Discussion Items. Discussion Items. Medicare Benefits Schedule. Image Registration in Radiotherapy: Consider the Costs as well as the Benefits

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1 Image Registration in Radiotherapy: Consider the Costs as well as the Benefits Kevina Choma Central Area Health Services Cancer Care Services - Medicare Benefits Schedule

2 The ability to better visualise the GTV and PTV CT based PTV PET based PTV The ability to better visualise the GTV and PTV Account for tumour motion through duration of scan Reduced interobserver variations Reduction in PTV size for some patients leading to dose escalation CT MRI image fusion: delineation of the clinical target volume (CTV) and critical organs. Red line, CT CTV; yellow line, MRI CTV; blue line, rectum (CT); green line, bladder (CT). Choose the best technique Mismatching non-rigid structures Sannazzari, G., Ragona, R., Redda, M, Giglioli, F., Isolato, G., Guarneri, A., (2002), CT-MRI Image Fusion for Delineation of Volumes in Three- Dimensional Conformal Radiation Therapy in the Treatment of Localized Prostate Cancer. The British Journal of Radiology, 75:

3 Choose the best technique Mismatching non-rigid structures Image Resolution differences between modalities Window levels Image Registration Workload

4 Image Registration Workload by Modality Tumour Type per Modality -PET Tumour Type per Modality-MRI Tumour Type per Modality -CT Start-up Costs Treatment planning system $1,600,000 Data transfer system $12-30,000 Flat Top Couch $20,000 Stabilisation equipment $10,000 Wall mounted lasers $19,500 Same equipment for RT dept $10,000 Staff Training approx 56 FTE hours

5 Ongoing Costs Imaging study $800 Patient travel/inconvenience up to ~ $600 RT staff in MI department 25FTE hrs/month Registration and QA 15FTE hrs/month Opportunity costs 25 less patients simulated/month 40 FTE hrs/month RO QA time RO voluming time Ongoing Costs Increased complexity of planning and treatment Ongoing staff training ~ 11/2 FTE hrs/month Poor registrations reduced value to patient and increased time involved in performing registration Work Processes Collaboration with Medical Imaging department Use of PET transmission scan for registration Alignment of patient appointments Limitation on staff who can perform registrations Use the PET transmission scan as the planning study Use of software based mutual information algorithm Conclusion The use of image registration potentially benefits patients having radiation therapy treatment provided it is used correctly. Demand for this tool is increasing Thanks for your attention Thank you to Greg Rattray for advice and helping with the images Important to develop and maintain processes to ensure quality and cost effectiveness

