 FX + RS WITH MicroMLC+LINAC 18 Gy /1 Fx – CORD DOSE : 42 Gy )

Using Field Width = 1cm and the cluster resolution with 512x512 image matrix,

it could be possible to decrease the dose by 30% in 1-2mm

Radiosurgery(18-24Gy /1 Fx)


Meningioma (45Gy / 15fx) …

BrainBrainstem 3 Gy

Not RCS but interesting with Tomotherapy


RE-IRRADIATION: HEAD & NECK(Standard: 54 Gy / 27 Fx - Hyper-fractionation: 54Gy / 36Fx)



TEMPORAL LESIONS CLOSE TO VITALS OAR(PTV1:55GY/30FX - PTV2 :66GY/30FX)

Brainstem

Optical Nerve<56Gy

Cord<35Gy



25 m

in

45-6

0 m

in

MANAGEMENT AND OPTIMIZATIONHOW CAN I SAVE TIME …… (STEREOTACTIC BODY RADIATION THERAPY)

Equivalence???

2 SBRT using Tomotherapy =50 minutes = 1 SBRT using LINAC + MicroMLC

2 SBRT using Tomotherapy means 50 minutes of free slot at the LINAC available for 3DCRT = 4-5 Patients?

6-7 Patients (2 SBRT +4-5 pts. 3DCRT) treated at the center with 1 Tomotherapy + 1 LINAC vs. 2 SBRT treated with 2 LINACs using same room occupation time


Debate SBRT - (LINAC+microMLC vs. Tomotherapy)

LINAC + micro MLC Tomotherapy

Setup * Body Frame + Localization system Thermoplastic mask with abdominal compressor

Images (CT/PET/RMI)Body Frame and localization system compatibility sometime not available for PET/RMI or have some limitation with small CT bore

None limitation with thermoplastic mask

4DCT studies With some body frame could not be possible Possible with thermoplastic mask

Collision (Patient and Equipments)

•Frequently with no coplanar beam•Some beam interference issues with Localization system and Body Frame•Many limitations in case of Arc techniques

None

IGRTComplicated with Micro MLC + EPIDPossible with kVCT

Available with MVCT

Planning

LINAC limitation:•Dose Rate (MU/min) – Frequently must be splitted the arc due to the maximum MU deliverable•Gantry angle•Couch angles•MLC dimension and beams eye view•MLC velocity•Small field dos profiles

No limitation for SBRT also with high dose per fraction

Multiple Lesions

•Multiple isocenters•Multiple setup•Multiple plans•Intersection of doses in case of multiple lesion, frequently is a limitation for the total dose deliverable to the targets

Single scan setup•Single delivery plan•None – Each lesions could be treated at specific doses prescribed by the doctors•Integral doses due the rotation

Dose AlgorithmUsually is a pencil beam or an evolution depend by the TPS

Collapsed cone independently by the techniques

Adaptive calculation (post treatment) NOT Available Available

Time of treatment > 50min <25 min

*it is possible to reduce the issue introduced by the body frame and localization systems, but must be consider also the decrease of accuracy in case of SBRT


Healthy Right Lung: 20 Gy to 10

%

BTVPTV

Right Bronchus

SECONDARY LUNG CANCER RELAPSED AFTER RFAMULTIMODALITY IMAGE FUSION (SIB: BTV 55 Gy / 5 Fx - PTV 40 Gy / 5 Fx )


4D CONTOURING FOR SAFETY PLAN….Paediatric treatment: 14Gy: 7Gy/fx

Dosimetric results for paediatric patients using Tomotherapy… …. with SBRT using LINAC was a problem due the anesthesia and body frame

Lung

Cord


SBRT Multiple Lesions (48Gy / 4 fx)

Rib

Lung

Cord


LUNG ADAPTIVE DOSE CALCULATION (Where are the differences? Images?)

May be:

1.Dosimetric error due to the algorithm?

