d205 simpósio varian - true beam initial experience in humanitas

8/7/2019 D205 Simpsio Varian - True Beam initial experience in Humanitas

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FILIPPO ALONGI M.D.Istitutostituto Clinicolinico HumanitasumanitasRadiotherapyadiotherapy andnd Radiosurgeryadiosurgery Deptept..

Introduction and overview ofTRUE BEAM

initial experience in Humanitas


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Humanitasumanitas cancerancer centerenter


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Radiotherapyadiotherapy Departmentepartment

Technologies:4 linear accelerators (Varian) OBI and Cone Beam CT1CT simulator (Philips, Big Bore, 16 slice)5 Treatment planning systems (4 Eclipse+1Ergo)4D system for gated respiratory motionTools for radiosurgery and SBRT

TRUEBEAM

CT SIMULATOR

DHX- OBI, CBCT


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Lung

Gyn

Brain

Breast

Metastasis

GIGU

Other

Sarcomas

H & N

Radiotherapy@Humanitas in 2010adiotherapy@Humanitas in 2010

Patients treated in the last year in RT


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PrecisionAccuracyEfficiency

Whathat iss ourur strategytrategy ?

MultimodalityimagesCT/PET/MRI

IMRT andVMAT Radiosurgeryand SBRT

IGRT andadaptive RT


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Robotic controle of Positioning Unit (PU) and IsoCal

Three roboticarms

Responsible forimaging anddetector units

kV-Source

kV-Source

Arm

MV-DetectorArm

kV-DetectorArm

kV-DetectorHand holder

MV-DetectorHand holder

Gantry Side

Creates an ideal image guidancemachine by alignment of the imagingsystem to isocenter

True isocenter is a single pointwhich coincides with the kV/MV

rotation centers and where the centerof the imagers project

Specification for imager to treatmentisocenter is 0.5mm

Treatment iso

MV imaging iso

kV imaging iso


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RapidArc IMRT with FFF (10X: 24 Gy/min) Automated Simultaneous, synchronized control points

for all axes(MLC, MV beam, gantry, table, collimator, 3rd party, kVbeam)

Collimator and couch rotation during beam-on

Jaw tracking for IMRT and RapidArc

Table tracking, MLC tracking

Connected Multiple isocenter plans (e.g., SRS, longfields, imaging fields)

Preventive Collision detection during machine motion(safety)

Isocal: automatic alignement of imaging and Txisocentres

Not all features available at first releaseCourtesy of L. Cozzi

TRUE BEAM

Some appealing features - beam


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D1 D2D1 = D2

Flattering filter vs FF free

D1pre >> D2pre


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TRUE BEAM: Beams profiles6FFF 6X

10X10FFF


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Combined (kV-MV) single and continuous

Synchronous acquisition using both

modalities

Combined (kV during MV) single and

continuous

Combined kV-MV single and continuous

synchronised with gating

kV 4D CBCT

Not all features available at first release

TRUE BEAMSome appealing features - imaging

Courtesy of L. Cozzi


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TrueBeam Imaging Examples


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Not all features available at first release

Observe motions before AND duringtreatment

Fluoroscopy-based respiratory gatedRapidArc

Fluoroscopy based motion detectionfor anatomical target tracking

TRUE BEAMSome appealing features - imaging

Courtesy of L. Cozzi


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TrueBeam Imaging Examples

Courtesy of Zurig

Fluoro_during_RA_LUNG.wmv


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TRUE BEAMRUE BEAM clincicallincical potentialotential advantagesdvantages

GREATER PRECISIONREATER PRECISIONin:

Delivery high doses

Image guidance

Higher doses to thetumor(improves local control)

Increased possibility touse non conventionalfractionation (decreases

toxicity with SBRT)

Flatteringlattering Filterilter Freeree(FFF)FFF)New clincal application

New Radiobiology

implications


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TrueBeam@Humanitas

Installation 10/7-15/8/2010

Acceptance tests 16/8-20/8/2010

Commissioning 23/8-19/9/2010

1st patient 20/9/2010

Total patients 123 @31/12/10


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TRUE BEAM initial clinical experience

123 patients(68 with FFF) 98/123 pts completed the treatment.

Brain and CNS= 8ptsH&N= 4pts

Lung= 73pts(49pts FFF)20 pts >4 fr.(20Gy-30)53 pts 4 fr.(32-48Gy)

Abdomen =25pts-Liver 13pts (9FFF) (75 Gy/3fr)-Ln 7pts (45 Gy/6 fr.) (3FFF)-Other 5pts (pancreas=3, adrenal glands=2)Other sites =13pts (7FFF)


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PrecisionAccuracySelectivityEfficiency

Greater precision (isocentre


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TRUE BEAM Clinical applications

First patients with 10FFFirst patients with 10FFF


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TRUE BEAM initial clinical experiencewith FFF beam

49 SBRT for lung lesions:Doses: 32-48 Gy in 4 fract.Toxicity:1 case of G1 esophagitis

9 SBRT liver lesions:Doses: 75 Gy in 3 fract.Toxicity:1 case of G1 nausea/vomit

Acute toxicities: no G28 FFF treatments


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TRUE BEAM initial clinical experiencewith FFF beam

7 other sites in the body:Doses: various.Toxicity: none

3 SBRT for abdominal lymph nodes:Doses: 45 Gy in 6 fract.Toxicity: none

Acute toxicities: no G28 FFF treatments


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Truerue Beameam potentialotential applicationspplications:SBRT LUNGBRT LUNG

RESULTS

The survival rate for SBRT is potentially

comparable to that for surgery.