6 References 1. Department of Health and Aging, Medicare Benefits Schedule Book (2007), Australian Government, Canberra, ACT. 2. Lavrenkov, K., Christian, J., Partridge, M., Niotiskou,E., Cook, G., Parker, M., Bedford, J., Brada, M. (2007), A Potential to Reduce Pulmonary Toxicity: The Use of Perfusion SPECT with IMRT for Functional Lung Avoidance in Radiotherapy of Non-Small Cell Lung Cancer. Radiotherapy and Oncology, 83: Rajasekar, D., Datta, N., Gupta, R., Pradhan, P., (2003), Multimodality Image Fusion in Dose Escalation Studies of Brain Tumours. Journal of Applied Clinical Medical Physics, 4(1); Harrison,R., (2006), Imaging in Radiotherapy Treatment Planning and Delivery. The British Journal of Radiology, 79: S1. 5. Lagerwaard,F., van de Vaart, P., Voet, P., Nijssen-Visser, M., Schuchhard-Schipper, H., Joosten, H., Oei, S., Senan, S., (2002), Can Errors in Reconstructing Pre-Chemotherapy Target Volumes Contribute to the Inferiority of Sequential Chemoradiation in Stage III Non-Small Cell Lung Cancer? Lung Cancer, 38: Senan, S., De Ruysscher, D., (2005) Critical Review fo PET-CT for Radiotherapy Planning in Lung Cancer. Critical Reviews in Oncology/Hematology, 56: Moureau-Zabotto,L., Touboul, E., Lerouge, D., Deniaud-Alexandre, E., Grahek, D., Foulquier, J., Petegnief, Y., Gres, B., El Balaa, H., Kerrou K., Montravers, F., Keraudy, K., Tiret,E., Gendre, J., Grange, J., Houry, S., Talbot, J., (2005), Impact of CT and 18 F-Deoxyglucose Positron Emission Tomography Image Fusion for Conformal Radiotherapy in Esophageal Carcinoma. International Journal of Radiation Oncology Biology Physics, 63(2): Fox, J., Rengan R., O Meara,W., Yorke,E., Erdi, Y., Nehmeh, S., Leibel, S., Rosenzweig, K., (2005), Does Registration of PET and Planning CT Images Decrease Interobserver and Intraobserver Variation in Delineating Tumor Volumes for Non-Small-Cell Lung Cancer. International Journal of Radiation Oncology Biology Physics, 62(1): Riegel, A., Berson, A., Destian, S., Ng, T., Tena, L., Mitnick, R., Wong, P., (2006), Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using CT and PET/CT Fusion. International Journal of Radiation Oncology Biology Physics, 65(3): Breen, S., Publicover, J., De Silva, S., Pond, G., Brock, K., O Sullivan, B., Cummings, B., Dawson, L., Keller, A., Kim, J., Ringash, J., Yu, E., Hendler, A., Waldron, J., (2007), Intraobserver and Interobserver Variability in GTV Delineation on FDG-PET-CT Images of Head and Neck Cancer Patients. International Journal of Radiation Oncology Biology Physics, 68 (3): References 11. Zelefsky, M., Yamada, Y., Fuks, Z., Zhang, Z., Hunt, M., Cahlon, O., Park., J., Shippy, A., (2008)Long-Term Results of Conformal Radiotherapy for Prostate Cancer: Impact of Dose Escalation on Biochemical Tumor Control and Distant Metastases-Free Survival Outcomes. International Journal of Radiation Oncology Biology Physics, Article in Press (February 2008): Kuban, D., Tucker, S., Dong, L., Starkschall G., Huang, E., Cheung, R., Lee, A., Pollack, A., (2008), Long-Term Results of the M.D. Anderson Randomized Dose-Escalation Trial for Prostate Cancer. International Journal of Radiation Oncology Biology Physics, 70(1): Rengan, R., Rosenzweig, K., Venkatraman, E., Koutcher, L., Fox, J., Nayak., R., Amols, H., Yorke, E., Jackson, A., Ling, C., Leibel, S., (2004), Improved Local Contol with Higher Doses of Radiation in Large-Volume Stage III Non-Small-Cell Lung Cancer. International Journal of Radiation Oncology Biology Physics, 60(3): Wulf, J., Baier, K., Mueller, G., Flentje, M., (2005), Dose-Response in Stereotactic Irradiation of Lung Tumors. Radiotherapy and Oncology, 77: Rasch, C., Barillot, I., Remeijer, P., Touw, A., van Herk, M., Lebesque, J., (1999), Definition of the Prostate in CT and MRI: A Multiobserver Study. International Journal of Radiation Oncology Biology Physics, 43(1): Sannazzari, G., Ragona, R., Redda, M, Giglioli, F., Isolato, G., Guarneri, A., (2002), CT-MRI Image Fusion for Delineation of Volumes in Three-Dimensional Conformal Radiation Therapy in the Treatment of Localized Prostate Cancer. The British Journal of Radiology, 75: Lips, I., Dehnad, H., Kruger, A., van Moorselaar, J., van der Heide, U., Battermann, J., van Vulpen, M., (2007) Health-Related Quality of Life in Patients with Locally Advanced Prostate Cancer after 76 gy Intensity-Modulated Radiotherapy vs 70gy Conformal Radiotherapy in a Prospective and Longitudinal Study. International Journal of Radiation Oncology Biology Physics, 69(3): Greco, C., Rosenzweig, K., Cascini, G., Tamburrini, O.,(2007), Current Status of PET/CT for Tumour Volume Definition in Radiotherapy Treatment Planning for Non-Small Cell Lung Cancer (NSCLC). Lung Cancer, 57: Sarkar, A., Santiago, R., Smith, R., Kassaee, A., (2005), Comparison of Manual vs Automated Multimodality (CT-MR) Image Registration for Brain Tumours. Medical Dosimetry, 30(1): Ireland, R., Dyker, K., Carber, D., Wood, S., Hanney, M., Tindale, W., Woodhouse, N., Hoggard, N., Conway, Robinson, M., (2007) Nonrigid Image Registration for Head and Neck Cancer Radiotherapy Treatment Planning with PET/CT. International Journal of Radiation Oncology Biology Physics, 68(3): Come to Australia for 16 th ISRRT World Congress Gold Coast - Australia Tomorrow and Beyond: Connecting and Communicating 9 12 September, 2010 For enquiries events@air.asn.au See us at the booth in Durban 2008