IMRT: dal presente al futuro L esperienza italiana

IMRT: dal presente al futuro L esperienza italiana Giuseppe Scielzo U.O.A. Fisica Sanitaria Ordine Mauriziano Reggio Emilia, 14-15 Ottobre 2003

Contents IMRT in Italy - AIFM BEV -AIRO BEV - OEV

Breaking the ice... I M artist in dose painting

AIFM journal Bollettino AIFM

Istituzione del gruppo IMRT-AIFM Incontro istitutivo del gruppo IMRT-AIFM il giorno Venerdì 17 Gennaio 2003 AIFM IMRT group

Bologna, 27 th March 2003 Multimodality Imaging Dosimetry IMRT AIFM group Quality assurance A computational approach on IMRT Radiobiological modelling and doseresponse function

UOA Radiobiologia clinica Università di Firenze Casa di cura S. Chiara - Firenze: Dynamic μmlc ERGO GAFchromic MD55 and Exradin micro-chamber Clnical experiences on IMAT IEO - Milano μmlc BrainLAB and 3D-Line dmlc. 60 dynamic arc stereotacties and 70 prostates Problem in leaves speed with BrainLab Ospedale S. Anna - Como TPS Varian-Eclipse Clinac 6EX Millenium 120MLC sliding window X-Omat V, EDR2, EPID and diodes linear array PMMA and anthropomorphic RW3 phantoms Bologna, 27 th March 2003

Istituto Regina Elena Roma TPS Helios-Cadplan Varian Clinac 2100CD 120-MLC Millenium sliding window LoSasso protocol pre-treatment QA with Films (evaluated with Gamma function) and ionization chamber IMRT executed on H&N and prostate Tests on maximum leaf speed vs predicted position IRCC di Candiolo e Ospedale Umberto I - Torino TPS Varian Helios-Cadplan Varian Clinac 600CD 120-MLC Millenium sliding window LoSasso protocol pre-treatment QA with films and ionization chamber 21 patients IMRT in complex cases: the aim is dose escalation and OAR sparing Bologna, 27 th March 2003

Ospedale S.Giovanni Calibita Fatebenefratelli Isola Tiberina - Roma TPS Helios-Cadplan 2X 2100CD Varian 80-MLC sliding window LoSasso protocol pre-treatment QA with Films, MapCheck and ionization chamber Fluence verification every 10 sessions Vicenza TPS Pinnacle step & shoot pre-treatment QA with Films and Exradin A14SL tests for small fields and small MU (down to 1 MU) Monte Carlo tests Bologna, 27 th March 2003

Firenze-Careggi TPS RenderPlan Elekta with 80-MLC step&shoot pre-treatment QA with films and ionization chamber (home-made software for evaluation) prostate patients Reggio Emilia TPS Helios-Cadplan Varian Clinac 600CD 80-MLC and Clinac 2100CD 120-MLC Millenium sliding window LoSasso protocol pre-treatment QA with films and ionization chamber 80 patients IMRT for high conformation and fractionated treatment SMART Bologna, 27 th March 2003

Vicenza ESTRO Meeting 2003 Talks and poster @ Geneva 90 116 DMLC & IMRT verification Monte Carlo verification... Reggio Emilia Torino Milano 152 154 238 239 267 292 295 Clinical exp of IMRT... Clinical exp of IMRT... Monte Carlo verification... Monte Carlo verification... IMRT implementation... Ion chamber for IMRT... IMRT implementation...

AIRO IMRT Group e.g. Quality assurance in IMRT

Gruppo AIRO IMRT Treated disease Immobilization devices Imaging Treatment planning Pre-treatment plan verification Treatment verification (and frequency) Tolerance limits on positioning Documentation on immobilization Immobilisation devices storage and conservation Quality manual

IMRT in Italy Great opportunity of starting something new together Will IMRT guide the exploitation of several relevant good things that already exist in all the radiotherapy chain? Insight view in the clinical practice and a glance into the crystal ball

IMRT present & future p overall infrastructure PACS+R&V+RIS p imaging multimodality p treatment planning & dose calculation p virtual vs real simulation p patient positioning and IGRT p delivery system p treatment verification p tumor response and radiobiological model

Overall infrastructure Integration and verification! Record and verify + RIS + Radiology PACS