2.Target delineation

3.Target Movement (Intra/Inter fraction)

4.Dose Lung Estimation

5.Dose at the interface (Bone/Lung/Fat)

6.Volume effect (image down sampling)

7.MVCT vs. kVCT

8.Morning Dose Output

9.Plan Optimization and Parameters?

10.Operators

• Doctor

• Physicist

• Therapist


LUNG ADAPTIVE DOSE CALCULATION (Where are the differences?)

May be:

1.Dosimetric error due to the algorithm?

2.Target delineation

3.Target Movement (Intra/Inter fraction)

4.Dose Lung Estimation

5.Dose at the interface (Bone/Lung/Fat)

6.Volume effect (image down sampling)

7.MVCT vs. kVCT

8.Morning Dose Output

9.Plan Optimization and Parameters?

10.Operators

• Doctor

• Physicist

• Therapist


IMAGING INTERFRACTION – INTRAFRACTION (MVCT1 vs MVCT2)

1. Different target dimension?

2. Is Day1 vs. Day2? (Interfraction)

3. Is Time1 vs. Time2 (Intrafraction)

4. Is the tumor shrinkage ?

5. Is the duty cycle? (Breathing)

6. Different dose calculation?

a) Where? In tumour or OAR?

7. Change the dose due to the OARs or Tumour position?

8. Isn’t it during the respiration breathing?

9. Why should i do a MVCT before and after the treatment?

10. Why should I believe at the MVCT of multiple days?

11. Is important the Volume effect for goals of the entire treatment?

12. …………………………………


LUNG ADAPTIVE (CAVITY COMPLEXITY)

Cavity at the beginning

Cavity after 5 fx


Site

Room Time MVCT Time Beam-On Time

Average

Min

MaxAverag

eMin Max

Average

Min Max

H-N 26,2 13 53 3,2 1,4 6,7 8 3,4 14

Thorax 35 23 50 3,5 2,5 6,2 11 7,6 15,6

Prostate

23 13 40 2,3 1,3 5,3 8,2 3,2 14,8

Global Average: 25,6 ± 8,7 minutes

MACHINE TIME MANAGEMENT

PHILOSOPHY OF THE CLINICAL AND TIME MANAGEMENT

Complex cases treated at the Tomotherapy Unit…..

….Treatment time is not a must…

…Room time occupation is not a must….

…Plan must cover the clinical requirements….

… with Tomo I have to resolve something otherwise complicate at the LINACs

By Guidi - Bertoni2008


LUNG OTHER CASES (No SBRT)Not SBRT but

interesting with Tomotherapy


SPINAL SARCOMA (PTV 70 Gy / 35 FX)

VERTEBRA (PTV 30Gy)

BODY RADIATION THERAPYPALLIATIVE CASES

Not SBRT but interesting with Tomotherapy


SPINAL METAL PROSTHESIS(Using MVCT)

H&N (PTV1:70Gy PTV2:64 Gy PTV3:54 Gy / 33

Fx )

Cases where Adaptive RT could be a need


ABDOMINAL TREATMENT (PTV 22,5 GY / 15 FX )

Kidney R.

Liver

Cord

Kidney L.

Not SBRT but interesting with Tomotherapy


PET FUSION & CT EXHALE & CT INHALE …. PROBLEMS HIDDEN

4DCT vs. PET(GTV4D= Red Contour)

4DCT vs CT with Max Inhale(GTV Max Inhale=Yellow contour)

4DCT vs CT with Max Exhale(GTV Max Exhale Green Contour)


4DCT - MOTION MANAGEMENT4DPET - MULTI MODALITY IMAGE FUSION


ADAPTIVE RADIATION THERAPY AND MOTION MANAGEMENT(4D-ART: RESEARCH AREA)

Target

Motion


Motion Artifacts


Result : difference of 0.08Gy (<1%) for one fraction of 5Gy after commissioning

The problem is the reliability and stability of the MVCT during the time…

The degradation of the target and the detector can change the data…

(UNDER INVESTIGATION)

MVCT SUITABLE FOR ART DOSIMETRIC EVALUATION, BUT….

