Gregoire H&N
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    Gregoire H&N Gregoire H&N Presentation Transcript

    • Conformal radiotherapy and IMRT in Head and Neck Tumors The “academic” view point
    • Target volumes in Radiation Oncology: ICRU definition • Gross Tumor Volume: GTV • Clinical Target Volume: CTV • Planning Target Volume: PTV ICRU report 62, 1999
    • Immobilization of Head & Neck patients l 15 head & neck tumors l 15 brain tumors l 3 different masks (3, 4 & 5 FP) l 3 fictitious isocenters
    • Immobilization of Head & Neck patients l 915 portals images acquired. l 98 % analysed. l Total Displacement. u SIM - EPIDi l Systematic Displacement. u M(SIM - EPIDi) l Random Displacement. u (SIM - EPIDi) - [ M(SIM - EPIDi)] l Intraobserver variation: 0.7 mm (1 Sd).
    • 1.0 Cumulative incidence 0.9 0.8 Head 0.7 0.6 (3-5 FP) Total 3-D 0.5 0.4 0.3 deviations 0.2 0.1 0.0 0 1 2 3 4 5 6 7 8 9 10 Deviation from the isocenter (mm) 1 1.0 0.9 Cumulative incidence Shoulder Cumulative incidence 0.9 0.8 0.8 Neck 0.7 0.7 (4 & 5 FP) 0.6 (3-5 FP) 0.6 0.5 0.5 0.4 0.4 0.3 0.3 0.2 0.2 0.1 0.1 0.0 0 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Deviation from the isocenter (mm) Deviation of the isocenter (mm)
    • Characteristics of current imaging modalities CT MRI PET fMRI Image characteristics skin contour + ± ± - soft-tissue contrast ± + - - bone contrast + ± - - air contrast + ± ± - metallic artefacts + ± - ± movement artefacts - + ± + Machine characteristics large “tunnel” size + - - - distortion - + ± + electron density + - ± - multiplannar imaging - + ± +
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Image acquisition • Dual detector spiral CT • 2.7 mm collimation, pitch 0.7, reconstruction of 2 - 2.5 mm • Display matrix of 512 x 512 pixels • Contrast enhancement (interstitial and blood vessel contrast)
    • Conformal radiotherapy: reference coordinates
    • Conformal radiotherapy: 3D reconstruction
    • Conformal radiotherapy: 3D reconstruction
    • Conformal radiotherapy: image display
    • The present … which CTV for the neck ? Cervical lymph node groups (MSKCC classification) Adopted by the Academy’s Committee for Head & Neck Surgery and Oncology Robbins et al, 1991
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Definition of the extend of the CTV in the neck State of the art • Predictive pattern of lymph node involvement in HNSCC • Selective neck treatment (irradiation or dissection) for selected N stage
    • The present …CT-based delineation of lymph node levels in the neck Ia Ib VI III RP V II Grégoire et al., 2000
    • Conformal radiotherapy: volume delineation
    • Conformal radiotherapy: volume delineation
    • Conformal radiotherapy: Beam selection
    • B E V
    • Conformal radiotherapy: Dose distribution
    • Conformal radiotherapy: Dose distribution
    • Conformal radiotherapy: Dose volume histogram
    • Conformal radiotherapy: Dose volume histogram
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01)
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01) Target volumes • T: CTV1: GTV + 1.5 cm margin CTV2: GTV + 0.5 cm margin PTV1&2 : CTV + 4 mm • N:CTV: R & L LII - IV PTV: CTV + 4 mm Dose prescription • T: PTV1: 50 Gy, 25x2 Gy PTV2: 70 Gy, 35x2 Gy • N:PTV: 50 Gy, 25x 2Gy
    • Conformal radiotherapy and IMRT in Head and Neck Tumors “Antique” (7 fields) Rx 6 MV Rx 6 MV 40 Gy 30 Gy Elect 8 MeV Rx 6 MV 10 Gy 50 Gy
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau PTV 55 Gy Dmean 63.2 60.1 59.2 Dmax 79,1 76.6 74.6 Dmin 10.0 39.1 44.4 SD 10.2 9.5 8.1 PTV 70 Gy Dmean 72.4 71.7 70.6 Dmax 76.9 76.5 74.6 Dmin 67.4 65.2 67.0 SD 1.8 2.1 1.5 L parotid Dmedian 68.7 52.1 50.7 Dmax 72.8 72.5 71.8 Dmin 46.4 8.4 5.4 SD 7.6 12.2 15.5 R parotid Dmedian 69.6 65.7 40.6 Dmax 72.9 72.6 55.9 Dmin 62.1 4.4 3.6 SD 1.7 24.9 16.7