2010

Flattering Filter Free beams:Higher doses delivered moreprecisiously

TRUE BEAM

Vassiliev ON et al. Stereotacticradiotherapy for lung cancer using aflattening filter free Clinac.J Appl Clin MedPhys. 2009 Jan 27;10(1):2880.


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SBRT in lung: 12Gyx4;10FFF;DR 2400.

Heart: mean dose = 2.6Gy

Lung: mean dose = 7.5

Gy (left) 5.7 Gy (right)Spinal Cord: max dose =13.0 Gy

4D CT

2 isocentres

2 full arcs

Jaws tracking

MU: 3014+3606

BOT:75+91s


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Heart: mean dose = 3 Gy

Lung: mean dose = 2 Gy

(left) 8 Gy (right)

V5Gy = 40%

V20Gy = 8%

Esophagus: V33Gy ~ 0%

1 isocentres

2 partial arcs

Jaws tracking

MU: 2212

BOT: 2x 32 s

SBRT in lung: 6Gyx6;10FFF;DR 2400.


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ACCEPTED 2011

SBRT IN ABDOMINAL TARGETS

Stereotactic body radiation therapy for abdominal targets using volumetric intensitytereotactic body radiation therapy for abdominal targets using volumetric intensitymodulated arc therapy with RapidArc: feasibility and clinical preliminary resultsodulated arc therapy with RapidArc: feasibility and clinical preliminary resultsMarta Scorsetti,1 Mario Bignardi M,1 Filippo Alongi,1 Antonella Fogliata c,2 Pietro Mancosu 1 Piera

Navarria,1 Simona Castiglioni,1 Sara Pentimalli,1 Angelo Tozzi MD,1 Luca Cozzi,2

1 IRCCS Istituto Clinico Humanitas, Rozzano (Milano), Italy2 Oncology Institute of Southern Switzerland, Bellinzona, Switzerland

SBRT in abdominal TARGETSBRT in abdominal TARGETS


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Truerue Beameam potentialotential applicationspplications:SBRT LIVERBRT LIVER

75 Gy in 3 fractions

TRUE BEAM

Liver metastasis treatment in ICHRadioablation

RAPID ARC

Better precision more ablative doses?


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Humanitas LIVER SBRT protocolumanitas LIVER SBRT protocol

Organ at risk Dose constraints(for 3 fractions) Other conditions

Normal liver(total liver - CTV) > 700 cc at < 15 Gy Volume > 1000 cc

Spinal cord < 18 Gy -

Kidneys V15 Gy < 35%Heart < 30 Gy Esclusion criteriaCTV at < 8mm

Stomach, duodenum, smallbowel, principal biliar ducts < 21 Gy(Dmax) Esclusion criteriaCTV at < 8 mm


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Humanitasumanitas LIVER SBRTIVER SBRT protocolrotocol

Dose/fraction Numberfractions Median dose

Standard dose 25Gy 3 75 Gy

Dose reduction 10% 22.5 Gy 3 67.5 Gy

Dose reduction 20% 20. 63 Gy 3 61.89 Gy

Dose reduction 30% 18.75 Gy 3 56.25 Gy


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Humanitasumanitas LIVER SBRTIVER SBRT protocolrotocol


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CB_CT

Day I CB_CT

Day III

CT simulation & CB CTT simulation & CB CT

Basal

ArterialphaseVenous

phase

Late Venous

phase


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Humanitasumanitas protocolrotocol


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SBRT with Rapid ArcBRT with Rapid Arc

Simulation CT

CT pos

CT pre

F, 62y, liver met, 75 Gy/3 fr


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FFF vs FF for liver metastases

13 liver lesion patients 25 Gy for 3 fractions optimized on PTV Variable PTV volumes (20 to 300cc) 4 plans/patient: FFF with collimator at 10 and 45

FF with collimator at 10 and 45

Parameters:

PTV Conformity Index

HT mean dose

CTV mean dose

%95

%95

_

_

VPTV

VBodyCI

FFFbetter sparing on HT

FF

For target best solutiondepends on lesionvolume


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FF coll 45

FFF coll 45

FFF vs FF for liver metastases

Reggiori ESTRO 2011 submitted

20-70cc 71-110cc 111-200cc

20-70cc 71-110cc 111-200cc


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1 isocentre, 1 arc

Jaw tracking

Spinal cord max dose = 17.3 GyRight kidney mean dose = 3.9 Gy

Liver mean dose = 15.7 Gy

Stomach mean dose = 19.3 Gy

SBRT liver with TB: 25Gy x 3; 6FFF; DR 1200.

