RADIOTHERAPY Giovanna Mantello

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1 F The impact on RADIOTHERAPY Giovanna Mantello AOU Osp. Riuniti Ancona

2 RADIOTHERAPY OF PULMONARY LESIONS INTENSITY MODULATION HIGH GRADIENT DOSE DOSE ESCALATION IPOFRACTIONATION STEREO BODY IMRT IJROBP 2005, 63(1):179 TAKAJAMA K, IJROBP 2005, 61(5):1565 WOLF J, IJROBP 2004, 60(1):186

3 O R G A N M O T I O N

4 - QUANTIFY - COMPENSATE - REDUCE PTV IM SM CTV interfraction SET UP ERROR ORGAN MOTION intrafraction ORGAN MOTION OAR

$interfraction SET UP ERROR$

5 IMAGING inside BUNKER ON BOARD IMAGER Clinac 21 EX RX tube max 150 kv Flat panel asi

6 kv DRR kv DRR kv 2D/2D MATCH kv -DRR

7 CBCT 3D/3D MATCH CBCT-CT sim Bone = isocentre surrogate on line adjustement of Set Up

8 CBCT 3D/3D MATCH CBCT-CT sim on line correction of interfraction OM

$of interfraction$

9 CBCT

10 INTRAFRACTION OM = IT S NOT CORRECTED BY CBCT

11 SO WHAT CAN WE DO TO STUDY AND TO CORRECT INTRAFRACTION OM

12 INTRAFRACTION Organ Motion measure reduce A) A) general interventions patient feedback, either auditory or or visual B) B) control the the tumor motion abdominal compression breath holding C) C) allow free free tumor motion but butmaintain a constant target position in in the the beam s eye eyeview when the the beam is ison: respiratory gating beam tracking couch-based motion compensation

C) allow free free tumor motion but butmaintain a constant target position in in the the beam s

13 MEASURE RX FLUOROSCOPY

14 MEASURE CT Exhale + CT Inhale EXHALE INHALE ITV EXHALE INHALE

15 MEASURE CT 4D End-exhale Mid-exhale Mid-inhale End-inhale ITV

16 End-exhale Mid-exhale Mid-inhale End-inhale >Margin = dose at healthy lung Tumor Dose Lung Dose 5 y local control rates increase 1.3 % for every 1 Gy above 70 Gy ( Kong FM - IJROBP 2005) Constraints to limit the risk of RP (QUANTEC IJROBP 2010)

17 INTRAFRACTION ORGAN MOTION : WHICH MARGIN? free breathing INSP EXP ADAPTED MARGIN free breathing ABDOMEN CONSTRICTION Breath hold Free breathing GATING Free breathing TRACKING

18 MARGIN REDUCTION by ABDOMEN CONSTRICTION

19 MARGIN REDUCTION by BREATH HOLD exp Active Passive ACTIVE BREATHING CONTROL DIBH insp BEAM ON FREE BREATH HOLD WITHOUT MONITORING

20 MARGIN REDUCTION by TUMOR TRACKING TECHNIQUES

21 MARGIN REDUCTION by RESPIRATORY GATING INSP BEAM ON EXP INSP BEAM OFF

22 RESPIRATORY GATING = RADIOTHERAPY SYNCRONIZED WITH RESPIRATORY CYCLE Marker box Shift = respiratory motion surrogate INSIDE BUNKER On console

23 RESPIRATORY GATING PATIENT SELECTION SIMULATION Work flow PLANNING SET UP AND DELIVERY

24 RESPIRATORY GATING REPRODUCIBILITY PATIENT SET UP : correspondence of isocentre/bone + TUMOR SET UP : reproducibility of home position overlapping track: sim = treatment Tumor in BEV (gated fluoroscopy + gated kv)

25 Diagnostic fluoroscopy EVALUATION OF LESION MOTION PA OBL LAT

26 SIMULATION INSIDE BUNKER COACHING AUDIO VIDEO FEED BACK TRACK ACQUISITION FLUOROSCOPY ACQUISITION

27 FLUOROSCOPY and TRACK analysis FLUOROSCOPY FIELD: GANTRY 20 OBL ANT SX

28 TUMOR MOTION vs EXTERNAL MARKER MOTION ATTILO ALDINA SCOPIA OBL A SX Spostamento (mm) 6 4 SURROGATO LL TARGET (+y=mediale) CC TARGET (+y=caudale) OBL A SX Tempo (s)

29 GATING TYPOLOGY ampiezza fase - Phase / amplitude INSP/ ESP TECHNIQUES -Gating window - Respiratory device audio - video How to choose the gating window? (beam on) best compromise between residual motion (min) and duty cycle (max) to warranty the right time to deliver the right dose.