Infrastructure for IMRT Treatment segment Workstation segment CLINAC 2100C/D CLINAC 2300C/D CLINAC 600C/D Varis server Verification Interface Verification Interface Treatment workstation Treatment workstation VerificationTreatment Interface workstation Vision server H U B H U B 9 Varis workstations 9 Vision workstations RT Simulator PLATO PINNACLE CADPLAN FOCUS Hospital LAN Hospital RIS Radiology and Nuclear Medecine PACS

DICOM standard for images INTEROPERABILITY & CONNECTIVITY TC Radiotherapy Simulator PACS TC Image diagnostic RM DR - Computed Radiography - Direct Radiograph - Computed Tomography - Digital Mammography Medical Physics DICOM types Nuclear medecine PET - Magnetic Resonance - Ultrasound - Secondary Capture - Nuclear Medicine γ camera

DICOMRT standard for radiotherapy Exomio Soma-Vision RTPX Umberto I e IRCC XIO-Focus 2 Cadplans IRCC Focal IRCC Cadplan Umberto I Pinnacle Plato Focal Umberto I DICOM-RT stucture DICOM-RT plan RT Structure set RT Plan RT Image DICOM RT RT Dose RT Beams Treatment Record, Brachy Treatment Record, Treatment summary record

Imaging multimodality CT MRI PET fmri MRSI electron density proton density morpho-functional metabolism morpho-functional CT-PET morpho-functional + anatomical Molecular Imaging

Image registration and fusion CT- MRI CT- PET Merging of anatomical-morphological information The future: Autocontouring? Courtesy of Kessler

Morphofunctional imaging: MRSI Brain - Standard MRI imaging - Spectroscopy on VOI Prostate - 3D Maps of metabolites concentration - Quantitation - Search of metaboilte peaks: Myoinositol Choline Creatine N-acetilaspartate Lipids Lactate Citrate

Morphofunctional imaging: PET Tumor staging GTV, PTV delineation Tumor response

Biological target

Treatment planning & dose calculation Inverse planning technique Dose calculation algorithms

Inverse Planning Cost function Search technique Dose calculation Optimisation with: geometrical uncertainties beam angle EUD TCP/NTCP

Dose calculation for IMRT High dose and density gradient Pencil beam Superposition/convolution Monte Carlo Geant4 Parallelised Monte Carlo Simulation on Beowulf Cluster of IMRT treatmnent Grant AIRC2001-02

Simulation Simulation: real vs virtual

Virtual vs real 2D visualization Fast acquisition Target and OAR are not clearly seen on projection 3D visualisation and rendering of target and OAR Low cost (no simulator needed) Correct set-up between CT and treatment Integration with imaging, TPS and machine Automatic isocentre positioning with mobile laser

Patient positioning Immobilization system Verification

Immobilization system Courtesy of Agosti Van Herk,,1998 Termoplastic mask Stereotactic system

Image Guided Radiotherapy Courtesy of Yan 4D treatment planning

Treatment verification Real time verification of -Isocenter -Dose distribution Dosimetry - matrix of ion chamber - amorphous Silicon

New delivery system Cyberknife On line organ motion monitoring with infrared tracking system and X-ray stereo-imaging

Courtesy of Francescon

New delivery system Tomotherapy On line simulation contouring and treatment with CT like MV source

Tomotherapy unit Courtesy of Webb Courtesy of Tomotherapy Inc

New delivery system IMPT Protontherapy and hadrontherapy in Italy???? Courtesy of Lomax

DVH and dose distribution 3D-CRT IMRT protons Thanks to Cozzi Fogliata 120% 100% 80% 60% 40% Midollo Parotide sin 20% Parotide des PTVI 0% PTVIII 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 120 100 80 60 40 20 0 PTVIII PTVI midollo

Tumor response and radiobiological model Immobilization system Verification

Tumor response and radiobiological model Some radiobiological issue in IMRT Dose distribution in the target less homogeneous than in 3DCRT greater number of MU: greater leakage polmone vescica dose paint: hypoxic regions? α/β ratio: prostate case esofago KAB ---- LBK integral dose unchanged polmone s=0.0061 esofago s=3.4 vescica s=1.3 Courtesy of IFO-Roma

And the future? All is possible: just do it. Thanks