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![Page 1: New Multimodal Imaging for Radiotherapy and its Benefit.icrp.org/docs/icrp2017/15 Gregoire Presentation.pdf · 2017. 10. 11. · FRCR (IE) Radiation Oncology Dept. Head and Neck Oncology](https://reader036.vdocuments.us/reader036/viewer/2022071109/5fe469990d27cc4a175ba875/html5/thumbnails/1.jpg)
ICRP, Oct. 2017
Multimodal Imaging for Radiotherapy
and its Benefit.
Vincent GREGOIRE, MD, PhD, hon. FRCR (UK), hon. FRCR (IE)
Radiation Oncology Dept. Head and Neck Oncology Program &
Center for Molecular Imaging, Radiotherapy and Oncology,
Université Catholique de Louvain, St-Luc University Hospital,
Brussels, Belgium
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ICRP, Oct. 2017
Myths and facts in Oncology: the challenge
of local therapies
Chemotherapy
Surgery
Surgery +radiotherapyRadiotherapy
not cure(local recurrence)
not cure(distal recurrence)
37%
18%
5%
22%
6%12%
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ICRP, Oct. 2017
Table of Content
• Set the scene
• Multimodality imaging
• Future prospects
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ICRP, Oct. 2017
From X-rays …
Discovered in 1895 and
immediately used for the
treatment of cancer…
Why so quickly?
Surgery was the only
option but it was not
armless…
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ICRP, Oct. 2017 Q-T Le, CCR, 2015
Evolution of Radiation Delivery
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ICRP, Oct. 2017
Arc therapy: the linac is constantly rotating while the coach is moving
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ICRP, Oct. 2017
Protontherapy
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ICRP, Oct. 2017
Protontherapy
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ICRP, Oct. 2017
Target volume: clinical examination
T1a glottic larynx T3 supra-glottic larynx
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ICRP, Oct. 2017
Evolution of Target Volume/normal
anatomy definition
Clinical judgment
Planar imaging
Multi-modal anatomic imaging
Molecular imaging
Single-modality anatomic imaging
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ICRP, Oct. 2017
3D- Reconstruction
Small intestine
Bladder
Target Volume
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ICRP, Oct. 2017
Oropharyngeal SCC
T2-N0-M0
SIB-IMRT: 30x2.3 Gy
30x1.85 Gy
PRV Spinal cord
Left parotidRight parotid
Larynx
PTV 55.5 Gy
PTV 69 Gy
IMRT for Head and Neck Tumors
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ICRP, Oct. 2017
Table of Content
• Multimodality imaging
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ICRP, Oct. 2017
• Gross Tumor Volume: GTV
Target volumes in Radiation Oncology:ICRU 50, 62 and 83:
ICRU report 62, 1999
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ICRP, Oct. 2017
Multimodality imaging for target visualisation
Gadolinium-enhanced T1 FatSat Contrast-enhanced CT (bone window)Courtesy of Th. Duprez
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ICRP, Oct. 2017
Multimodality imaging for target visualisation
Courtesy of Th. Duprez
CE T1-W (fat Saturated) T1-W (fat Saturated) ConeBeam CT scanner
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ICRP, Oct. 2017 Courtesy of L. Renard
11c-methionineCE-CT
T1-MRI FLAIR-MRI
Multimodality
imaging for target
visualisation
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ICRP, Oct. 2017 Courtesy of X. Geets
Multimodality imaging for target visualisation
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ICRP, Oct. 2017 Courtesy of K. Haustermans
T2w MRI DCE MRI
DW MRI: b1000 DW MRI: ADC map
11C-Choline PET-CT
MRS
Multimodality imaging for target visualisation
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ICRP, Oct. 2017 Courtesy of K. Haustermans
Multimodality imaging for target visualisation
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ICRP, Oct. 2017
R/ PET-based IMRT treatment
MR T2
FDG-PET based target volume delineation
CT MR T2 FS
FDG-PET
CT
CT-based IMRT planning
No difference in target volume conformity: p = nsLeclerc & Grégoire, R&O, 2015
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ICRP, Oct. 2017 S. Differding, RO, 2017
SCC oropharynx: T4b-N0-M0 – FDG-PET-CT
Imaging the target: intra-tumour heterogeneity
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ICRP, Oct. 2017
• Clinical Target Volume: CTV
Target volumes in Radiation Oncology:ICRU 50, 62 and 83:
ICRU report 62, 1999
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ICRP, Oct. 2017
Of 88 slides from 10 patients with oral cancers, 44 (50%) had signs of microscopic
extension. The maximum distance from the border was 7.8 mm. Ninety-nine percent of
all MD was within 4.75 mm and 95% was within 3.95 mm of the GTV.
Campbell et al. IJROBP, 2012
From primary tumor GTV to CTV
Geometrical margins
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ICRP, Oct. 2017
#
A
P
RL
From macroscopic (GTVP) to microscopic (CTVP)
target volumes
Grégoire, 2017
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ICRP, Oct. 2017
CT-based delineation of lymph node levels in the
neck (revised version 2013)
Gregoire et al., 2013
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ICRP, Oct. 2017 27
II
Ib
Ia
Va
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ICRP, Oct. 2017 Grégoire, 2014
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ICRP, Oct. 2017 Brouwer et al., 2015
Imaging the Organ at Risk
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ICRP, Oct. 2017 Brouwer et al., 2015
Multimodality imaging for Organ at Risk visualisation
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ICRP, Oct. 2017 DAHANCA.dk
Thirty years of progresses: the Danish example
Courtesy of Overgaard 2015
Standard 2013
Standard 1985
Loco
-reg
ion
al c
on
tro
l
1985
2013
2D
IMRT
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ICRP, Oct. 2017 Peters et al, JCO 2010
Clinical Impact of Radiotherapy Compliance
(TROG 02.02)
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ICRP, Oct. 2017
Table of Content
• Future prospects
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ICRP, Oct. 2017 Weersink et al Med. Phys 38 6458, 2011 Weersink, US Patent: 9,138,597
And in the “foreseeable” future…Augmented reality?
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ICRP, Oct. 2017 Weersink et al Med. Phys 38 6458, 2011 Weersink, US Patent: 9,138,597
Contour tumor visible in
endoscopic imageProject onto 3D “Virtual Image”
Clinical Impact: Endoscopic Contouring
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ICRP, Oct. 2017
Radiomics for treatment individualization
Yip, PMB, 2016
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ICRP, Oct. 2017
Multidisciplinary
Tumor board
From care to the “average” …
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ICRP, Oct. 2017
… to personalized care
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ICRP, Oct. 2017
"Here's my sequence..."
Nature, 2000
One patient …
One disease …
One treatment …