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Tomoterapia: esperienza dell’Ospedale

S. Raffaele e prospettive future

F. FAZIO

IBFM-CNR, University Milano-Bicocca, H.S.Raffaele

Milano

CONFORMAL RT TECHNIQUES

3D-conformal-RT FORWARD PLANNING

Static

Dynamic

Tomotherapy (helical IMRT)

IMRT INVERSE PLANNING

Helical Scan/Delivery: accurate tomographic target segmentation

TomoTherapyHi-ART System

Helical Scan/Delivery

Helical Delivery

Axial 0.2 mm error in table indexing

Helicalpitch 0.5

Axial correct table indexing

HELICAL TOMOTHERAPY

HELICAL TOMOTHERAPY MACHINE :

combination of

• Inverse treatment planning system

• Automated moving couch

• Linear accelerator : 6 MV photon beam rotating gantry

• Binary MLC : slice thickness beam of 0.5-5 cm

• MV-CT scanner : xenon detectors for 3.5 MV ( detuned ) photons

HELICALDOSEDELIVERY

SET-UP/DOSEDELIVERYVERIFICATION

Energy Fluence Sinogram: highly conformed dose distribution

BeamIntensity

Bea

m d

irec

tion

& c

ouch

pos

ition

Leaf #

3D-CRT Tomotherapy

R.C. 65 yrs; prostate carcinoma HSR Milan

3D-CRT Tomotherapy

HSR MilanA.C. 76 yrs; lung carcinoma

IMRT

HSR MilanA.C. 76 yrs ; oropharynx carcinoma

Tomotherapy

RT TARGET OPTIMIZATION at HSR

IMRT

helical IMRT(TOMOTHERAPY)

High conformaltreatment planning / delivery

MLC

PET/CTBiological TargetVolume

IMMOBILIZATIONDEVICES

RESPIRATORY GATING (4D)

Correction forbody/organ motion

PET/CT in RT planning

a) Patient selection

b) Biological Target Volume (BTV)

Lung cancer

Pt referred to RT radical treatment

HSR Milan

Lung cancer

PET/CT evidence of adrenal metastasis:esclusion from RT radical treatment

HSR Milan

[18F]FDG-PET in M staging

Author Tumor Site Sens Spec

Valk (1999) Colon Liver 95% 100%

Pieterman (2000) Lung Various 82% 93%

Hellwig (2001) Lung Adrenal gland 96% 99%

Bury (1998) Lung Bone 92% 98%

Ohta (2001) Breast Bone 78% 98%

PET evidence of unknown metastases in 6%-17% of cases *

* Lardinois D et al. NEJM 2003

PET/CT in RT planning

a) Patient selection

b) Biological Target Volume (BTV)

PET/CT: BTV definition ( GTV )

Atelectasic Area

Viable Tumor

HSR Milan

PET/CT-based BTV ( GTV )

Fused PET/CT:Lung lesion withoutpathologicallymph-nodal uptake

CT:Lung lesion + Lymph-node with diameter > 10 mm

HSR Milan


CT PET/CT

TREATMENTPLAN

PET/CT-based TTCT-based TTHSR-Milan

CT:Lymph-nodeswith diameter < 10 mm

Fused PET/CT:Pathologicallymph-nodal uptake


HSR Milan

Impact of PET in radiation therapy: lung cancer

Co-registration29%52%81%21Messa2005

Co-registration36%64%100%11Erdi2002

Co-registration--22%22%30Mah2002

Co-registration--41%41%12Giraud2001

Qualitative35%--35%34Nestle1998

Qualitative--34%34%35Munley1999

Qualitative34%18%52%105Debois1998

Qualitative--27%27%15Kiffer1998

PET/CTGTVGTVModifiedGTVPatientsAuthor

RT TARGET OPTIMIZATION at HSR

IMRT



MLC

PET/CTBiological TargetVolume

IMMOBILIZATIONDEVICES



TOMOTHERAPY : WORKFLOW

Patient immobilization

Vacuum pillow * Thermoplatic mask ** MedTec

Immobilization devices : 6±3 3±3 mm set-up errors

RESPIRATORY GATINGRespiration control during PET/CT

Target volume with precise motion information

TREATMENTUNDER

RESPIRATION CONTROL

PET/CT : BTV and OARs definition

BTV

OAR

HSR-Milan

Treatment Planning

HSR-Milan

Dosimetry

Calculated/delivered dose correspondence verificationHSR-Milan

Treatment

kV-CT

( Reference Image )MV-CT

( TomoImage )

AutomaticRegistration

Patient repositioning and treatmentHSR-Milan

Baseline 50 GyGA , 66 yrs

NSCLC

PET/CT

MVCT/kVCT

Tomotherapyplan

HSR-Milan

50 GyGA , 66 yrs

NSCLC 60 Gy

MVCT/kVCT

Tomotherapyplan

Initial plan

HSR-Milan

TOMOTHERAPY PROTOCOLS AT HSR

a) Physics and dosimetry

b) Clinical protocols

Tomotherapy:

Acceptance test procedures and Quality Assurance Program

• during ATP all parameters were below the pre-defined tolerance levels

• QA results indicated good reproducibility of all helical tomotherapy mechanical/dosimetric performance