30 GATING TYPOLOGY PHASE vs AMPLITUDE ampiezza fase fase fase fase

31 TRACK ( PATIENT ADAPTED DATA) DATI TRACCIATO RESPIRATORIO: Tempo di inspirazione= 2.8 s Tempo di espirazione= 4.9 s Periodo respiratorio= 7.7 s DATI FINESTRA DI GATING: Finestra scelta: 90%-10% Duty Cycle= 21% Increase Treatment Time= X 4.8 Gated Motion= 3.9 mm IMPOSTAZIONI AUDIO SIMULAZIONE: Automatico Inhale increment = 0.5s Exhale increment = 0.5s TIPOLOGIA GATING = FASE - INSPIRAZIONE

32 INSPIRATORY PROSPECTIVE CT insp eu

33 Residual motion measurement: MARGIN CTV - ITV ATTILO ALDINA SCOPIA OBL A SX Spostamento (mm) Tempo (s) SURROGATO OBL 20 TARGET (+y=mediale) CC TARGET (+y=caudale) GATE Treatment plan

34 SET UP inside BUNKER : CBCT patient position verify SET UP ERROR CORRECTION

35 SET UP inside BUNKER tumor home position verify COACHING TO HAVE pre treatment TRACK = simulation TRACK +/- Simulation track

36 SET UP inside BUNKER: TUMOR home position verify gated kv gated fluoroscopy BEAM ON BEAM OFF TO VERIFY TUMOR POSITION INSIDE SELECTED GATING WINDOW

37 Gated PVI during RT to confirm tumor home position TO VERIFY TUMOR POSITION INSIDE SELECTED GATING WINDOW

38 PVI cine to confirm home position TO CONFIRM CORRECTNESS OF PRE- TREATMENT RESIDUAL MOTION EVALUATION

39 TREATED PATIENTS DEPT RADIOTHERAPY OF ANCONA 35 patients treated for pulmonary nodule by IGRT (LINAC 21ex) 15/35 evaluated for respiratory GATING - target motion > 5 mm - peripheral primary lesions in non-operable patients - single metastatic lesion - close connection with OAR (heart) to keep off the lesion to heart - target = left breast 10/35 really treated by GATING

40 CASE CASE AA Single metastasis in pneumectomy patient

41 CASE CASE BB Lung tumor in heart patient

42 CASE CASE CC Retrocardiac mass Insp GATING BEAM ON BEAM ON GATED PVI

43 CASE CASE DD LEFT BREAST RT VOLUME POLMONARE TOTALE EUPNOICO 2404 cm 3 INSPIRATORIO 4893 cm 3 POLMONE SN EUPNOICO 1095 cm 3 INSPIRATORIO 2222 cm 3 DENSITA POLMONARE EUPNEA 0,374 g/cm 3 INSPIRAZIONE 0,162 g/cm 3 gated fluoroscopy gated PVI Beam On

44 Take home RESPIRATORY GATING : 1. Lesion shift > 5 mm at least in a spatial coordinate 2. Optimal visualization of target (directly or by implanted markers) during simulation and treatment 3. Clinical advantage Patient selection 4. Good patient compliance

45 Take home RESPIRATORY GATING : advantage Reduce ITV / Reduce pulmonary density/ Reduce dose at healty lung To keep off target to OAR disadvantage Increase of time for planning and delivery (physisist and physician ) > time inside bunker for the patient > linac occupacy > quality assurance of device > dose for imaging

46 The importance of reproducibility Take home of home position

47 Take home The importance of reproducibility of home position +/- - camera position - Bunker light coaching marker box Position and Angle

48 Take home The importance of reproducibility of home position CT Acquisition

49 WARNING!! The MOTION OF EXTERNAL SKIN MARKER IS ONLY A SURROGATE OF RESPIRATORY CYCLE ATTILO ALDINA SCOPIA OBL A SX 12 evaluate correlation between marker motion and tumor Spostamento (mm) SURROGATO LL TARGET (+y=mediale) CC TARGET (+y=caudale) Tempo (s)

50 Conclusions?

51 Conclusions measure reduce A) A) general interventions patient feedback, either auditory or or visual B) B) control the the tumor motion abdominal compression breath holding C) C) allow free free tumor motion but butmaintain a constant target position in in the the beam s eye eyeview when the the beam is ison: respiratory gating beam tracking couch-based motion compensation

52 Conclusions INTRAFRACTION ORGAN MOTION free breathing INSP EXP ADAPTED MARGIN free breathing ABDOMEN CONSTRICTION Breath hold Free breathing GATING Free breathing TRACKING

Innovative RT SBRT. The variables with REQ in superscript are required.

Innovative RT SBRT. The variables with REQ in superscript are required. The variables with REQ in superscript are required. The variables with a are single-select variables; only one answer can be selected. The variables with a are multi-select variables; multiple answers