Trend of decreasing


……During treatment, the weight loss of 11 kg has changed the anatomy…….The dosimetric evaluation calculated for re-contoured volumes on MVCT shows…..

20 % of left parotid gland vol. received 0,01 Gy / Fx less

5% of PTV vol. received 0,01 Gy /F less and a maximum of 0,06 Gy /F more (1%Vol)

H&N ADAPTIVE CALCULATION STRATEGIES (Case I)


H&N ADAPTIVE CALCULATION STRATEGIES (Case II)

……During treatment, the weight loss of 15 kg has changed the anatomy…….The dosimetric evaluation shows high dose increase anywhere…

…The MVCT Daily check can guaranties the quality of the treatment changing and re-planning before any dosimetric error

5% of PTV vol. received from 0.06 to 0,1 Gy /Fx anywhere


GATING vs. TRACKING(Breathing Model)

Tracking

XRay XRay

Tracking

XRay XRay

1° Point Of View

(Create Model)

2° Point Of View

(Reproduce the Model)

What’s happen inside?

With Tracking, you don’t know!


You need Marker

May be the Xray doesn't see the tumours

You need makers!!

Asynchrony of the model, means a mistake

You don’t see anything inside....

.....you believe in your model


GATING VS. TRACKINGBreathing surrogates could be a worst way to treat patients

Tracking

XRay XRay

Tracking

XRay XRay

Outside Point Of View Inside Point Of View


With Tracking you don’t know

Need to synchronize the beamIf you lost the synchronization,

than you will not treat any tumours

You don’t see anything inside....

... you believe than you treat the tumours


ORGAN MOTION: BASIC CONCEPT, PROBLEMS AND ISSUES

3DCRTStatic Target

3DCRTDynamic Target

NO Motion evaluation

4DRTDynamic Target

4DRT technologies

Internal Marker TrackingDynamic MLCRobotic Couch

Organs Motion Compensation

Daily Adaptive RT

3DCRTDynamic Target

4DCT Motion Evaluation (ITV)

“4DRT”Dynamic Target

4DCT Motion Limitation

Phases beam-on 20-60%Abdominal Compressor

MIP 4DCT ReconstructionDeformation analysisDose accumulation

Reduce margins ??? Are you sure it is a good solution for patients?


4D CONE-BEAM & 4D DOSE ACCUMULATION & ORGAN DEFORMATION & SHRINKAGE

Courtesy of Marcel van Herk& J-J Sonke – ESTRO IGRT Course 2009


THE DUEL ...... Which is the best plan, which are the best parameters

1.Same Patients

2.Same Doctor

3.Same Contours

4.Same Constrains

5.Same Target Objectives

6.Different Point of View

7.Which is the best plan?

Lele


DVHs COMPARISON (AHHGGGG!!!!......)

May be, compare DVH is not the best way to compare technologies...

....and for sure is not the right way to compare the clinical outcome

Doctor must look at the clinical outcome!!

Technologies will show to you what you want!!!


ESCHER : DIFFERENT POINT OF VIEW


OVERDOSED – UNDERDOSED(LOW DOSE LEVEL)

Lung Dx: Overdosed Target: Underdosed

Objectives (1°PoV)

• Save Healthy Lung

• Minimize Integral Dose

• OARs Objectives

• Treat Target

Objectives (2°PoV)

• Target Objectives

• OARs Objectives




OVERDOSED – UNDERDOSED(HIGH DOSE LEVELS)

Objectives (1°PoV)



• OARs Objectives

• Treat Target

Objectives (2°PoV)

• Target Objectives

• OARs Objectives



Lung Sin: Overdosed Target: Underdosed


PATIENT SYSTEMATIC & RANDOM SETUP ERROR EFFECT(2mm of shift close to the tumours)

Lung analysis

Which is the best plan after 5 fx or 25 fx?


PROTON - THERAPY ..... (Proton-Tomo?)