MU: 5642

BOT: 137 s


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1 isocentre, 3 arcs

Jaw trackingPTV1&PTV2: V95%=99.5%

Spinal cord: Max dose=17.3 Gy

Stomach: Max=21.0Gy, Mean=9.5 Gy

Liver: Mean=15.5 Gy, D15Gyfree=712cc

SBRT liver: 25Gy x 3; 10FFF; DR 2400.

MU:3216+3527+563

BOT: 80+82+14s


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Prospective Phase II multicentric study of SBRTfor liver metastases

From December 2009 to December 201024 patients (21 with Rapid arc, 3 FFF with TBFFF with TB)

16 total dose, 8 reduction of dose to 30%

Only 1 acute toxicity gr2 (vomiting)

Increase ofGT in 5 patients without altered hepatic function

Median FU: 8 months

7 CR - 4 PR - 5 SD - 5 PD (local, out of treatment volume)


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SBRT abdominal lymph nodesBRT abdominal lymph nodesAbdomen:LN mts

2009

2010

DOSE: 45 Gy/ 6 Fr


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1 isoc, 1 arcsJaws tracking

MU: 1065

BOT: 66 s

Rectum mean dose = 9.9 Gy

Femoral heads mean dose = 1.6 Gy

SBRT: 3.5Gyx10;6FFF;DR 1200.


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1 isoc, 1 arcs

Jaws tracking

MU: 1697

BOT: 60 s

Kidneys mean dose = 1.5 Gy

Spine: max dose = 7.5 Gy

SBRT: 7.5Gyx6;10FFF;DR 2400.


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Other special techniques: Total Marrow Irradiation (TMI) Partial Breast Irradiation

Vertebral re-treatments

Cervico-facial district re-treatments

Whole brain irradiation withintegrated boost on cerebral lesions.

Intensity Modulated Radio Therapy(IMRT) and Image Guidance (IGRT):

Locally advanced lung tumour Pleuric mesothelioma Breast irradiation with Simultaneous

Integrated Boost

Cervico-facial district neoplasiae

Esophagus tumours

Pre operatory rectum cancer

Radical and post-operatory prostatecancer

Vertebral metastasis with spinal cordsaving

Otherther Clinicallinical Applicationspplications


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Nasopharynx re-treatment: 6Gy x 5; 10FFF; DR 2400.

MRI

PET

1 iso, 2 arcs

Jawstracking

MU:925+1105

BOT:60+60s


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Nasopharynx re-treatment: clinicalresponse

Pre-RT

Pre-RT After 45days


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1 isoc, 1 arcs, 4 lesions

Jaws tracking

MU: 1523

BOT: 68.4 s

Optical nerves max dose = 10.5 Gy

Brainstem mean dose = 7.5 Gy

SBRT brain: 6Gy x 4; 6FFF; DR 1200.


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A second protocol is in assessment: TMLI in lymphomaFirst patient treated on October 26:

TMLI for Hodgkin lymphoma stage IVB.

Marrow stem cell transplant from his son.

Low intensity conditioning + ciclophosphamide

PTV TML: 2.2 Gy. PTV boost: 2 GyDelivery on TrueBeam with 10 arcs and 5 isocentres.

10 MV photons

Lower legs with AP-PA fields.

Both plans are summed in Eclipse,

AP-PA used as base dose plan for RA

Pre-treatment QA done with MatriXX and PortalImaging

Image guidance: CBCT at every isocentre

TotalTotal MarrowMarrow LymphLymph--nodenode IrradiationIrradiation -- 11

First patient treated


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Good dose homogeneityand good QA results

PTV: V2Gy=99.8%

HT: mean dose=1.2Gy

Total Marrow LymphTotal Marrow Lymph--node Irradiationnode Irradiation -- 33


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Phase II trial

Total marrow irradiation (TMI) using VMAT-Rapid Arc as part ofpreparative regimen for allogeneic stem cell transplantation and

autologous stem cell transplantation

Primary objective and end-point:

Response Rate: CR and PR

100-d treatment related mortality

Secondary objective and end point: OS,

PFS, response rate, incidence of severe

toxicities (grade III/IV)

Pre-clinical phase:

In silico evaluation of planning

techniques and delivery accuracy

Age 18-65. 2x36 patients

Allogenic: Acute Myeloid Leukemia

Autologous: Multiple Myeloma relapsed afterautologous stem cell transplantation

Allogenic regimen: 12 Gy TMI + Fludarabine,

Busilvex, ATG

Autologous regimen: 12 Gy TMI + Melphalan

100mg/m2

Total Marrow Irradiation with TrueBeamTotal Marrow Irradiation with TrueBeam


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TRUE BEAM: CONCLUSIONTRUE BEAM: CONCLUSION

IMPROVE

CLINICALOUTCOME

CONE BEAM

SBRT with FFF

delivery

RAPID ARC

VMAT delivery

PATIENT BASED APPROACHPATIENT BASED APPROACH

FLUOROSCOPY


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TRUE BEAM TEAM:TRUE BEAM TEAM: ThanksThanks!!!!!!

d205 simpósio varian - true beam initial experience in humanitas

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