ESTRO meeting 2005

Tomotherapy and head&neck cancer:

dosimetric comparison with IMRT

• better coverage of PTVs and greater homogeneity within PTVs

• better sparing of parotids (Dav 20.8 Gy vs 26.2 Gy)

ESTRO meeting 2005

Tomotherapy and NSCLC: dosimetric comparison with 3DCRT

• 6 pts NSCLC, stage III

• Planned dose: 61.2-70.2 Gy, 1.8 Gy/f

26%18%Lung, V30

<16%<16%Heart, V45

<40 Gy<40 GySpinal cord, Dmax

27 Gy23 GyOesophagus, Dav

83%93%PTV , V100%D

3DCRTTomotherapy

ESTRO meeting 2005


a) Physics and dosimetry

b) Clinical protocols

Tomotherapy and retreatments

Case 1: Head&Neck cancer

Case 2: Metastatic breast cancer

CASE 1

• Male, 67 yrs

• previous EBRT on neck for hypopharynx cancer (1992)

• Relapse at soft palate (PTV1), right pterygoid region (PTV2) and rightparapharyngeal tissue (PTV3)

Tomotherapy planPET/CT

Radical Tomotherapy: 60 Gy, 2 Gy/f on PTV1,2,3

ESTRO meeting 2005

CASE 2

• Female, 50 yrs with metastatic breast cancer previously treated withChemoTRP and hormonal TRP

• previous RT on left breast, supraclavicular fossa, internal mammarian LN (1991) and chest wall (2003)

• mediastinal LN relapse

Tomotherapy plan

Radical Tomotherapy: 60 Gy, 2 Gy/f on PTV

ESTRO meeting 2005

PET/CT 2 months after TTPET/CT baseline

HSR-Milan

TARGET OPTIMIZATION IN RADIOTHERAPY


IMRT


MLC

Biological TargetVolume

PET/CT


IMMOBILIZATION DEVICES


HYPOFRACTIONATION


13 Gy3radicalI/II , mts

> 8 5radicalmax 4 , < 3cmLIVER MTS

1.8-2.1535radicalIVa/b

RETREATMENTS

LUNG MTS

PROSTATE

PANCREAS

LUNG

H&N

SITE

III

IIIa/b

varvarradicalvar

> 6

2.9

> 3.2

2.5

2

1.8-2.15

Gy / fn fractions

20adjuvantpT3pN0

radical

radical

radical

radical

adjuvant

INDICATION

6max 3 , < 3cm

15

25

35

30

SCHEDULESTAGE

Tomotherapy and locally advanced pancreatic cancer

• pancreas adenocarcinoma T4N0

• 5 FU c.i.

PTV

Tomotherapy

plan

Radical Tomotherapy: 60 Gy, 2 Gy/f on PTV

ESTRO meeting 2005

Tomotherapy and prostate cancer

• 20 pts

• 58 Gy, 2.9 Gy/f

• PTV, V95%D: 96%-99%

• rectum, Dav: 26.5 Gy ( 24-31 )

• bladder, Dav: 34 Gy ( 21-40 )

• femurs, Dmax 17-30 Gy

• Gastro-intestinal toxicities >G1 : 0%

• Genito-urinary toxicities G2: 18%

CLINICAL CASE (prostate cancer)

• prostate adenocarcinoma pT3apN0

• adiuvant Tomotherapy: 58 Gy , 2.9 Gy/f

HSR-Milan

TT TREATMENTS ( NOV 2004 – SEP 2005 )

5 9 6

47

4 1 15

50403020100

H&Nlung

ancre

as

rostat

eng mts

vermts

other

p p lu li

TOT. : 87 Pts

Tomotherapy down time

2

1

1-3 days

47 *

10

< 1 day*

1 (17 days)1Jan-Sep 2005

--Nov-Dec 2004

> 5 days3-5 days

* usually less than 30 minutes

PET/CT PLANNED TOMOTHERAPY :

CONCLUSIONS AND PERSPECTIVES (1)

• Accurate set-up verification ( MVCT )

• Accurate target definition

• Plan modification in itinere

• Highly conformal dose distribution and hypofractionation(particularly indicated for: H&N, lung, pancreas, prostate, tumor relapse in previous irradiated areas, metastases)

• Hypofractionation

PET/CT PLANNED TOMOTHERAPY :

CONCLUSIONS AND PERSPECTIVES (2)

• time required for planning , dosimetry and treatmentcomparable to IMRT

• sophisticated hardware and software equipment: need for in house maintenance

To be implemented:

• gated Tomotherapy

• actual delivered dose verification and adaptive Tomotherapy

Conventional fractionation

nanaradicalmax 4 , < 3cmLIVER MTS

235radicalI/II

1.835-37radicalIVa/b

RETREATMENTS

LUNG MTS

PROSTATE

PANCREAS

LUNG

H&N

SITE

III

IIIa/b

nanaradicalvar

na

1.8

2

2

1.8

Gy / fn fractions

39adjuvantpT3pN0

radical

radical

radical

adjuvant

INDICATION

namax 3 , < 3cm

33-34

35

30-32

SCHEDULESTAGE

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