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau Spinal cord Dmean 22.8 19.6 22.7 Dmax 43.0 41.9 47.6 Dmin 5.5 3.3 2,7 SD 16.0 16.1 18.0 Mandibula Dmedian 71.5 68.9 60.5 Dmax 76.8 74.5 72.2 Dmin 51.1 4.8 3.7 SD 2.2 22.0 17.4 Internal contour Dmedian 41.6 13.6 19.3 Dmax 79.2 76.6 74.6 Dmin 2.0 1.2 1.1 SD 21.5 23.4 22.2
    • Conformal radiotherapy and IMRT in Head and Neck Tumors “Middle Age” (9 fields) Rx 6 MV Rx 6 MV 40 Gy 10 Gy Elect 8 MeV Rx 6 MV Rx 6 MV 10 Gy 20 Gy 50 Gy
    • Conformal radiotherapy and IMRT in Head and Neck Tumors “Middle Age” (9 fields) Rx 6 MV Rx 6 MV 40 Gy 10 Gy Elect 8 MeV Rx 6 MV Rx 6 MV 10 Gy 20 Gy 50 Gy
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau PTV 55 Gy Dmean 63.2 60.1 59.2 Dmax 79,1 76.6 74.6 Dmin 10.0 39.1 44.4 SD 10.2 9.5 8.1 PTV 70 Gy Dmean 72.4 71.7 70.6 Dmax 76.9 76.5 74.6 Dmin 67.4 65.2 67.0 SD 1.8 2.1 1.5 L parotid Dmedian 68.7 52.1 50.7 Dmax 72.8 72.5 71.8 Dmin 46.4 8.4 5.4 SD 7.6 12.2 15.5 R parotid Dmedian 69.6 65.7 40.6 Dmax 72.9 72.6 55.9 Dmin 62.1 4.4 3.6 SD 1.7 24.9 16.7
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau Spinal cord Dmean 22.8 19.6 22.7 Dmax 43.0 41.9 47.6 Dmin 5.5 3.3 2,7 SD 16.0 16.1 18.0 Mandibula Dmedian 71.5 68.9 60.5 Dmax 76.8 74.5 72.2 Dmin 51.1 4.8 3.7 SD 2.2 22.0 17.4 Internal contour Dmedian 41.6 13.6 19.3 Dmax 79.2 76.6 74.6 Dmin 2.0 1.2 1.1 SD 21.5 23.4 22.2
    • Conformal radiotherapy and IMRT in Head and Neck Tumors “Art nouveau” (10 fields, 12 segments ) SRAO SLAO Post. Seg. 1 Post. Seg. 2 Rx 6 MV 50 Gy RPO LPO Ant. …
    • Conformal radiotherapy and IMRT in Head and Neck Tumors “Art nouveau” (11 fields, 12 segments ) Ant. RAO LPO Rx 6 MV 20 Gy LAO1 LAO2
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau PTV 55 Gy Dmean 63.2 60.1 59.2 Dmax 79,1 76.6 74.6 Dmin 10.0 39.1 44.4 SD 10.2 9.5 8.1 PTV 70 Gy Dmean 72.4 71.7 70.6 Dmax 76.9 76.5 74.6 Dmin 67.4 65.2 67.0 SD 1.8 2.1 1.5 L parotid Dmedian 68.7 52.1 50.7 Dmax 72.8 72.5 71.8 Dmin 46.4 8.4 5.4 SD 7.6 12.2 15.5 R parotid Dmedian 69.6 65.7 40.6 Dmax 72.9 72.6 55.9 Dmin 62.1 4.4 3.6 SD 1.7 24.9 16.7
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Dose (Gy) at various organs at risk Antique Middle-age Art nouveau Spinal cord Dmean 22.8 19.6 22.7 Dmax 43.0 41.9 47.6 Dmin 5.5 3.3 2,7 SD 16.0 16.1 18.0 Mandibula Dmedian 71.5 68.9 60.5 Dmax 76.8 74.5 72.2 Dmin 51.1 4.8 3.7 SD 2.2 22.0 17.4 Internal contour Dmedian 41.6 13.6 19.3 Dmax 79.2 76.6 74.6 Dmin 2.0 1.2 1.1 SD 21.5 23.4 22.2
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Forward planning IMRT • « human optimization » Inverse planning IMRT • Dose-volume constraints & weights for PTV and OARs • optimization algorithms • Penalty function
    • Inverse planning IMRT for Head and Neck Tumors Cummulative % of MUs l Spare cord Segment # l Spare left parotid 1 6. l 15 segments l 10 levels Courtesy of C. Field
    • Inverse planning IMRT for Head and Neck Tumors PTV Spared parotid gland Courtesy of C. Field
    • Parotid gland function lemon juice 370 MBq 99mTc-pertechnetate
    • Parotid gland function Objective assessment 100 90 R= 0,77 Maximum secretion (%) 80 70 60 50 40 30 20 Bilateral irradiation 10 Unilateral irradiation 0 0 10 20 30 40 50 60 70 Mean parotid dose (Gy)
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Duration of treatment planning procedure 2D planning Forward planning Inverse planning (St-Luc) (Edmonton Cancer center) Volume delineation 0 - 0.25h 2 - 3h 1 - 1.5h Planning 0.25h 2 - 8h 1 - 2h Individualized QC 0h 0.25h 1h Treatment (per session) 10 - 15 min 20 - 25 min 15 min
    • Conformal radiotherapy and IMRT in Head and Neck Tumors Definition of the extend of the CTV in the neck State of the art • Predictive pattern of lymph node involvement in HNSCC • Selective neck treatment (irradiation or dissection) for selected N stage