Few questions in my mind.....may be I need to change my mind!!!...are we sure about the dose calculation? Is there any clinical impact or benefit vs. Tomotherapy with Photons...we will try to investigate the problems comparing photon (using Tomotherapy) and proton a collaboration with CNAO , ATrep and National Mesothelioma group

Stability of the dose calculation due to the variation of the density during motion……

Simulation of Protons Treatment with multiple gantry angles between -20 to 120°(by G.Guidi 2009)

PTV1=85Gy

PTV2=60Gy

Cord<40Gy

I hope, one day, to work with Protons (by G.Guidi 2010)


TAKE HOME MESSAGES (I)

• 4D Motion have many issues– Multi-modality images (4DCT-4DPET-4DMRI-fMRI-4DUS…….)– Target Delineation– Organ Movement (Interfraction – Intrafraction)– Organ Constrains– Fractionation based on Evidence Base Medicine data

• Multiple approach can be done for the same plan– 4D Tracking / Gating– Different plan optimization parameters (Robustness)– Clinical objectives

• Doesn't exist a best plan a best way– DVH is not the “absolute true” vs. Imaging multimodality– Plan can not be robust due to the setup and organ movement (dose can change)– Many issues for the physicist

• Dose calculation• Algorithm• Adaptive strategies....

• Integral dose and prescription must be consider

– Woman fertility (Breast and contra lateral breast)– Second cancer induction– Paediatric patient– .... – IGRT Dose is a problem, but anyone consider the same problem for the ARC Therapy?

– Is it possible the ADAPTIVE RT? (YES!!!)


TAKE HOME MESSAGES (II)

• Tomotherapy– Innovative machine– Faster and relatively easily to implement– Flexible for clinical routine and requirements– Easy way to treat complex cases

• Morphological area have not or few limitations– Target Delineation– Organ Movement (Interfraction – Intrafraction)– Organ Constrains– Fractionation based on Evidence Base Medicine data

• Multiple approach can be done and can be found– Different plan optimization parameters (Point of View)– Clinical objectives– 4D Tracking / Gating (Research area)– RCS and SRBT are very easy to treat and could have an Adaptive RT approaches– No invasive system and/or frame needs

• Doesn't exist a best plan or a best machine– DVH is not the “absolute true”– Plan can not be robust due to the setup and organ movement (dose can change)

• Daily patient check should be a must for the future (Setup, dose and adaptive re-plan)

• Management– Full optional should be a must also for Tomotherapy Inc. (Dynamic Jaws, Deformation Software,

etc… should be available for all customers due the unique characteristic of the machine)– Service full risk also for upgrade and update– 3 th part software can help to resolve few problems of obsolescence of the system, but Adaptive RT

need a total integration to reasonably be used in clinical routine

It is not perfect, but it’s a “good” technology to try to fight the cancer or ADAPT the treatment!!


ACKNOWLEDGES

“… under the “Ghirlandina” Tower….…..new opportunities and ideas are growing

……and many people are working on it”

4D

Physicist(Lele)

Doctors

Medical Physics Dpt.Director: T.Costi

Physicist:• G.Guidi• E.Cenacchi• G.GottardiDosimetrist• A.Bernabei• L.Boni• L.MoriniContract Physicist• P.Ceroni

Doctor:• A.Bruni• G.De Marco• P.Giacobazzi• M.Parmiggiani• S.Pratissoli• S.Scicolone• G.Tolento• E.Turco• All thereapist

U.O. Radiation OncologyDirector: F.Bertoni

Special Thanks to Elisa, Luciano

Will I see a 4D Tomotherapy Treatment?

In my mind: “Thank you guys, without you would not been possible this!Special Thanks to Luca and Marcello

about the 4D and Adaptive Time


“That’s too much!!!”(Praha 2009 : Tomotherapy Meeting)

THANK YOU FOR YOUR ATTENTION AND INVITATION

2010 poznan g guidi adaptive rt rcs sbrt

Documents

daily mvct

mvct re

shrinkage evaluation

weekly mvct

tx adaptive evaluation

patient mvct resolution

weekly replanning

weekly recontouring