maria do carmo lopes, tiago ventura, miguel capela ipocfg ... · icaro 2, vienna, austria, 20-23...
TRANSCRIPT
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO-RADIOSURGERY: What do we gain, what do we lose comparing to Linac based SRS?
Maria do Carmo Lopes, Tiago Ventura, Miguel CapelaIPOCFG, E.P.E., Coimbra, PORTUGAL
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
1. RADIOSURGERY at IPOCFG – different phases and experience
2. TOMO-RADIOSURGERY vs. LINAC BASED SRS – a planning study
3. TOMO-RADIOSURGERY - what do we gain, what do we lose?
OUTLINE
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Cones
1996-2003
Conformal Dynamic Arcs- micro-MLC
2008 - 2016
Localizing system from Fischer-Liebinger
Since Nov. 2016
RADIOSURGERY at IPOCFG
Tomotherapy (IMRT)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Fame fixation
Planning CT acquisition
Micro-MLC positioning and machine QA
Structures delineation and treatment planning
Patient localization and treatment
LINAC BASED SRS – Steps of the procedure
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Metástase65%
Neurinoma16%
Meningioma6%
Adenoma4%
MAV5% Outro
2%
498 Lesions
Metástase
Neurinoma
Meningioma
Adenoma
MAV
Cavernoma
Glioblastoma
Outro
LINAC BASED SRS – Total number of treated lesions
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
240 Metastases study (2014)
Lesions
104 1
43 2
11 3
3 4
1 5
11 1+1
1 2+2
1 1+1+1
2 1+2
1 1+3
1 2+3
Total 240
46%
25%
6%
10%
3%10%
Primary pathology
Pulmão
Mama
Melanoma
Coloretal
Gástrico
Outro
64%
26%
7%
2%
1%
Nº of lesions- 240; Nº of patients- 162
1
2
3
4
5
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
22%
73%
240 Metastases study (2014)
Andrews DW et al., 2014, Lancet
Minniti G et al, 2011, Rad. Onc.
Molenaar R et al, 2009, J.Neurosurg.
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMOTHERAPY (Since April 2016)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO-SRS (2005 – 2010)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
During the last decade…
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
HYPERARC (Varian) Dynamic Wave Arc (VERO)
Or even…
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
• 26 treated cases• 6 groups of lesions:
• GROUP I - VPTV > 7 cm3
• GROUP II - 3cm3< VPTV < 7 cm3
• GROUP III - 1cm3< VPTV < 3 cm3
• GROUP IV - VPTV < 1 cm3
• GROUP V – Close to brainstem
• GROUP VI - Neurinomas
A planning study
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO - Normal TOMO - High
Group II
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
V50%/V100% V20%/V100% V20%/V50%
HIGH 3,642 16,005 4,389NORMAL 4,692 19,817 4,221iPlan 3,002 9,776 3,249HIGH 4,756 23,761 5,031NORMAL 6,671 31,332 4,740iPlan 3,504 11,685 3,332HIGH 6,310 33,350 5,278NORMAL 8,631 44,213 5,098iPlan 4,246 15,086 3,550
HIGH 8,931 44,343 4,935NORMAL 12,238 57,776 4,670iPlan 5,400 18,855 3,488HIGH 5,012 27,620 5,483NORMAL 5,723 34,035 5,926iPlan 7,172 24,642 3,526HIGH 6,384 36,401 5,700NORMAL 8,106 45,910 5,659iPlan 4,611 17,290 3,740
GROUP IVPTV> 7 cc
GROUP II3< VPTV< 7 cc
GROUP III1< VPTV> 3 cc
GROUP IVVPTV< 1cc
GROUP VClose to
brainstem
GROUP VINeurinoma
GRADIENT INDEXES
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
0
2
4
6
8
10
12
14
Grupo I Grupo II Grupo III Grupo IV Grupo V Grupo VI
HIGH
NORMAL
iPlan
GRADIENT INDEX - GIIan Paddick, M.SC., and Bodo Lippitz, M.D. , J Neurosurg (Suppl) 105:194–201, 2006, A simple dose gradient measurement tool to complement the conformity index
Wilcoxon signed rank test for paired samples:Stat. signif. dif. between both NORMAL/HIGH and iPlan; also between NORMAL and HIGH
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
CONFORMITY INDEX - COIN
0,000
0,100
0,200
0,300
0,400
0,500
0,600
0,700
0,800
0,900
1,000
Group I Group II Group III Group IV Group V Group VI
HIGH
NORMAL
iPlan
V>7cc 3<V<7cc
1<V<3cc V<1cc Neurinomas
Close to Brainstem
Lomax NJ, Scheib SG. (2003) Quantifying the degree of conformity in radiosurgery treatment planning. Int J Radiat Oncolo Biol Phys. 55:1409-Van’t Riet A, et al.(1997) A conformation number to quantify the degree of conformality (…). Int J Radiat Oncol Biol Phys 37(3): 731-736Baltas D,, et al. (1998) A conformal index (COIN) (…). Int J Radiat Oncol Biol Phys. 40(2): 515-524
Wilcoxon signed rank test for paired samples:Stat. signif. dif. between both NORMAL/HIGH and iPlan; NS between NORMAL and HIGH
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Dmin
82,0
84,0
86,0
88,0
90,0
92,0
94,0
96,0
98,0
100,0
Group I Group II Group III Group IV Group V Group VI
HIGH
NORMAL
iPlan
V>7cc 3<V<7cc 1<V<3cc V<1ccNeurinomas
Close to Brainstem
Wilcoxon signed rank test for paired samples:Statistically significant differences between NORMAL and iPlan (p<10-5 )
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMOTHERAPY (Since April 2016)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO-SRS
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO SRS – Steps of the procedure
Mouth mold execution
Treatment planning
Patient specific QA
Image acquisition and structures delineation
Localization, IGRT andTreatment
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
TOMO-SRS
• 1 patient in ONCOR – 10 fractions• 2 doentes in TOMO – 10 fractions• 2 doentes em TOMO – 3 fractions• …• 1st patient in TOMO – 1 fraction !
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
FRAMELESS OPTION – Previous Immobilization study
TOMO-SRS – Intrafraction immobilization accuracy
-3
-2
-1
0
1
2
3
0 5 10 15 20 25 30
Tran
slat
ion
al (
mm
)
Lesion number
Lateral
Longitudinal
Vertical
(0,0±-0,3)
(-0,1±-0,5)
(0,0±-0,4)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
WHAT DO WE LOSE?• Conformity of low doses (steep dose gradients)• Based frame immobilization
WHAT DO WE GAIN?• IGRT with MVCT• Possibility to treat/plan in different days• Better conformity for irregular lesions even close to critical structures• Better target coverage (higher minimum dose)
WHAT IS COMPARABLE?• Total treatment time (?) – it depends on the number and lesions localization…• Patient confort ????
CONCLUSIONS: TOMO-SRS
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
6 weeks later
TOMO-SRS – first patient on November 11, 2016(already 35 treated lesions in 24 patients)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
6 weeks later
TOMO-SRS – first patient on November 11, 2016(already 35 treated lesions in 24 patients)
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017
Acknowledgement to:Tania Santos for the statistics analysis
Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017